Final Review - NURS 106

Med-Surg - 67 Care of Patient with Male Reproductive Problems

Benign Prostatic Hyperplasia (BPH) Pathophysiology Overview - Glandular units in the prostate undergo nodular tissue hyperplasia - Bladder outlet obstruction affects elimination Etiology and Genetic Risk Unmodifiable risk factors - Race - Genetic susceptibility - Family history of cancer Modifiable risk factors - Obesity and metabolic syndrome - Beverage consumption Incidence and Prevalence - 40-50% of men between 51-60 years old - Over 80% of men older than 80 years old Health Promotion and Maintenance - Teach that BPH is common - Teach that addressing modifiable risk factors can improve overall health Nursing Process Assessment: Recognize Cues History - International Prostate Symptom Score (I-PSS) - Elimination patterns - Ask whether hematuria is present Physical assessment - Health care provider performs prostate gland examination Psychosocial Assessment - Frustration or depression due to sleep interruption - Embarrassment due to post-void dribbling or overflow incontinence Diagnostic Assessment Laboratory assessment ---Urinalysis and culture ---CBC ---BUN ---PSA ---Serum acid phosphatase ---Biopsy ---Culture and sensitivity of prostatic fluid Other diagnostic assessment ---Transrectal ultrasound ---Cystoscopy ---Bladder ultrasound Analyze Cues and Prioritize Hypotheses - Urinary retention due to bladder outlet obstruction - Decreased self-esteem due to overflow urinary incontinence and possible sexual dysfunction Planning and Implementation: Generate Solutions and Take Action Improving urinary elimination -Nonsurgical management ----Behavioral modification ----Drug therapy ----Complementary and Integrative Health ----Other nonsurgical interventions - Surgical management ----TURP or TUIP-may have CBI after surgery. ----Minimally invasive surgeries - Improving Self-Esteem ----Teach to toilet when the urge occurs ----Remind to keep surrounding area clean and dry ----Small absorbent pad can be used Care Coordination and Transition Management Home Care Management - Catheter Self-education management - Re-establishment of urinary control Health care resources - Follow-up care as recommended Evaluation: Evaluate Outcomes - Improved urinary elimination - Improved self-esteem Prostate Cancer Pathophysiology Overview - Slow growing cancer with predictable metastasis - Advanced age is leading risk factor Etiology and Genetic Risk - Advanced age - First-degree relative with disease - African-American men Incidence and Prevalence - Most commonly diagnosed non-skin cancer in men in the U.S. - Has nearly 100% cure rate if found and treated early - Men > 65 years old are at greatest risk Health Promotion and Maintenance - Teach current evidence-based guidelines-age 55 or what health care provider recommends. Age 40-45 if high risk. - Nutritional habits that can be modified-decreased consumption of red meat. Increase fruits and veges. Nursing Process Assessment: Recognize Cues History - Age, race/ethnicity, family history - Nutrition habits - Elimination issues - Pain - Weight loss - Changes in sexuality Physical assessment - May be diagnosed as part of routine examination - Hematuria - Pain in pelvis, hips, spine, ribs - Weight - DRE (health care provider)-digital rectal exam. Psychosocial Assessment - Fear, anxiety - Shock, fear, anger - Grieving process - Concern regarding sexual function Diagnostic Assessment - Laboratory assessment ----PSA ----EPCA-2-early prostate cancer antigen - Other diagnostic assessment ----TRUS-transrectal ultrasoound ----Other testing ordered after prostate cancer diagnosis Analysis: Analyze Cues & Prioritize Hypotheses - Potential for cancer metastasis due to lack of, or inadequate, treatment Planning and Implementation: Generate Solutions and Take Action Preventing metastasis - Active surveillance (AS) - Nonsurgical management ----Radiation therapy ----Drug therapy - Surgical management ----Radical prostatectomy (laparoscopic or open) *****Nursing care is the same as for a patient undergoing major surgery *****Pain management *****Indwelling catheter *****Ambulate no later than the day after surgery *****May have erectile dysfunction or urge incontinence Care Coordination and Transition Management Home care management Self-management education - Indwelling catheter care - Walk short distances - Use stool softener if prescribed - Shower (do not soak in bathtub) Health care resources - Agencies or support groups Evaluation: Evaluate Outcomes - Remain free from metastasis Testicular Cancer Pathophysiology Overview - Rare cancer affecting men usually between 20 and 35 years of age but leading cause of cancer in men 15-44. - 95% cure rate with early detection by testicular self-examination and treatment Nursing Process Assessment: Recognize Cues History - Consider risk factors-those with undescended testes (cryptorchidism), HIV, AIDS, history of testicular cancer. - Painless, hard swelling or enlargement of testicle - Assess for concerns of sexuality, reproduction Physical Assessment/Signs & Symptoms - Health care provider performs testicle examination Psychosocial Assessment - Concerns regarding sexuality and the desire to have children-may need to recommend sperm banking. - Refer as needed Diagnostic Assessment - Laboratory assessment ----AFP, hCG, LDH -lactate dehydrogenase - Other diagnostic assessment ----Scrotal ultrasound ----Chest x-ray ----CT of chest, abdomen, pelvis ----MRI of the brain Planning and Implementation: Generate Solutions and Take Action - Sperm bank storage if patient desires - Nonsurgical management ----Chemotherapy or radiation - Surgical management ----Orchiectomy *****Preoperative care *****Operative procedures *****Postoperative care Care Coordination and Transition Management - Scrotal support - Sutures to be removed in 7 to 10 days by health care provider - Teach to avoid lifting, stair-climbing, driving for 1 week - Monthly testicular self-examination - Refer as needed Erectile Dysfunction (ED) Pathophysiology Overview - Also called "impotence" - Organic-gradual deterioration, causes DM obesity vs. psychogenic-episodes of ED, can be related to stress. Interventions: Take Action - Diagnostic testing - Doppler ultrasonography - Treatment ------Lifestyle modifications ------Management of medications that may cause ED ------Penile self-injection with prostaglandin E1 ------Drug therapy ------Psychotherapy ------Surgery ------Vacuum-assisted erection devices

Med-Surg - 37 Care of Patients with Hematologic Problems

Hematologic System - Most important function of the hematologic system is the production of blood cells and blood cell products that are vital for perfusion, immunity, clotting and gas exchange. Sickle Cell Disease Pathophysiology Overview - Genetic hemoglobin disorder - Formation of abnormal hemoglobin chains - Cells are distorted into sickle shapes which clump together - Clumps block blood flow; tissues become hypoxic Etiology and Genetic Risk - Autosomal recessive pattern of inheritance-patient has two Hbs gene alleles, one inherited from each parent. If patient with SCD has children, each child will inherit one or two of the abnormal gene alleles and at least have sickle cell trait. Incidence and Prevalence Occur in people of all races and ethnicities - Most common among African Americans in the U.S. - Occurs in 1 in 500 African Americans - About 1 in 13 African Americans are carriers Nursing Process Assessment: Recognize Cues History - Assess for previous crises, severity, usual management, assess S&S of infection. Physical Assessment/Signs and Symptoms - Pain-the most common symptom and reduced perfusion-compare peripheral pulses, skin temp, cap refill. Pallor or cyanosis. Psychosocial Assessment - Support systems, coping patterns, impact on patient and family Laboratory assessment - Percentage of hemoglobin S (HbS) on electrophoresis - Hematocrit usually low during crisis r/t RBC shortened lifespan and destruction. - Reticulocyte count-high indicating anemia, WBC high r/t chronic inflammation. Imaging assessment - X-rays, CT, PET, MRI Other diagnostic assessment - ECG Analysis: Analyze Cues and Prioritize Hypotheses - Pain due to poor tissue perfusion and joint destruction with low oxygen levels - Potential for infection, sepsis, multiple organ dysfunction syndrome (MODS), and death Planning and Implementation : Generate Solutions and Take Action Managing pain - Drug therapy-morphine, hydromorphone IV or PCA, Hydroxyurea-is a teratogen (can cause birth defects). - Integrative therapies Prevent sepsis, MODS, and death - Prevention and early detection strategies - Hydration-oral water or juice or IV hypotonic solutions-NS 200 ml/hr. - Oxygen - Drug therapy-prophylaxis oral PCN bid - Transfusion Care Coordination and Transition Management - Self-management education-Drink at least 3-4 liters liquid/day. Avoid alcohol/cigarettes, get yearly flu vaccine, avoid hot and cold temp extremes, avoid travel to high altitudes. - Health care resources-refer to genetic counselors. Evaluation: Evaluate Outcomes - Report pain to be maintained at an acceptable level - Maintain perfusion and gas exchange to extremities and vital organs - Remain free of infection, sepsis, and multiple organ dysfunction syndrome (MODS) Anemia - Reduction in either the number of RBCs, amount of hemoglobin, or hematocrit - Clinical indicator (not specific disease); occurs with many health problems Common Causes of Anemia - Dietary problems - Genetic disorders - Bone marrow disease - Excessive bleeding (e.g., GI bleeding) Key Features of Anemia General - Pallor - Cool to the touch - Intolerant of cooler temperatures - When chronic, nails become brittle and concave Cardiovascular Signs and Symptoms - Continuous rapid heartbeat that increases after meals and with activity - Murmurs and gallops - Orthostatic hypotension Respiratory Signs and Symptoms - Breathless on exertion - Decreased oxygen saturation levels Neurologic Signs and Symptoms - Fatigue - Increased need for sleep - Reduced energy levels Types of Anemia - Iron deficiency-most common, older adults, women, poor diets. - Vitamin B12 deficiency-vegan diets, small bowel resection, chronic diarrhea. - Folic acid deficiency Anemia Interventions: Take Action Iron deficiency anemia - Increase oral intake of iron-red meat, organ meat, egg yolks, kidney beans. - Iron supplements Vitamin B12 deficiency anemia - Increase intake of foods rich in B12- animal proteins, fish, eggs, nuts. - Injections, oral preparations, nasal spray, sublingual cobalamin Folic acid deficiency anemia - Prevent deficiency with diet rich in folic acid and vitamin B12 Immunohemolytic - Immunotherapy-caused by immunity problems that allow person to form antibodies that attack and destroy own RBC's. Destruction is followed by accelerated production of abnormal RBC's. - Splenectomy-if spleen is enlarged or destroying normal RBC's. - Immunosuppressive therapy with chemotherapy-if steroid therapy fails. Polycythemia Vera Cancer of the RBCs-causes loss of cellular regulation. - Massive production of RBCs-causes hyperviscous-(thicker than normal blood). - Excessive leukocyte production - Excessive platelet production Assessment: Recognize Cues - Facial skin and mucous membranes are dark purple or cyanotic - Intense itching r/t dilated vessels and poor perfusion. - Blood flow slower causing Vascular stasis causes thrombosis - Poor gas exchange with severe tissue hypoxia of heart, spleen, and kidneys. - Bleeding problems because of platelet impairment with poor clotting. Interventions: Take Action - Fatal if untreated - Apheresis-withdrawal of whole blood (RBC's), plasma then reinfused. (take out clotting factor) - Increase hydration-to promote venous return and help prevent clot formation. - Anticoagulants, other drug therapy-ASA, oral chemotherapy agents. Leukemia and Preleukemia Pathophysiology Overview - Blood cancer - uncontrolled production of WBCs (blast cells) in bone marrow - Blast cells = immature cells - Acute or chronic - Classified by cell type -lymphocytic or lymphoblastic- come from lymphoid pathways Etiology and Genetic Risk Genetic and environmental factors Damage to genes that control cell growth leads to loss of cellular regulation. Risk factors - Ionizing radiation-exposure to radiation therapy for CA - Viral infection - Exposure to chemicals and drugs Incidence and Prevalence - 3-4% of new cases of cancer and all deaths from cancer - 61,780 new cases annually in U.S.; 6200 in Canada Nursing Process Assessment: Recognize Cues History - Ask about risk and genetic factors - Occupation, hobbies, medical history, exposure - History of infections, bleeding or bruising, weakness, fatigue Physical Assessment/Signs and Symptoms - Integumentary-Ecchymosis, petechiae - Gastrointestinal-bleeding gums, anorexia - Renal-Hematuria - Musculoskeletal-bone pain - Cardiopulmonary-tachycardia, orthostatic hypotension - CNS-fatigue, HA, fever Psychosocial assessment - Anxiety, fear, lifestyle changes, off work for treatment Laboratory assessment - Low hemoglobin and hematocrit - Low platelets-thrombocytopenia - Leukopenia-reduced circulating WBC's - Abnormal WBC count-elevated r/t immature blast cell production. - Bone marrow aspiration and biopsy - Blood clotting times - Chromosome analysis Imaging assessment - Chest x-ray-may show leukemic infiltrates in the lung. - Skeletal x-rays show bone density loss. Nursing Process Analyze Cues and Prioritize Hypotheses - Potential for infection due to reduced Immunity and chemotherapy - Potential for injury due to poor clotting from thrombocytopenia and chemotherapy - Fatigue due to reduced gas exchange and increased energy demands Planning and Implementation Preventing infection - Goal is to halt infection, and control new infection early ----Drug therapy-combo chemo-cause severe bone marrow suppression with neutropenia. ----Handwashing ----Strict aseptic technique - catheter care ----HSCT-Hematopoietic stem cell transplant. Minimizing injury-bleeding precautions r/t thrombocytopenia. Nadir-period of greatest bone marrow suppression. Conserving energy-Nutrition therapy, blood transfusions, drug therapy. Care and Coordination and Transition Management - Home care management to assist with dressing changes of central venous catheter and transfusions. - Self-management education-teach proper hygiene. - Health care resources-HHA Malignant Lymphomas - Hodgkin's lymphoma- affects any age group, but mostly teens and young adults and adults in 50's and 60's. Exact cause uncertain but some research shows link b/t Epstein-Barr virus, HIV and exposure to chemicals. Lymph nodes contain Reed-Sternberg cell (marker for HL). - Non-Hodgkin's lymphoma-includes all lymphoid cancers that do not have Reed-Sternberg cell. Exact cause unknown, incidence higher among patients with solid organ transplants, immunosuppressive therapy and HIV. (Non-Hodgkin's does NOT have the marker) Nursing Process Assessment: Recognize Cues - Large, painless lymph node(s) - Fevers, drenching night sweats, unplanned weight loss - Some have no symptoms at time of diagnosis Interventions: Take Action - External radiation of lymph node regions - For more extensive disease, radiation and combination chemotherapy is used - CAR-T therapy Other: Multiple Myeloma - - WBC cancer of mature B-lymphocytes called plasma cells that secrete antibodies. - Fatigue, easy bruising, bone pain - Treatment involves watchful waiting; proteasome inhibitors, immunomodulating drugs, HSCT-stem cell transplant. - Teach patient about symptoms. Drug therapy can cause peripheral neuropathy, N/V. Thrombocytopenic Purpura - Destructive reduction of circulating platelets after normal platelet production; impaired clotting occurs ---ATP-autoimmune thrombocytopenia purpura ---TTP-Thrombotic thrombocytopenia purpura ---HIT-Heparin induced thrombocytopenia - Ecchymosis, purpura, anemia may be present - Treatment involves platelet transfusions; anticoagulants; splenectomy-in ATP only because of excessive platelet destruction. Transfusions Pretransfusion responsibilities - Review agency policy - Verify prescription with another RN - Test donor's/recipient's blood for compatibility - Use two identifiers for patients who receive transfusion; verify with another RN - Examine blood bag label, attached tag, and requisition slip for ABO and Rh compatibility with the client - Check expiration date/time with another RN - Inspect blood for discoloration, gas bubbles, cloudiness Transfusion Responsibilities - Administer the blood product using the appropriate filtered tubing to remove aggregates and possible contaminates. - Unless directed otherwise infuse blood products only with IV normal saline solutions because some other IV solutions can cause hemolysis. - Stay with the patient for the first 15 to 30 minutes of the infusion because this is the time severe reactions occur. - Infuse the blood product at the prescribed rate for the transfusion type to avoid the possible complication of fluid overload. - Monitor vital signs at least as often as agency policy and the patient's condition indicates to identify early indications of adverse transfusion reactions. Transfusions RBC transfusions - Replaces cells lost from trauma or surgery Platelet transfusions - Given for low platelet counts, active bleeding, scheduled for invasive procedure Plasma transfusions - Replaces blood volume and clotting factors Granulocyte (WBC) transfusions - Given (rarely) to neutropenic clients Massive transfusion protocol - - Given when H&H levels are low Acute Transfusion Reactions - Febrile-chills, tachycardia, fever-occurs mostly with WBC and platelet transfusions. - Hemolytic-caused by blood type or Rh incompatibility. Sx-Fever, chills or DIC. Patient may c/o HA, chest pain, low back pain. - Allergic-patient with other allergies. Sx-itching, bronchospasm. During transfusion or up to 24 hours. - Bacterial-contaminated blood product. - Circulatory overload-if blood infused too quickly. Sx. HTN, bounding pulse, JVD, Dyspnea, confusion. - Transfusion-associated graft-versus-host disease (TA-GVHD) Sx-dyspnea or hypoxia within 6 hours. Autologous Blood Transfusions - Collection and infusion of patient's own blood - Eliminates compatibility problems - Reduces risk for transmitting bloodborne disease

Maternal Child - 25 Pregnancy-Related Complications

Hemorrhagic Conditions of Early Pregnancy Spontaneous abortion - leading cause of pregnancy loss - most commonly due to chromosomal abnormalities incompatible with life - rate increases with age - treatment : 1) preventing complications such as hypovolemic shock and infection, 2) providing emotional support for grieving Types of spontaneous abortions - threatened - inevitable - incomplete - complete - missed - recurrent - habitual abortion Disseminated Intravascular Coagulation (DIC) DIC (consumptive coagulopathy) - a life-threatening complication of missed abortion, abruptio placentae, and preclampsia - pro-coagulation and anti-coagulation factors are simultaneously activated - the priority in treating DIC is delivery of the fetus and placenta - blood replacement products and cryoprecipitate are administer to maintain circulating volume Ectopic Pregnancy Implantation of the fertilized ovum in an area outside of the uterine cavity - 95% occur in the fallopian tubes - the incidence of ectopic pregnancy is increasing as a result of pelvis inflammation Therapeutic Management - medical management - prevent severe hemorrhage - salpingectomy Number one cause of infertility Risk Factors - Hx of sexually transmitted diseases such as chlamydia, gonorrhea - hx of pelvic inflammatory disease - hx of pervious ectopic pregnancy - failed tubal ligation - IUD - multiple induced abortions - maternal age greater than 35 - use of some assisted reproductive technologies Gestational Trophoblast Disease Hydatidiform mole - as a result of abnormal cell growth, the placenta develops but not the fetus - Gestational trophoblastic mole Management - Evacuation of molar pregnancy - regular follow up for 1 year to detect malignant changes Hemorrhagic Conditions of Late Pregnancy Placenta previa - implantation of the placenta in the lower uterus - marginal - partial - complete - painless uterine bleeding in the latter half of pregnancy - May lead to preterm labor, normally c-section - Diagnosed by US No digital exam Abruptio placentae aka placental abortion - separation of normally implanted placenta before the fetus is born - bleeding and formation of a hematoma on the maternal side of the placenta - bleeding may be visible or concealed - is painful, uterine tenderness, and uterine hyperactivity - placenta tearing away from the body Signs and symptoms of Abruptio Placentae (concealed hemorrhage) - Increased fundal height - bard board-like abd - high uterine base-line tone on electronic monitoring strip - persistent abd pain - Tachycardia, falling BP, restlessness - persistent late decelerations in fetal heart rate - vaginal bleeding can be slight or absent - Risk factor is hypertension Signs and Symptoms of Impending Hypovolemic Shock - increased pulse rate, failing BP, increased resp rate - weak, diminished, or thready peripheral pulses - cool, moist skin, pallor - decreased urinary output (less than 30ml/hr) - decreased in hemoglobin/hematocrit levels (because bleeding out) - changes in mental status (because loss of O2 from blood loss) - only sends blood to core organs like heart, brain, lungs - later stage - BP is down HR up, Resp rate up, thready pulses Hyperemesis Gravidarum - Persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout Management - reducing N/V - maintaining nutrition and fluid balance - providing emotional support - watch for dehydration - small frequent meals - not anything ordorous - eat food with magnesium/sodium (electrolytes) Gestational Hypertension - Blood pressure elevation after 20 weeks of pregnancy - not accompanied by proteinuria (never good) - may progress to preeclampsia - if it presists more than 6 weeks after the birth, chronic hypertension is diagnosed - anything over 140/90 Risk factors - First pregnancy, for mother and father - men who have fathered one preeclamptic pregnancy - age greater than 35 years - anemia - family or personal hx of preeclampsia - chronic HTN - chronic renal disease - obesity - diabetes - multifetal pregnancy - pregnancy from assisted reproduction techniques Preeclampsia Patho - generalized vasospasm decreases circulation to all organs of the body including placenta Manifestations (symptoms can go unnoticed) HTN with proteinuria Systolic greater then 140 Diastolic greater than 90 Seizure precautions - get oxygen ready and O2 mask page 544 Home care for mild preeclampsia - activity restrictions - monitoring of fetal activity - BP monitoring - wt measurement - UA for protein - diet w/o salt - fetal assessmet - Dr appt q 3-4 days Eclamsia - Progression of preeclampsia is generalized seizures - mag sulfate is used to prevent seizures in preeclampsia - hypoflexia precedes resp depression - control external stimuli and initiate measures to protect the woman in care preeclampsia proceeds to eclamptic seizures - Can continue into postpartum Interventions for Seizures - initiate preventative measures - monitor for signs of impending seizure - prevent seizure- related injury - protect the woman during a seizure - support the family - monitor for signs of magnesium toxicity - roll on side, time of begin/time of stop, make sure to see if she is safe, do not leave them alone, VS when stops and monitor the baby HELLP Syndrome Hemolysis, elevated liver enzymes and low platelets (HELLP) - Hemolysis occurs as a result of the fragmentation and distortion of erythrocytes during passage through damaged blood vessels - liver enzyme levels increase when hepatic blood flow is obstructed by fibrin - low platelet levels are caused by vascular damage resulting from vasopasm - pain in right upper quadrant (Main symptom) Chronic Hypertension Hypertension that preceded the pregnancy or less than 20 weeks gestation - women with chronic HTN are at risk for preeclampsia - monitor closely for proteinuria and edema - antiHTN meds should be initiated if diastolic BP is higher than 100 - Heredity and race play a significant role Incompatibility between Maternal and Fetal Blood Rh incompatibility - Rh-negative women conceives an Rh-positive child - maternal antibodies may develop after exposure to fetal Rh-positive blood - Admin of RhoGAM IM shot ABO incompatibility - O blood type women naturally occurring and anti-A and anti-B antibodies - may result in hyperbilirubinemia of the infant - increases the risk of jaundice

Maternal Child - 16 Giving Birth

Physiologic Effects of the Birth Process Maternal response - Labor contractions are intermittent, allowing placental blood flow and exchange of O2, nutrients, and waste products between maternal and fetal circulation during interval - the upper uterus contracts actively during labor as it pushed the fetus down - these actions bring about cervical effacement and dilation - cardiovascular, gastro, urinary, hematopoietic systems Fetal Response Placental circulation - enough reserves to tolerate labor Cardio system - reacts quickly Pulmonary system - fetal lung fluid production decreases and its absorption into lung tissue increases during late pregnancy and labor - thoracic compression during labor aids in the expulsion of additional fluid Components of the Birthing Process Powers Passage - natural mechanisms of labor favor efficient passage of the fetus through the mother's pelvis Passenger- presentation and position further describe the relation of the fetus (passenger) to the maternal pelvis Psyche Powers The two powers of labor are uterine contractions and the maternal pushing efforts - during the 1st phase of labor (onset through dilation) uterine contractions are the primary force moving the fetus through the maternal pelvis - during the 2nd stage of labor (dilation through birth) the women uses her voluntary pushing efforts to propel the fetus through the pelvis Passage The passage of birth of the fetus consists of the maternal pelvis and its soft tissues - the boney pelvis is more important to the outcome of labor, because the bones and joints are not readily yield to the forces of labor - Softening fo the cartilage linking the pelvis bones increases as term approaches and the hormone relaxin increases Passenger - fetal head - fetal lie - attitude - presentation : cephalic, breech- position Psyche State of mother's psyche is a crucial aspect of childbirth - anxiety, fear, or fatigue decreased a woman's ability to cope with labor pain (can make labor more painful thus making it take longer - maternal catecholamines are secreted in response to anxiety and fear : inhibit uterine contractility and placental blood flow -Relaxation boosts the natural process of labor - Interrelationships between the components of birth Individual and Cultural Values Culture gives her cues about how she should behave and react labor and how she should interact with her newborn - knowledge of the values and practices of cultural groups that the nurse encounters provides a framework to assess and care for the woman and her family - Birth is an emotional experience Normal Labor Theories of onset - changes in maternal estrogen - prostaglandin secretion - increased secretion of oxytocin - oxytocin receptors increase - fetal role - stretching, pressure, and irritation of the uterus Premonitory Signs - Braxton Hicks contractions - lightening - Increase in clear and nonirritating vaginal secretions - "bloody show" - also called ripening - Energy spurt (nesting) - small weight loss True Labor and False Labor The difference between true and false labor is progressive effacement and dilation of the cervix - some do not have symptoms typical of true labor - she should enter the birth center for eval is she is uncertain or has concerns False Labor Contractions are inconsistent in frequency, duration, intensity - change in activity does not alter contractions Discomfort - felt in abd and groin, more annoying then painful Cervix (main indication - no significant change in effacement or dilation True Labor Contractions - a consistent pattern of increasing intensity, duration, frequency; walking increases intensity Discomfort - begins in low back and wraps around to abd Cervix (main indication - effacement and dilation occurs Mechanisms of Labor - Descent - engagement of the presenting part - flexion of the fetal head - internal rotation - extension of the fetal head - external rotation - expulsion of the fetal shoulders and body Stages of Labor First Stage - onset of contractions to full dilation of the cervix Second Stage - full dilation to birth Third Stage - Birth of the fetus until delivery of the placenta Fourth Stage - 2 hours after the delivery of the placenta Duration of Labor -Total duration is different for : women who have never given birth, women who have given birth previously - parous women usually deliver more quickly - each women labors differently - first stage is usually longer then all other stages combined - hx of rapid delivery Nursing Care During Labor and Birth Admission to the birth center - establish a therapeutic relationship - assess the condition of the mother and fetus - determine the family expectations about birth Regular assessments after admission - monitor mother - monitor fetus When to Go to the Hospital or Birth Center Contractions - a pattern of increasingly regular intensity, duration, and frequency Ruptured membranes - a gush or trickle of fluid from the vagina should be evaluated Bleeding - bright red bleeding that is not mixed with blood or mucous should be evaluated Decreased fetal movement - a decrease in baby's movement should always be evaluated Other concerns - seek treatment for any concerns or feelings that something may be wrong Fetal Oxygenation Promoting placental function - persistent contractions may reduce placental blood flow and fetal oxygen, nutrient, and waste exchange - a maternal supine position can reduce placental blood flow, because the uterus compresses the aorta and inferior vena cava (roll to left lateral side) Measures/Impending Birth Promotes the woman's ability to relax and cope with labor - lighting and temperature - cleanliness and mouth care - bladder - positioning - water - providing encouragement - pharmacologic pain relief Impending Birth - "the baby is coming" - grunting sounds - "I need to have a bowel movement" - Bearing down - Check the perineum - "I feel like I need to push" Responsibilities During Birth/After Birth During - Preparation of the sterile table (blue) - perineal cleansing preparation - initial care and assessment of the newborn, including calling neonatal staff if indicated - admin of medication such as oxytocin to contact the uterus and control blood loss After - care of the infant : promote normal respirations, support thermoregulation, identify the infant - care of the mother : observe for hemorrhage, promote further uterine contraction, promote parent - infant attachment Promoting Early Attachment - First hour after birth is ideal for bonding - neonate is alert and responsive - Provide privacy - initial assessments can be done in the mother's arms - place the infant at the breast - consider cultural variations

Maternal Child - 53 Psychosocial Problems in Children and Families (Abuse Only)

Childhood Physical and Emotional Abuse - Emotional abuse - Physical abuse ---Increases during times of hardship or emotional stress - Sexual exploitation or molestation - All suspected child abuse must be reported to the appropriate authorities. - Document all injuries in detail ---A trained RN will take photographs of the injuries for the chart Child Neglect - Deliberate failure to provide for a child's needs ---Physical ------Inadequate weight gain ------Failure to thrive ------Poor growth pattern ---Emotional - Delays in physical and emotional development - Sexual abuse ---Difficulty in sitting and walking, bladder infections Physical Abuse Physical signs that raise suspicion - Bruises, especially in various stages of healing - Bite marks - Burns in unusual locations. - Multiple bone fractures - During an interview the child's parents may reveal an inconsistent story about how the child sustained the injuries. Sexual Abuse - It is common that a toilet trained child will revert back to incontinence of urine if they are sexually abused. - These children may use a different language for anatomical terms. Characteristics of Abusive Families - Isolated from community - Intense competition for emotional resources - Lack of a support system - Exhibit low levels of trust - Resolve conflict through aggression - Assume fixed and traditional roles - Establish rigid rules Other Specific Abuse Situations Abusive head trauma (AHT) - Also known as shaken baby syndrome or shaken infant - Caused by vigorous shaking of the baby while being held - Results in intracranial and retinal bleeding Munchausen syndrome by proxy - A psychiatric disorder where a caretaker falsifies illness in the child to gain attention Trafficking (child labor and sexual exploitation) - 2nd largest criminal activity in the world - Most commonly from runaway from home children - Often parents or relatives that perpetrators of trafficking

Maternal Child - 45 The Child with a Respiratory Alteration

Differences in the Respiratory System Lack of or insufficient surfactant Smaller airways and undeveloped cartilage Obligatory nose breather (infants) Less well-developed intercostal muscles Brief periods of apnea common (newborn) Mucus and snot can block airway - bulb syringes, suction can increase ICP Faster respiratory rate; increases metabolic needs - 30-60 bpm normal Eustachian tubes (ear tubes) relatively horizontal Respiratory Clinical Manifestations Vary with age - 6months-3years have more severe reactions General s/s and local manifestations differ in young children - Fever and meningismus, anorexia, vomiting, diarrea, and abd pain, cough, sore throat, nasal blockage, or discharge Ibuprofen - only in 6 months infants and older, but can take acetaminophen Acute Viral Nasopharyngitis (Common cold) Therapeutic : antipyretics, honey = cough suppressant, and harmful bacteria - 1 year and older Prevention : hand hygiene Care Management : Fluids, rest, cool mist Allergic Rhinitis Signs : inflammation disorder of the nasal mucosa - seasonal, recurrent, triggered by specific allergy, family hx, year round Rhinorrhea, itching, and paroxysmal sneezing Allergic salute - upward turning of the nose Allergic shiners - dark circle under the eyes from congestion Sinusitis Signs : inflammation and infection of the sinuses - can be chronic or acute, may lead to life-threatening complications if left untreated Often follows an URI - may also have allergic rhinitis or otitis media S/S of a cold w/o improvement x 10 days - low grade fever, cough, feeling of fullness over sinus area Otitis Media Definitions Otitis media - Effusion and infection or blockage of the middle ear Have they been sick recently? Etiology : follows the flu, cleft palate increases risk Diagnostic : Otoscope Therapeutic management : pharmacologic, surgical Prevention : avoid smoke exposure, propping bottle, administer flu vaccine Care management : abx, relieve pain Acute otitis media (AOM) - effusion in the middle ear that occurs suddenly and is associated with other illness Signs : earache; infant pull their ears or roll heads, fever, bulging tympanic membrane that may appear red, decreased mobility, diffuse light reflex; and obscured landmarks Drainage, usually yellow/green, purulent, and foul smelling (indicates perforation) -Extremely common Otitis media with effusion (OME) - presence of fluid behind the tympanic membrane w/o signs of infection; often follows an episode of AOM and usually resolves in 1 to 3 months Gets further in the ear Signs : tinnitus (ringing), popping sounds, hearing loss, mild balance disturbances, flattened tracing and negative pressure on tympanogram Influenza - A, B, and C Signs : dry throat, dry cough, hoarseness, flushed face, photophobia (light sensitivity), myalgia, lack of energy, sudden onset of fever and chills Therapeutic : antipyretics, antiviral Prevention : Vaccine for >6 months Care management : same as other URI Mononucleosis Kissing disease - spread by saliva Herpes - like Epstein-Barr virus (EBV) Signs : spleen and liver enlarges Diagnostic : Monospot Therapeutic : Prognosis Care management : No contact sports, analgesics Viral Pharyngitis (Strep Throat) Signs : gradual onset with sore throat, erythema (redness), inflammation of pharynx and tonsils, vesicles or ulcers on tonsils, fever (usually low grade, may be high), hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia (early), cervical lymph nodes may be enlarges and tender, normally lasts 3-4 days Bacterial Pharyngitis Signs : abrupt onset (may be gradual in younger than 2 years, sore throat (severe), erythema (redness), inflammation of the pharynx and tonsils, fever usually high, abd pain, headache, vomiting, cervical lymph nodes may be enlarges and tender, usually lasts 3-5 days Pharyngitis (Strep Throat) Signs : pharyngitis, HA, fever, tonsils may be exudate Causes : Group A B-hemolytic streptococcal infection (GABHS), Risk for rheumatic fever Diagnostic : throat culture Therapeutic : abx, antipyretics Pharyngitis and tonsillitis Tonsillitis : inflammation and infection of the two palatine tonsils Adenoiditis : infection and inflammation of the pharyngeal tonsils and adenoids Incidence peaks during middle childhood Tonsillitis Signs : frequent co-occurrence with pharyngitis, difficulty swallowing, breathing, breathing through mouth Therapeutic : tonsillectomy and adenoidectomy Care management : minimize risk for bleeding, soft or liquid diet, pain control Tonsillectomy Preop : Maintain NPO, check for gag reflex Postop : Prone/lateral, elevate the HOB when awake, assess for bleeding - can happen up to 14 days, no suction in mouth Education : Frequent swallowing, if bleeding increases HR, decrease BP, increase respirations Care management : give Zofran if nauseous, reduce cough, vomiting, no long utensils, reduce gagging, no gargling, keep bed at 30-45 degrees, prone (belly) or lateral (on side) until awake, vomiting bright red blood - concern, restless not associated with pain Laryngomalacia Signs : congenital laryngeal stridor - narrowing of the airway - no retractions w/this Noisy, crowing, respiratory sounds w or w/o retractions in the neonatal period, flaccidity of the epiglottis and supraglottic aperture and weakness of the airways Caused by immature neuromuscular development of the airway Therapeutic : Symptoms resolve by 18 to 24 months Croup Signs : often begins at night - gets worse at night; may be proceeded by several days of symptoms of URI, sudden onset of harsh; metallic; barky; cough, sore throat, inspiratory strider, hoarseness use of accessory muscles to breath, frightened appearance, agitation, cyanosis This is a virus = no abx Usually proceeded by an URI - increasing respiratory distress and hypoxia, can progress to respiratory acidosis and respiratory failure Therapeutic : maintain airway, maintain hydration - orally or IV, nebulizer treatments - steroids, racemic epi Reduce crying with respiratory distress, but during the duration of the medication crying helps get the medication deeper into the lungs. Epiglottis (Supraglottitis) MEDICAL EMERGENCY Cardinal Signs and Symptoms : drooling - constant stream, Dysphagia (difficulty swallowing), dysphonia (difficulty talking), distressed respiratory efforts - will see retractions Therapeutic : Stay in the room and call for help, set up for intubation or tracheostomy DO NOT - leave child unattended, examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction - not even thermometer Bronchitis Acute : viral, rhinoviruses most common agent, inflammation of the trachea and bronchi or Chronic : may indicate underlying respiratory dysfunction Signs : dry, hacking, non-productive cough that worsens at night and becomes productive in 2-3 days Therapeutic : cough suppressants, fluids, rest, increase humidity Bronchiolitis Bronchiolitis = umbrella term Respiratory syncytial bronchioles (RSV) - Do not kiss the baby Signs : rhinorrhea, low grade fever - first, cough, wheezing, retractions, crackles, dyspnea, tachypnea, and diminished breath sounds - inflammation and dilation of the bronchioles, RSV is the cause of 50% of bronchiolitis, RSV is a significant cause of hospitalization in children under 1 year - Highly communicable - Contact isolation and hand hygiene Diagnostic : secretions from nasal passages Therapeutic management : oxygenation, fluids, suction nasal passages, maintain temperature and droplet isolation, prevention of RSV - hand hygiene Pneumonia/Aspiration Pneumonia Inflammation of the lung parenchyma - primary , secondary -viral or bacterial -community acquired -marked decrease since the introduction or routine vaccination Aspiration pneumonia - risk for children with feeding difficulties, prevention, feeding techniques, avoidance of aspiration risks -infants with tachycardia >60 bpm Foreign Body Aspiration Frequent in age 6months to 5 years Give honey for swallowed battery if one year or older Diagnostic : H&P, may have x-ray Therapeutic : monitor respiratory distress Prevention : Educate parents - things that are easily swallowed or aspirated Care management : bronchoscopy under sedation Pulmonary Noninfection Irritations Acute respiratory distress syndrome (ARDS) - severe diffuse lung injury Passive smoking - children exposed to cigarette smoke have more frequent upper and lower respiratory complication Smoke inhalation - 50% of all fire-related deaths are due to smoke - smoke will kill before fire most of the time Apnea Cessation of breathing for 20 seconds or longer Note the following in an episode of apnea -time/duration -color -bradycardia -o2 sat -action that stimulated breathing Asthma Clinical manifestation : chest tightness, dyspnea, cough, audible wheezing, coarse lung sounds, possible crackles, mucus production, restlessness, irritability, anxiety, sweating, use of accessory muscles, low O2 sat, tripod, retractions EMERGENCY - Asthma Management Signs : worsening wheeze, cough, or SOB - no improvement after bronchodilator use - trouble with waking or talking - difficulty breathing - listlessness or weak cry - discontinuation of play - gray or blue lips or fingernails Therapeutic management : - albuterol - carry w/ and at school - administer medications and treatments - Educate child and family - avoidance of triggers - recognize early signs of an asthma episode - measures to prevent an asthma attack EMEREGENCY - Status Asthmaticus - respiratory failure and death if untreated - continuation of reap distress with therapeutic measures - concurrent infection in some cases Therapeutic Intervention - improving ventilation - pharmacologic agents this is a prolonged asthma attack when albuterol did not help wheezing means moving air* monitor o2 and HR - albuterol affects HR - increases Bronchopulmonary Dysplasia Chronic obstructive pulmonary disease (COPD) - acute lung injury in some infants who have received supplemental o2 and mechanical ventilation Occurs primarily in low birth wt and premature infants - chronic lung disease of infancy Management of TB TB skin tests administer antiTB meds as ordered importance of adequate rest Nutritionally adequate adherence to medication regime ways to prevent the transmission of TB infection Cystic Fibrosis Inherited multisystem disorder - dysfunction of exocrine glands - abnormal secretions of thick, tenacious mucus - obstruction and dysfunction of pancreas, lungs, salivary glands, sweat glands, and reproductive organs - both parent have to have the recessive gene Diagnostic : - sweat chloride test — universal newborn screening - DNA identification of mutant genes Presentation: 1st sign-meconium ileus - distal intestinal obstruction syndrome - excretion of indigestion food in stool; increased bulk, frorhiness, and foul odor - wasting of tissues - prolapse of the rectum - increased fat, increased calorie diet, increase risk for DM - wheezing respiration, dry nonproductive cough - generalized obstruction emphysema - cyanosis - clubbing of fingers and toes - repeated bronchitis and pneumonia - delayed puberty in girls - sterility in boys - skin tastes salty - dehydration - hypoatremia/hypochloremia alkalosis - hypoalbuminemia Therapeutic : - maintain an airway - administer bronchodilator - respiratory treatment - administer antibiotics and pancreatic enzymes - increased exercise tolerances - teach about CF and treatment to child/family - fat soluble vitamins need to be taken

Maternal Child - 52 The Child with a Neurologic Alteration

Assessment parameters for ICP Look at pages 1289-1292 -LOC -Pupillary reaction -Vital signs - increase of S and decrease of D = kushing response; change RR = apnea -Frequent assessment - depending on condition; ranges from 15min - 2hrs -GCS Signs of ICP in Infants - Poor feeding or vomiting - change in behavior - irritable, restless, lethargy - bulging fontanel - high pitched cry - increased head circumference - distended scalp veins - eyes downward (setting sun) - increase/decrease response to pain Signs of ICP in Children - headache, - dipolpia (double vision) - mood swings - slurred speech - papilledema (after 48hrs) brain swelling that leads to blindness - altered LOC - nausea/vomiting, especially in the morning Late Signs of ICP - Bradycardia (kushing triad/response) - decreased motor response to command (not waking) - decreased sensory response to painful stimuli (sternal rub) - alterations in PERLA (pupils fixed) - decreased LOC - coma ICP Nursing Activities : Patient positioning - avoid neck vein compression, - provide alternating-pressure mattress - elevate HOB 30-45 degrees Avoid activities that may increase ICP - lights, noises, stimuli Eliminating or minimizing environmental noise Suctioning issues Care Management : thermoregulation (antipyretics) - Elimination, hygiene care, positioning and exercise, stimulation (suction only if required), regaining consciousness, family support, keeping pt calm Nutrition and Hydration : IV fluids and parenteral nutrition, avoid overhydrating, continues monitoring for aspiration Later - Gastric feedings vis nasogastric or gastrostomy Medications : Antibiotics for infectious processes -corticosteroids (most potent) for inflammation/edema -Sedatives or antiepileptics (prevent seizures) -Sedation or amnesic anxiolytics (combo decreases ICP) - Barbiturates (controversial) - used when all else fails - Paralytic agents (used when intubating also given pain medication) Neurologic Examination - LOC - GCS : eye, verbal, and motor response - Behavior - alter in normal pattern of behavior - Pupil evaluation - Motor function - flexation/extension - Vital signs - kushing's response Decorticate = limbs drawn in Decerebrate = limbs outward -"celebrate" LOC Earliest indicator of changes in neurological status, most patients at least know their name/dob - patient may be helpful during assessment, they will know if the child has an abnormal change in LOC - Motor activity, reflexes, and vital signs (kushings) are not parallel to the depth of comatose state Full consciousness - awake, alert, interacts w/ environment Confused - lacks ability to think clearly and rapidly Delirious - impairment of reality with hallucinations possible Disoriented - lacks ability to recognize place or person Obtunded - sleeps, limited interaction w/environment Stupor - requires stimulation to arouse Coma - Vigorous stimulation produces no response Lethargic - awakens easily but exhibits limited responsiveness, hard time staying awake Nursing Care of the Unconscious Child Emergency management Airway/ ABC's Reduction of ICP Treatment of shock Outcome and recovery of unconscious child may depend on level of nursing care and observational skills Respiratory Comatose Management -Airway management is primary concern -Cerebral hypoxia lasting >4min may cause brain damage - CO2 retention = vasodilation, increased cerebral blood flow and increased ICP - Gag/cough reflex may be minimal or none - Risk of aspiration of secretions is increased - Airway- suction, sitting up, NPO Pain assessment in the comatose child - requires astute nursing observation - Signs of pain - increased agitation/rigidity, facial grimaces, muscle flexing - ICP increased by pain - Alterations in vital signs - increase in HR, RR, BP; decrease in O2 sat. - Opioids - controversial, fentanyl + midazolam + vecuronium; acetaminophen and codeine - Adequate dosage and regular administration - comfort measures, quiet, dimly lit environment Spina Bifida Congenital Neural Tube Defects (NTD) - incomplete closure of the vertebrate, happens in utero - Spina bifida occulta. spina bifida cystica (myelomeningocele) Clinical manifestations - small tuft of hair or dimple in the lower lumbar sacral area Most common defect of CNS, failure of neural tube to close at some point, folic acid deficiency Medical emergency - surgery if ruptured Therapeutic Management - postnatal care, orthopedic considerations, management of GU function - latex allergy, bowel control, surgery 24-48hrs after birth - moist sterile dressing to prevent drying Care management - prevent trauma to cyst, assess for level of neuro involvement, monitor urinary output, use of incubator, carefully clean sac, prevent complications, provide postoperative care, support family, may need a feeding tube, parents are unable to hold baby, careful diaper changes to avoid touching sac Hydrocephalus Develops as the result of an imbalance of production and absorption of CVF - often associated with myelomeningocele Therapeutic management - - Relief of hydrocephalus - Treatment of complications - assessment of motor development - Treatment : most often surgical - (VP Shunt) Ventriculoperitoneal shunt - fever is a medical emergency with shunt, shunt is typically for life Cerebral Palsy Chronic, nonprogressive disorder of posture and movement, difficulty controlling muscles Clinical Manifestations : delayed gross motor development, abnormal motor performance, alterations in muscle tone, abnormal postures, reflex abnormalities, associated disabilities Head Injury -Skull fracture, -Contusion, -Concussion Causes - falls, MVA, bicycle Concussion - jarred or shaken brain from a fall or blow to the head, nausea/headache Contusion - visible bruising Laceration - tearing of tissue Coup - bruising at point of impact Contrecoup - bruising at a site far removed from point of impact Possibility of multiple sites of injury Complications - Submission Injury - a major cause of accidental death in children, can occur with small amount of water, near drowning - survival for at least 24hrs after submersion Therapeutic : Emergency resuscitative efforts at the scene, management : based on degree of cerebral insult - irreversible, aspiration pneumonia, observation Care Management : care depends on condition, help parents cope with guilt/anxiety of prognosis, teaching prevention Seizures -Consists of brief paroxysmal behavior caused by excessive d/c of neurons -symptoms of an underlying disease process Therapeutic : antiepileptic mediation - numerous side effects, vagus nerve stimulation, ketogenic diet, status epilepticus, triggering factors Epilepsy : two or more unprovoked seizures, caused by pathologic process in brain, requires an accurate diagnosis and determination for optimal treatment Therapeutic management of epilepsy : control seizures or reduce the frequency and severity, discovery of cause, management Febrile seizure : transient disorder of childhood, 2%-5% of children, Cause - uncertain Meningitis Most common infectious process affecting the CNS, early dx and prompt abx therapy reduces morbidity and mortality Transmission of Bacterial Meningitis : Droplet infection, extension of other bacterial infection, organisms then spread through CSF Clinical manifestations : photophobia, vomiting, irritability, headache Diagnostics: Lumbar puncture Therapeutic : isolation precautions, antimicrobial therapy, maintain hydration, vaccination, family support Care Management : - quiet with minimal stimuli, HOB elevation, Side-lying position, monitor pain, treatment depends on symptoms Guillian-Barre Syndrome Autoimmune neurologic disorder of the peripheral nervous system - rapid progressing limb weakness - loss of deep tendon reflexes - acute demyelinization of nerves - a viral infection or reaction to the flu vaccine Neurologic Conditions Requiring Critical Care Encephalitis : inflammatory process of CNS with altered brain and spinal cord, caused by a virus, vector reservoir in US - mosquitoes and ticks -swelling in brain/like ICP Reye's Syndrome : Can happen in children are given aspirin to treat fever, cause not well understood, most cases follow flu/varicella, signs: lethargy, irritability, combativeness, confusion, vomiting, seizures, LOC Diagnostic : Liver biopsy Therapeutic: Early dx, aggressive therapy Headache : Migraine - aura may precede headache Tension-type headaches - pain generalized, tight neck

Med-Surg - 66 Care of Patients with Gynecologic Problems

Common Gynecologic Concerns - Pain or impaired comfort - Vaginal discharge - Abnormal bleeding - Urinary elimination problems Uterine Leiomyoma Also called fibroids or myomas Excessive local growth of smooth muscle cells Classified by position in layers of the uterus ◦Intramural ◦Submucosal ◦Subserosal Etiology and Genetic Risk Etiology is not fully known Risk factors ◦Black women have higher incidence than white women ◦Vitamin D deficiency ◦Reproductive tract infection ◦Early menarch ◦Red meat, alcohol ◦Hypertension Incidence and Prevalence - Most commonly diagnosed pelvic tumor - Black women have higher prevalence than other races Nursing Process Assessment: Recognize Cues History ◦Some have pain; others do not ◦Heavy vaginal bleeding ◦Intermenstrual or prolonged bleeding Physical Assessment/Signs & Symptoms ◦Abdominal, vaginal, rectal examinations performed by health care provider Psychosocial Assessment ◦Quality of life ◦Fear ◦Significance of loss of uterus for patient and partner Diagnostic - Hematocrit - TSH - Pregnancy test - Transvaginal ultrasound Analysis: Analyze Cues Potential for prolonged or heavy bleeding due to abnormal uterine growth Planning and Implementation: Generate Solutions and Take Action Managing bleeding ◦Nonsurgical management ◦Observation ◦Hormonal therapies ◦Myolysis-laparoscopic thermal cryoablation ◦Uterine artery embolization ◦Surgical management ◦Myomectomy ◦Hysterectomy Care Coordination and Transition Management Home Care Management ◦Teach about postsurgical limitations-usually go home the same day unless uterus and cervix removed. Self-Management Education ◦Report excessive or increasing bleeding Health care resources ◦Referral may be needed if patient goes through grieving process Evaluation: Evaluate Outcomes Has relief from bleeding Pelvic Organ Prolapse (POP) Pathophysiology Overview ◦Uterine prolapse ◦Cystocele ◦Rectocele Nursing Process Assessment: Recognize Cues - May report sensation like "something falling out" - Assess for elimination problems, anxiety or depression - Health care provider conducts examination - Diagnostic assessment based on type of symptoms Interventions: Take Action Based on degree of POP Conservative treatment preferred over surgical, when possible Nonsurgical management ◦Kegel exercises ◦Vaginal pessary ◦Bowel management Surgical management ◦Least invasive method preferred ◦Anterior colporrhaphy-tightens pelvic muscles for bladder support. ◦Posterior colporrhaphy-reduces rectal bulging Pelvic Organ Prolapse (POP): Endometrial Cancer - Most common gynecologic malignancy - Slow-growing - Adenocarcinoma is most common type - Risk factors-Early or late menarche, use of estrogen after menopause, use of birth control pills or tamoxifen, use of IUD, Nulliparity, HX of Type 2 DM. Assessment: Recognize Cues - Abnormal uterine bleeding (AUB) is main symptom - Ask how many pads/tampons are used daily - Watery/bloody discharge, low back, low pelvis, or abdominal pain - Pelvic examination (performed by health care provider) may reveal palpable uterine mass Diagnostic assessment ◦CBC ◦CA-125 tumor marker; alpha-fetoprotein (AFP); hCG ◦Transvaginal ultrasound ◦Endometrial biopsy ◦Other tests are based on patient status and possibility of metastasis Interventions: Take Action Nonsurgical management ◦Radiation ----- Brachytherapy-used when uterus and cervix removed to prevent disease recurrence. Teach to report heavy vaginal bleeding, uretheral burning >24 hrs, blood in urine, fatigue, diarrhea, fever over 100. ----- EBRT-External beam radiation therapy. Teach to monitor signs skin breakdown in perineal area. Avoid sunbathing, do not remove markings. ◦Drug therapy ------Chemotherapy-causes alopecia ◦Complementary and Integrative Health Surgical management ◦Total hysterectomy and bilateral salpingo-oophorectomy (BSO) Care Coordination and Transition Management - Home care is the same as that after a hysterectomy-no stairs, driving, sex. - Goal is to exceed 5-year survival mark without recurrence - Referral may be needed for hospice care, home health care, social services Ovarian Cancer Pathophysiology Overview ◦Leading cause of gynecologic cancer death ◦Second most common type of gynecologic cancer ◦Risk factors-older age, obesity, nulliparity, use of estrogen. ◦Symptoms ◦----Bloating ◦----Urinary urgency or frequency ◦----Difficulty eating or feeling full ◦----Pelvic pain Nursing Process Assessment: Recognize Cues - "Think ovarian" at onset of vague abdominal and GI symptoms - Pelvic examination will be conducted by health care provider - CA-125, CT/MRI of abdomen and pelvis, chest x-ray Interventions: Take Action - Diagnosis depends on surgical exploration and diagnostic testing - Nursing care is the same as for patients having abdominal surgery - Chemotherapy used most often after surgery - Radiation may be used for more widespread cancer (but not for ovarian cancer alone) Care Coordination and Transition Management - Avoid tampons, douches, and intercourse for 6 weeks or as directed - Keep follow-up surgical appointment - Community health resources; support groups; grief counseling; spiritual leader (if desired) - Possible hospice referral Cervical Cancer Pathophysiology Overview ◦Premalignant changes classified on a continuum ◦Most cases caused by HPV types 16 and 18 ◦HPV vaccine available-Gardisal ages 9-26 and Cervarix ages 9-25. ◦Follow evidence-based recommendations for Pap and HPV testing-screening recommended for ages 25-69. Nursing Process Assessment: Recognize Cues - May be asymptomatic - Classic symptom is painless vaginal bleeding and bleeding after intercourse - Pelvic or back pain, hematuria, hematochezia, vaginal passage of stool or urine (in advanced disease) Diagnostic assessment ◦Pap ◦HPV-typing DNA test of cervical sample ◦Coloposcopy-procedure which application of acetic acid is applied to cervix. Can show dysplasia or cancer. ◦Cervical biopsy ◦Endocervical curettage Interventions: Take Action Nonsurgical Management ◦Radiation therapy ◦Concurrent chemoradiation Surgery ◦LEEP-Loop electrosurgical excision procdure. ◦Laser surgery ◦Cryosurgery ◦Conization ◦Radical trachelectomy ◦Total hysterectomy Care Coordination and Transition Management - Provide discharge teaching congruent with procedure used - Refer to psychosocial support as needed - Remind to keep follow-up appointments Other: Vulvovaginitis •Inflammation of lower genital tract resulting from disturbance of the balance of hormones and flora in vagina and vulva •Can be caused by multiple agents •Symptoms include itching, change in vaginal discharge, odor, or lesions •Treatment focuses on the causative agent for infection Toxic Shock Syndrome (TSS) - Usually results from leaving a tampon, contraceptive sponge, or diaphragm in the vagina - Can also be caused by surgical wound infection, minor trauma, viral infection - Can be fatal - Develops within 5 days after onset of menstruation - Fever, diffuse macular rash, myalgias, hypotension - Treatment focuses on removal of infection source, restoring fluid and electrolyte balance; drug therapy

Med-Surg - 67 Care of Patient with Male Reproductive Problems - Practice Questions - Case Study Answers

1. Ask the patient about urinary pattern, frequency, nocturia, and changes in the force and size of the urinary stream. Ask about blood in the urine—BPH is a common cause of hematuria in older men. 2. In a patient with BPH, a distended bladder is anticipated. 3. Finasteride is a 5-alpha reductase inhibitor (5-ARI) that lowers DHT and shrinks the prostate as well as prevents further growth. It is important to remind clients taking a 5-ARI drug that it may take up to 6 months before improvement occurs. Side effects include erectile dysfunction and decreased libido. 4. The client should be helped out of bed to the chair as soon as permitted to prevent complication of immobility. The nurse will assess for signs of infection, check urinary output every 2 hours, remind the client that urine may be blood-tinged, and administer pain and antispasmodic medications as needed.

Maternal/Child - 28 The Woman with a Postpartum Complication

Postpartum Hemorrhage Definition : •Remains a major cause of maternal mortality and morbidity •Early postpartum hemorrhage (PPH) •First 24 hours •Cumulative blood loss of 1000 mL or greater •Late PPH •From 24 hours up to 6 weeks postpartum •Subinvolution of the uterus •Retained placental fragments Uterine Atony •Manifestations •Fundus is difficult to locate •"Boggy" or soft feel to the fundus •Becomes firm when massaged •Excessive lochia and clots •Management •Measures to contract the uterus •Provide fluid replacement Predisposing Factors •Overdistention of the uterus ----- •Multiple gestation, •Large infant , •Hydramnios •Multiparity (greater than 5) •Precipitate labor or delivery •Prolonged labor •Use of forceps or vacuum extractor •Cesarean birth •Manual removal of placenta •Uterine inversion •Placenta previa, accreta, or low implantation •Drugs -----•Oxytocin, •Prostaglandins, •Tocolytics, •Magnesium sulfate •General anesthesia •Chorioamnionitis •Clotting disorders •Previous postpartum hemorrhage or uterine surgery •Disseminated intravascular clotting •Uterine leiomyomas (fibroids) Trauma •Soft tissue trauma •May cause postpartum hemorrhage •Predisposing factors •Lacerations •Hematomas •Management •Involves repairing the trauma before excessive blood loss occurs •Visualization of lacerations may be difficult. Hypovolemic Shock •Pathophysiology •During and after birth, women can tolerate a blood loss approaching that of blood added during pregnancy. ----•1500-2000 mL •Compensatory mechanisms maintain the blood pressure so that vital organs are perfused. •Manifestations •Shock occurs with excessive blood loss. •Therapeutic management •Nursing considerations Interventions for Hemorrhage Preventing hemorrhage •Identify predisposing factors. Collaborating with the provider •Uterine massage •Check bladder for distention. •Laboratory studies •Administer fluids and medication. Subinvolution of the Uterus A slower than expected return of the uterus to its nonpregnant size and consistency •Retention of placental fragments •Pelvic infection •May not be evident until well after discharge Therapeutic management Nursing considerations •Nurses should teach the family signs and symptoms that may need to be reported to the health care provider. Thromboembolic Disorders Thrombus - Collection of blood factors on a vessel wall (platelets and fibrin) Thrombophlebitis - Vessel wall develops an inflammatory response to the thrombus Embolus - A mass composed of a thrombus and amniotic fluid •Three major causes •Venous stasis •Hypercoagulation •Blood vessel injury •Additional predisposing factors •Varicose veins •Obesity •Smoking •History of thrombophlebitis •Superficial venous thrombosis (SVT) •Associated with varicose veins •Limited to the calf area •Swelling, redness, tenderness, warmth •Deep vein thrombosis (DVT) •Signs and symptoms absent in 75% of those affected •Venous ultrasonography Risk Factors of Thrombosis •Inactivity or bed rest •Obesity •Cesarean birth •Sepsis •Smoking •History of previous thrombosis •Varicose veins •Diabetes mellitus •Trauma •Prolonged labor •Prolonged time in stirrups in second stage of labor •Maternal age older than 35 years •Increased parity •Dehydration •First-degree relative with thrombosis •Use of forceps •Antiphospholipid antibody syndrome •Inherited thrombophilias •Air travel Pulmonary Embolism Serious complication of DVT •Can lead to maternal mortality •Fragments of a blood clot dislodge and are carried to the lung. •Anaphylactoid syndrome •Death may occur in minutes •Therapeutic management •Nursing considerations Other: Puerperal Infection types •Endometritis •Wound infection •Urinary tract infection •Septic pelvic thrombophlebitis •Mastitis Affective Disorders Affective Disorders •Peripartum depression •Postpartum blues: "baby blues" •Postpartum depression ---- •A disabling affective disorder that affects the entire family ---- •Begins after birth and lasts at least 2 weeks •Postpartum psychosis •A much rarer condition •Bipolar II disorder Anxiety Disorders •Panic disorder - •Tachycardia, shortness of breath - •Fear of dying or "going crazy" •Postpartum obsessive-compulsive disorder - •Consuming thoughts of harming the baby - •Posttraumatic stress disorder - •Women perceive childbirth as a traumatic event

Med-Surg - 21 Care if Clients with Infection - Practice Questions

1. The nurse is conducting a handwashing refresher session. For which situation will the the nurse remind all staff that cleansing hands with an alcohol-based hand rub is appropriate? A.After using the bathroom B.To cleanse visibly soiled hands C.After handing oral medications to a client D.After caring for a client with Clostridium difficile 2. When caring for four clients, which client does the nurse identify at highest risk for infection? A.20-year-old with stomach pain B.31-year-old with chronic kidney disease C.44-year-old using a 10-day steroid taper D.62-year-old with history of prostate hyperplasia 3. When caring for a client with MRSA, which precaution will the nurse institute? A.Droplet B.Contact C.Airborne D.Neutropenic

Maternal Child - 27 The Woman with an Intrapartum Complication

Dysfunctional Labor Problems of the powers - ineffective contractions - uterine overdistention - hydramnios - hypotonic labor dysfunction - hypertonic labor dysfunction - ineffective maternal pushing Problems with the passager - fetal size - macrosomia - shoulder dystocia (MEDICAL EMERGENCY) - abnormal fetal presentation or position - multi-fetal pregnancy - fetal abnormalities Problems of the passage - pelvis - maternal soft tissue obstructions Problems of the psyche - a perceived threat caused by fear, pain, or one's situation - stress response of flight or fight Abnormal Labor Duration Prolonged Labor - maternal infection - neonatal infection - maternal exhaustion - higher levels of anxiety and fears Precipitate Labor - a rapid birth that occurs within 3 hours of onset of labor - increases infant's risk for resp distress - longer labor more risk for infection- Signs of Associated with Intrapartum Infection - fetal tachycardia (greater than 160bpm - maternal fever (38 degrees C or 100.4 degrees F) - Foul or strong smelling amniotic fluid - cloudy or yellow amniotic fever Premature Rupture of Membranes PROM : rupture of the sac before the onset of true labor PPROM : preterm premature rupture of membranes occurs before 37 weeks of gestation - associated with preterm labor - STD/Strep B Etiology - chorioamnionitis, infections, weak amniotic sac, etc Complications Therapeutic management Nursing Considerations Preterm Labor - labor that begins after the 20th week but prior to the end of the 37th week of gestation Early indications - complaints are often vague - prompt identification enables the most effective therapy to delay preterm birth Associated factors, manifestations, therapeutic management Preventing Preterm Birth - community educations - improving access to care - identifying risk factors - progesterone supplementation - promoting adequate nutrition - educating and empowering women and their partners - Table 27.2 Therapeutic Management : Preterm Birth - Predicting preterm birth - cervical length - fetal fibronectin - infections Identifying preterm birth - women at risk - more frequent prenatal visits Therapeutic Management : Stopping Preterm Birth - Stopping preterm labor - initial measures - identifying and treating infections - other causes for preterm contractions - limiting activity - hydration -Tocolytics -Accelerating fetal lung maturity Prolonged Pregnancy Defined as one that lasts longer than 42 weeks - accurate calculation of the estimated date of delivery is essential Complications - insufficiency of placental function - meconium aspiration - dysfunctional labor due to continued fetal growth Therapeutic management Nursing Considerations Intrapartum Emergencies Placental abnormalities - at risk for hemorrhage during the antepartum or intrapartum period - Placenta accreta- - Placenta increta- - Placenta percreta- Umbilical cord prolapse - a prolapsed umbilical cord slips down after the membranes rupture and becomes compressed between fetus and pelvis - prompt delivery of the fetus remains a priority - Primary intervention is to relieve pressure on the cord w/o compression of the blood vessels - Delivery must be expedited Factors that increase risk of prolapsed umbilical cord -ruptured membranes - fetal presenting part at high station - fetus that poorly fits pelvis inlet because small size or abnormal presentation - excessive volume of amniotic fluid (hydroamnios) Alleviating Pressure on a Prolapsed Cord - A gloved hand in the vagina pushed the fetus upward and off of cord - knee-chest position uses gravity to shift the fetus off of the cord - Elevate the woman's hips on two pillows combined with us of the Trendelenburg position Uterine Rupture - EMERGENCY Clinical Manifestations - abd pain and tenderness - chest pain or pain in shoulder - hypovolemic shock - abnormal fetal heart rate patterns - absent fetal heart sounds - cessation of contractions - palpation of the fetus outside of the uterus Uterine Inversion - EMERGENCY Occurs when the uterus completely or partly turns inside out - often accompanied by massive blood loss and shock - usually occurs during the third stage of labor Uncommon but potentially fatal - recovery care promotes uterine contractions and maintenance of adequate circulating volume Anaphylactoid Syndrome - EMERGENCY Also known as amniotic fluid embolism (AFE) Amniotic fluid is down into the maternal circulation and carried to the woman's lungs Rapid Management - cardiopulmonary resuscitation -O2 with mechanical ventilation - correction of hypotension - blood component therapy Trauma Most often caused by MVA, assault, or suicide - separation of the placenta or hemorrhage - injury to the fetus Treatment of trauma is similar to that in a nonpregnant person - cardiopulmonary support - controlling bleeding - careful evaluation of the uterus and fetus Nursing Considerations

Maternal Child - 50 The Child with a Musculoskeletal Alteration

Traction Pulling bones into line/ place, wt hangs from the floor, pins in bones, unable to get up - immobile Care management: - regular assessment of child and apparatus - skeletal traction never released by nurse - pin site care - pain management - weights must hang freely Neurovascular Assessment CSM (circulation, sensation, and motion) - asses every 2 hours during first 48 hours - strength of the pulse distal to the site - capillary refill time - signs of circulatory impairment - parasthesia, numbing -temp, color ( dusky/pallor) compare bilaterally EMERGENCY - Compartment Syndrome Anything that can cause swelling assess neurovascular - swelling cut off blood supply Five Ps of Ischemia - pain - pallor - pulselessness - paresthesia - paralysis - pressure * Pain or a burning sensation may indicate tissue ischemia- prompt intervention is crucial and requires referral to the physician Immobility One of the most difficult aspects of illness in a child is immobility - kids are meant to be mobile -this can be hard mentally and physically Muscular - decrease muscle strength and mass, atrophy, loss of joint mobility Skeletal - bone demineralization, neg calcium balance Metabolism - decreased metabolic rate, neg nitrogen balance, hypercalcemia, decreased production of stress hormones Cardiovascular - decreased efficiency of orthostatic neurovascular reflexes, diminished vasopressor mechanism, altered distribution of blood volume, venous stasis (risk for DVT), dependent edema Respiratory - decreased need for O2, diminished vital capacity, poor abdominal tone and distention, mechanical or biochemical secretion retention, loss of respiratory muscle strength Gastrointestinal - distention caused by poor abd muscle tone, difficulty feeding in prone position, gravitation effect on feces, anorexia - reduce in BMs, increased risk for constipation Urinary - alteration of gravitational force, difficulty voiding in supine position, urinary retention, impaired ureteral peristalsis Integumentary - decrease circulation and pressure, leading to decreased healing capacity Effects of Immobilization Psychological - diminished environmental stimuli, altered perception of self/environment, increased frustration - helplessness - anxiety - depression - anger - aggressive behavior, developmental regression Effects on Family - family function disturbed, extended periods of immobilization, coping skills Care Management - skin monitoring or care, DVT prevention, high protein - high calorie foods (helps with wounds), encourage activity as able, play therapy, move child out of room Fractures Trauma - young children at risk, common injury in children/not infants - warrants investigation - Distal forearm : most frequent broken bone in childhood Inadequate motor and cognitive skills - accidental trauma, nonaccidental trauma, child abuse, pathologic conditions - osteogenesis imperfecta Treatment - -Reduction (repositioning of bone - closed or ((only in ER)) open reduction) - Retention (aligned fracture site protected with application of splint, cast, traction, or external fixation) Diagnostic - Radiographs (xrays), history taking, suspicion of fracture in a young child who refuses to walk or bear weight (cancer or broken bone?) Management goals - - Reduction and immobilization, restoring function, preventing deformity Growth Plate Injuries - Weakest point of long bones : cartilage growth plate (epiphyseal plate) - frequent site of damage during trauma - may effect bone growth - Limb will not grow if growth plate effected Treatment - may include open reduction and internal fixation to prevent growth disturbances Salter - Harris classification system Soft Tissue Injury R I C E / I C E S Rest, Ice, Compression, Elevation Ice, Compression, Elevation, Support 20min on, 20min off -wraps OTC help with edema -elevate at level of the heart -12-24hrs most critical Osteomyelitis Bacterial infection of the bone - Acute or chronic, chronic or chronic recurrent multifocal Nursing Care - assessment/documentation, pain control, admin of abx w/o iatrogenic injury *give abx after culture/blood culture drawn Duchenne Muscular Dystrophy Duchenne - most common - 1st sx : difficulty running, stairs, biking -progressive muscle atrophy and weakness, - ages 3-7 years - walking ability lost by ages 9-12yrs -shortened life span - death from respiratory or cardiac failure Therapeutic Management : - Primary goal : maintain function in unaffected muscles as long as possible -no effective treatment - ROM exercises, bracing, daily activities, surgical release of contractures -genetic counseling for family - avoid contact w/ resp infections Care Management : - multidisciplinary team helps with child/family cope with disease - design program to foster independence/activity for as long as possible - Teach self help skills - Provide appropriate health care assistance as needs intensify (home health/skilled nursing facility, respite care for family) Juvenile Idiopathic Arthritis Autoimmune inflammatory disease with no known cause - onset commonly between ages 2-4, and more common in girls -persistent swelling and pain in one or more joints - sx may 'burn out' and become inactive - decreased movement, stiffness worse in the morning = more painful Developmental Dysplasia of the Hips (DDH) Clinical manifestations : Infant : - hip joint laxity - shortened limb on affected side - restricted abd of hip on affected side - unequal folds when infant prone -positive ortolani test, positive barlow test (providers only) Therapeutic Management - early intervention - birth to 6 months : pavlik harness (soft cast) - ages 6 to 24 months : closed reduction and spica cast (hard cast), dislocation unrecognized until child begins to stand and walk - older child : operative reduction, tenotomy, osteotomy, correction is very difficult after age 4 Clubfoot Complex deformity of foot and ankle Therapeutic Management - three stages : correction of the deformity, maintenance of the correction until normal muscle balance is regained, follow up to avert possible recurrence -Ponseti method (serial casting) - neurovascular assessments, footless onesies, foot stretches Metatarsus Adductus (Pigeon toed) Common congenital foot deformity, - related to abdnormal uterine positioning - three types, management depends on the type - nurses role to identify the defect - teaching the parents *Feet bones inward Osteogenesis Imperfecta A group of heterogeneous inherited disorders of connective tissue -rule out abuse with infant bone breaks -Brittle bone disease - fragile bones Therapeutic Management : - supportive care, - IV bisphosphonate therapy - may rule out OI is multiple fractures occur - rehab approach for preventative of further complications - increase muscle/increase bone density Legg-Calve-Perthes Disease - aseptic necrosis of femoral head, children 2-12 yrs, most common in white males 4-8 yrs, most cases delayed bone age Clinical manifestations : limp, soreness, stiffness, limited ROM, vague hx of trauma Diagnosis : looking at pervious studies, and current findings on xray and MRI Therapeutic management : Goal : keep head of femur in acetabulum - treatment options - containment with various appliances/devices; rest, no weight bearing; NSAIDs; sometimes surgery; home traction Slipped Capital Femoral Epiphysis Known as "coxa vara" - spontaneous displacement of proximal femoral epiphysis in a posterior-inferior direction, develops ages 9 to 16 years, bilateral involvement in 40-60% of cases Develops in periods of growth - hip/thigh/knee pain, non-weight bearing Kyphosis (Spinal Curvature) - abnormal increased convex angulation in the curvature of the thoracic spine, - most common form is postural - can result from tuberculosis, arthritis, osteodystrophy or compression fracture Lordosis (Spinal Curvature) - accentuation of the cervical or lumbar curvature beyond physiologic limits -may be idiopathic or secondary complication of trauma - may occur with flexion contractures of hip, congeital dislocated hip - in obese children - alteration in center of gravity by abd fat Scoliosis (Spinal Curvature) - Most common - spinal deformity in three places - may be congenital or develop during childhood -Multiple cases ; most causes idiopathic - generally more noticeable after preadolescent growth spurt - clothes may be "ill fitting" - school screenings Spinal Curvatures (Kyphosis, Lordosis, Scoliosis) Diagnostic : standing xray Therapeutic management : Team approach treatment, bracing, exercise, surgical intervention (severe) - wear tight t-shirt under brace Care Management - concerns of body image, concerns of prolonged treatment, preop/postop care, family issues

Med-Surg - 20 Care if Clients with Cancer

Impact of Cancer on Physical Function - Immunity and clotting-r/t decreased production of healthy bone marrow when cancer starts. Tumor cells can metastasize into bone marrow and reduce production of healthy WBC's. Chemo reduces neutrophil WBC numbers making patient more prone to infection. - Blood cells produced in bone marrow - GI function - Peripheral nerve sensory perception-Chemotherapy injures peripheral nerves. - Central motor and sensory deficits-when cancer invades bone or brain. - Respiratory and cardiac function-tumors in airway or lung tissue. - Comfort and quality of life - Blood cells carry o2 so if not enough they will be SOB/fatigue Cancer Management Surgery - Can remove all or part of the affected body part - In addition to physiologic care, provide psychosocial support - Refer to support groups - if loosing body part like breast, or reproductive Radiation Therapy - Uses high-energy radiation to kill cancer cells, with goal of having minimal damaging effects on surrounding normal tissue - Usually given in divided doses over a set time Can be used as standalone treatment or combined with other treatments - Brachytherapy - internal radiation therapy inserted into tumor using radioactive isotopes in solid form or within fluids. - Prostate - Provide accurate information - Teach about skin care needs - Do not remove temporary ink or dye markings Side Effects of Radiation Therapy - Acute and long-term - Vary according to radiation site - Radiation dermatitis-skin redness or rash - Altered taste - Fatigue-can be debilitating and last for months. - Bone marrow suppression causes reduced immunity. More susceptible to infections. - not making red/white/platelets is higher risk for infection Cytotoxic Systemic Therapy - Can be used alone, before or after treatment, or in combination - Kills cancer cells and normal cells - Neoadjuvant chemotherapy - used to shrink tumor before surgery or radiation - because of blood supply to tumor - Genomic profiling allows individualized approach - Places patients at high risk for infection, immunosuppression, complications Chemotherapy Drugs - Antimetabolites - Antimitotic antibiotics - Antimitotics/Mitosis inhibitors - Topoisomerase inhibitors - Miscellaneous agents Combination Chemotherapy - Using more than one drug for treatment - Different mechanisms of action work together to impact cell division - Have to be chemo certified before admin chemo meds Treatment Issues - Dosage - Scheduling - Administration * Intrathecal-into cerebral spinal fluid, * Intraperitoneal-into abdominal cavity-used for Ovarian Cancer * Intravesicular-instilled directly into bladder to treat bladder cancer. * Topical-applied to skin lesions. * Intra-arterial-liver tumors. - Extravasation - monitor blood return at access site during infusion at regular intervals - Oral anticancer drugs are just as toxic to patient taking drug, and person handling drug - Never give chemo at peripheral site - Normally at a port Extravasation - See photo Handling Safety - Avoid direct skin contact with agents - Proper disposal Side Effects of Chemotherapy - Temporary and permanent damage can occur to normal tissues - CTCAE - common terminology for cancer adverse events-standardized grading scale to evaluate and document common side effects - Examples of side effects Neutropenia-decreased WBC-leads to immunosuppression. Thrombocytopenia-decreased platelets-leads to impaired clotting and bleeding. Alopecia-hair loss Mucositis-open sore in mucus membranes Skin changes Anxiety - Electric razor instead of razor, no hard food - chips/ice/ no fresh flowers or fruit Changes with Cancer Bone Marrow Suppression - Protect patient from infection - Teach AP (assistive personnel) , patient and family how to reduce infection in the home Report signs of infection Good handwashing Bleeding precautions Electric shaver Mouth care Avoid contact sports, activities involving bumping, scratching, scraping - Decreases bone integrity, no sports ever again - even kids Chemotherapy-Induced N/V - Can occur at any time (acute is most common) - Drug therapy-antiemetics before the N/V occurs, before chemo therapy begins. Mucositis - Ice water, ice chips - Frequent mouth assessment and oral hygiene-non alcohol based mouth rinse. Alopecia - Cooling cap may decrease hair loss - For those who lose hair, teach to avoid direct sunlight, apply sunscreen, cover head - Planning before hair loss can be helpful (e.g., wigs) Changes in Cognitive Function - "Chemo brain" - reduced ability to concentrate, memory loss, difficulty learning new information - Brain fog = normal - Support the patient, provide resources for cognitive training - Discourage use of alcohol, recreational drug use, activities that increase risk for head injury - Helmet Chemotherapy-Induced Peripheral Neuropathy - Loss of sensory perception of motor function of peripheral nerves associated with exposure to certain anti-cancer drugs - Teach prevention - Coordinate with occupational therapist Immunotherapy types - no need to memorize, all cause bone marrow suppression Oncologic EMERGENCIES - Sepsis-severe infection-sometime only indication is low grade fever can lead to shock and Disseminated Intravascular Coagulation (DIC)-problem with blood clotting process and is often caused by sepsis. Extensive bleeding occurs. - Syndrome of Inappropriate Antidiuretic Hormone - Spinal cord compression - Hypercalcemia-Bone metastasis stimulates bone breakdown. Early symptoms-fatigue, loss of appetite. N, V, constipation and increased urine output. - Superior vena cava syndrome- MEDICAL EMERGENCY - Tumor lysis syndrome - potassium runs out of the cell causing hyperkalemia = can be fatal, uric acid in urine, bound pulse is not normal Other - Survivorship - Unique physical and psychosocial needs - Educate patients on importance of routine follow-ups and adherence to the recommended schedule

Maternal Child - 46 The Child with a Cardiovascular Alteration

Transitional and Neonatal Circulation Major changes in the circulatory system that occur at birth after the first birth - gas exchange from the placenta to the lungs - fetal shunts close - resistance to flow in the pulmonary system decreases as systematic resistance increases - pulmonary vascular resistance decreases - increase in pulmonary blood flow follows Cardiovascular Dysfunction (Nursing Process) Assessment History and physical examination - maternal infection - alcohol use - DM uncontrolled - hx of congenital heart disease - syndrome like down syndrome - congenital or chromosomal abnormalities Other - poor feeding, tachypnea, tachycardia, failure to thrive, poor weight gain, activity intolerance, developmental delays, positive prenatal history, positive family history of cardiac disease Inspection -nutritional status, color, chest deformities, unusual pulsations, respiratory excursion, clubbing of fingers Palpation and percussion -chest abdomen, peripheral pulses Auscultation -Heart rate and rhythm: tachycardia, bradycardia, irregular rhythms -Heart sounds: distinct sounds, muffled sounds, murmurs, extra sounds (S3) (110 HR is elevated for teen but low normal for infant) Diagnostic Evaluation - ECG, EKG, ECHO, MRI, cardiac catheterization: diagnostic, interventional, electrophysiology studies Care Management: Cardiac Catheterization Pre/postprocedural care - pulses, temp of extremity, VS, BP, dressing, fluid intake, BG levels, ht/wt Congenital Heart Disease Left to right shunting lesions - patent ductus arteriosus - atrial septal defect - ventricular septal defect - atrioventricular septal defect Obstructive or stenotic lesions - pulmonary stenosis - aortic stenosis - coarctation of the aorta Cyanotic lesions with decreased pulmonary blood flow - tetralogy of fallot - tricuspid atresia - pulmonary atresia with intact ventricular septum Cyanotic lesions with increased pulmonary blood flow - truncus arteriosus - hypoplastic left heart syndrome - transposition of the great arteries Cardiac Defects Obstructive Defects Anatomic narrowing of the blood vessel exiting the heart (Focus on these when reading) - Coarctation of the aorta - aortic stenosis - pulmonic stenosis Defects causing decreased pulmonary blood flow Obstruction of pulmonary blood flow and an anatomic defect (pulmonary stenosis) - tetralogy of fallot - cyanosis, tachycardia, dyspnea - tricuspid atresia Mixed defects Many complex cardiac anomalies - transposition of great arteries or vessels - truncus arteriosis - hypoplastic left heart syndrome Consequences of CHD Congestive heart failure (if heart works harder, heart will grow = not good) - the inability of the heart to pump an adequate amount of blood into the systemic circulation - in children, occurs as result of structural abnormalities - heart muscle: may become damaged if left untreated - right or left sided failure Pathophysiology (fatigue, weakness, diaphysis (sweat)) - right or left sided failure - clinically seen together - abnormalities precipitate HF Clinical manifestations (irritable, hungry, FtoT, wt increase, increase edema - do they have edema? controlled daily wt needed) - impaired myocardial function - pulmonary congestion - systemic venous congestion Diagnostic evaluation - made on the basis of clinical symptoms Heart Failure Manifestations - difficulty feeding, poor wt gain - mild tachypnea, tachycardia - cardiomegaly - galloping rhythm - poor perfusion, edema - liver and spleen enlargement - mottling, cyanosis, pallor Therapeutic Management of CHF - improve cardiac function - remove accumulated fluid and sodium - decrease cardiac demands (Digoxin) - improve tissue oxygenation Care Management - assist in measures to improve cardiac function (digoxin - therapeutic window 0.8-2) - Monitor afterload reduction (before vs after) - Decrease cardiac demands - Reduce respiratory distress (Calm down) - maintain nutritional status - assist in measures to promote fluid loss - Support child and family Feeding - feed in relaxed environment; frequent small feedings are less tiring - hold infant in upright position (less stomach compression and improve resp effort - consider NG tube if unable to consume a certain amount in 30min or 15min qhr - concentrate formula to 30kcal/oz (increase caloric intake w/o increasing infant's work Educating Parents - S/S of HF - increased cyanosis (lips first/mucus membrane) - dehydration - Infection - Dysrhythmias - decreased nutritional intake Signs of Digoxin Toxicity (VS before and after admin) - nausea/vomiting, anorexia, bradycardia, dysrhythmias The Child Undergoing Cardiac Surgery Preop Postop -monitoring cardiac output - supporting resp function - monitoring fluid and electrolyte balance (wt of diaper/daily wts/strict I&O - promoting comfort - treat pain pharm/nonpharm ways - Healing and recovery - promote deep breathing (prevent pnemonia) Hypoxia (Cyanosis) - condition in which arterial o2 tension is less than normal - identified by a decrease in arterial o2 sat (hypoxia, cyanosis, polycythemia, clubbing) Polycythemia = increase in RBC/viscous blood Diagnostic - hyperoxia test Therapeutic management Cyanosis - prostaglandins (cause vasodilation and smooth muscle relaxation Hypercyanotic spells - morphine - shunt Keep well hydrated - because of polycythemia Avoid resp infection - can lower o2 sat Care of the Family and Child - help family adjust to disorder - educate family about disease - help families manage the illness at home - prepare child and family for invasive procedures - provide postop care - plan for D/C and home care - Call Childlife department - EX: bring doll = distractions Infective Endocarditis IE most commonly in presence of CHD - inflammation from infection of cardiac valves and endocardium - Bacteria, fungus, or viral agent - infection can result from poor hygiene or an invasive procedure or dental work - most commonly streptococcus and strephylococcus aureus - immediate treatment with high dose abx lasting for 2-8wks Prophylaxis for IE - dental procedures, tonsillectomy, surgery, biopsy involving resp or intestinal mucosa - Amoxicillin given PO 1hr prior to the procedure Cardiac Dysthymias -Brief overview, going over in 4th semester- Can occur in children with normal hearts - Bradydysrhythmias - slow rate - Tachydysrhythmias - rapid rate - Conduction disturbances - irregular HR Rheumatic Fever and Rheumatic Heart Disease Rheumatic fever - inflammatory disease occurs after GABHS (group A B-hemolytic streptococcal pharyngitis - Treatments: need prompt treatment of strep infections, rest and medication compliance -arthritis, carditis, chorea, erythema marginatum, subq nodules, jerky movements Rheumatic Heart Disease - Permanent valve damage - mitral valve "Have they been sick recently?" Kawasaki Disease Mucocutaneous lymph node syndrome - acute, febrile, exanthematous illness - generalized vasculitis of unknown etiology - major cause of acquired heart disease - cause remains unknown - coronary artery aneurysms are seen in 25% pf children left untreated -Echo is given, increased risk of coronary artery aneurysm - Treatment with high dose IVIG, anticoagulants used Hypertension Primary Hypertension Treatments - wt reduction - physical conditioning - diet modification - relaxation techniques - pharmacologic treatments Infusing IV Antihypertensive Medications - infuse very slow - maintain an arterial line for monitoring - a sudden hypotension may result after initiation of hypertensives Hyperlipidemia - Excessive lipids - children at risk : identify and treat early, monitor risk factors, universal screening needed, family history - care management : compliance with drug regimen, dietary prevention of disease Shock - inadequate tissue perfusion - varied causes with same physiologic outcomes : hypotension, hypoxia, metabolic acidosis - causes : compensated shock, decompensated shock, irreversible or terminal shock, septic shock

Med-Surg - 37 Care of Patients with Hematologic Problems - Practice Questions - Case Study Answers

1. A The client's pain must be controlled first and foremost. All other problems can be addressed after the acute pain is managed. 2. D, E A client in sickle cell crisis often needs approximately 48 hours of IV analgesia. Morphine and hydromorphone (Dilaudid) are given IV on a regular schedule, or by using a patient-controlled analgesia (PCA) pump. Once relief is obtained, the IV dose can be tapered and oral drugs may be given. PRN dosages should be avoided because they do not provide adequate pain relief. Acetaminophen will not address the degree of pain that is being experienced. IM injections should be avoided because absorption is impaired by poor perfusion and sclerosed skin. 3. B The HbS is reflective of a client with sickle cell disease (SCD). Clients with SCD usually have low Hct, high WBC, and high total bilirubin. The other values shown here are within normal limits. 4a. Hydroxyurea has been successfully used to reduce the sickling of RBCs. 4b. CBC—Hydroxyurea suppresses bone marrow function, so it is important to monitor complete blood counts. 5. A, B, E Hydration helps decrease the duration of pain episodes. Flu shots are important because the client is at risk for infections due to decreased spleen function. Low-impact exercise is recommended, but clients should avoid strenuous exercise. Genetic testing is a very personal choice and should not be emphasized unless the client desires. Also, genetic testing does not ensure that a disease is or is not passed on to others. Alcohol should be avoided.

Med-Surg - 66 Care of Patients with Gynecologic Problems - Practice Questions Answers

1. A The patient will no longer have a period after a total abdominal hysterectomy, and menopausal symptoms will be experienced since the ovaries are removed in this procedure. Although vaginal discharge may be present for a few days after discharge, it should not persist for a month. Weight gain is not associated with a hysterectomy. 2. A, C, D, E Healthy lifestyle habits can reduce the severity and incidence of perimenopausal symptoms. Routine exercise decreases bone loss and improves mood and cognitive function. Proper nutrition is also important in the management of blood sugar, weight, and treatment of bone calcium loss associated with menopause. It is also important to inquire about the cardiac history and medication history, including over-the-counter medications, when conducting a health history of a middle-aged woman. Asking about using caution on the ladder is inappropriate and would likely be perceived as rude. 3. A This client may be at risk for toxic shock syndrome. Symptoms include fever (which remains elevated despite treatment), diffuse macular rash (which often resembles a sunburn), myalgias, and hypotension. The health care provider must be notified, as TSS can lead to death if left untreated. All other options delay treatment and do not address the priority problem.

Med-Surg - 65 Care of Clients with Breast Disorders - Practice Questions Answers

1. A The rate of breast cancer in African-American women younger than 60 years is higher than for others in that age-group (Centers for Disease Control and Prevention [CDC], 2018). African-American women are also 40% more likely to die from breast cancer than white women (CDC). African-American women have the highest risk for triple-negative breast cancer (Anders & Carey, 2019). The other female clients do not have high risk factors. 2. D The nurse should allow the client to continue expressing feelings by verbalizing the implied meaning of the client's statement. Other statements either minimize the client's feelings or discourage ongoing expression of emotion that is often associated with breast cancer and surgical intervention. 3. A Analgesics may decrease pain for clients who have FBC. Dairy and salt intake should be discouraged. Wearing a bra at all times can increase comfort.

Med-Surg - 37 Care of Patients with Hematologic Problems - Practice Questions

1. A 33-year-old client with a history of sickle cell disease had an emergent open reduction and internal fixation of the right femur after a car crash. Which nursing intervention is the priority following surgery? A.Treating pain B.Ensuring adequate IV hydration C.Titrating oxygen to Spo2 > 95% D.Examining the surgical incision for infection 2. What is the priority nursing intervention when caring for an older client with a history of diverticular disease and pernicious anemia? A.Preventing falls B.Monitoring intake and output C.Turning the client every 2 hours D.Encouraging a diet high in vitamin B12 3. A client with polycythemia vera is admitted with shortness of breath, hypertension, and loss of pulses in the right foot. Which nursing intervention is the priority? A.Assess hydration status B.Evaluate for hypertensive crisis C.Elevate lower extremities on pillows D.Use soft-bristle toothbrush to prevent bleeding

Med-Surg - 65 Care of Clients with Breast Disorders - Practice Questions - Case Study Answers

1. Age is the primary risk factor for breast cancer. Additional risk factors include family history with first-degree relatives, nulliparity, smoking, and alcoholic consumption of two or more drinks per day. 2. C, D Evidence shows that screening mammograms, clinical breast examinations, and breast self-awareness are the best approaches toward health promotion and maintenance for average-risk women. An MRI is not needed annually. Changes in breasts should be reported to the health care provider. BSE, for women who choose to practice this, can be performed to establish a baseline for breast familiarity, but it is not the best way to detect breast cancer early. 3. An excisional biopsy removes the mass itself for histologic (cellular) evaluation for cancer. 4. D The client's left breast was removed; the left arm is affected, so it should not have BPs, injections, or venipunctures performed on it. Those types of procedures should be performed on the right arm. Vital signs should be checked every 30 minutes twice, then every hour twice, and then every 4 hours. The client should be positioned with the head of the bed elevated at least 30 degrees to facilitate drainage. Drainage should be assessed for color and odor.

Med-Surg- 69 Care of Patients with Sexually Transmitted Infections - Practice Questions - Case Study Answers

1. Age younger than 26; symptoms of abdominal pain, painful urination and intercourse, mild fever, and green discharge; multiple sexual partners; smoking; history of sexually transmitted disease 2. B An elevated temperature of >101° F or 38.3° C supports the diagnosis of PID. 3. B, C, D, E The patient should be instructed to get plenty of rest, check her temperature to be sure she is not developing further fever, abstain from intercourse until healed, take all medications as directed, and to follow up with her provider. She should remain off work until she is better.

Med-Surg - 37 Care of Patients with Hematologic Problems - Practice Questions Answers

1. B Anesthesia and stress can precipitate a sickle cell crisis. Adequate hydration is a postoperative priority to support vital signs, as well as treat sickle cell symptoms and sickle cell-associated pain. Effective hydration will augment additional pain management strategies necessary for treating sickle cell pain and postoperative pain. Ensuring adequate oxygenation is also important because hypoxemia initiates or worsens the sickling of cells. Examination of the surgical site can continue after hydration is ensured. 2. A The client will have difficulty absorbing vitamin B12 because of diverticular disease and may have developed paresthesia in the feet, increasing the risk for falls. Anemia may also increase the client's symptom of weakness, thereby increasing fall risk. Preventing falls is a priority intervention in the care of older clients. All other interventions can take place after safety has been ensured. 3. A Polycythemia vera, a form of malignant RBC hyperproduction and clotting factor dysfunction, requires evaluation of intravascular hydration, preparation of laboratory tests for possible therapeutic phlebotomy, and anticoagulant therapy to decrease clots. clients with this disease are at risk of hypertension and experience poor tissue oxygenation as well, requiring assessment. Raising lower extremities may assist with perfusion and symptoms but would not be a priority in this scenario. Using a soft-bristle toothbrush is helpful to prevent bleeding, yet hydration is still the priority.

Med-Surg - 21 Care if Clients with Infection - Practice Questions Answers

1. C •Alcohol-based hand rubs (ABHRs) are not appropriate if one's hands are visibly dirty, soiled, or feel sticky, or after toileting. In these cases, the nurse will teach to wash hands instead of using ABHRs. ABHRs are also ineffective against spore-forming organisms such as C. difficile. The only situation where using an ABHR is appropriate is after handing an oral medication to a client. 2. B •The client's immune status plays a large role in determining risk for infection. Congenital abnormalities, acquired health problems (for example, kidney injury, steroid dependence, cancer, AIDS) and advancing age can increase a client's risk of developing immunologic deficiencies. Chronic physical and psychological stress can also depress the immune system, making the client more susceptible to infection. 3. B •MRSA is spread by contact; therefore, the nurse will institute contact precautions.

Med-Surg - 67 Care of Patient with Male Reproductive Problems - Practice Questions Answers

1. D ´Benign prostatic hyperplasia (BPH) can lead to chronic urinary retention causing a backup of urine with gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis). These problems can lead to chronic kidney disease. 2. D The patient may be at risk for pain, infection, and bladder spasms after a TURP, but the highest risk of concern is for hemorrhage. After a TURP, assess for postoperative bleeding. Patients who undergo a TURP or open prostatectomy are at risk for severe bleeding or hemorrhage after surgery. Although rare, bleeding is most likely to occur within the first 24 hours. Blood transfusions are commonly given after a TURP surgery, but not needed after the HoLEP procedure. Bladder spasms or movement may trigger fresh bleeding from previously controlled vessels. This bleeding may be arterial or venous, but venous bleeding is more common. 3. B Phosphodiesterase-5 inhibitors can lower blood pressure so the nurse will teach the client to use caution when standing up quickly. This drug, which comes in pill form, must be taken approximately 15 minutes before intercourse and should not be taken with grapefruit juice.

Med-Surg - 65 Care of Clients with Breast Disorders - Practice Questions

1. The nurse is caring for four female clients. Which client does the nurse identify at the risk for breast cancer? A.28-year-old African-American with early menarche B.36-year old Asian-American with 3 children C.45-year-old Native American with family history of lung cancer D.50-year-old Caucasian American with ongoing menarche 2. The nurse is caring for a client who just had a bilateral mastectomy. When the client states, "my partner is going to hate how I look", what is the appropriate nursing response? A."I'm sure your partner will be accepting." B."Have you asked your partner about their feelings?" C."We can work on that after you are feeling stronger." D."It sounds like you are concerned about how your body looks after surgery." 3. The nurse is caring for a client who has been recently diagnosed with fibrocystic breast condition. What teaching will the nurse provide? A.Use analgesics for pain control B.Eat yogurt to increase calcium intake C.To be comfortable, do not wear a bra at home D.Increase salt intake before menses each month

Med-Surg - 20 Care if Clients with Cancer - Practice Questions

1. What does the nurse teach a client undergoing chemotherapy about the expected outcome related to hair loss? A.Hair loss may be permanent. B.Viable treatments exist for the prevention of alopecia. C.Hair regrowth usually begins about 1 month after completion of chemotherapy. D.New hair growth is usually identical to previous hair growth in color and texture. 2. For which side effect does the nurse assess in a client undergoing radiation for breast cancer? A.Fatigue B.Hair loss C.Mucositis D.Nausea and vomiting 3. When does the nurse determine that a client with Non-Hodgkin's Lymphoma is at greatest risk of developing tumor lysis syndrome? A.After the first cycle of chemotherapy B.During the second cycle of chemotherapy C.Anytime during the client's treatment course D.While undergoing radiation and chemotherapy

Med-Surg - 67 Care of Patient with Male Reproductive Problems - Practice Questions

1. What priority question will the nurse ask when taking a history of a client with BPH? A."Do you have high blood pressure?" B."Have you had a recent urinary tract infection?" C."Do you have a family history of kidney disease?" D."Do you have difficulty starting and continuing urination?" 2. The nurse is caring for a client who has had a transurethral resection of the prostate (TURP). Which assessment finding requires immediate nursing intervention? A.Temperature 99.9 ℉ B.Pain of 6 on 0-10 scale C.Report of bladder spasms D.Bleeding from the surgical site 3. The nurse is caring for a client who has just been prescribed sildenafil for erectile dysfunction. Which teaching will the nurse provide? A. Take one hour before intercourse B. Be cautious when standing up quickly C. Drink grapefruit juice when taking drug D. Perform handwashing before giving injection

Med-Surg - 66 Care of Patients with Gynecologic Problems - Practice Questions

1. What teaching will the nurse provide to a client scheduled for a total abdominal hysterectomy? A.The client will no longer have a period. B.Vaginal drainage may be bloody for the first month. C.Proper nutrition must be consumed to avoid weight gain. D.This surgical procedure eliminates menopausal symptoms. 2. A 53-year-old perimenopausal female broke her wrist after falling from a ladder. She reports no health concerns other than intermittent fatigue, insomnia, and hot flashes. What assessment questions should the nurse ask? Select all that apply. A."What kind of exercise do you normally do?" B."Weren't you using caution on the ladder?" C."What kinds of foods you usually eat?" D."Are you currently taking any drugs or supplements?" E."Is there a family history of heart disease?" 3. The nurse is caring for a 24-year old female client who is menstruating reports running a temperature and aching for 2 days, and having "a sunburn". Which nursing action is appropriate? A.Contact the health care provider B.Apply aloe vera to the sunburned area C.Administer acetaminophen as prescribed D.Recommend increasing fluids and resting

Med-Surg - 21 Care if Clients with Infection - Practice Questions - Case Study

A 51-year-old client is in the emergency department with cellulitis of the right leg. Laboratory results from a culture taken earlier in the week by the primary health care provider indicate that the wound is positive for MRSA. 1. Based on the information provided from the ED during the SBAR report, what type of isolation room should the medical-surgical nurse prepare for the client? 2. When providing care, what special precautions does the nurse implement based on the client's diagnosis? (Select all that apply.) A.Keep the door closed at all times. B.Wear gloves when entering the room. C.Wear a mask when working within 3 feet of the client. D.Wear a gown to prevent contact with contaminated items. E.Dedicated equipment should be used for this client alone. 3. An hour later, the nurse is preparing to administer the client's medications. Which drug was likely ordered by the health care provider to address MRSA? A.Amoxicillin B.Ciprofloxacin C.Vancomycin D.Erythromycin 4. After lunch, the client asks how MRSA was contracted. What is the appropriate nursing response? A."MRSA is spread by direct contact in the hospital and community settings." B."People who travel to third-world countries always return with MRSA." C."MRSA is transmitted through the aiterm-28r like TB." D."The most common way to get MRSA is when someone coughs on you."

Med-Surg - 65 Care of Clients with Breast Disorders - Practice Questions - Case Study

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. 1. What factors place this client at risk for breast cancer? (List all that apply.) 2. What information will the nurse include when teaching this client about health promotion? (Select all that apply.) A.Mammograms are not effective in diagnosing breast cancer. B.An MRI of the breasts should be completed every year. C.Ask your provider to perform a clinical breast examination (CBE). D.Notify your provider if you notice changes in your breasts. E.Breast self-examination (BSE) is the best way to detect breast cancer early. Six months later, the client returns because she has noticed a lump in her left breast. Upon examination, a small mass is palpated. A diagnostic mammogram is ordered and confirms the presence of a 2 × 3 cm mass. The client is scheduled for a surgical excisional biopsy. 3. What should the client be taught about this procedure? Pathologic examination of the removed breast lump tissue reveals malignancy. The client undergoes a modified radical mastectomy with lymph node dissection, which will be followed by radiation and chemotherapy. 4. What immediate postoperative intervention will the nurse implement? A.Check vital signs every four hours. B.Position the client supine to facilitate drainage. C.Instruct assistive personnel (AP) to avoid taking blood pressure (BP) in the client's right arm. D.Measure the Jackson-Pratt tube drainage and assess color and odor.

Med-Surg - 21 Care if Clients with Infection - Practice Questions - Case Study Answers

1. •The client should be admitted to a private room under Contact Isolation precautions. 2. B, D, E •Health care personnel and visitors should wear gloves upon entering the room to prevent contact with the client, contaminated items, or uncontrolled body fluids. There should also be dedicated equipment for this client to prevent the spread of infection. A mask should be worn with Airborne and Droplet Precautions. The door should be kept closed with Airborne Precautions, not Contact Precautions. 3. C •MRSA is susceptible to only a few antibiotics such as vancomycin (Vancocin) and linezolid (Zyvox), as well as ceftaroline fosamil. 4. A •MRSA is spread by direct contact, such as with indwelling catheters, vascular access devices, and endotracheal tubes, in the hospital and community settings.

Med-Surg - 20 Care if Clients with Cancer - Practice Questions - Case Study

Case Study A 44-year-old woman with breast cancer is admitted for severe dehydration from nausea and vomiting associated with chemotherapy 10 days ago. She has had two adjuvant treatments for with doxorubicin and cyclophosphamide. She has a Groshong port that was inserted 2 months ago for chemotherapy administration. The health care provider's orders include - Strict I&O every 12 hours - May use port for blood draws and IV fluids - Call for vomiting or temp of 100º F or greater - D5½ NS at 125 mL/hr - Ondansetron 8 mg IV every 8 hours - Clear liquid diet and progress as tolerated - CBC, Ca level, and basic metabolic panel in AM - Bed rest with bathroom privileges - Knee-high support stockings 1. What does the nurse identify as the rationale for each of the provider's orders? 2. Which provider order will the nurse implement first when caring for this client? A.Feed clear liquid diet B.Apply support stockings C.Obtain laboratory samples D.Administer D5½ NS at 125 mL/hr Two hours later, the client reports difficulty swallowing because of sores in her mouth. 3a. What does the nurse anticipate is the problem with the client's mouth? 3b. What nursing interventions will be implemented?

Maternal Child - 43 The Child with a Gastrointestinal Alteration

Dehydration Signs : Tachycardia, no tears, no wet diapers, Diagnostic : Physical assessment, specific illness, plasma sodium Therapeutic management : ORS, parenteral fluid therapy, frequent small amounts of fluid Vomiting/diarrhea = loss of potassium quickly Vomiting Therapeutic : detect and treat cause, prevent complications, provide fluids, antiemetic in some cases Care : Observe and report vomiting, reduce vomiting, prevent aspiration, brush teeth after vomiting Diarrhea Diagnostic : History, travel, contact with animals Therapeutic : Assess fluid and electrolytes, rehydrate, home perianal skin care, prevention - Dangerous in infants Rota Virus Constipation Signs : Newborn - first meconium (stool) in 24-36hrs Infancy - related to diet, less common with breastfeeding Childhood - Environmental, attempts to withhold stool Therapeutic : Promote regular bowel movements, may be self-perpetuating, increase fiber, apple juice Encopresis (pooping pants) - not infants Therapeutic for Encopresis: overcoming withholding, dietary changes, changing retention habit, emotional support, home care, no negative reinforcement, no punishment Edema Signs : peripheral edema (swelling in limb), ascites (abdomen cavity swelling), pulmonary edema Assessment : Measure abdominal girth, monitor weight gain/loss Therapeutic : Treat underlying problem Cleft Lip and Cleft Palate Signs : most commonly together Surgery : 2-3 months for lip, 6-12 months for palate Therapeutic : Feeding is an immediate concern, surgical correction Teaching: burping, ear infections, feed upright, monitor temp, speech therapy, soft elbow restraint Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) Signs : EA: failure of esophagus to develop as a continuous passage TEF: failure of the trachea to separate into a distinct structure Therapeutic : head of bed 30-45 degree (for reflex), NG tube placed, IV antibiotics (prevent pneumonia), surgery, airway management, IV fluids Anorectal Malformations/Imperforate Anus Signs : Failure to pass 1st stool after birth Diagnostic : based on physical findings of an absent anal opening Therapeutic : Surgery, toilet training delayed Gastroesophageal Reflux (GER)/GERD Signs : Transfer of gastric contents into the esophagus GER - painless emesis after meals, rarely occurs during sleep GERD - failure to thrive, aspiration pneumonia or asthma, apnea, coughing, or choking, frequent emesis, abdominal pain, crying Chronic vs acute Therapeutic : GER -Pharmacologic and medical management GERD - may require surgery and pharmacologic treatment diet, poisoning, medications, tx of acute bleeding Appendicitis Signs : Pain, anorexia, or nausea and vomiting and fever simultaneously - symptoms develop slowly over a 12 hour period, increase in intensity - normally caused by fecal matter stuck in appendix - Pain in right lower quadrant Hypertrophic Pyloric Stenosis (HPS) Signs : Projectile vomiting, olive shaped mass in quadrant, metabolic acidosis Diagnostic : History, physical exam Therapeutic : Surgery, pre/postop care, IV fluids, NG decompression, I&Os Intussusception Signs : Sausage shaped mass in quadrant, bloody stool, mucus-y stool Diagnostic : Subjective findings, ultrasonography Therapeutic : Spontaneous resolution in 10% of patients, prognosis, air enema, recurrent cases require surgery Malrotation and Volulus Signs : Malrotation: abnormal rotation of intestine around the superior mesenteric artery during embryologic development Volvulus: twisting of intestine around itself, thereby compromising blood in intestine Bowel obstruction billions vomiting Therapeutic : surgery required Hirschsprung Disease Signs : no peristalsis, no pass of 1st stool ribbon like stool, absence of ganglion cells, boys with down syndrome, accumulation of stool with distention, failure of internal anal sphincter to relax Diagnostic : X-ray, barium enema studies, anorectal manometric examination, rectal biopsy Therapeutic : Surgery *temporary ostomy *"pull-through' procedure Meckel Diverticulum Signs : Rectal bleeding usual painless, abdominal pain, bloody mucus stools, ulceration, bleeding, intestinal obstruction Therapeutic : Transfuse to correct hypovolemia, IV antibiotics, bedrest, monitor blood loss in stools, NPO, GI tube Malabsorption Disorders Lactose intolerance : Frothy stools Celiac disease : "gluten-sensitive enteropathy" and "celiac sprue", characteristics include steatorrhea; general malnutrition; abdominal distention; secondary vitamin deficiencies, fatty stools Provide folate and fat-soluble vitamin supplements Short Bowel Syndrome (SBS) : results from decreased mucosal surface area, usually results from small bowel resection Surgically retract bowel - fatty bulky stools that are foul smelling Biliary Atresia (BA) Signs : bile is blocked and backed up, appear healthy at birth and jaundice persists Therapeutic : If left untreated, will result interm-102 cirrhosis, likely liver transplant before year 2

Med-Surg- 69 Care of Patients with Sexually Transmitted Infections

Introduction to Sexually Transmitted Infections (STIs) •Passed through intimate contact •CDC uses term "sexually transmitted disease" (STD) •Prevalence is major public health concern worldwide •Assess and educate all people equally •Can cause physical and emotional pain, infertility, ectopic pregnancy, cancer, death Notifiable STI •Chlamydia •Gonorrhea •Syphilis •Chancroid •HIV infection •(Others per local legal requirements, e.g., genital herpes) Connection to Human Trafficking •Work with patients by: o--Interviewing the patient without the presence of a partner or other person who accompanies them o--Providing professional interpreters, if needed; never rely on the partner or others to speak for the patient o--Collaborating with social workers, Sexual Assault Nurse Examiners (SANE), and other members of the interprofessional team, as indicated o--Ensuring that documentation is consistent if there are concerns regarding trafficking. Gender Health Considerations •Women are more easily infected, and have more asymptomatic infections •Lesbian women who have had sex only with women are at lower risk for STIs than women who have had sex with men •Transgender women have a higher rate of HIV infection •Postmenopausal women who do not use barrier methods are at risk Health Promotion and Maintenance Healthy People 2020 objective --Reduce sustained domestic transmission of primary and secondary syphilis Largely preventable with safer sex practices Safer Sex Practices •Using a latex or polyurethane condom for genital and anal intercourse •Using a condom or latex barrier (dental dam) over the genitals or anus during oral-genital or oral-anal sexual contact •Wearing gloves for finger or hand contact with the vagina or rectum •Practicing abstinence •Practicing mutual monogamy •Decreasing the number of sexual partners Genital Herpes •Pathophysiology overview oAcute, recurring, common viral disease oHSV-1, HSV-2 oIncubation is 2 to 20 days oPrimary outbreak may be asymptomatic but patient is still infectious Assessment: Recognize Cues •History •Focused Assessment •Viral culture, polymerase chain reaction assays of lesions, direct fluorescent antibody •Serology testing can identify HSV type 1 or 2 Interventions: Take Action •Drug therapy ---Antivirals ---Treat severity, promote healing, decrease frequency of recurrent outbreaks but are not curative •Self-management education ---Education about infection, transmission, recurrence, drug therapy, sexual activity, condom use Syphilis Pathophysiology overview •-- Can become systemic and cause serious complications, including death •Early and late categories •Primary, secondary, early latent, tertiary stages •Chancre is first sign of primary syphilis •Secondary syphilis develops in 25% of untreated individuals within a few months Secondary Syphilis oFlu-like symptoms •---Malaise •---Low-grade fever •---Headache •---Muscle aches •---Sore throat •---Adenopathy •---Joint pain oRash on palms, soles, trunk, and mucous membranes Tertiary Syphilis oUncommon due to antibiotics o4 to 20 years after initial infection oSigns and symptoms •---Cardiovascular infection with T. pallidum •---Neurosyphilis, including progressive dementia and locomotor ataxia. •---Gummatous syphilis lesions on the skin, bones, or internal organs. Nursing Process Assessment: Recognize Cues •History of ulcers or rash •Sexual history •Risk assessment •Focused assessment •Chancre specimen •VDRL, RPR, or TRUST-tests based on antibody-antigen reaction that determines the amount of antibodies produced by the body in response to an infection. Interventions: Take Action oDrug therapy •----Benzathine penicillin G oSelf-Management Education •----Maintain privacy •----Discuss partner notification and treatment •----Remind to keep follow-up appointments •----Assess emotional responses; refer as needed Genital Warts •Caused by certain types of HPV •Very common viral disease •Certain types associated with precancerous or dysplastic lesions, and cancer Nursing Process Assessment: Recognize Cues oSmall papillary growths that may grow into large cauliflower-like masses oWarts may disappear and resolve, or recur oTesting •----Screening for HPV and cervical dysplasia •----Pap smear •----Blood tests •----HIV test •----Cultures for chlamydia and gonorrhea •----Possible biopsy Interventions: Take Action oNonsurgical management •----Cryodestruction •----Immune-mediated therapies oSurgical management •----Excision •----Cryoablation or laser ablation •----Electrocautery •----Ultrasonic aspiration •----Carbon dioxide laser •----Intra-lesion interferon injections •----Surgical removal oSelf-Management Education •----Patient and partner education •----Local care for post-surgical lesions or patient-applied treatment •----Inform about recurrence •----STI testing •----Sexual partner evaluation •----Use condoms •----Follow Pap and HPV testing recommendations •----Vaccination Chlamydia oChlamydia trachomatis—intracellular bacterium, causative agent of cervicitis, urethritis, proctitis oReportable to local health departments in all states oOften asymptomatic oHigh prevalence of rectal and pharyngeal infection in MSM Nursing Process Assessment: Recognize Cues •Complete history •GU review •Psychosocial history •Sexual history •Focused assessment Interventions: Take Action •Drug therapy ---Doxycycline ---Expedited Partner Therapy (EPT) •Self-Management Education ---Patient and partner education ---Follow-up for re-screening ---Complications Gonorrhea oSexually transmitted bacterial infection oCan be asymptomatic oFirst symptoms occur within a week after sexual contact with infected person oCan cause PID, endometriosis, and salpingitis, and pelvic peritonitis in females oCan cause epididymitis (which can lead to infertility) in males Nursing Process Assessment: Recognize Cues •Complete history •GU history •Sexual history •Focused assessment •Diagnostic testing for other STIs Interventions: Take Action oDrug Therapy ---Injected ceftriaxone oSelf-Management Education ---Patient and partner education ---Risks (e.g., PID) ---Use condoms ---Reportable disease Pelvic Inflammatory Disease oOrganisms move from endocervix upward through uterine cavity into fallopian tubes oMultiple pathogens oInfection may spread oUterus oFallopian tubes (most common) oAdjacent pelvic structures oSepsis and death can occur if treatment is delayed or inadequate Nursing Process Assessment: Recognize Cues •Complete history •Menstrual, obstetric, sexual, and family histories •History of previous PID and/or STI diagnosis •Contraceptive use •Reproductive surgery •Other risk factors •Sexual abuse •Lower abdominal or pelvic pain •Irregular vaginal bleeding, dysuria, vaginal discharge, dyspareunia, malaise, fever, chills •Pelvic examination may show discharge, "friable" cervix-bleeds easily. •Patient may be anxious and fearful •Laboratory assessment ----Cervical, urethral, and rectal specimens ----Pregnancy test for females •Other diagnostic assessment ----Abdominal ultrasound ----CT or MRI Analyze Cues & Prioritize Hypotheses Infection due to invasion of pelvic organs by sexually transmitted pathogens Planning and Implementation: Generate Solutions & Take Action ----Managing Infection and Pain oAntibiotic therapy oMild analgesics oApply heat to lower abdomen or back oIncrease fluid intake oEat nutritious foods oRest in semi-Fowler position oLimit ambulation oMay need surgery if no response to other treatment Care Coordination and Transition Management Home Care Management ----Coordinate if patient has had surgery Self-Management Education •Teach about persistent or recurring infection •Oral antibiotic therapy Health Care Resources •Collaborate with case manager or social worker Evaluation: Evaluate Outcomes •Evidence that infection has resolved •Report or demonstrate relieved or reduced pain •Plan for partner treatment and follow-up care

Maternal/Child - 29 The High-Risk Newborn: Problems Related to Gestational Age and Development

Preterm/Late Preterm Preterm Infants •Preterm (also called "premature") - Born prior to the beginning of 38 weeks •Low-birth-weight (LBW) - Infants weighing 2500 g at birth (5 lb, 8 oz) or less •Very low-birth-weight (VLBW) - Infants weighing 1500 g or less (3 lb, 5 oz) •Extremely low-birth-weight (ELBW) - Infants weighing 1000 g or less (2 lb, 3 oz) Later Preterm Infants •Born between 34 and 36 6/7 weeks •Respiratory disorders •Problems with temperature maintenance •Hypoglycemia •Hyperbilirubinemia •Feeding difficulties •Acidosis •Sepsis Characteristics of Preterm Infants •Appearance - Frail and weak - Less developed muscles - Limp extremities - Lack subcutaneous fat - Ears contain little cartilage •Behavior - Easily exhausted by noise and outside activity Problems with Respiratory •Lack of adequate surfactant - May develop respiratory distress syndrome (RDS) •Other factors - Poor cough reflex, narrow respiratory passages, and weak muscles •Positioning - Prone and side-lying positions are used for preterm infants. - Increases oxygenation and reduces energy expenditure Problems with Thermoregulation •Heat loss is significant for the preterm infant. - Thin skin with blood vessels near the surface - Less brown fat for nonshivering thermogenesis - Little white fat for insulation - A large surface area - Extended extremities - Immature temperature-control center •Decreased muscle tone •Skin pale, cool to the touch, mottled, or acrocyanotic •Hypoglycemia •Respiratory distress •Poor feeding and weight gain Signs of Fluid Imbalance in the Newborn •Dehydration - Urine output less than 2 mL/kg/h - Urine specific gravity greater than 1.01 - Weight loss greater than expected - Dry skin and mucous membranes - Sunken anterior fontanel - Poor tissue turgor - Blood: elevated sodium, protein, and hematocrit levels Overhydration - Urine output greater than 5 mL/kg/h - Urine specific gravity less than 1.002 - Edema - Weight gain greater than expected - Bulging fontanels - Moist breath sounds - Blood: decreased sodium, protein, and hematocrit levels Problems with the Skin Fragile, permeable skin - Easily damaged - IV lines, electrodes, endotracheal tubes - Risk to the skin during adhesive removal - Disinfecting the skin can be harmful. - Increased risk for infection Environmentally Caused Stress •Infants demonstrate that they are receiving too much stimulation by changes in oxygenation and behavior. •Appropriate nursing care - Scheduling care - Reducing stimuli - Promoting rest Gavage Feeding/Facilitating Breastfeeding Gavage Feeding - •Preterm babies often cannot feed at first •They will eat through an NG tube •Check placement before each feed •Slowly increase feeds, and add nipple feeds slowly Facilitating Breastfeeding •Breast milk is best for almost all infants and especially for preterm infants. •Protects against necrotizing enterocolitis (NEC) •Teach mothers how to use a breast pump and store milk. •Explain to parents the immunologic benefits of breast milk. •Nutrients are more easily digested. •Ongoing support and encouragement for the mother Parenting •Extended hospitalization of the preterm infant - Providing information about the infant's condition - Orienting parents to the NICU - Explaining specialized equipment and routine care - Offering therapeutic communication and realistic encouragement - Involving parents in caring for their infant - Instituting kangaroo care Common Complications of Preterm Birth Respiratory distress syndrome (RDS) •Bronchopulmonary dysplasia (chronic lung disease) •Intraventricular hemorrhage (IVH) •Retinopathy of prematurity (ROP) •Necrotizing enterocolitis (NEC) Postterm Infants/Small for gestational age infants/large for gestational age infants Postterm •Postmaturity syndrome •Born after the 42nd week of gestation - Appear thin with loose skin - Cracked, peeling skin - Meconium staining - Respiratory difficulties at birth - Hypoglycemia - Inadequate temperature regulation Small for Gestational Age Infants •Fetal growth restriction - Falls below the 10th percentile - Small for gestational age (SGA) at birth - Symmetric growth restriction - (The infant is proportionately small.) - Asymmetric growth restriction - (The head and length are normal, and the body is thin.) Large for Gestational Age Infants •Macrosomia - Greater than the 90th percentile - Weigh more than 4000 g (8 lb, 13 oz) •Birth injuries - Fractures - Nerve damage - Bruising •Hypoglycemia/polycythemia

Maternal Child - 17 Intrapartum Fetal Surveillance

Purposes of Fetal Surveillance Evaluate the fetal condition during pregnancy - Identify possible hypoxic insult - Two approaches to intrapartum fetal monitoring : 1) intermittent auscultation with palpation of uterine activity (low tech) 2) Electronic fetal monitoring (high tech) Fetal Oxygenation/Heart Rate Regulation Adequate fetal oxygenation requires five related - normal flow of oxygenated maternal blood into placenta - normal exchange within the placenta - patent umbilical cord vessels - normal fetal circulation - oxygen carrying function Mechanisms that regulate the fetal heart rate include: - Autonomic nervous system - Baroreceptors - Chemoreceptors - Adrenal glands - Central nervous system Pathologic Influences on Fetal Oxygenation - Maternal cardiopulmonary alterations - uterine activity - placental disruptions - interruptions in umbilical flow - fetal alterations Risk Factors for Fetal Compromise Antepartum period - maternal history - problems identified during pregnancy Intrapartum period - maternal problems - fetal problems - placental problems Auscultation Advantages - mobility is the primary advantage of auscultation of the fetus in low-risk women - the women is free to change position and walk - the atmosphere is more natural Limitations - 1-1 nursing care - Uterine activity is assessed for only a small part of the total labor Electronic Fetal Monitoring Advantages - supplies more data about the fetus and auscultation - provides a permanent record - gradual trents in FHR and uterine activity are apparent Limitations - reduced mobility is the major limitation External Fetal Monitoring Remote surveillance Ultrasound transducer - Secured on the mother's abdomen with elastic straps - less accurate than internal devices but are noninvasive and suitable for most women in labor Toco transducer - a pressure-sensitive area detects changes and abdominal contour to measure uterine activity Internal Fetal Monitoring Accuracy is main advantage - requires ruptured membranes and about 2cm of cervical dilation - slightly increased risk for infection Fetal scalp electrode (FSE) - detects electrical signals from the fetal heart Intrauterine pressure catheter (IUPC) - two kinds of IUPCs can be used to measure uterine activity Baseline Fetal Heart Rate p343 Rate - normal, bradycardia, tachycardia Variability - Absent, minimal, moderate, marked Periodic Patterns in FHR Accelerations - Temporary increase FHR - 15bpm increase for 15seconds - associated with fetal movement - reassuring - May also occur : with vaginal examination, during contractions, mild cord compressions, breech presentation Early Decelerations - associated with fetal head compression - not associated with fetal compromise - consistent in appearance - return to baseline FHR by end contraction - maternal position changes usually have no effect on pattern - Mirror images of contraction Late Decelerations - impaired oxygen exchange - begin after the peak of the contraction and return to baseline after contraction ends -not reassuring - Late decelerations look similar to early decelerations but not shifted to the right - nursing intervention required to improve placental blood flow and fetal oxygen supply Variable Decelerations - Caused by reduced blood flow through umbilical cord (cord compression) - Shape, duration, and degree of fall below baseline rate are variable - fall and rise in rate are abrupt - may be nonperiodic - require nursing intervention Uterine Activity Assessment of uterine activity has four components - Frequency - Duration - Intensity of contractions - Resting tone Nonreassuring Patterns Absent variability - recurrent late decelerations - recurrent variable decelerations - bradycardia Sinusoidal pattern - a visually undulating pattern (Rare) Interventions - Identify cause of pattern - increase placental perfusion - increase maternal blood oxygen saturation - reduce cord compression -left lateral position, stop oxytocin Clarification of Data Three methods may be used during the intrapartum period 1) fetal scalp stimulation (more invasive 2) vibroacoustic stimulation 3) fetal scalp blood sampling Cord blood gases and pH - umbilical cord blood analysis preformed immediately after birth - do not if baby is having bradycardia Nursing Diagnosis and Planning - promote adequate fetal oxygenation - take corrective action to increase fetal oxygenation - report nonreassuring patterns to the physician or nurse midwife - support the woman and her partner if a complication develops - document assessment and care

Maternal/Child - 30 The High-Risk Newborn: Acquired and Congenital Conditions

Respiratory Complications Asphyxia Lack of oxygen and increase in carbon dioxide Transient tachypnea of the newborn Rapid respirations after birth Meconium aspiration syndrome Meconium in the infant's lungs Persistent pulmonary hypertension (PPHN) Persistent fetal circulation Neonatal resuscitation - Equipment should be readily available and functioning properly. - All personnel should know how to perform resuscitative measures. - Assist the physician or nurse practitioner with -------------------(Intubation, Insertion of umbilical vein catheters, Medication administration) Hyperbilirubinemia Nonphysiologic or pathologic jaundice - May lead to bilirubin encephalopathy and, if severe, kernicterus - Excessive hemolysis results in erythroblastosis fetalis. - Infants severely affected may develop hydrops fetalis. Therapeutic Management Phototherapy - Most common treatment - Involves placing the infant under special fluorescent lights Exchange transfusions - Performed when phototherapy cannot reduce dangerously high bilirubin quickly enough - Removes sensitized red blood cells, maternal antibodies, and unconjugated bilirubin Infection/Sepsis Infection In utero by passage of organisms across the placenta - Rubella, cytomegalovirus, syphilis, HIV, toxoplasmosis During labor and birth bacteria ascend vagina. - Group B (GBS) herpes and hepatitis After birth from infected mothers, family members, caregivers, or contaminated equipment Sepsis Neonatorum General signs - Temperature instability (usually low) - Nurse's feeling that the infant is not doing well Respiratory signs - Tachypnea - Respiratory distress: nasal flaring, retractions, grunting - Apnea Signs of Sepsis in the Newborn Cardiovascular signs - Color changes: cyanosis, pallor - Tachycardia - Hypotension - Decreased peripheral perfusion - Edema Gastrointestinal signs - Decreased oral intake - Vomiting - Increased gastric residuals - Diarrhea - Abdominal distention - Hypoglycemia or hyperglycemia Central nervous system signs - Decreased muscle tone - Lethargy - Irritability - Full fontanel - High-pitched cry Signs that may Indicate Advanced Infection Jaundice Evidence of hemorrhage (petechiae, purpura, pulmonary bleeding) Anemia Enlarged liver and spleen Respiratory failure Shock Seizures Infant of a Diabetic Mother Characteristics - Large or small for gestational age - At risk for birth trauma due to macrosomia - More likely to have congenital anomalies - Face is red, body is obese - Respiratory distress syndrome - Polycythemia - Hypocalcemia Nursing responsibilities - Early identification - Follow-up with complications - Monitoring blood glucose levels - Ensuring early and adequate feeding - Supporting the parents Prenatal Drug Exposure •Behavioral signs - Irritability, yawning - Jitteriness, tremors, seizures - Muscular rigidity, increased muscle tone - Restless, excessive activity - Exaggerated Moro reflex - Prolonged cry, difficult to console - Poor sleeping patterns •Signs related to feeding - Excessive sucking - Uncoordinated sucking and swallowing - Frequent regurgitation or vomiting - Diarrhea - Weight loss •Respiratory signs - Nasal stuffiness, sneezing - Tachypnea, apnea - Retractions - Grunting •Other signs - Fever - Diaphoresis - Excoriation - Mottling NOTE: Some infants with prenatal drug exposure have no abnormal signs at all, or symptoms may be delayed. Neonatal Abstinence Syndrome Nursing care for infants with neonatal abstinence syndrome (NAS) - Decreasing stimuli from lights or noise - Keep handling to a minimum - Baby-wearing or other soothing techniques - Increasing feeding abilities - Fostering the mother's attachment to and ability to care for her infant Phenylketonuria - Phenylketonuria (PKU) is a genetic disorder that causes central nervous system injury from toxic levels of the amino acid phenylalanine in the blood. - Severe intellectual disability occurs if untreated. - All newborns in the U.S. are screened for this condition. - Treatment includes a diet low in phenylalanine.

Med-Surg - 37 Care of Patients with Hematologic Problems - Practice Questions - Case Study

The nurse is caring for a 25-year old client with a history of sickle cell disease (SCD). Today the client reports pain that is rated as a "9" on a 0-to-10 scale. Nursing assessment reveals grimacing, abdominal guarding, fever of 103.9º F, pale yellow hard palate, and several very small ulcers on the lower extremities. 1. Which concern will the nurse address as the priority? A.Acute pain B.Hyperthermia C.Potential for infection D.Impaired tissue perfusion 2. The health care provider diagnoses the client with acute sickle cell crisis. Which drug does the nurse anticipate will be prescribed for pain control at this time? (Select all that apply.) A.Meperidine IV push prn B.Acetaminophen rectally prn C.Morphine sulfate IM scheduled doses D.Hydromorphone IV push scheduled doses E.Morphine sulfate IV push scheduled doses 3. Laboratory results have been completed. When reviewing the report, which result does the nurse anticipate? A.Hct 40% B.HbS 90% C.WBC 8000/mm3 D.Total bilirubin 0.5 mg/dL The health care provider's orders include hydroxyurea. When the nurse administers the drug, the client asks about the purpose of this medication. 4a. What is the appropriate nursing response? 4b. What follow-up laboratory value will the nurse monitor while the client is receiving hydroxyurea? Four days later, the client is preparing for discharge. 5. Which teaching point will the nurse provide? (Select all that apply.) A.Be sure to get a flu shot annually. B.Drink at least 3 to 4 L of fluid daily. C.Alcoholic beverages may be consumed moderately. D.Get genetic testing to prevent passing this disease to children. E.Engage in mild low-impact exercise three times weekly when not in crisis.

Med-Surg- 69 Care of Patients with Sexually Transmitted Infections - Practice Questions

1. What does the nurse identify as an expected outcome when planning care for a client with genital herpes being treated with antiviral drugs? A.Eradication of the infection B.No chance of transmitting the virus to a partner C.Decrease in the severity and frequency of recurrent outbreaks D.Prevention of viral shedding even when the patient is asymptomatic 2. The nurse is assessing a female client with genital warts. What assessment finding does the nurse anticipate? A.Chancre B.No symptoms C.Abdominal pain D.Small flesh-colored growths 3. A 22-year-old sexually active male reports a low-grade fever and headache, and a rash on his hands. What condition does the nurse anticipate? A.HIV B.HPV C.Syphilis D.Gonorrhea

Med-Surg - 65 Care of Clients with Breast Disorders

Nonproliferative Breast Lesions - Fibrocystic Changes and Cysts Pathophysiology overview - Affect at least half of women over the life span - Premenopausal women between 20 and 50 (slow stop to monthly) - May have pain or discomfort (imbalance to hormones) - Caused by an imbalance in estrogen-to-progesterone ratio - Does not increase chance for developing cancer - Cysts - spaces filled with fluid lined by breast glandular cells - may need to take estrogen replacement Interventions: Take Action - Analgesics for discomfort - Limit salt intake - Ice or heat - Draining of cysts - Oral contraceptives or SERMs-selective estrogen receptor modulators to suppress oversecretion of estrogen. Breast Disorders/Conditions Large Breasts In men - Gynecomastia - breast tissue - Certain drugs can cause this-spironolactone - SERMs or surgery In women - Pain; fungal infection under the breasts; backache - Reduction mammoplasty Small Breasts - Some women choose breast augmentation surgery ---Saline ---Silicone - Teach how to care for incision and drains (if applicable) - Breast cancer surveillance Breast Abscess - Non-lactational breast abscess are often related to diabetes, clogged sweat glands, acne, or trauma - Treatment = broad-spectrum antibiotics, ultrasound-guided aspiration, and/or incision and drainage Mastitis - Infection, pain - Can occur in women whether they are lactating/breastfeeding or not - More common in women who smoke or have nipple piercings - Treatment = antibiotic therapy, steroid therapy, watchful waiting Breast Cancer Pathophysiology Overview - Heterogeneous disease with different presentations and therapy responses - Sometimes presents as a lump; other times presents only on mammogram - Noninvasive versus invasive - Most common sites of metastasis are brain, bones, liver, and lung Non-Invasive (In Situ) Breast Cancer Types - Ductal carcinoma in situ (DCIS) -early non invasive form located within the duct. - Lobular carcinoma in situ (LCIS)-noninvasive-looks like cancer and contained within the milk producing glands of the breast. Invasive Breast Cancers Invasive ductal carcinoma - Originates in mammary ducts and break through wall of ducts into surrounding tissue - Fibrosis develops around the cancer - Peau d'orange Inflammatory breast cancer (IBC) - Diffuse erythema - Pain; rapidly growing breast lump; breast itching - Peau d'orange Incidence and Prevalence of Breast Cancer - One of every eight women in the U.S. will develop breast cancer in her lifetime (similar in Canada) - Second leading cause of cancer death in women Etiology and Genetic Risks - Increased age - Family and genetic history - Early menarche, late menopause - Postmenopausal obesity, physical inactivity - Use of combination postmenopausal HRT - Mutations in BRCA1 and BRCA2 Health Promotion and Maintenance - American Cancer Society (ACS) and Canadian Cancer Society (CCS) establish evidence-based guidelines for screening in women --- Teach to use multiple methods for early detection --- Mammography-average risk age 45 - Clinical breast examination --- Breast self-awareness - Options for high-risk women-known BRCA1/BRCA2. Mammo and annual breast MRI. Nursing Process Assessment: Recognizing Cues History - Risk factors-family hx - Breast mass - Health maintenance practices - OBGYN history-age of menarche and menopause, birth of first child after age 30 - Alcohol use - Medication review (including supplement and birth control use) Physical Assessment - Location, shape, size, consistency, mobility of mass - Skin changes - Enlargement of nodes - Pain or tenderness Psychosocial Assessment - Fear, shock, disbelief - Previous history of mental illness, age, and life circumstances can increase distress - Encourage expression - Refer to counselor and community resources - Assess for concerns related to sexuality Laboratory assessment - Pathologic study of breast mass tissue and lymph nodes - Liver enzymes, serum calcium, alkaline phosphatase - Potential for cancer metastasis due to lack of, or inadequate, treatment - Potential for impaired coping due to breast cancer diagnosis and treatment Decreasing the risk for metastasis Nonsurgical management - Complementary and integrative health Surgical management (including breast reconstruction) - Preoperative care - Operative procedures - Postoperative care Adjuvant therapy - Systemic chemotherapy, radiation, or combination Enhancing coping strategies - Assess need for knowledge - Use outside resources - Full-service cancer center Home care management - May need assistance with drains, dressings, ADLs - Teach about activities and restrictions Self-management education - Post-surgical care - Avoidance of lymphedema - Improvement of body image, coping, relationships, etc. Health care resources - National breast cancer organizations - No recurrence or metastasis of breast cancer after completion of treatment; if metastasis occurs, have optimal palliative and end-of-life care. - Reports adequately coping with the uncertainty of having breast cancer and its treatment.

Med-Surg - 21 Care if Clients with Infection

Infection Infection Exemplar : Infection •Invasion of pathogens into the body that multiply and cause disease or illness - Chemo pt - very high risk for infection Transmission of Infectious Agents •Reservoir •Susceptible host •Route and method of transmission Toxin Production •Exotoxins-produced and released by certain bacteria into the surrounding environment. Ex. Botulism, tetanus, diphtheria. •Endotoxins-produced in the cell walls of certain bacteria and released only with cell lysis. Ex. Typhoid and meningococcal diseases - Meningitis Immune System •Plays a large role in determining infection •Factors that impact immune system -Congenital abnormalities and acquired health problems -Environmental factors -Age -Medical and surgical interventions Routes of Transmission •Respiratory tract •GI tract •Genitourinary tract •Skin/mucous membranes •Bloodstream Methods of Transmission •Contact - indirect and direct •Droplet •Airborne •Contaminated food or water •Vectors •Portal of exit - know all modes of transmission Physiologic Defenses for Infection •Body tissues •Phagocytosis - cells eating virus cells •Inflammation •Immune systems Health Promotion and Maintenance •Recognize high-risk patients-immunocompromised and older adults. •Immunizations - flu shot yearly Infection Control Infection Control in Health Care Settings •Health care-associated infection (HAI) acquired inpatient setting that is not present or incubating at admission -Endogenous infection—from patient flora -Exogenous infection—from outside the patient, often from health care workers' hands, tubes, implants) Methods of Infection Control and Prevention •Hand hygiene •Disinfection/sterilization - Sani wipes •Standard precautions •Transmission-based precautions •Staff and patient placement and cohorting Protection of Visitors of Patients on Transmission-Based Precautions •Hand hygiene •Wear gowns and gloves •Wear surgical mask •Do not visit if you have an active cough or fever Multidrug-Resistant Organism Infections and Colorizations •"MRDOs" •Microorganisms have become resistant to certain antibiotics •Biofilm (glycocalyx) on medical devices •Most common MRDOs -Methicillin-resistant Staphylococcus aureus -Vancomycin-resistant Enterococcus -Carbapenum-resistant Enterococcus Methicillin-Resistant Staphylococcus aureus (MRSA) •S. aureus that does not respond to methicillin or other penicillin-based drug •HA-MRSA •Spread by -Indwelling urinary catheters -Vascular access devices -Open wounds -Endotracheal tubes •Susceptible to IV vancomycin, oral linezolid, IV ceftaroline fosamil Community-Associated MRSA (CA-MRSA) •Causes infections in healthy, non-hospitalized people •Health teaching is important -Perform frequent hand hygiene, including use of hand sanitizers -Avoid close contact with people with infectious wounds -Avoid large crowds -Avoid contaminated surfaces -Use good overall hygiene Other MDROs •Vancomycin-resistant Enterococcus (VRE) •Carbapenum-resistant Enterobacteriaceae (CRE) - Bleach wipes need to be used Emerging Infections Disease and Bioterrorism •Transmission -Global travel -Pandemic infections -Contaminated food •C. difficile -Direct contact -Fecal microbiota transplantation (FMT) •Bioterroristic agents - Liver failure/liver cancer @ a later time Problems Resulting from Inadequate Antimicrobial Therapy •Incorrect choice of drug, inadequate dosing •Noncompliance/nonadherence •Directly observed therapy (e.g., TB) •Bacteremia, septicemia or bloodstream infection (BSI) •Septic shock - sepsis-induced distributive shock - take abx as directed Nursing Process Assessment •History •Physical assessment/Signs and Symptoms •Psychosocial assessment •Laboratory assessment -Culture and sensitivity -Rapid cultures -WBC with differential -ESR - inflammatory marker -Serologic testing •Imaging assessment Analysis •Fever due to the immune response triggered by the pathogen - fever is a huge cue Planning and Implementation •Managing fever -Eliminate underlying cause of fever -Destroy causative microorganism -Drug therapy with antimicrobials -Antipyretics -External cooling -Fluid administration - get culture and sensitivity Care Coordination and Transition Management •Home care management •Self-management education •Health care resources Evaluation Evaluating the care of the client with an infection on the basis of the identified priority problems is important. The expected outcomes include that the client -Has body temperature and other vital signs within baseline -Does not experience complications such as dehydration and sepsis -Adheres to drug therapy regimen

Maternal/Child - 21 The Normal Newborn: Adaptation and Assessment

Initiation of Respiration Development of the lungs - During fetal life the alveoli produce fetal lung fluid that aids in lung development. - Surfactant lines the alveoli and reduces surface tension in order to keep the alveoli open. - Fetal lung fluid moves into the interstitial spaces before, during, and after birth. - Lung fluid is absorbed by the lymphatic and vascular systems. Cardiovascular Adaptation Transition from fetal to neonatal circulation - Increases in blood oxygen level - Shifts in pressure in the heart and lung - Closing of the umbilical vessels - Closing of the ductus arteriosus, foramen ovale, and the ductus venosus at birth Asphyxia and pulmonary hypertension - May cause the foramen ovale to open Neurologic Adaptation: Thermoregulation Newborn characteristics leading to heat loss - Skin with little subcutaneous (white) fat - Blood vessels close to the surface - Large skin surface Methods of heat loss - Evaporation - Conduction - Convection - Radiation Thermogenesis Methods of heat production - Restlessness and crying - Flexion and increased activity - Metabolism rises - Vasoconstriction - Nonshivering thermogenesis (brown fat) These factors increase oxygen and glucose consumption and may result in respiratory distress, hypoglycemia, and jaundice. Effects of Cold Stress - Increased oxygen need - Decreased surfactant production - Respiratory distress - Hypoglycemia - Metabolic acidosis - Jaundice Hematologic Adaptation Erythrocytes, hemoglobin, and hematocrit - Higher for newborns than for adults because less oxygen was available in fetal life than after birth Leukocytes - Elevated white blood count Clotting - Newborns are given helpful levels of vitamin K, which is necessary to activate clotting factors. Gastrointestinal System Stomach Intestines Digestive enzymes Stools Progress from thick, greenish black meconium to loose, greenish brown transitional stools to milk stools. Stools of breastfed infants are frequent, seedy, and mustard-colored. Hepatic System Important liver functions include Maintenance of blood glucose levels Conjugation of bilirubin Production of factors necessary for blood coagulation Storage of iron Metabolism of drugs Blood Glucose Maintenance -The neonate uses glucose rapidly and may be at risk for hypoglycemia. - Infants at increased risk for hypoglycemia Preterm and late preterm Small for gestational age Large for gestational age Born to diabetic mothers Exposed to stressors Cold stress Hyperbilirubinemia Physiologic jaundice - Occurs after the first 24 hours of life as a result of hemolysis of red blood cells and liver immaturity Nonphysiologic (pathologic) jaundice - Begins in the first 24 hours - phototherapy Breast milk jaundice - Often caused by a lack of sufficient intake True breast milk or late-onset jaundice - Occurs after 3-5 days of life - 3 weeks to 3 months to resolve Risk Factors for Elevated Bilirubin - Excess production of erythrocytes (RBCs) - Short red blood cell life - Lack of albumin-binding sites - Liver immaturity - Blood incompatibility - Preterm and late preterm infants - Lack of intestinal flora - Delayed feeding - Trauma resulting in bruising or cephalohematoma - Fatty acids from cold stress or asphyxia - Family background - Other factors : Diabetic mother, some drugs, Hypoglycemia, infection Urinary System Kidney function - The ability of the newborn kidneys to filter, reabsorb, and maintain fluid and electrolyte balance is less than that of the adult kidney. Fluid Balance - The newborn body is composed of a greater percentage of water (75%). - The first void should occur within 24 hours. - Normal diuresis after birth causes a 5-10% weight loss. Immune System Neonates are less effective at fighting off infection than the older child or adult. - IgG crosses the placenta in utero and provides a newborn with passive temporary immunity. - IgM helps protect against gram-negative bacteria. - lgA does not cross the placenta and must be produced by the infant. Periods of Reactivity First period of reactivity - Wide awake, alert, and seems interested in his or her surroundings - Temperature may be decreased and heart rate may be elevated. Period of sleep or decreased activity - Falls into a deep sleep Second period of reactivity - Becomes interested in feeding Early Assessments Assess immediately after birth for cardiorespiratory problems and anomalies. Thermoregulation - Axillary temperatures are preferred over rectal temperatures. Normal Vital Signs in the Newborn - Respirations: 30-60 breaths per minute - Apical pulse: 120-160 beats per minute (bpm) (100 sleeping, 180 crying) - Blood pressure 65-95 mm Hg systolic 30-60 mm Hg diastolic - Temperature - Axillary 36.5-37.3° C 97.7-99.5° F Assessing for Anormalies Head - Molding - Fontanels - Caput succedaneum - Cephalhematoma - Facial symmetry Neck and clavicles Cord - Three vessels (two arteries and one vein) Extremities - Hands and feet - Hips Vertebral column Measurements An important way to learn about growth that occurred prior to birth - Weight - Length - Head and chest circumference - Reflexes - Eyes and ears Abnormal measurements alert the nurse that complications may occur. Assessing the Hepatic Function Blood glucose - Observe for signs of hypoglycemia during nursing care. - Blood glucose 30 mg/dL in the first hour or two of life - Stabilizes at 45 mg/dL by 12 hours of age - Blood samples obtained by heel puncture Signs of hypoglycemia - Jitteriness, tremors - Poor muscle tone - Sweating - Tachypnea - Grunting - Cyanosis - Apnea - Diaphoresis - Low temperature - Poor suck - High-pitched cry - Lethargy - Irritability - Seizures, coma - some infants may be asymptomatic Assessing the Gastrointestinal System The nurse visualizes the parts that can be seen and evaluates the initial feeding. Mouth Suck Initial feeding Abdomen Stools Assessing the Genitalia Female - Labia majora should be large and completely cover the clitoris and labia minora. - Genitalia may be darker than the surrounding skin. - A small amount of vaginal discharge is normal. Male - At term the scrotum should be pendulous. - Genitalia may be dark brown. - Palpation of the scrotum determines if the testes have descended. Assessing the Integumentary System Skin - Harlequin color change - Vernix caseosa - Mottling - Lanugo - Milia - Erythema toxicum - Birthmarks - Marks from delivery - Acrocyanosis - Mongolian spots/Dermal melanocytosis Breasts, hair, and nails Gestation Age Assessment Assessment tools - The New Ballard Score Neuromuscular characteristics - Posture - Square window - Arm recoil - Popliteal angle - Scarf sign - Heel to ear Physical characteristics - Skin - Lanugo - Plantar surface - Breasts - Eyes and ears - Genitals Gestational age and infant size Review Reflexes

Med-Surg - 23 Care of Clients with Skin Problems

Pressure Injuries Pathophysiology Overview ØLoss of tissue integrity caused when skin and underlying soft tissue are compressed between a bony prominence and external surface Can occur on any body surface Etiology and Genetic Risk Dependent upon mechanism and timing Friction Shearing force Incidence and Prevalence 3 million adults affected annually 0.6% - medical device-related pressure injuries Health Promotion and Maintenance Recognize risk and implement interventions to prevent injury Begin interventions early for any existing injury Key health team members can assist Assessment History Ø Conduct with risk factors in mind Ø Identify cause for any existing injury Ø Contributing factors -------•Bedrest, immobility -------•Incontinence -------•Diabetes mellitus and/or peripheral vascular disease -------•Malnutrition -------•Decreased sensory perception or cognitive problems Physical Assessment/Signs and Symptoms ØInspect entire body, especially bony prominences ØWound assessment ØStage I, II, III, IV Document location, size, color, extent of tissue involvement, cell types in wound base and margin, exudate, condition of surrounding tissue, presence of foreign bodies Record by length, width, depth (using mm or cm) "Clock concept" Psychosocial Assessment ØBody image ØRefer to social service or case worker if financial barrier is noted ØRefer to home care nurse if patient or caregiver can't safely carry out plan of care Laboratory Assessment ØWound culturing is not routinely performed ØIf performed, tissue culture is done (not just wound swab) Other Diagnostic Assessments ØArterial blood flow studies if arterial occlusion is suspected ØDuplex ultrasound imaging ØBlood tests for nutritional deficiencies Analyze Cues and Prioritize Hypotheses Compromised tissue integrity due to vascular insufficiency and trauma Potential for infection due to insufficient wound management Planning and Implementation: Generate Solutions and Take Action Improving tissue integrity ØNonsurgical management ------•Dressings ------•Physical therapy ------•Drug therapy -------Nutrition therapy ------•Adjuvant therapies ØSurgical management Preventing infection ØMonitor for signs and symptoms of infection ØReport changes to primary health care provider ØMaintain safe environment Care Coordination and Transition Management Home care management Self-management education Health care resources Evaluation: Evaluate Outcomes Experience progress toward wound healing by second intention as evidenced by granulation, epithelialization, contraction, and reduction or resolution of wound size Re-establish skin tissue integrity and restore skin barrier function Remain free from local or systemic infections. Pressure Injuries I, II, III, IV, Unstageable Stage I Intact skin with localized area of non-blanchable erythema (may appear differently in skin with darker pigmentation). May be preceded by changes in sensation, temperature or firmness. Color changes are not purple or maroon. Stage II Partial-thickness loss of skin with exposed dermis. Wound bed is viable, pink or red, and moist. May look like intact or ruptured serum-filled blister. Stage III Full-thickness skin loss with adipose (fat) visible in the ulcer. Granulation tissue and rolled wound edges are often present. Slough and/or eschar may be present. Undermining and tunneling may be present. Subcutaneous tissues may be damaged or necrotic. Stage IV Full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. May have slough or eschar. Rolled edges, undermining, or tunneling may be present. Skin Irritations Pruritis ØExample: detergent chemical that irritates skin ØAddress dry skin, keep nails short, antihistamine may be prescribed Urticaria ØExamples: drugs, temperature extremes, foods, infection, diseases, cancer, insect bites ØRemove triggering substance, antihistamine Inflammatory Skin Disorders (See pictures in book) Eczema Contact dermatitis Atopic dermatitis Drug eruption Identify causative agent, and then avoid it Steroid therapy Antihistamines Comfort measures Psoriasis Chronic autoimmune disorder Exacerbations and remissions Scaled lesions with underlying dermal inflammation from epidermal cell growth abnormality Can be triggered by environmental factors, stress, skin injuries, medications, infections History ØAsk about family history due to genetic component ØFlares and precipitating factors ØTreatments that have helped in the past Physical Assessment/Signs & Symptoms ØPlaque (most common); guttate; inverse; pustular; erythrodermic Interventions ØTopical therapy ØLight therapy ØSystemic therapy ØEmotional support Common Skin Infections Bacterial ØCutaneous anthrax ØFolliculitis ØFuruncles and carbuncles ØCellulitis ØMRSA Viral ØHerpes Simplex ØHerpes Zoster Fungal ØTinea ØCandidiasis See pictures in book Health Promotion and Maintenance Avoidance of offending organism Practice of good hygiene ----ØHandwashing ----ØDo not share personal items Vaccination History ØRisk factors ØLiving conditions, sanitation, hygiene, activities Physical Assessment/Signs & Symptoms ØSigns and symptoms of specific disorder ØLaboratory assessment Interventions ØDrug therapy ØAvoid spread of disorder ØSkin care Parasitic Disorders Pediculosis Scabies Bedbugs Skin Trauma/Wound Healing Phases of wound healing ØInflammatory ØProliferative ØMaturation First intention—edges brought together with skin lined up in correct anatomical position Second intention—requires gradual filling in of dead space with connective tissue Third intention—delayed closure; high risk for infection with resulting scar Mechanisms of Wound Healing Partial-thickness wounds ØDamage to epidermis, upper layers of dermis ØHeal by re-epithelialization within 5 to 7 days Full-thickness wounds ØDamage extends into lower layers of dermis, underlying subcutaneous tissue ØMust be filled with granulation tissue to heal ØContraction develops in healing process Skin Cancer Etiology and Genetic Risk Actinic keratoses - sun-damaged skin Squamous cell carcinoma - chronic skin damage Basal cell carcinoma - genetic predisposition, UV exposure Melanomas - genetic predisposition, UV exposure, chemical carcinogens, precursor lesions Incidence and Prevalence Difficult to discern (not reportable) Often occurs in people who spend time outdoors, use tanning beds Health Promotion and Maintenance Avoid or reduce exposure to sun or tanning beds Sunscreen Wear hats and opaque clothing Sunglasses Monthly skin checks Report skin changes ABCDE guide for melanoma Assessment Family history of skin cancer Past surgery for removal of skin growths Recent changes in moles, birthmark, wart, scar Demographic information Occupational and recreational activities (sun exposure) Interventions Surgical ØCryosurgery ØCurettage and electrodesiccation ØExcision ØMohs' surgery ØWide excision Nonsurgical ØTopical therapies ØTargeted therapy ØImmunotherapy ØRadiation (usually palliative) Life-threatening Skin Disorders Stevens-Johnson Syndrome Toxic Epidermal Necrolysis Disorders usually triggered by a drug Classified by percentage of body surface affected Treatment involves discontinuation of the drug, and supportive care See Pictures in book

Med-Surg - 20 Care if Clients with Cancer - Practice Questions Answers

1. C Chemotherapy-induced hair loss is usually temporary, and regrowth usually begins 1 month after chemotherapy is finished. New hair growth may differ from the original hair in color, texture, and thickness. No known treatment completely prevents alopecia. 2. A Radiation-induced fatigue can be debilitating and may last for weeks to months. Mucositis, alopecia, and nausea and vomiting are side effects associated more frequently with chemotherapy. 3. D Tumor lysis syndrome can occur when a large number of tumor cells are rapidly destroyed. This is usually seen in patients with high-grade cancers or those with bulky tumor burden, and occurs after receiving radiation and chemotherapy.

Med-Surg - 20 Care if Clients with Cancer - Practice Questions - Case Study Answers

1. •I&O: Because the client was admitted with dehydration, it is very important to monitor intake and output (I&O). •Using port for blood draws/IV fluids: When the client has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss. •Call for vomiting or ≥100° F temperature: Any temperature elevation may be a sign of infection and should be reported immediately. •D5½NS: This is to replace fluids. •Ondansetron: This medication is to prevent nausea and vomiting caused by cancer chemotherapy. •Clear liquid diet: This is to replace fluids and to provide some nutrition with decreased risk of nausea and vomiting. •CBC, Ca, BMP: When the client has nausea and vomiting, you often see a decrease in electrolytes from the excessive fluid volume loss. •Bed rest, bathroom privileges: Because the client is weak and dehydrated, these restrictions are for safety. Having bathroom privileges is often less stressful than using a bedpan. •Knee-high stockings: There is a concern for DVT with prolonged bedrest, so support hose is ordered for the client to increase venous return and prevent pooling of the blood. 2. D Based on the client's diagnosis, IV fluids should be started first. The client is admitted with dehydration, so the Groshong port should be accessed and IV fluids initiated immediately. The provider has ordered clear liquids, but because the client has been experiencing nausea and vomiting, she may not be able to ingest enough fluids to correct the dehydration. The laboratory values are ordered for the morning, so they should not be obtained until then. The support stockings can be obtained by the AP while IV fluids are started. 3a. The client is most likely experiencing mucositis (sores in mucous membranes). With chemotherapy, mucous membrane cells are killed more rapidly than they are replaced, resulting in the formation of mouth sores. Mouth sores are painful and interfere with eating. 3b. Examine the mouth and between the teeth every 4 hour for fissures, blisters, lesions, or drainage. Document the findings. Provide frequent good mouth care. Encourage the client to avoid mouthwashes that contain alcohol. For mouth care, use a soft-bristled toothbrush or disposable mouth sponges. Do not use dental floss or pressure gum cleaners. Rinse the mouth with ½ peroxide and ½ normal saline every 8 hour. Normally the client should drink at least 2 L of fluids, but due to the client's nausea and vomiting, this is not possible. Continue to monitor IV fluid replacement.

Med-Surg- 69 Care of Patients with Sexually Transmitted Infections - Practice Questions Answers

1. C There is no cure for genital herpes. Drugs can reduce the severity, promote healing, and decrease the frequency of recurrent outbreaks, but they cannot prevent viral shedding. 2. D A chancre is found in syphilis; gonorrhea may have no symptoms; PID is accompanied by abdominal pain 3. C Symptoms of secondary syphilis usually develop 6 weeks to 6 months after the onset of primary syphilis. During this stage, syphilis is a systemic disease because the spirochetes circulate throughout the bloodstream. Common signs and symptoms include malaise, low-grade fever, headache, muscular aches and pains, sore throat, and generalized rash (usually on the hands and feet).

Med-Surg - 67 Care of Patient with Male Reproductive Problems - Practice Questions - Case Study

A 70-year-old man reports difficulty with starting a urine stream and dribbling after urination. 1.What questions will the nurse ask when taking the client's history? When assessing the patient with benign prostatic hyperplasia (BPH). 2. Which assessment finding does the nurse anticipate? The health care provider orders a prostate ultrasound; the client is soon diagnosed with BPH, and prescribed finasteride. 3. What teaching will the nurse provide? Six months later, the client's symptoms have not significantly improved. After consulting with a surgeon, he is scheduled for a transurethral resection of the prostate (TURP). 4. Which postoperative interventions will the nurse provide?

Maternal Child - 51 The Child with an Endocrine or Metabolic Alteration

Diabetes Mellitus - Both type 1 and type 2 diabetes involve abnormal carbohydrate metabolism and hypoglycemia. - Worldwide increase in the incidence of type 1 diabetes ◦Pancreas is unable to produce and secrete an adequate amount of insulin. - Type 2 diabetes is increasing in the pediatric population. ◦Insulin resistance and insufficient insulin Insulin Therapy for the Child with Type 1 Diabetes Mellitus Insulin ◦Store insulin in a cool, dry place; do not freeze or expose to heat or agitation. ◦Check the expiration date on the vial before using. ◦Once opened, date the vial; discard as recommended. ◦When mixing two different types of insulin, inject the appropriate amount of air into both vials, and then withdraw the short-acting (clear) insulin first. Nutrition for the Child with Type 1 Diabetes Mellitus Nutrition ◦Meals and snacks are balanced with insulin action. ◦Both the timing of the meal or snack and the amount of food are important in avoiding hyperglycemia or hypoglycemia. ◦Adherence to a daily schedule that maintains a consistent food intake combined with consistent insulin injections aids in achieving metabolic control. Managing the Child with Type 1 Diabetes Exercise ◦Avoid exercising during insulin peak. ◦Add an extra 15- to 30-gram carbohydrate snack for each 45-60 minutes of exercise. Blood glucose monitoring ◦Record blood glucose results in a diary. ◦A 3- to 4-day alteration in glucose levels requires an adjustment of insulin dosage. Hypoglycemia Too much insulin with neuroglycopenic symptoms ◦Personality changes ◦Slurred speech ◦Decreased level of consciousness ◦Adrenergic signs ◦--Trembling ◦--Sweating ◦--Tachycardia ◦--Pallor and clammy skin Hyperglycemia Excess of carbohydrate intake with inadequate insulin ◦Increased urine output ◦Thirst and hunger ◦Fatigue ◦Blurred vision ◦Headache ◦Emotional lability Diabetic Ketoacidosis Severe hyperglycemia ◦Ketones in the blood ◦Metabolic acidosis ◦Management requires intensive care to lower glucose, reverse acidosis, and correct fluid and electrolyte imbalance Goals of Diabetes Management - Glycemic control - Reasonable weight for height - Age-appropriate lifestyle - Prevention of acute and long-term complications

Med-Surg- 69 Care of Patients with Sexually Transmitted Infections - Practice Questions - Case Study

The nurse is caring for a 23-year old client who reports abdominal pain, greenish vaginal discharge and dysuria. She has a mild fever. The client admits to smoking a pack of cigarettes daily. She reports having 3 current sexual partners, and discomfort during intercourse. The electronic health record indicates that she was treated for a gonococcal infection two years ago. 1. Which findings does the nurse identify that indicate risk for pelvic inflammatory disease (PID)? 2. The client's vital signs are BP 120/68, HR 76/min, RR 18/min, T 101.9º F. Which assessment finding does the nurse identify that supports the diagnosis of PID? A.Heart rate 76/min B.Temperature 101.9º F C.Blood pressure 120/68 D.Respiratory rate 18/min 3. What teaching will the nurse provide when the client is being discharged to home? Select all that apply. A."You can return to work tomorrow." B."Check your temperature twice daily." C."Abstain from sexual intercourse at this time." D."Take all the medications as prescribed." E."Make an appointment for follow-up in several days."