daily notes NCLEX
2nd stage of labor
- starts w/ full dilation / effacement of cervix - ends with delivery of neonate - lasts about 1-3 hours in primp - lasts about 30-60 min. in multipara - freq of contractions slows to 1 every 3-4 min. - duration of contractions continues to be 60-90 seconds - contractions are accompanied by uncontrollable urge to push or bear down
L-Levothyroxine LevO = HYPO
"Leaves" T3 & T4 in the body L-Life Long + Long slow onset (3-4 weeks till relief) E-Early morning /Empty stomach x 1 daily (NOT at night) V-Very active (HIGH HR & BP) Report "agitation/confusion" O-Oh the baby is fine! (pregnancy safe) NO FOOD-take 1 hour BEFORE breakfast NO Cure-med will NOT cure, only treat NO Doubling doses (missed dose? Take it!) NEVER "abruptly" STOP = Myxedema Coma VERY HYPER (HIGH HR, BP, Temp.) REPORT ''agitation/confusion'
reactive nonstress test
"Reactive" indicates a healthy fetus. The result requires two or more FHR accelerations of at least 15 beats/ min, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period.
newborn at preterm gestation
( LESS THAN 37 weeks gestation) is at risk for respiratory immaturity and may have respiratory distress after birth. When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief history to elicit essential information relevant to potential newborn resuscitation. Identifying clients with recent medication or illicit drug use, multiple gestation or high-risk maternal conditions, meconium-stained amniotic fluid, or preterm gestational age is essential.
WBC count
5,000-10,000/mm3 Elevated values occur in the following: inflammatory and infectious processes, leukemia Below normal values occur in the following: aplastic anemia, autoimmune diseases, overwhelming infection, side effects of chemotherapy and irradiation
hemorrhage numbers indication in mL
500 vaginal 1000 C-section ≥500 ml based on change of ... loss of at least 500 ml in a vaginal birth or 1000 ml in a cesarean section.
Older adults IV
(24-26 gauge)5-15-degree angle. The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following: · The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. · Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option 1). · Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. · Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. · Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. · Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. · Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). · Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5). Educational objective: Important age-related considerations for the older adult receiving IV therapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique 5-15-degree angle for insertion of an IV into fragile veins.
immunosuppressed client
(e.g., on steroids/chemotherapy, HIV positive, new post-operative, multiple chronic co-morbidities, splenectomy, diabetes, very young/elderly).
Green on peak flow meter
(≥80% of personal best and good control),
SSRI side effects
*BAD SSRI* B - Body weight increase; A - Anxiety/Agitation; D - Dizziness; Dry mouth S - Serotonin syndrome; S - Stimulated CNS; R - Reproductive/Sexual dysfunction I - Insomnia;
atropine
- Anticholinergic - Treats muscarinic effects ( sweating, diarrhea) used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine).
BUN
6-20 mg/dL
seratonin syndrome
-agitation, fever, rigidy, Confusion. seizure, irregular HR, high fever. -Life threatening. -If patient suddenly stops taking SSRI's drug this occurs. (Selective serotonin reuptake inhibitor) do not combine with MAOI risk for serotonin syndrome.
S2 heart sound
-second heart sound -closure of semilunar valves aortic and pulmonic -signals end of systole -loudest at base -diaphragm 2PA
responding to their name by turning toward the sound when spoken
6-7 months
Digioxin Therapeutic Index
0.8-2.0 ng/mL
5 TB Tips
1. Meds Last 6 - 12 months 2. N-95 mask worn all the time 3. Family tested for TB 4. Sputum samples every 2 - 4 Weeks 5. 3 Negative cultures on 3 different days = NO Longer infectious
. Pharmacologic treatment for acute asthma includes the following
1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect.
going up the stairs
1. UP with Strong leg first 2. Cane moves next cane move second 3. Weak leg last goes last scw
urine specific gravity
1.003 to 1.030
Normal urine specific gravity is
1.003-1.030.
Magnesium lab value
1.5-2.5
alba
11 days to 6 weeks white and yellow
Serosanguineous (pink) drainage would be expected
2 hours after surgery, but a dressing saturated with sanguineous (bright red) drainage indicates excessive blood loss with possible hemorrhage; it should be reported immediately to the health care provider for evaluation. A pressure dressing may be required to provide wound hemostasis, or the client may need to return to the operating room for cauterization of a bleeding vessel. This client is at highest risk for morbidity and mortality
therapeutic INR for most conditions
2-3 but can be up to 3.5 for heart valve disease.
INR goal for patients with A-fib
2.0 to 3.0 for atrial fibrillation 3.2 is expected
artificial heart valve INR
2.5 - 3.5 Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio (INR) of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve.
phosphorous
2.5-4.5
IM injections
21 G and 1in needle
sub-q injections
25 G and 5/8 degree. 45-90 degree angle, 25G needle, 1/2-1" length, below dermis/above muscle
aPTT
25-35 seconds therapeutic is 46 to 70 greater than 100 is increase bleeding risk.
sublingual nitroglycerin (NTG) tablets relives pain in - min and last recommended dose after the first dose, unchanged/worst in symptoms in 5 min
3 min 30 to 40 min 1 tablet or 1 spray 1 tablet every 5 minutes for a maximum of 3 doses. emergency medical services (EMS) should be contacted
postpartum clients resume sexual activity
4- 6 weeks after birth
Head lag disappears
4-6 months
normal contraction pattern
5 or fewer contractions in 10 mi utes averaged over a 30 minute window
normal WBC
5,000-10,000
Serosa
4th postpartum day to 10 /14 post partum day serosanguinous pink brown in color
normal" fasting glucose level
70-99 mg/dL
first words with meaning (e.g., mamma, dada) until approximately age
9-11 months.
Infant heart rate 1-12 months
90-160/min
Chest tubes draining what to report
>3 ml/kg/hr for 3 consecutive hours or >5-10 ml/kg in 1 hour should be reported immediately to the health care provider. 50 mL out put for a child who weighs 4 kg means that the drainage was 12 ml. winch is over the 5 to 10 ml per hour.
Status epilepticus
A condition in which seizures recur every few minutes or last more than 30 minutes. is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.
Hemophilia description and priority nursing intervention
A hereditary disease where blood does not coagulate to stop bleeding. administration of factor 8 to a client with hemophilia is the first order of action, followed by a CT scan. risk for intracranial bleeding (which sometimes occurs spontaneously). When intracranial or another form of bleeding is suspected, administration of factor VIII is a priority as the client's body cannot form a clot without it.
postoperative abdominal aortic aneurysm
A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity indicate the presence of an arterial or graft occlusion and poses the greatest threat to survival.
Letting-go:
A phase of maternal adaptation that involves relinquishment of previous roles and assumption of a new role as a parent. After 10 days postpartum, the mother becomes comfortable with the new role.
SSRI indications
Indication: Depression, Anxiety, PTSD
Rifampin (Rifadin)
Antitubercular. Use: prevention and treatment of TB. Latent TB INH: 6-9 months. Active TB: multiple therapy up to 24 months. Precautions: risk of neuropathies and hepatotoxicity, consume foods high in vitamin B6, avoid alcohol, discoloration of urine, saliva, sweat, and tears. used to treat tuberculosis, normally causes red-orange discoloration of all body fluids. The client should be alerted to expect this change but does not need to notify the HCP.
Atypical presentation Myocardial infarction
Associated symptoms with no chest pain More common in women, older adults & clients with neuropathy (diabetes)
cerebellum
Balance and coordination involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing.
terbutaline
Beta 2 agonist bronchodilation tocolytic to suppress preterm labor adverse effect - hypotension, tachycardia, pulmonary edema, and hyperglycemia.
Osmolality is HIGH
Body is DRY dehydration
Calcium channel blockers adverse effect
CNS: dizziness, fatigue. CV: peripheral edema, angina, bradycardia, hypotension, palpitations. GI: gingival hyperplasia, nausea. Derm: flushing
Nursing interventions for PAD includes
Check extremities for paleness, coolness or necrosis Meticulous foot care: warm water, gently dry thoroughly, use lubricants, wear clean cotton socks Do not cross legs Regular exercise No smoking Weight loss
7 to 11 years Piaget's theory of cognitive development
Concrete operational Able to reason if concrete objects are used to teach
once open replace nito tablets- storage for nitro tablets-
every 6 months stored away from light and heat sources keep tablets in original container- not pill bottle.
methylprednisolone (Solu-Medrol)
Corticosteroid used for copd asthma can cause hyperglycemia, especially in clients with diabetes mellitus.
coup-contrecoup injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds. injuries usually affect the frontal and occipital lobes. The frontal lobe controls executive function, memory, speech, and motor skills. The occipital lobe processes vision.
Taking-in
First phase of maternal adaptation during which the mother passively accepts care, comfort, and details about the newborn. • In the first 24-48 hours postpartum, the mother is physically recovering from childbirth. During this time, she is more dependent on the health care team to help with care of the baby.
What do you do when chest tube gets dislodged?
First** Cover hole with gloved hand Best** Cover with Vaseline gauze
bacterial meningitis with sepsis.
For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.
Serotonin syndrome
HYPERreflexive muscle activity Hyperthermia sweat tachycardia increased blood pressure anxiety, disorientation timer rigidity clonus
INH ISONIAZID
I - Interferes with absorbtion of B6 (pyridoxinde) - Low Vitamin B6 = Peripheral Neuropathy - Take Vitamin B6 25 - 50mg/day N - Neuropathy REPORT: - New Numbness - Tingling extremities - Ataxia H - Hepatotoxicity REPORT Immediately!!! - Jaundice (yellow) Skin / Sclera - Dark urine - Fatigue - Elevated liver enzymes (AST/ALT) HOLD the Med - Teach: NO ETOH!!
NPH (Humulin N)
INTERMEDIATE ACTING insulin onset 6 hours peak 8 to 10 hours duration 12 hours cloudy insulin- can not run IV if given in the morning , peak time early evening
suction control chamber
Intermittent bubbling: Always bad, suction isn't high enough* Continuous bubbling: Always good, document*
ETHAMBUTOL - Eye
KEY POINT: REPORT! • Blurred vision • Color changes This information has come up in multiple sections! TEACH to have baseline eye exams and routine EYE appointments! For EEEEthambutol
What if the water seal breaks? on the chest tube
It's an emergency* because positive pressure can get in plural space. 1. Clamp the water seal 2. Cut it away 3. Submerge in sterilized water 4. Unclamp because we reestablished the water seal. **In a best/priority question you only get to pick one. In a first question you get to do the rest of the options, but you have to pick which one is first*
Atrial Fibrillation (A-Fib)
disorganized electrical activity in the atria and an irregular pulse rate electrolyte imbalance
subtherapeutic INR
Low INR increase risk for thrombi and stroke clot
MAOI what to be cautions of
Massive HTN crisis Risk- assess for Headache Increased Agitation. AVOID TYRAMINE OTC drugs = HTN CRISIS!!!-C - Calcium A - Anti acids A - Acetaminophen N - NSAIDS (Naproxen, Ibuprofen). Other Antidepressants- Serotonin Syndrome 2 week wash-out KEY DRUGS: NO! Escitalopram (SSRI). Increased Suicide risk- When starting med. Increasing Dose.
Methylergonovine
Methergine utarine stimulant contract utarus. do not give it patient has hypertension
lactase deficiency what clients can eat and what should be avoid
Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance. Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency.
Orthodox Jewish faith kosher
Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. consult with pharmacist regarding alternatives.
major adverse effects of statin
Muscle cramps and liver injury
digoxin or beta blockers pulse guidelines
Notify health care provider if <50 or 60/min as instructed or if >120/min.
RIFAMPIN RED-FAMPIN
NORMAL - Red, Orange: Tears, Urine, Sweat Teach: - Wear glasses instead of contacts due to discoloration of tears 2. Oral contraceptives ineffective "Use non-hormonal Back-up birth control" 3. Monitor for Jaundice
2 to 7 years Piaget's theory of cognitive development
Preoperational Improved language, poor causality (e.g., magical thinking), egocentrism
magical thinkers
Preschool children (age 3-5)
Meningocele
Protrusion involves meninges and a sac-like cyst that contains CSF in the midline of the back, usually in the lumbosacral area. b. The spinal cord is not involved. c. Neurological deficits are usually not present.
Babinski reflex
Reflex in which a newborn fans out the toes when the sole of the foot is touched The normal finding in adults is an absent Babinski reflex (ie, toes point downward with stimulus to the sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion.
S1 heart sound
S1—mitral and tricuspid valve closure. Loudest at mitral area. 1MT
5 serotonin syndrome
SERTRALINE CITALOPRAM ESCITALOPRAM PAROXETINE FLUOXETINE
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
STOPs urination (LOW urine output) STICKY & THICK "urine" HIGH Sp. Gravity 1.030+ SOAKED Inside "Low & Liquidy" Labs HYPO osmolality (LOW ) HYPOnatremia below 135 Na+ (LOW ) SODIUM Low!! (Headache Early Sign ) SEIZURES- key words: Headache, Confusion SEVERE HIGH blood pressure STOP ALL FLUIDS + GIVE Salt + Diuretics (NO IV or drinking) + (IV 3% Saline + Eat Salt ) S
Taking-hold:
Second phase of maternal adaptation during which the mother assumes control of her own care and initiates care of the infant. During 2-10 days postpartum, the mother still is learning the technical skills of mothering but may feel inadequate.
Birth to 2 years Piaget's theory of cognitive development
Sensorimotor Learning by sense & movement, exploration, early verbal skills
Goodell sign/Hegar sign
Softening of the cervix, a probable sign of pregnancy, occurring during the second month
expected symptoms of albuterol
Tachycardia & palpitations Tremor Toss & Turning at Night Insomnia & difficulty sleeping If Not working after 3 doses? · NOTIFY HCP!!!
Pressure Support Ventilation (PSV)
The application of positive pressure on inspiration that eases the workload of breathing. May be used in combination with PEEP as a weaning method. As the weaning process continues, the amount of pressure applied to inspiration is gradually decreased. mode of mechanical ventilation in which preset positive pressure is delivered with spontaneous breaths to decrease work of breathing
For children age <7 months, the site for immunizations
anterolateral thigh (vastus lateralis).
Ventilator rate
The number of ventilator breaths delivered per minute
localization of pain
The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away
Fraction of inspired oxygen (FiO2)
The percentage of oxygen in inhaled air.The oxygen concentration delivered to the client; determined by the client's condition and ABG levels
symptoms of hypovolemia
Thirst, Dry oral mucosa Increased: Temp, Heart Rate Decreased: Urine output, Arterial venous pressure, orthostatic hypotension. Confusion or lethargy, Headache, Delayed Capillary refill, Poor skin turgor, cool/clammy/pale skin on arms and legs. hypotension, tachycardia, and decreased urinary output.
Depression symptoms in adolescents
disciplinary issues absenteeism and angry outbursts lost over two ponds per week. sleeping during class or activities quit sports vague somatic symptoms (e.g., headache, stomachache irritable or cranky mood · Hypersomnolence or insomnia; napping during daily activities · Low self-esteem; withdrawal from previously enjoyable activities · Outbursts of angry, aggressive, or delinquent behavior (e.g., vandalism, absenteeism); inappropriate sexual behavior (Option 1) · Weight gain or loss; increased food intake or lack of interest in eating
Lithium
Treat bipolar 1.5 or grate is toxic increase sodium and water 2-3L per day report dehydration diarrhea , low urine output do not take with NSAIDs - reduce renal/ kidney functions.
Riluzole (Rilutek)
Treatment of ALS the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it
BRADYcardia treatment and cause
Treatment: Atropine ONLY if symptomatic showing low perfusion (pale, cool, clammy) Causes: Vagal maneuver (bearing down), meds (CCB, Beta Blockers)
manifestation of DVT
Unilateral edema and calf pain could be signs of a deep venous thrombosis (DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications (e.g., pulmonary embolism). Prolonged immobilization (e.g., airplane travel, bed rest) increases the risk for DVT.
Beta Blockers
Used to treat --• Hypertension • Cardiac arrhythmia • Heart failure • Angina • Glaucoma • Prevention of MI.
Aortic stenosis (AS) heart sound
When assessing a client with AS, the nurse should auscultate in the aortic area (i.e., second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. aloud murmur after S1. soft at S2.
contraindicated during pregnancy's
Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy) It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception
Myelomeningocele
a. Protrusion of the meninges, CSF, nerve roots, and a portion of the spinal cord occurs. b. The sac (defect) is covered by a thin membrane prone to leakage or rupture. c. Neurological deficits are evident. C. Assessment 1. Depends on the spinal cord involvement 2. Visible spinal defect 3. Flaccid paralysis of the legs 4. Altered bladder and bowel function 5. Hip and joint deformities 6. Hydrocephalus D. Interventions 1. Evaluate the sac and measure the lesion. 2. Perform neurological assessment. 3. Monitor for increased ICP, which might indicate developing hydrocephalus. 4. Measure head circumference; assess anterior fontanel for bulging. 5. Protect the sac; as prescribed, cover with a sterile, moist (normal saline), nonadherent dressing to maintain the moisture of the sac and contents. 6. Change the dressing covering the sac on a regular schedule or whenever it becomes soiled because of the risk of infection; diapering may be contraindicated until the defect has been repaired. 7. Use aseptic technique to prevent infection. 8. Assess the sac for redness, clear or purulent drainage, abrasions, irritation, and signs of infection. 9. Early signs of infection include elevated temperature (axillary), irritability, lethargy, and nuchal rigidity. 10. Place in a prone position to minimize tension on the sac and the risk of trauma; the head is turned to 1 side for feeding. 11. Assess for physical impairments such as hip and joint deformities. 12. Prepare the child and family for surgery. 13. Administer antibiotics preoperatively and postoperatively, as prescribed, to prevent infection. 14. Teach the parents and eventually the child about longterm home care. a. Positioning, feeding, skin care, and range-of-motion exercises b. Instituting a bladder elimination program and performing clean intermittent catheterization technique if necessary c. Administering antispasmodics (that act on the smooth muscle of the bladder) as prescribed to increase bladder capacity and improve continence d. Implement a bowel program, including a high-fiber diet, increased fluids, and suppositories as needed. e. The child is at high risk for allergy to latex and rubber products because of the frequent exposure to latex during implementation of care measures
The stable client in Ventricular Tachycardia with a pulse is treated with
antiarrhythmic medications (e.g., amiodarone, procainamide, sotalol). life threatening bazar pattern
Adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade)
are common tumor necrosis factor inhibitor, biologic disease modifying antirheumatic drugs. Major adverse effects include immunosuppression and infection.
Supraventricular Tachycardia (SVT) medication to give
adenosine IV bolus over 1-2 seconds followed by a 20-ml saline flush.
Cranial nerve VIII (vestibulocochlear)
affects hearing and equilibrium
voluntary control of the anal and urethral sphincters occurring at
age 18-24 months
*Take off PPE in this order:*
alphabetical Gloves, goggles, gown, mask
femoral-popliteal angioplasty After the procedure, the client should be able to
ambulate without evidence of extremity ischemia (e.g., leg pain)
amikacin
aminoglycoside antibiotic gentamicin, tobramycin ototoxicity and nephrotoxicity Age, renal function, and drug dose affect the occurrence of these adverse reactions. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client's hearing, balance, and urinary output
Atropine
an anticholinergic agent, is used to treat bradycardia.
Levetiracetam (Keppra)
anticonvulsant prescribed for seizure disorders cause drowsiness, somnolence and fatigue. report anxiety, and/or depression or mood change - may indicate suicide. can trigger Stevens-Johnson syndrome Report: Rash, blistering, muscle/joint pain avoid driving or operating heavy machinery until they have permission from their health care provider
APETM
aortic, pulmonic, erb's point, tricuspid, mitral
developmental dysplasia of the hip (DDH)
assymetrical gulteal and thigh folds. limited abduction of hips. Barlow and ortolani tests given.trendelenburg sign used in toddler. complaint of clicking sound with diaper changes
Asystole treatment
atropine and epinephrine (first) do CPR- Compression give oxygen. 1. call for help verify pulse start cpr give oxygen during CPR Do not shock with defibrillator because client has no pulse.
The temporal lobe receives
auditory input.
cold stress
baby can not shiver when cold they use brown fat made is 3rd trimester. for thermogenesis. Once BAT Brown adipose tissue (BAT) is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake. Clinical manifestations of cold stress include: · Neurological - altered mental status (irritability or lethargy) (Option 1) · Cardiovascular - bradycardia · Respiratory - tachypnea early, followed by apnea and hypoxia · Gastrointestinal - high gastric residuals, emesis, hypoglycemia (Option 2) · Musculoskeletal - hypotonia, weak suck and cry (Option 4)
Cerebellar deficits affects
balance and require fall precautions
peak flow meter
best indication of moving air in a client with asthma is
3rd stage of labor
birth of baby to expulsion of placenta
locia rubra
birth- 3 to 4 days
age two and a half to 3 and a half years
bladder training requires more self-awareness and self-discipline from the child and is usually achieved at Readiness for toilet training is dependent on the child's ability to voluntarily control the anal and urethral sphincters, which usually occurs at age 18-24 months. Other developmental and behavioral indicators of toilet training readiness include the child's ability to express the urge to defecate or urinate, understand simple commands, pull clothing up and down, and walk to and sit on the toilet.
medication that decrease heart rate and cause brady cardia
calcium channel blockers (eg, diltiazem, verapamil) beta blockers (e.g., metoprolol, timolol, atenolol),
RN is responsible for
calling the x-ray or other departments to communicate pertinent information about the client, including the need to maintain airborne isolation precautions before and while transporting the client for diagnostic tests. The RN is responsible for explaining to the client that wearing a mask during transport to another department prevents transmission of airborne microorganisms from the client to others. This is client teaching and must be done by the RN. The UAP can implement the task of applying the mask before transport.
ventricular tachycardia
can be pulseless or have a pulse (VT) can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (e.g., amiodarone, procainamide, sotalol). (Option 2) Oxygen saturation should be assessed after the presence of a pulse has been established. (Options 3 and 4) CPR and defibrillation should be initiated only in a client who is pulseless. Educational objective: The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion.
IM epinephrine is administered for
cardiac arrest, anaphylactic reactions, or severe asthma attacks
varicella-zoster virus
chicken pox and shingles
reported sexual transmitted disease
chlamydia, gonorrhea, syphilis and chancroid.
Unilateral extremity swelling is concerning for
concerning for deep venous thrombosis (DVT) in a hospitalized client. Bilateral swelling indicates volume overload or venous stasis
Sulfasalazine (Azulfidine)
contains sulfapyridine and aspirin (5-ASA) and is used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in inflammatory bowel disease (IBD). When the 5-ASA is combined with the sulfa preparation, the drug does not become absorbed until it reaches the colon. Dehydration is a risk with IBD as the client can have up to 20 diarrheal stools a day. The client usually does not feel thirsty until after there is a fluid volume deficit. Sulfa can crystallize in the kidney if the client is dehydrated. Normal urine specific gravity is 1.003-1.030. Elevated specific gravity can indicate concentrated urine and be a sign of dehydration
Carboprost
contraindicated in asthma patient utarine stimulant contract utarus.
Expected findings post anesthesia
difficult to arouse Pinpoint pupils-small pupil size hypothermia Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment.
Lisinopril, an ACE inhibitor, impact on heart rate / and adverse effects of meds
does not lower HR and is not contraindicated in clients with bradycardia. dry nonproductive hypotension dizziness hyperkalemia
Pertussis requires
droplet precautions
The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of
enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia
Chest tube output
greater that 5-10 ml/ kg 1 hr indicate hemorrhage
Ventricular tachycardia (V-tach)
has a pattern -and pulse sharp peak and jagged edges can be life threating treat with amiodarone / Tyron may impair perfusion and often leads to cardiac arrest and/or VF clients may have a pulse
2 - 3 months developmental milestones
head control hold rattle cooing sound smile recognize faces
1 month developmental milestones
hold head up fisted had look at parents Lifts head, follows a moving object and exhibits reflex stepping, postivie support reflex, decreased flexion, and hands fisted with indwelling thmub most of the time, reciprocal and symmetrical kicking, and neonatal reaching.
knee-chest position is used to treat
hypoxia and cyanosis in infants and young children with tetralogy of Fallot (TOF).
tricyclic antidepressant
imipramine, amitriptyline, nortriptyline
receptive aphasia (Wernicke's aphasia)
impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe
RSV (respiratory syncytial virus)
in peds supportive care no meds use saline drops and bulb suction.
cystic fibrosis nursing care
increase caloric intake eat meal with enzyme increase fluid excecise chest physiotherapy postural drainage. use acetylcysteine for medication. do not take acetometophine / Tylenol.
the client retracts from the stimulus,
it is recorded as "withdrawal"
Enoxaparin (Lovenox)
low molecular weight heparin anticoagulant assess for heparin induced thrombocytopenia - can cause thrombosis or PE. normal platelet count is 150-450, 000
MI - Elderly
nausea and upper back and shoulder pain
school-age years (6-12), sleep requirement
need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12 Quiet activity (e.g., coloring, reading) prior to bedtime should be planned to promote restful sleep.
Lantus (insulin glargine)
no peak 12 to 24 hours duration long acting insulin slow absorption decresed risk of hypoglycemia can be given at bed time.
Pulmonary artery wedge pressure (PAWP)
normal value 6-12 mm Hg indicating increased left ventricular preload.
water seal chamber bubbling
ntermittent bubbling: Always good, document* Continuous bubbling: Always BAD, tape it* If it's sealed should it be continuously bubbling? No, it's leaking! Intermittent = air still in pleural space Constant = air leak Tidling = normal / water moves up and down with breathing
cooperative play
one or two children direct the activity and assign roles while others follow. This type of play is typical of school-age children (age 6-12 years) and may involve a formal game or task (e.g., building a castle from blocks).
infant glucose levels
over 40-60mg/dL day 1, 50-90 day 2+; preterm, posterm, LGA or SGA are at risk for hypoglycemia; depends of glucose storage
post lumbar puncture
patient should lie flat in supine to prevent headache and leaking of CSF. The client should lie flat for at least 4 hours. The prone or supine position is recommended to help prevent a headache. After a lumbar puncture, cerebrospinal fluid leakage from the puncture site requires health care provider notification for a blood patch. A headache after the procedure is an expected finding. The client should lie flat and increase fluid intake afterwards.
The new nurse has the basic skills to
provide insulin coverage if necessary, perform wound care (e.g., assessment, sterile dressing changes, documentation), and provide diabetic teaching for this client.
The occipital lobe .
receives visual images.
4-5 Months Milestones
roll from front to back sit with support palmer grasp put things in mouth laugh make sound calm by parents voice.
indication for Coronary artery bypass grafting
segment elevation myocardial infarction (STEMI) cardiovascular disease uncontrolled angina
status epilepticus nursing priority and assessment finding
seizing for 5 minutes or longer Grunting and a dazed appearance give IV benzodiazepines (diazepam or lorazepam)
The parietal lobe receives
sensory input.
Selective serotonin reuptake inhibitors (SSRIs)
sertraline paroxetine fluoxetine citalopram escitalopram
convection
shielding the newborn from drafts circulating air
Psoriasis treatment
topical therapy (e.g., corticosteroids, moisturizers), phototherapy (e.g., ultraviolet light), and systemic medications, including cytotoxic (e.g., methotrexate) and biologic (e.g., infliximab) agents
Tinnitus is commonly associated
toxicity related to salicylate-containing NSAIDs (e.g., aspirin) or aminoglycosides (e.g., gentamicin, neomycin, tobramycin); its onset should be reported by a client taking these medications. The medication may need to be discontinued to prevent permanent hearing loss.
anticholinesterase drugs
treatment for Myasthenia gravis pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal
amiodarone
treatment for Ventricular tachycardia (V-tach)
Leukemia is characterized by
unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity. This disorder is the most common form of childhood cancer. Infection is a major concern due to neutropenia. In addition, anemia occurs due to decreased red blood cell production, and bleeding is common as a result of decreased platelet production.
Supraventricular Tachycardia (SVT)
use ABCD to treat 1. Adenocard - push in 1-2 sec 2. Bata Blocker 3. CCB dipine and verapamil- better for asthma patient. 4. digoxin
CPR (cardiopulmonary resuscitation)
use heal of the hand. center of the chest between nipple and breast bone. 2-2.4 inches in depth. 100 to 120 compression per min. 30 compression for 2 breaths.
Bipolar meds
valproic acid and lithium, Carbamazepine
10-12 months milestones
walk with help crawl up steps 2 finger picher say 3-5 words wave goodbye separation anxiety search for hidden objects. takes simple action upon request purposefully says "mama" or "dada" sits independently and plays pulls to standing/cruise furniture communicates by reaching and pointing moves purposefully to get desired object has increasing curiosity recognizes people uses both hands equally well
Unstable Ventricular Tachycardia treatment
with a pulse synchronized cardioversion.
Beta 2 Agonist
"-buterol" Albuterol Levalbuterol 1st drug used during SEVERE asthma attacks THE ONLY "rescue inhaler" BEFORE steroid inhaler!!!! · S - Salmeterol · S - Slower Acting (NOT rescue inhaler) DO NOT use fluticasone or salmeterol for first sign of acute asthma attack! AIM for Acute Asthma Attack A - Albuterol 1st M - Methyl-predniso-lone (brand: Solu Medrol)
yellow on peak flow meter
(50%-79% of personal best and caution)
Red on peak flow meter
(<50% of personal best - a medical alert).
What do you do when you knock out a closed chest drainage device
(Ex: Pneumovac, Pleur-evac, etc.) Set it back up have pt take deep breaths, NOT an emergency*
HELLP syndrome
(Hemolysis, Elevated Liver enzymes, Low Platelets). HELLP syndrome requires prompt action because the definitive treatment is giving birth, but the client may be able to have labor induced.
Levetiracetam
(Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately
methotrexate
(Rheumatrex) is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines (e.g., influenza, pneumococcal) and avoiding crowds and persons with known infections. Live vaccines (e.g., herpes zoster) are contraindicated in clients receiving immunosuppressants, such as methotrexate. Alcohol should be avoided in clients taking methotrexate as it is hepatotoxic and drinking alcohol increases the client's risk for hepatotoxicity
appropriate-size pouching system for stoma
(approximately 0.1 in [0.25 cm] larger than the stoma) prevents decreased perfusion and skin irritation. Using a larger drainage bag, especially at night, prevents urine backflow through the stoma and reduces the risk for infection.
Intramuscular (IM) injections for infants
(e.g., hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass (Option 4). (Option 1) For IM injections, the needle length should be 5 inch for newborns and 5/8 to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues (e.g., nerves, bone). A 22- to 25-gauge needle is appropriate for clients age <12 months. (Option 2) The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution (e.g., alcohol) is appropriate. (Option 3) A 1-mL syringe (e.g., tuberculin) should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal places. Educational objective: The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A 5/8-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn.
Thrombolytic agents
(eg, alteplase, Tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemie stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage
Thrombolytic therapy
(eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms (Option 5). A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments (Option 4). The initial plan of care for a client with an acute stroke should include performing baseline neurologic assessment to begin monitoring neurologic status trend, obtaining an immediate CT scan of the head to determine stroke type, and anticipating administration of thrombolytics (if indicated) within 4.5 hours of symptom onset.
Anticholinergic medications contraindication
(eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia).
client with a neurological injury
(eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.
Kawasaki disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. IVIG, high-dose aspirin
Caput succedaneum
(mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days.
central venous pressure (CVP)
(normal value 2-8 mm Hg) indicating increased systemic circulation volume and increased right ventricular preload.
Dopamine (Intropin)
*class*: inotropic, vasopressor, adrenergic *Indication*: used to improve blood pressure, cardiac output, and urine output *Action*: -Smaller doses result in renal vasodilation -Doses 2-10mcg/kg/min result in cardiac stimulation by acting on beta1 receptors -Doses >10mcg/kg/min stimulate alpha receptors leading to vasoconstriction (↑SVR) *Nursing Considerations*: -Monitor hemodynamics closely: BP, HR, EKG, CVP, and PAOP if available - Obtain parameters for hemodynamic values - Titrate to obtain appropriate BP (more potent vasoconstrictors may be required) - Irritation may occur at IV site - Beta blockers may counteract therapeutic effects is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced (Option 2). (Options 1, 3, and 4) These measurements fall within the respective reference ranges and do not indicate a need to adjust dopamine administration. Normal central venous pressure is 2-8 mm Hg; normal mean arterial pressure ([systolic blood pressure + (2 x diastolic blood pressure)]/3) is 70-105 mm Hg; and normal systemic vascular resistance is 800-1200 dynes/sec/cm-5. Educational objective: Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely
Lithium carbonate therapeutic level
0.6-1.2 same as creatinine *will let the level go up to 1.5 if we are treating mania*
A. Stage 1: Latent phase Cervical dilation Uterine contractions occur every
1 to 4 cm. every 15 to 30 minutes, are 15 to 30 seconds in duration, and are of mild intensity.
soak pad in less than - hours
1-2 concern
4th stage of labor
1-4 hours after birth, maternal physiologic readjustment.
going down the stairs
1. Descend with Cane- cane goes first 2. Weaker leg down - weak leg goes down second 3. Strong leg- strong lag goes last. cws
Anorexia nervosa
1. Description a. Onset often is associated with a stressful life event. b. Intensely fears obesity c. Body image is distorted and a disturbed self-concept is common. d. Preoccupied with foods that prevent weight gain and has a phobia against foods that produce weight gain e. The eating disorder can be lifethreatening. f. Death can occur from starvation, suicide, cardiomyopathies, or electrolyte imbalances. 2. Assessment a. Appetite loss and refusal to eat b. Appetite denial c. Feelings of lack of control d. Compulsive exercising e. Overachiever and perfectionist f. Physical alterations: Many occur and can include decreased temperature, pulse, and blood pressure; weight loss; gastrointestinal disturbances such as constipation; teeth and gum deterioration; esophageal varices from induced vomiting; electrolyte imbalances; dry, scaly skin; presence of lanugo on extremities; sleep disturbances; hormone deficiencies; amenorrhea for at least 3 consecutive menstrual periods; cyanosis and numbness of extremities; and bone degeneration.
lumbar puncture
1. Empty the bladder before the procedure (Option 2) 2. The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3). 3. A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4) 4. Pain may be felt radiating down the leg, but it should be temporary (Option 1) After the procedure, instruct the client as follows: 1. Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache 2. Increase fluid intake for at least 24 hours to prevent dehydration
Drugs commonly associated with orthostatic hypotension include:
1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (e.g., metoprolol) and alpha blockers (e.g., terazosin) 2. Antipsychotic medications (e.g., olanzapine, risperidone) and antidepressants (e.g., selective serotonin reuptake inhibitors) (Option 4) 3. Volume-depleting medications such as diuretics (e.g., furosemide, hydrochlorothiazide) 4. Vasodilator medications (e.g., nitroglycerine, hydralazine) 5. Narcotics (e.g., morphine)
Standard Precautions
1. Nurses must practice standard precautions with all clients in any setting, regardless of the diagnosis or presumed infectiveness. 2. Standard precautions include hand washing and the use of gloves, as well as washing hands after gloves are removed. Additionally, standard precautions include the use of masks, eye protection, and gowns, when appropriate, for client contact. 3. These precautions apply to blood, all body fluids(whether or not they contain blood), secretions and excretions, nonintact skin, and mucous membranes B. Interventions 1. Wash hands between client contacts; after contact with blood, body fluids, secretions or excretions, nonintact skin, or mucous membranes; after contact with equipment or contaminated articles; and immediately after removing gloves. 2. Wear gloves when touching blood, body fluids, secretions, excretions, nonintact skin, mucous membranes, or contaminated items; remove gloves and wash hands between client care contacts. 3. For routine decontamination of hands, use alcoholbased hand rubs when hands are not visibly soiled. For more information on hand hygiene from the Centers for Disease Control and Prevention (CDC), see www.cdc.gov/handhygiene/ 4. Wear masks and eye protection, or face shields, if client care activities may generate splashes or sprays of blood or body fluid. 5. Wear gowns if soiling of clothing is likely from blood or body fluid; wash hands after removing a gown. 6. Steps for donning and removing personal protective equipment (PPE) (Table 13-2) 7. Clean and reprocess client care equipment properly and discard single-use items. 8. Place contaminated linens in leak-proof bags and limit handling to prevent skin and mucous membrane exposure. Dispose according to agency policy. 9. Use needleless devices or special needle safety devices whenever possible to reduce the risk of needle sticks and sharps injuries to health care workers. 10. Discard all sharp instruments and needles in a puncture-resistant container; dispose of needles uncapped or engage the safety mechanism on the needle if available. 11. Clean spills of blood or body fluids with a solution of bleach and water (diluted 1:10) or agency-approved disinfectant.
locia alba
11th day to 6 weeks
Hemaglobin
12-18 g/dL
Normal Hgb levels
12-18 g/dL for a male is 14-18 g/dL (140-180 mmol/L) and 12-16 g/dL (120-160 mmol/L) for a female
Pulse newborn
120-160
minimum day between MAOI and SSRI use
14 days
normal platelet count
150,000-400,000
Normal platelet count
150,000-400,000/mm3
normal respiratory rate in a neonate
30-60
respiration rate in infant
30-60 crackles in lungs is normal for the first hour of life.
Newborns normally have respirations of
30-60/min, with periodic pauses lasting <20 seconds.
2-year-old should have a vocabulary of about
300 words string 2 or more words together in a meaningful phrase
normal Hct
35-55% for a male is 42-52% (0.42-0.52) and 37-47% (0.37-0.47) for a female.
Hematocrit
36-54
locia serosa
4th postpartum day to 10th or 14 post partum day
active 1
6-10 cm moderate to strong contractions regular q 3-5 min lasts 40-70 sec During this period, apprehension and pain increase, and the ability to follow instruction decreases. The client's demeanor is more serious. Pain management, reassurance, and encouragement are priorities.
Vancomycin should be infused over at least
60 minutes (100 minutes if infusing ≥ 1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect.
Temperature (Infant)
97.7-99.7 36.5- 37.6
Wernicke encephalopathy and Korsakoff syndrome
A condition that occurs in alcoholics due to a thiamine deficiency, in which the mammillary bodies and dorsomedial nuclei of the thalamus are damaged (contains 2 parts, 1st: opthalmoplegia, ataxia, confusion; 2nd: amnesia, confabulation, personality change). Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.
post op tonsillectomy
A tonsillectomy may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep apnea. Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (e.g., frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and notify the health care provider (Option 4). Expected postoperative findings include ear pain when swallowing (i.e., referred pain from the throat) and low-grade fever (<101 F [38.3 C]); analgesics (e.g., acetaminophen) may be administered as needed (Option 1). Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (i.e., bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days (Option 2). (Option 3) Drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to bleeding. The client should avoid use of straws or other pointed objects in the mouth. (Option 5) Routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available but used only for emergency airway obstruction. Educational objective: Postoperative tonsillectomy interventions include close observation for signs of bleeding (e.g., frequent swallowing) as well as avoidance of routine oral suctioning and the use of straws. Expected findings include white, fluid-filled exudate in the throat with halitosis, low-grade fever, and referred ear pain.
Intussusception treatment
A. Description 1. Telescoping of one portion of the bowel into another portion 2. The condition results in obstruction to the passage of intestinal contents. B. Assessment 1. Colicky abdominal pain that causes the child to scream and draw the knees to the abdomen, similar to the fetal position 2. Vomiting of gastric contents 3. Bile-stained fecal emesis 4. Currant jelly-like stools containing blood and mucus 5. Hypoactive or hyperactive bowel sounds 6. Tender distended abdomen, possibly with a palpable sausage-shaped mass in the upper right quadrant C. Interventions 1. Monitor for signs of perforation and shock as evidenced by fever, increased heart rate, changes in level of consciousness or blood pressure, and respiratory distress, and report immediately. 2. Antibiotics, IV fluids, and decompression via nasogastric tube may be prescribed.3. Monitor for the passage of normal, brown stool, which indicates that the intussusception has reduced itself. 4. Prepare for hydrostatic reduction as prescribed, if no signs of perforation or shock occur (in hydrostatic reduction, air or fluid is used to exert pressure on area involved to lessen, diminish, or resolve the prolapse). 5. Posthydrostatic reduction a. Monitor for the return of normal bowel sounds, for the passage of barium, and the characteristics of stool. b. Administer clear fluids, and advance the diet gradually as prescribed. 6. If surgery is required, postoperative care is similar to care after any abdominal surgery; procedure may be done via laparoscope. Diagnosed by xray, ultrasound, air or barium contrast enema, which sometimes reduces the obstruction without need for surgery Surgery is indicated when barium or air contrast enema does not reduce the intussusception
Teratogenic medications
ACE inhibitors - Lisinopril aminoglycosides like gentimycin Fluoroquinolones abx- theoretical cartilage damage in kids and fetus Atovastatin Cabamazepine and valproic acid- antiseizure drugs that cause neural tube defects- pts need to be taking more folic acid than normal Methotrexate also interferes with folate metabolism
tricyclic antidepressants
Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, doxepin, amoxapine. The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.
Calcium channel blockers
Amlodipine Diltiazem Verapamil
Tidal volume
Amount of air that moves in and out of the lungs during a normal breath.
contact precautions
Anything enteric (fecal/oral) C-diff, Hep A (stands for anus), Herpes, Staph infections, MERSA and RSV (Respiratory Syncytial Virus, babies get it) transmitted by droplet but works best still on contact precautions Private room, but can be in the same room if in cohort PPE- Gloves, Gown, Disposable supplies/dedicated supplies Clostridium difficile respiratory syncytial virus Influenza Wound infections diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, and varicella zoster conjunctivitis 2. Barrier protection a. Private room or cohort client b. Use gloves and a gown whenever entering the client's room.
while on albuterol you should avoid
Beta Blockers - Atenolol NSAIDS - Naproxen, Ibuprofen MONITOR FOR HYPOKALIMIA
Rubra
Birth - 3/4 days Blood and decidual debris (small clots - less than the size of a walnut) Can be: Red → pinkish red → reddish-brown
beta blockers adverse effects
CV: Orthostatic hypotension, bradycardia, PULMONARY EDEMA, ENDO: May cause ^ BUN, serum lipoprotein, potassium, triglyceride, and uric acid levels. May cause ^ blood glucose levels. In labile diabetic patients, hypoglycemia may be accompanied by precipitous ^ of BP. RESP: bronchospasm (hx of asthma)
Pyridostigmine (Mestinon)
Category: Cholinergic, Anticholeristinase, Use: Myasthenia Gravis, Precautions: May cause cramps, increased peristalsis
Torsades de Pointes
Causes: Post MI, Hypoxia, Low magnesium Magnesium Sulfate Rate: 120 - 200 usually P wave: Obscured by ventricular waves QRS: Wide QRS - "Twisting of the Points" Conduction: Ventricular only Rhythm: Slightly irregular
SVT - Supraventricular Tachycardia
Causes: Stimulants, Strenuous exercise, hypoxia, heart disease treatment - Vagal Maneuver (bear down like having a bowel movement, ice cold stimulation) 1. Adenosine - RAPID PUSH & flush with NS - HR may stop 2. 3. Cardioversion - *Push Synch
Ventricular Fibrillation (V Fib)
Causes: Untreated V Tach, Post MI, E+ imbalance, proarrhythmic meds V Fib treatment - Check pulse start CPR- get ready to defib. Defib #1 Defibrillation immediately Stop CPR to do it & before drugs! *NO synchronization needed 1. Drugs: LAP - Lidocaine, Amiodarone, Procainamide
Atrial Fibrillation (A Fib)
Causes: Valvular disease, Heart failure, Pulm. HTN, COPD, after heart surg. treatment - Cardioversion (after TTE to rule out clots) *Push Synch 1. Digoxin - Deep Contraction Check ATP Before giving: 2. Anticoagulants: Warfarin (monitor INR, Vit. K antidote, moderate green leafy veggies) 3. Apical pulse 60 Toxicity (Max 2.0 range) visual disturbances, N/V, Anorexia Potassium below 3.5 - HIGHER risk for toxic
Levofloxacin (Levaquin) side effects
Common: Nausea, Diarrhea, Rash, Dizziness, Photosensitivity, Bone and joint problems in <18 year olds; Increased INR with warfarin; Hypoglycemia in DM, Crystalluria Rare: Seizures (Do not use with history of seizure), Tendon Rupture (more common in elderly, patients on corticosteroids or transplant patients) quinolone an1ibio1ic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective
Asystole (nursing interventions)
DO NOT SHOCK palpating for a pulse call for help CPR oxygenated ventilation give epi and atropine Defibrillation is not indicated when there is no electrical activity present (ie, asystole) or when the heart muscle is not contracting despite an organized rhythm (ie, pulseless electrical activity [PEA]). Defibrillation attempts 1o convert lethal ventricular dysrhythmias (ie, ventricular fibrillation and pulseless ventricular Tachycardia) into an organized rhythm by passing an electric shock through the heart. Defibrillation cannot create an organized rhythm if there is no electrical activity in the heart
cystic fibrosis (CF)
Fatty stool. Steatorrhea. Salty skin. vitamin deficiency. client should increase salt on hot day. barrel chest diabetes cachexia. clubbing. MEDS- acetylcysteine antidote do not give these kids tylenol. a defective protein responsible for transporting sodium and chloride causes exocrine gland secretions to be thicker and stickier than normal. Viscous respiratory secretions accumulate, resulting in impaired airway clearance and a chronic cough. Clients eventually develop chronic lung disease, which predisposes them to recurrent respiratory infections. Pancreatic enzyme secretion, needed for digestion and absorption of nutrients, is also impaired because thick secretions block pancreatic ducts. Therefore, the client needs supplemental enzymes with all meals and snacks (Option 2). The client also requires multiple vitamins and a diet high in carbohydrates, protein, and fat to help meet nutritional requirements for growth (Option 4). Sweat gland abnormalities prevent sodium and chloride reabsorption, causing increased salt loss, dehydration, and hyponatremia during times of significant perspiration. Therefore, parents should increase the child's salt intake and fluids during hot weather, exercise, or fever (Option 3). (Option 1) Regardless of symptoms, clients should incorporate chest physiotherapy (e.g., percussion, vibration, postural drainage) into their daily routine to improve mucus clearance and lung function. (Option 5) The parents should encourage physical activity as tolerated, which helps to thin secretions and remove them from airways and improves muscle strength and lung capacity.causes increased viscosity of exocrine gland secretions. Clients require pancreatic enzyme supplements with meals and snacks; a diet high in carbohydrates, protein, and fat; and increased salt intake during times of significant perspiration. Clients should also incorporate chest physiotherapy and exercise into their daily routine.
11+ years Piaget's theory of cognitive development
Formal operational Abstract thinking & reasoning
Infant growth
Gain 150-210g (5-7oz) per week in first 6 months 6 months = birth weight x2 12 months = birth weight x3 Grow 2.5 cm (1 in) per month in first 6 months Grow 0.5 cm (0.2 in) per month in month 6-12 6-8 teeth eruptions by age 1
epiglottitis are caused by
Haemophilus influenza type B (HiB) prevented by standard vaccinations given during the 2-and 4-month visits. Epiglottitis is rarely seen in vaccinated children.
Malignant hyperthermia (MH) manifestation
Hypercapnia Generalized muscle rigidity (e.g., jaw, trunk, extremities). Hyperthermia can exceed 105 F treatment dantrolene, cooling blanket, fluid resuscitation.
Sumatriptan
Imitrex is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.
Hyperkalemia
Manifestations Related Pathophysiology Cardiac manifestations: • ECG changes: peaked T waves, prolonged PR and QRS intervals Mild increases in serum K+ levels affect the repolarization phase of the cardiac action potential; further increases slow the cardiac conduction system. • Dysrhythmias (bradycardia, heart blocks, ventricular tachycardia) Slowed conduction and impaired repolarization allow development of abnormal rhythms. • Possible cardiac arrest Severe hyperkalemia (levels higher than 8 mEq/L) can lead to ventricular fibrillation or asystole, with no effective ventricular contractions and cardiac arrest. Neuromuscular: • Paresthesias • Muscle tremors, twitching, and weakness • Ascending paralysis • Dyspnea; possible respiratory failure Excess potassium in ECF interferes with the membrane potentials of cells, increasing the threshold needed to generate an action potential. This impairs neuromuscular function, affecting skeletal, smooth, and cardiac muscle. Effects initially are seen in lower extremities, progressing upward. If the diaphragm is affected, respiratory failure can result. Gastrointestinal: • Abdominal cramping, ileus • Nausea, vomiting, diarrhea The effect of hyperkalemia on smooth muscle can impair intestinal peristalsis.
Airborne precautions
Measles, Mumps, Rubella, TB, and Varicella. Private room required unless cohort. Mask, Gloves, Special filter mask (ONLY FOR TB), Pt wear mask when leaving room, Negative airflow room. TB is spread by droplet but airborne precaution. suspected infection with pathogens transmitted by respiratory droplets, generated when coughing, sneezing, or talking. b. Private room or cohort client (a client whose body cultures contain the same organism) c. Wear a surgical mask when within 3 feet of a client; place a mask on the client when the client needs to leave the room.
Droplet (sneezing/coughing):
Meningitis, H-flu (causes epiglottis) Private room, unless cohort They need a lumbar puncture for cultures PPE- Gloves, Mask, Pt wears mask when leaving room, Disposable supplies/dedicated supplies, No gown a. Adenovirus b. Diphtheria (pharyngeal) c. Epiglottitis d. Influenza (flu) e. Meningitis f. Mumps g. Mycoplasmal pneumonia or meningococcal pneumonia h. Parvovirus B19 i. Pertussis j. Pneumonia k. Rubella l. Scarlet fever m. Sepsis n. Streptococcal pharyngitis
MAOI
PHENELZINE Brand: Nardil SELEGILINE ISOCARBOXAZID TRANYLCYPROMINE
latent 1
Phase of 1st stage of labor with 0-5 cm dilated - mother talkative, cheerful, anxious. can provide education . During this phase, pain is usually well managed. Although possibly apprehensive, the client is usually able to maintain focus and follow directions. For these reasons, - the best time to provide client education.
risk factors for FTT failure to thrive
Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: · Poverty - most common · Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing · Cognitive disability or mental health disorder · Lack of nutritional education - parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child
postop chest surgery chest tube placement
Place apical & basilar on same side of surgery Always assume chest sx / trauma is unilateral unless otherwise specified The only time its bilateral is when they say it's bilateral
uterine atony meds
Please Make Hemorrhage Cease Pitocin (30 units in 500 mL bag @ 200 mL/hour) *used first, but receptors may be oversaturated Methergine Methylergonovine (0.2 mg IM) *POTENT vasoconstrictor; MUST be w/in BP protocol Ergotamine Misoprostol
Types of chest tubes and lines
Pneumothorax- The chest tube removes air Hemothorax- The chest tube removes blood Pneumohemothorax- The chest tube removes air & blood Report in Hemothorax if- The chest tube isn't draining Report in Pneumothorax if: The chest tube isn't bubbling -Endotracheal tubes (ET) - Chest tubes (thoracostomy) - Central venous pressure lines (CVP)- IV
positive endexpiratory pressure (PEEP)
Positive pressure is exerted during the expiratory phase of ventilation, which improves oxygenation by enhancing gas exchange and preventing atelectasis. The need for PEEP indicates a severe gas exchange disturbance. Higher levels of PEEP (more than 15 cm H2O) increase the chance of complications, such as barotrauma tension pneumothorax.
Conduction heat transfer
Prevent heat loss resulting from conduction by performing all treatments on a warm, padded surface. the transfer of heat to another object during direct contact. - the body transfers heat to and ice pack, causing the ice to melt
omeprazole/sodium bicarbonate
Proton Pump Inhibitor/Antacid combo is a proton pump inhibitor (PPI) that suppresses the production of gastric acid by inhibiting the proton pump in the parietal cells of the stomach. In most hospitalized clients without a history of GERD or ulcers, PPIs are prescribed to prevent stress ulcers from developing during surgery or a major illness. Although evidence has shown that two-thirds of clients who receive PPls do not need them, these medications are still widely prescribed in hospitalized clients. PPls can be identified by their "-prazole" ending (e.g., pantoprazole, lansoprazole, esomeprazol
Pasero Opioid-induced Sedation Scale
S - Sleeping, easy to rouse · No action necessary 1 - Awake, alert · No action necessary · May increase sedation 2 - Slightly drowsy but easy to rouse · Acceptable, no action necessary 3 - Falls asleep during conversation · Unacceptable · Monitor respiratory status · Notify health care provider to decrease sedation by 25%-50% 4 - Somnolent, minimal or no response to verbal & physical stimuli · Stop sedation · Consider using naloxone · Notify health care provider · Monitor respiratory status Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.
HYPOthyroidism HashimOtos LOW & SLOW
S/s: Obese, flat/boring/dull personality, heat tolerance, cold intolerance, pulse & BP low, slow people, myxedema Tx: Thyroid hormone Synthroid (levothyroxine) Do not sedate these people! They will get into a myxedema coma NEVER HOLD THYROID HORMONES THE DAY OF SURGERY! Myxedema Coma (Mini hypothyroid) VERY Low/Slow: Airway, Breathing, Low BP = DEATH! LOW T3 & T4 Thyroid hormones • Low Iodine, Antithyroid Treatmens • Pituitary Tumor • AUTOIMUNE: HashimOtos | LOW & SLOW. LOw T3 & T4 hypO - HIGH TSH "TSH always opposite of T3 & T4" LOW energy "fatigue, weakness, muscle pains, aches" LOW metabolism-Weight GAIN/Water Gain (Edema eyes) LOW digestion "Constipation" NOT diarrhea LOW HAIR LOSS "alopecia" NOT hirsutism LOW mental-, ALOC (altered) LOW mood-depression, "apathy, forgetful confusion" LOW Libido-Low sex drive, infertile SLOW DRY skin turgor LOW & SLOW-menstruation "irregular" NO period "missed"-Amenorrhea "AMEN no period!" SLOW heavy period-Hypermenorrhea (Hyper Menstruation). PRIORITY: EXTREME LOW = Myxedema Coma Low RR—Respiratory FAILURE PRIORITY: Place "Tracheostomy Kit" by bedside KEY WORD: "Endotracheal Intubation set up" Low BP & HR "hypotension" "bradycardia" (below 60) Low Temp. "cold intolerance" NO electric blankets LOW Metabolism LOW Calories LOW energy "Frequent rest periods"
hyperthyroidism/ grave's disease treatment
SSKI (Potassium Iodide) S-Shrinks the Thyroid S-Stains Teeth (use straw + juice) K-Keep 1 hour apart of other meds METHIMAZOLE NOT baby safe PTU-Propylthiouracil "Puts Thyroid Underground" Baby safe REPORT: Fever/Sore Throat BETA BLOCKERS "-lol" Propranolol L-Low BP L-Low HR RAIU-Radioactive Iodine Uptake (Destroys the Thyroid) BEFORE: Pregnancy test before REMOVE neck jewelry & dentures 5-7 days before Hold antithyroid Meds AWAKE-NO anesthesia or Conscious Sedation Diet: Before-NPO 2-4 hrs After-NPO 1-2 hrs AFTER: AVOID EVERYONE! NO pregnant people NO crowds NOT same restroom (Flush 3 x) NOT same food utensils NOT same laundry as your family E-Exophthalmos" (grape eyes) Eye Exercise "full range of motion" (YES MOVE EYES) Eye Drops "artificial tears in conjunctiva" (NO dry eye) Dark Sunglasses (avoid irritation) NO Massaging T-Tape the eyelids closed or use Eye Patch AVOID 5 S's Can Trigger THYROID STORM! NO Sodium (eye swelling) + HOB Up (drain the eyes) NO Stimulants (Cluster care/ Dim Lights) NO Smoking, Stress, Sepsis "sickness" (infection) *Don't Touch Neck... release MORE T3 & T4* Post Op Risks: In the first 12 hrs, top priority is airway 2nd is hemorrhage. 12-48hrs for Total is Tetany r/t hypocalcemia. 12-48hrs for Subtotal is Storm NEVER PICK INFECTION IN FIRST 72 HRS! Risk for THYROID STORM! Priority: Stridor/Noisy breathing A-Airway-Endotracheal Tube bedside #1 Priority Tracheostomy Set B-Breathing-Laryngeal Stridor "Noisy breathing" Keywords: "Monitor Voice strength & Quality" C-Circulation-bleeding around pillow & Incision site Neutral head & neck alignment - NOT SUPINE! HOB 30-45 degree - NO FLEXING or Extending Neck C-Calcium LOW below 8.6 (normal: 8.6-10.2) Chvostek (Cheek Twitch when touched) Trousseau ("Twerk arm" with BP cuff x 3 min.) Tingling around mouth/Muscle Twitching MEMORY TRICK: "Remove the T (thyroid) Check the C (calcium)"
A healthy stoma should be
Shiny and moist, and a pinkish red color. pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or any shade of blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This finding is considered a medical emergency
Regular insulin (Humulin R, Novolin R)
Short-acting insulin 1 hour onset 2 hours peak 4 hours duration can give IV clear solution Administer 30 to 60 min before meals to control postprandial hyperglycemia.
signs of newborn respiratory distress
Sustained tachypnea, nasal flaring, retractions, and grunting -Cough is NOT reliable -Nasal flaring -Grunting -Intercostal retractions -Asymmetrical chest motion -Central cyanosis
Albuterol, salmeterol, terbutaline use and risk factors
Sympathomimetic B2 agonist primarily Use: Albuterol for acute asthma Salmeterol for long-term asthma or COPD Terbutaline to decrease premature uterine contractions The nurse should clarify the prescription if hypokalemia or tachycardia, common adverse effects, are present can cause hypokalemia or tachycardia,
bacterial meningitis with sepsis
The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: · Administer vasopressors. · Obtain relevant labs and blood cultures prior to administering antibiotics. · Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. · Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). · Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.
Peak airway (inspiratory) pressure (PIP)
The pressure needed by the ventilator to deliver a set tidal volume at a given compliance Monitoring peak airway inspiratory pressure reflects changes in compliance of the lungs and resistance in the ventilator or client.
Spina bifida
a. Posterior vertebral arches fail to close in the lumbosacral area. b. Spinal cord remains intact and usually is not visible. c. Meninges are not exposed on the skin surface. d. Neurological deficits are not usually present. 2. Closed neural tube defect a. This type consists of a diverse group of defects; the spinal cord is marked by malformations of fat, bone, or meninges. b. Usually there are few or no symptoms; in some situations the malformation causes incomplete paralysis with urinary and bowel dysfunction.
Premature ventricular contractions
abnormal electrical impulses in the ventricles this may occur spontaneously or in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful
autism spectrum disorder manifestation
abnormal functioning before age 3 social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. lack the acquisition of communication skills during the first 2 years of life. 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a meaningful phrase. restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the toy, and insist on the same play routine.
Indications for spinal immobilization include
abnormal neurological findings, significant mechanism of injury, change in orientation or level of consciousness, intoxication, distracting injury, and point tenderness over the spine.
Major side effects of metformin
are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect.
Preschoolers (age 3-5 years) play
are more likely to interact with each other and borrow each other's toys in associative play.
Statins (eg, simvastatin, atorvastatin) used for? and take when?
are typically taken in the evening as they are more effective during that period.
Endometrial cancer
arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (i.e., hyperplasia). Although typically slow growing, it can metastasize to the myometrium (i.e., uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (e.g., lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (e.g., heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (e.g., BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: · Conditions associated with infrequent or anovulatory menstrual cycles (e.g., polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) · Obesity · Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk. Educational objective: Endometrial cancer is a slow-growing malignancy that arises from the inner lining of the uterus. Major risk factors include conditions associated with infrequent or anovulatory menstrual cycles (e.g., polycystic ovary syndrome, infertility), obesity, and tamoxifen therapy.
placement of a cervical cerclage
at 12-14 weeks gestation for clients with a history of cervical insufficiency (i.e., painless, premature cervical dilation and miscarriage or preterm delivery) or up to 23 weeks gestation if signs of cervical insufficiency (e.g., short cervix) are noted. Discharge instructions include activity restriction and recognition of signs of preterm labor (e.g., low back aches, contractions, pelvic pressure) and rupture of membranes (Option 2). (Option 1) Bed rest is usually recommended for a few days after the procedure. Long-term bed rest is individualized but uncommon and increases the risk for complications (e.g., deep vein thrombosis). Pelvic rest (e.g., avoiding sexual intercourse) is determined by the health care provider. (Option 3) Mild abdominal cramping following cerclage placement is common; however, regular contractions, pelvic pressure, and low back aches may indicate preterm labor. (Option 4) The cerclage remains in place until 36-37 weeks gestation. Early removal is indicated by rupture of membranes (to prevent infection) or preterm labor (to prevent damage to the cervix as it dilates). Educational objective: Following cerclage placement, discharge teaching includes recognizing and reporting signs of preterm labor (e.g., low back aches, contractions, pelvic pressure) or rupture of membranes and understanding activity restrictions (e.g., bed rest for a short time after placement).
PEEP is usually kept at what happens if it is too high
at 5 cm H20 (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. ) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation. (Option 3) Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension. (Option 4) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity. Educational objective: High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H20 [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.
Chadwick sign
bluish discoloration of cervix that occurs normally in pregnancy at 6 to 8 weeks' gestation
Vancomycin
can cause nephrotoxicity Red mans Syndrome Rapid infusion Hypotension Flushing & pruritis "itching" Red rash on face, neck, chest & extremities. Signs of Toxicity Ear Damage "Ototoxicity" - Vertigo (loss of balance) - Tinnitus (ringing of the ears). Creatinine OVER 1.3 = Bad Kidney BUN Over 20 Urine output 30ml/hr or LESS = Kidney Distress ANAPHYLAXIS Hive Wheezing IMMEDIATELY STOP infusion & administer Epinephrine! E - Edema "Angioedema" P - Pruritis & Hives I - Insp. / Exp. "Wheezes". Assess site every 30 minutes for: pain, redness & swelling. Monitor BP Infuse SLOWLY at least over 60 minutes (<10mg/min) Avoid direct sun exposure Oral birth control ineffective Monitor QT interval Monitor creatinine and BUN
respiratory syncytial virus (RSV)
cause Bronchiolitis is common viral illness of childhood. It typically begins with viral upper respiratory symptoms (e.g., rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as tachypnea, cough, and wheezing. self-limited illness and supportive care is the mainstay of treatment. Most children can be managed in the home environment. Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting. Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove secretions prior to feedings and at bedtime. Medications such as cough suppressants, antihistamines, bronchodilators (e.g., albuterol), and corticosteroids have not been found to be effective and are not recommended.
Amyotrophic lateral sclerosis
causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management.
Iron deficiency during infancy
causes reduced hemoglobin production, resulting in anemia, decreased immune function, and delayed growth and development. During gestation, the fetus stores iron received from the mother; the amount of iron stored is dependent on the length of gestation. After birth, iron stores are progressively depleted and nutritional sources of iron are eventually required. Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically deplete iron stores by age 2-3 months and require additional iron supplementation (e.g., oral iron drops, iron-fortified formula). Therefore, a 3-month-old infant born at preterm gestation who is exclusively receiving breastmilk is most at risk for anemia
cerebellum is involved in 2 major functions
coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to- toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: 1. Finger tapping — ability to touch each finger of one hand to the hand's thumb (Option 4). 2. Rapid alternating movements — rapid supination and pronation 3. Finger-to-nose testing — clients touch the clinician's finger and then their own nose as the clinician's finger varies in location 4. Heel-to-shin testing — client runs each heel down each shin while in a supine position The cerebellum is involved in coordination of voluntary movements and maintenance of balance and posture. Balance is assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-shin testing.
CABG (Coronary Artery Bypass Graft) recovery instruction
daily shower light house work may begin in 2 weeks no lifting of any object weighing >5 lb no isometric activities---until 6 weeks after discharge. no driving for 4-6 weeks resume sexual if can walk 1 block or climb 2 flights Notify the HCP if the following symptoms occur: Chest pain or shortness of breath that does not subside with rest Fever >101 F (38.3 C) Redness, drainage, or swelling at the incision sites Avoidance of crossing legs
Key signs of refeeding syndrome
declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Refeeding syndrome is a serious complication of nutritional replenishment. It is marked by declines in serum phosphorus, potassium, and/or magnesium (mnemonic PPM). Clients can also develop fluid overload. Low-calorie feedings and a gradual increase in calories can prevent refeeding syndrome. Electrolytes should be monitored frequently.
dinoprostone and misoprostol
directly softens and dilates the cervix/to ripen the cervix and induce labor induce a medical abortion given via vaginal insertion and to always give before the induction of labor
antisocial personality disorder
disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit.
Tissue plasminogen activator (tPA)
dissolves clots and restores perfusion in clients with ischemic stroke. lt must be administered within a 3- to 41/2-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option 1).
Heprin-induced thrombocytopenia (HIT)
drop in platelet count after administration of heparin or enoxaparin. immune reaction to heparin that reduce platelet count. this increase risk for PE and thrombosis action is to stop the infusion give antidot or use non heparin anticoagulant such as rivaroxaban sentinal even due to heprin
Hypothyroidism/ Levothyroxine (Synthroid)
during pregnancy places clients at increased risk for other complications of pregnancy (e.g., preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option 4). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option 1) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option 2) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option 3) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels. Educational objective: Levothyroxine is the first-line treatment for hypothyroidism during pregnancy to maintain adequate levels of maternal thyroid hormones, which are critical for fetal brain development. Symptoms of hypothyroidism typically begin to improve approximately 3-4 weeks after initiating levothyroxine. Therapy should not be stopped, even if symptoms resolve.
ventricular bigeminy
every other beat is a PVC amiodarone is the treatment rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).
post surgery drainage to report
exceeding 100 to 150 mL/hr
The frontal lobe controls
executive function and personality
hyperthyroidism/ grave's disease
exophthalmos Thyroid Storm ''thyrotoxicosis' HIGH T3 & T4 Thyroid Hormones • Too much lodine • Too much Thyroid Meds. (Levothyroxine) • Autoimmune: Grave = GAINS ''HIGH'' AUTOIMMUNE: Graves = GAINS ''HIGH'' HIGH T3 & T4 HYPER Low—TSH (look at T3 & T4 levels FIRST). GRAPE EYE ''Exophthalmos'' (Use Eye patch/Tape Eyelids down) G GOLF BALLS in throat ''Goiter'' HIGH BP-HTN Crisis 180/100+ (MI,CA, Aneurysms) HIGH HR-Tachycardia 100+ (normal 60-100) HEART PALPITATIONS + Atrial Fibrillation HIGH TEMP. = NOT DRY! HOT & Sweaty Skin ''diaphoresis'' Heat Intolerance HIGH GI ''Diarrhea'. PRIORITY: EXTREME HIGH = Thyroid Storm "Agitation & confusion" early sign diet HIGH METABOLISM HIGH calories (4,000-5,000 per day) HIGH protein & Carbs (meals & snacks) NOT high fiber = LOW FIBER! (unless constipated) NO caffeine (coffee, soda, Tea) NO spicy food Hyperthyroidism: Graves Disease Turn thyroid into metabolism (hyper metabolism) "You're going to run yourself into the grave". Missy Elliot is a closet Elsa, the cold never bothered her anyway, and she hates the beach. S/s: Weight loss, high HR, low BP, irritable/hyper, heat intolerance, cold tolerance, exophatalmos (bulging eyes) Tx: 1. Radioactive Iodine- Pt should be isolated for 24 hrs, They have to be careful with their urine If they spill it you need to call hospital hazmat team 2. PTU (cancer drug) - Puts Thyroid Under Monitor WBC's 3. Thyroidectomy- Total vs. Sub Total's need lifelong hormone replacement & at risk for hypocalcemia Subtotal's don't need lifelong hormone replacement. Subs are at risk for thyroid storm/crisis/thyrotoxicosis: Very high temps of 105+, very high BP (stoke category), severe tachycardia, psychotically delirious. VERY BAD! Causes brain damage Tx: Ice pack (First), Cooling blanket (Best), 02 per mask @ 10 L Do not medicate. They will either come out on their own or die 2 staff to 1 pt Post Op Risks: In the first 12 hrs, top priority is airway 2nd is hemorrhage. 12-48hrs for Total is Tetany r/t hypocalcemia. 12-48hrs for Subtotal is Storm NEVER PICK INFECTION IN FIRST 72 HRS! Hypothyroidism (Hypo
percutaneous coronary intervention post surgical expectation
expected to have no chest pain at rest. Chest pain at rest indicates myocardial ischemia.
Bell palsy
facial paralysis caused by a functional disorder of the seventh cranial nerve. Manifestations of Bell palsy include: • Inability to completely close the eye on the affected side • Alteration in› tear production (e.g. decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) • Flattening of the nasolabial fold on the side of the paralysis (Option 3) • Inability to smile or frown symmetrical} (Option 4) Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue.
Heparin
fast acting anticoagulant used for DVT nd PE stop clot for getting bigger give IV or subcutaneous protamine sulfate is antidote normal 25-35 1.5-2 therapeutic 46 to 70 can give to pregnant monitor platelet 150-4000, 000 is normal
Symptoms of hypothyroidism may include
fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails
lactase deficiency (lactose intolerance) manifestation
flatulence, diarrhea, bloating, and cramping Clients with lactase deficiency can prevent unpleasant gastrointestinal symptoms by avoiding lactose-containing dairy products (e.g., milk, ice cream), eating cheese or yogurt in moderation, and supplementing with lactase enzymes. Vitamin D and calcium supplementation is also recommended.
Clients with chronic kidney disease (CKD) are at risk for
fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia (Option 2). To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: · Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option 1). · Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice (Option 3). · Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (e.g., popsicles, gelatin), because fluid is often restricted (Option 4). · Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein intake is recommended to prevent malnutrition. · Low-phosphorus diet - Avoid foods high in phosphorus (e.g., chicken, turkey, dairy). Educational objective: Clients with chronic kidney disease are at risk for fluid overload and hyperkalemia. An appropriate renal diet includes low sodium, low potassium, low phosphorus, and low protein.
alcoholic cirrhosis nursing knowledge and associated risk
gastritis, clotting abnormalities (eg, thrombocytopenia, coagulation disorder), esophageal varices that increase the risk for hemorrhage Hypotension and tachycardia, hypovolemia. hemodynamic instability (eg, hypotension, decreased urine output, peripheral vasoconstriction, pallor
cystic fibrosis patho
genetic in nature thick sticky mucus involves the cells that line the GI track respiratory tract and reproductive tract defect in protine that make sodium and chloride. client have short life span impaired nutritional absorption.
Methyl-predniso-lone (brand: Solu Medrol)
glucocorticoid reduce airway inflammation in asthma patient can elevate WBC
Methylprednisolone (Solu-Medrol)
glucocorticosteroid used to reduce airway inflammation in asthma. Glucocorticoids can cause an expected, transient elevation in the white blood cell count during initiation of treatment. elevated glucose
Percutaneous kidney biopsy nursing consideration.
highly vascular organ uncontrolled hypertension - is a big risk is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy. The kidney is a highly vascular organ and the risk of bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk
Phenytoin toxicity
horizontal nystagmus, cerebellar ataxia, confusion commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus.
thiazide diuretics
hydrochlorothiazide reduce potassium (K+) loss. increase potassium Thiazide diuretics can cause hypokalemia when used as monotherapy. cause increase glucose. increase risk for digoxin toxic tell client eat potassium food Potassium-sparing diuretics (e.g., spironolactone, amiloride, triamterene eplerenone) are generally very weak diuretics and antihypertensives. However, they are useful when combined with thiazide diuretics to reduce potassium (K+) loss. Thiazide diuretics can cause hypokalemia when used as monotherapy. A potassium level of 4.2 mEq/L (4.2 mmol/L) falls in the normal range (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), which indicates that spironolactone has been effective in preventing hypokalemia in this client receiving a thiazide diuretic (e.g., hydrochlorothiazide, chlorthalidone) (Option 2). (Option 1) Blood glucose levels can be increased by thiazide diuretics but are not affected by potassium-sparing diuretics. (Option 3) All diuretics, including spironolactone, have the potential to cause dizziness. The nurse should monitor the client for orthostatic hypotension and implement safety precautions. (Option 4) Potassium-sparing diuretics exchange sodium for potassium in the kidneys; potassium is saved but sodium is lost. Therefore, a normal sodium level (135-145 mEq/L [135-145 mmol/L]) is not the desired effect. Educational objective: Potassium-sparing diuretics (e.g., spironolactone, amiloride, triamterene, eplerenone) are often combined with thiazide diuretics to reduce potassium loss.
ACE inhibitors ("prils" - captopril, enalapril, lisinopril, ramipril) and angiotensin receptor blockers ("sartans" - valsartan, losartan, telmisartan) cause
hyperkalemia
MAOI can cause and interactions
hypertensive crisis avoid tyramine avoid over the counter meds. avoid other antidepressant. increase suicide risk. vasodilation - hypotension The isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation. It should be held when the systolic blood pressure is <90 mm Hg. Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg. minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin syndrome; these medications cannot be administered concurrently
carotid endarterectomy post surgical complication manifestation
hypotension, tachycardia) or neurological impairment (e.g., decreased level of consciousness, altered mental status)
neutropenic precautions
immunocompromised, strict hand washing, private room, no raw veggies/fruits, daily baths, visitors are restricted. • A private room • Strict handwashing • Avoiding exposure to people who are sick • Avoiding all fresh fruits, vegetables, and flowers • Ensuring that all equipment used with the client has been disinfected. The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.
Aphasia
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding). refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option 1). The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual.
major side effects of phenytoin use are
increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis. diet high in folic acid and calcium should be recommended
Cushing's triad/reflex
indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).
STAT order
indicates that the medication should be given immediately and only one time. A new prescription for the medication must be acquired before the dose can be repeated. The most appropriate action is to contact the health care provider to request an as-needed prescription for pain medication.
solitary play is at what age
infant less than 12 years
endometritis
inflammation of the inner (lining) of the uterus (endometrium) Risk factors · Cesarean delivery · Intraamniotic infection · Group B Streptococcus colonization · Prolonged rupture of membranes · Operative vaginal delivery Clinical features · Fever >24 hr postpartum · Uterine fundal tenderness · Purulent lochia Etiology · Polymicrobial infection Treatment · Clindamycin & gentamicin Postpartum endometritis is an infection of the endometrium (uterine lining) and is characterized by fever, chills, tachycardia, uterine tenderness, and foul-smelling or purulent lochia. The nurse's priority intervention is initiation of broad-spectrum antibiotics to treat the infection and reduce the risk of complications (e.g., abscess, peritonitis). Subsequent interventions include antipyretics, IV fluids, and (possibly) uterotonics for uterine subinvolution.
Acute stress disorder (ASD)
intrusive memories negative mood, dissociative symptoms arousal and reactivity symptoms (e.g., hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. post traumatic event it is expected that the client will relive some of those feelings and experience. Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's anxiety. Clients with (ASD) should be encouraged to discuss the traumatic event and explore the associated feelings. The nurse should validate the client's feelings; assess risk for self-harm and ineffective coping (e.g., drug and alcohol use); and evaluate the impact of ASD on the client's sleep, occupation, and relationships.
Psoriasis
is a chronic autoimmune disease that most often affects the skin by causing dry, scaly, red rashes. Psoriasis is not contagious.
Atopic dermatitis (AD), also known as eczema
is a chronic skin disorder characterized by pruritus, erythema, and dry skin. The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and resulting immune response to invading allergens. The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching leads to formation of new lesions and potential secondary infections. · Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry skin and should be avoided (Option 3) · Skin should be gently patted dry after bathing, followed by immediate application of an emollient (e.g., Eucerin, Cetaphil) to seal in moisture (Option 1). · Nails should be trimmed short and kept filed to reduce scratches (Option 4) · Clothing should be soft (e.g., cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long sleeves should be worn at night. · Avoid trigger factors such as heat and low humidity (Option 2) Wool pajamas and other rough fabrics can cause itching and sweating. Soft cotton fabrics are a better choice. (Option 5) Rubbing or vigorously drying can damage the skin and lead to exacerbations or infection. Skin should be patted dry gently. Educational objective: Atopic dermatitis (eczema) is a chronic skin disorder manifested by pruritus, erythema, and very dry skin. The goal of management is to reduce scratching with key measures such as giving tepid baths, moisturizing skin with emollients, wearing soft cotton clothing, and keeping nails trimmed short.
Parkinson's disease (PD)
is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine- producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait.
carbidopa-levodopa
is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: • implementing fall precautions (e.g., changing positions slowly, removing rugs), as orthostatic hypotension is. a common side effect (Option 1) • Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) • Understanding that harmless discoloration (e.g, red brown black) of secretions (e.g. urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) • Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa most helpful for treating bradykinesia in Parkinson disease and can also improve tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped sudden as doing so can lead to akinetic crisis (complete loss of movement).
etonogestrel and ethinyl estradiol vaginal ring (NuvaRing)
is a combined hormonal contraceptive. The client inserts the ring into the posterior vagina, though positioning is not crucial. Unlike some contraceptives that are placed vaginally (e.g., diaphragm, cervical cap), the ring is not a barrier method and requires time for hormone absorption. For clients initiating contraception with the etonogestrel and ethinyl estradiol vaginal ring, abstinence or a barrier method (e.g., condom) is necessary during the first 7 days of use until hormones produce their full contraceptive effect (Option 3). (Option 1) Hormones from the vaginal ring are absorbed into circulation through the vaginal mucosa and work systemically to prevent ovulation. (Option 2) If the ring is displaced (e.g., during intercourse or bowel movements), it should be rinsed and placed back in the vagina within 3 hours; otherwise, backup contraception is required for 1 week. (Option 4) The client should insert and leave the ring in place for 3 weeks. When the client removes the ring, withdrawal bleeding occurs. The client should place a new ring after 7 hormone-free days. Educational objective: The client using the etonogestrel and ethinyl estradiol vaginal ring (NuvaRing) for contraception absorbs hormones systemically through the vaginal mucosa and leaves the ring in place for 3 weeks before removing it for the fourth. A barrier method (e.g., condom) is necessary for 7 days when initiating contraception or if the ring is removed from the vagina for >3 hours
Tinea corporis (ringworm)
is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human. This condition is treated with topical antifungals (e.g., tolnaftate, haloprogin, miconazole, clotrimazole).
Montelukast (Singulair)
is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (e.g., fluticasone, budesonide) to provide longterm asthma control.
Extended-release oxycodone (Oxycontin)
is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (e.g., immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours. Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect
Autonomic dysreflexia
is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause. --- in a client with a spinal cord injury is a priority and requires emergency intervention. Classic triggers are distended bladder or rectum. Management includes raising the head of the bed and then treating the cause (eg, Foley catheter kinks).
Codeine
is a narcotic analgesic used for acute pain or as a cough suppressant. Depressing the cough reflex can cause an accumulation of secretions in the presence of chronic obstructive pulmonary disease (COPD), leading to respiratory difficulty. In general, sedatives (e.g., narcotics, benzodiazepines) can also depress the respiratory center and effort; therefore, they should not be given to clients with respiratory diseases (e.g., asthma, COPD). (Option 1) Calcium channel blockers (e.g., amlodipine, nifedipine) are used to treat hypertension and do not worsen bronchoconstriction, unlike beta blockers (e.g., metoprolol, atenolol). (Option 3) Ipratropium (Atrovent) is a short-acting inhaled anticholinergic often used in combination with a short-acting beta-agonist (e.g., albuterol) to promote bronchodilation and reduce bronchospasm. (Option 4) Methylprednisolone (Solu-Medrol) is a systemic glucocorticoid that improves respiratory symptoms and overall lung function in clients experiencing an exacerbation of COPD. Educational objective: Codeine is a narcotic medication with antitussive properties that can cause an accumulation of secretions in clients with chronic obstructive pulmonary disease and lead to respiratory distress. Caution is advised when sedatives are prescribed for clients with respiratory diseases.
Placental abruption
is a potential complication of preeclampsia related to hypertension that can be life-threatening to the client or fetus. It causes premature detachment of the placenta from the uterine wall, resulting in bleeding from uterine blood vessels. Common manifestations include abdominal pain, dark red vaginal bleeding, a rigid uterus, abnormal fetal heart rate patterns, and uterine tachysystole. Once placental abruption occurs, fetal distress and maternal hypovolemia can develop quickly. Therefore, the nurse should report vaginal bleeding to the health care provider (HCP) immediately because emergency cesarean birth is very common if the client's or fetus' condition deteriorates
Malignant hyperthermia
is a severe reaction to certain drugs used for anesthesia. This severe reaction typically includes a dangerously high body temperature, rigid muscles or spasms, a rapid heart rate, hypercapnia, and other symptoms. Without prompt treatment, the complications caused by malignant hyperthermia can be
An arteriovenous malformation (AVM)
is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage
Aortic stenosis (AS)
is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (i.e., calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. When assessing a client with AS, the nurse should auscultate in the aortic area (i.e., second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion.
Epidural hematoma
is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.
scopolamine
is an anticholinergic medication used to prevent nausea and vomiting from motion sickness and as an adjunct to anesthesia to contra secretions. Transdermal scopolamine is placed on a hairiest. clean, deg area behind the ear for proper absorption (Option. 4) Clients should be instructed to: • Apply the patch 4 hours before starting travel to allow for absorption and medication onset (Option 1). Transdermal patches have a slower onset but a longer duration of action. • Replace the patch every 72 hours as prescribed to ensure continuous medication delivery. • Remove and discard the old patch before placing a new one to prevent accidental overdose (Option 3). • Dispose of the old patch out of reach of children and pets to avoid accidental ingestion (Option 2) • Wash hands with soap and water after handling the patch› to avoid inadvertent drug absorption or contact with the eyes (Option 5)
Phenytoin
is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin. Common symptoms of phenytoin toxicity involve the central nervous system (eg, nystagmus, ataxia, slurred speech, decreased mentation) and can occur when serum phenytoin levels exceed the therapeutic range (10-20 mcg/mL [40-79 mcmol/L]).
Guillain-Barré syndrome
is an ascending symmetrical paralysis. It can move upward rapidly or relatively slowly (over days/weeks). Respiratory compromise is the worst complication. A client with paralysis at the level of the knee after 24 hours would not take priority over a client who will have a seizure in few minutes.
Clozapine (Clozaril)
is an atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (e.g., sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve. Educational objective: Clozapine, an atypical antipsychotic, is used to manage schizophrenia in clients who have not improved with other medications. Clozapine may cause agranulocytosis, which increases the risk of life-threatening infection. Clients receiving clozapine should be monitored for signs of infection (e.g., fever, flulike symptoms).
Myasthenia gravis
is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.
Mannitol
is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.
cleft palate (CP)
is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: · Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). · Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. · Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). · These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). · Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. · Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth.
Erythema toxicum neonatarum
is characterized by firm, white or yellow papules or pustules surrounded by erythema. This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days. There are no additional systemic effects, and the rash requires no treatment
precipitating factor for angina
is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: · Physical exertion (e.g., exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) · Intense emotion (e.g., anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload · Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) · Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release · Stimulants (e.g., cocaine, amphetamines): Increase heart rate and cause vasoconstriction · Coronary artery narrowing (e.g., atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium
vaginal hematoma
is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma. (Option 1) Cervical lacerations should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Severe pain or a feeling of fullness is not associated with cervical lacerations. (Option 2) Complete inversion of the uterus presents with a large, red mass protruding from the introitus. (Option 3) Uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding. Educational objective: Vaginal hematomas are formed following trauma to the tissues of the perineum during vaginal delivery (e.g., vacuum- or forcepsassisted delivery, episiotomy). The client reports severe pain or a persistent feeling of fullness in the region. Assessment shows a firm, midline uterine fundus with minimal or unchanged vaginal bleeding.
An AIR (formerly negative-airflow room) airborne infection isolation room
is indicated when the client has an organism transmitted by the airborne route (e.g., tuberculosis) No other client should be in the room with a client with this type of infection
Cranial nerve IX (glossopharyngeal)
is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: 1. Inhale deeply 2. Hold breath tightly to close the vocal cords 3. Place food in mouth and swallow while continuing to hold breath 4. Cough to dispel remaining food from vocal cords 5. Swallow a second time before breathing Clients who undergo a partial laryngectomy are at increased risk for aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.
when is a stroke client considered stable
is not considered stabilized until approximately 48 hours have passed without changes.
Bumetanide (Bumex)
is prescribed for clients with heart failure to promote diuresis and mobilize excess fluid in the systemic circulation and the lungs, which results in increased cardiac output and improved gas exchange.
Trigeminal neuralgia
is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminai neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. lt is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia} and infection risk. Clients should be advised to report any fever or sore throat. Behavioral. interventions include the following: 1. Oral care - use a small soft-bristled toothbrush or a warm mouth wash 2. Use lukewarm water, avoid beverages or food› that are too hot or cold (Option 1) 3. Room shouJ6 be kept at an even and moderate temperature 4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. 5 Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected I side of the mouth.
epi and nore epi and dopamin
is used as vasoconstrictor for hypovolemic shock they improve contraction and cardiac output. in increase blood volume. they must be tapered off do not stop abruptly.
Niacin (nicotinic acid or B3)
is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues.
Prevent heat loss resulting from radiation by
keeping the newborn away from cold objects and outside walls.
capillary refill time
less than 3 seconds/ 2-3
Heparin-induced thrombocytopenia (HIT)
lethal complication caused by heparin or low-molecular-weight heparin (e.g., enoxaparin causes a drastic decrease in platelet count (i.e., ≤50% of pretreatment levels and/or platelet count <150,000. Paradoxical increase in risk for arterial and venous thrombosis. Risk for deep venous thrombosis, pulmonary embolism. Development of IgG antibodies against heparin- bound platelet factor 4 (PF4). Antibody-heparin-PF4 complex activates platelets leading to thrombosis and thrombocytopenia. The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping enoxaparin therapy and initiating a nonheparin anticoagulant (e.g., rivaroxaban, argatroban)
Ventricular fibrillation (V-fib)
lethal- life threatening Chaotic no pattern no pulse treatment is to defibrillate check the pulse, start CPR, and prepare the client for debilitation
pacemaker discharge teaching
limitation of physical activity, including no lifting, pulling, or pushing more than 5 pounds not raising the arm on the affected side above the level of the heart for the first few weeks insertion site may be bruised, swollen, tender, and instructions may include gentle washing of incision site, and not applying lotion or powder
Atrioventricular (AV) canal defect
loud cardiac murmur is a cardiac anomaly often associated with trisomy 21 (Down syndrome). As an echocardiogram is already scheduled for that day, documenting the assessment finding would be the appropriate action for the nurse to complete at this time.
Aortic stenosis
low oxygenated blood supply - exertional dyspnea, anginal chest pain, and syncope. obstructs blood flow from the left ventricle to the aorta loud, ejection systolic murmur decreased ejection fraction results in a narrowed pulse pressure calcification of aortic valve cusps that restricts forward flow of blood during systole S2 is soft or absent. pulses are weak due to obstruction of outflow from the left ventricle aortic stenos is produces a loud, ejection systolic murmur over the aortic
Urine output of less than 30 mL/hr may indicate
low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). fluid in the lungs-assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics.
Tension pneumothorax causes
marked compression and shifting of mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-threatening emergency that requires urgent largebore needle decompression followed by chest tube placement.
tonsillectomy
may be indicated in some cases of chronic tonsillitis, peritonsillar abscess, or obstructive sleep apnea. Postoperative bleeding is a primary concern after a tonsillectomy because the surgical site is not easily visualized and is vulnerable to irritation and trauma from swallowing and coughing. The nurse should observe for signs of postoperative bleeding (e.g., frequent, increased swallowing or clearing of the throat; vomiting bright red blood) and notify the health care provider (Option 4). Expected postoperative findings include ear pain when swallowing (i.e., referred pain from the throat) and low-grade fever (<101 F [38.3 C]); analgesics (e.g., acetaminophen) may be administered as needed (Option 1). Superficial infection at the surgical site is common and causes white, fluid-filled exudate in the throat with halitosis (i.e., bad breath); this is not concerning because it usually resolves spontaneously after 5-10 days (Option 2). (Option 3) Drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to bleeding. The client should avoid use of straws or other pointed objects in the mouth. (Option 5) Routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available but used only for emergency airway obstruction. Educational objective: Postoperative tonsillectomy interventions include close observation for signs of bleeding (e.g., frequent swallowing) as well as avoidance of routine oral suctioning and the use of straws. Expected findings include white, fluid-filled exudate in the throat with halitosis, low-grade fever, and referred ear pain.
Lithium carbonate indication and precisions
mood stabilizer used for the treatment of bipolar disorder. take some time to reach therapeutic levels, often up to a few weeks. affect the renal excretion therapeutic 0.6 to 1.2 low sodium intake can cause lithium high level to be high and toxic. clients on lithium must consume adequate sodium in the diet. avoid dehydration, drink 2-3 liters of water avoid dehydration, so diuretic medications and substances with a diuretic effect (e.g., coffee, cola, tea, alcoholic beverages) must be limited or avoided, and clients are advised to drink 2-3 liters of water each day. Clients initiating - therapy should be instructed that therapeutic effects may take several weeks to achieve. Clients taking lithium should maintain a normal dietary sodium intake, consume 2-3 liters of fluids per day, and be advised to avoid diuretics or products with diuretic effects
level of consciousness
most important, sensitive, and reliable indicator of the client's neurological status Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma. A change in level of consciousness for the neurological client should be reported to the HCP. The level of consciousness is the most sensitive and reliable indicator of the client's neurological status.
furosemide complication
muscle weakness, cramps, cardiac arrhythmia
Eczema
noninfectious, inflammatory skin disease characterized by redness, blisters, scabs, and itching. s a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious.
Critical laboratory results and notification of healthcare provider
notify healthcare provider as soon as possible in less than 60 min. (e.g., positive blood cultures, severe electrolyte derangements) require immediate intervention for client safety. The nurse receiving a critical laboratory result should notify the health care provider (HCP) as soon as possible. Hospital organizations have individual policies regarding the time frame for notification of the HCP and HCP response, usually ≤60 minutes. Bacteremia requires timely treatment to prevent further complications
Abnormal neurological assessments
nuchal rigidity; new-onset unilateral drift of a limb; pupils <3 mm or >5 mm in diameter; absent oculocephalic reflex; and presence of Babinski reflex in an adult client.
Misoprostol (Cytotec)
occurs before the onset of labor in which the cervix softens and becomes more so that dilation and effacement can occur more easily during contractions. Mechanical or pharmacologic cervical ripening methods simulate this process and increase the client's probability of achieving a vaginal birth. In addition to ripening the cervix, prostaglandins (e.g., misoprostol, dinoprostone) can stimulate frequent contractions. Therefore, administration of misoprostol is contraindicated if: · the client is receiving another uterotonic simultaneously (e.g., oxytocin) (Option 1). · the client has a history of uterine surgery (e.g., cesarean birth) due to an increased risk of uterine rupture at the surgical scar site (Option 2). · the client has an abnormal fetal heart rate pattern or uterine tachysystole (i.e., >5 contractions in 10 min) (Option 4). (Option 3) A client with this cervical examination would especially benefit from cervical ripening because it may reduce the amount of oxytocin required later in the labor induction process (oxytocin administered at least 4 hr after last misoprostol dose if needed); less oxytocin reduces postpartum hemorrhage (PPH) risk. (Option 5) The health care provider prescribes misoprostol orally or vaginally for labor induction. Rectal administration is only appropriate during PPH. Educational objective: Misoprostol (Cytotec) is a cervical ripening agent administered orally or vaginally. It is contraindicated in clients who are receiving another uterotonic simultaneously (e.g., oxytocin), have had previous uterine surgery (e.g., cesarean birth), or have abnormal fetal heart rate patterns or uterine tachysystole.
Autism Spectrum Disorder (ASD)
onset by age 3 delayed social interaction and communication repetitive actions and routine interest and activity restricted language assessment is priority
Naloxone
opioid antagonist Respiratory depression occurring after the ingestion of an unknown substance (eg, depressants [opioids, benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone, flumazenil). Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death (Option 1).
Oral candidiasis,
or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother's breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child's mouth. However, oral candidiasis is significantly less contagious than tinea corporis.
post partum hemorrhage atony meds
oxytocin methylergonovine- can cause hypertension ergotamine misoprostol carboprost -- cause bronchoconstriction and fever
Peripheral artery disease,
pain with exercise. Paresthesias Arterial ulcers critical limb ischemia Ankle-brachial index, or ABI claudication. HEART: decreased peripheral pulses DERM: cool shiny skin, hair loss, ulcers, gangrene, impaired sensation MISC.: intermittent claudication S: shiney skin H: hair loss to the extremity I: intermittent claudication N: nasty ulcers E: extremities will be cool
Age 12 to 36 months types of play
parallel play Rapid growth rate of infancy beings to slow significantly, appetite decreases markedly at approximately 1 year of age, gain 5.5 to 7.5 inches, average 9-11 pounds, and higher energy expended for increased activity levels.
Separation anxiety, also known as anaclitic depression
particularly affects children age 6-30 months. There are 3 stages of separation anxiety: protest, when the child refuses attention from others, screams for the parent to return, and cries inconsolably; despair, when the child is withdrawn, quiet, uninterested in activities or meals, and displays younger behavior (e.g., use of pacifier, wetting the bed); and detachment, when the child suddenly appears happy and interested in building relationships. Nursing care of hospitalized clients experiencing separation anxiety focuses on maintaining a calm environment and a supportive demeanor to build trust between the nurse and the child, and encouraging connection with family and familiar environments, even when they are absent. Key interventions include: · Encouraging the parents to leave favorite toys, books, and pictures from home · Establishing a daily schedule that is similar to the child's home routine · Maintaining a close, calming presence when the child is visibly upset · Facilitating phone or video calls when parents are available · Providing opportunities for the child to play and participate in activities (Option 3) When the child is visibly upset, it is important to provide a calming presence and implement strategies to reduce the child's anxiety. Leaving the child alone at such times can further increase stress. (Option 5) Providing pictures of the child's family is actually beneficial, as it reminds the child of something familiar and safe. Educational objective: Toddlers and preschool-age children experience separation anxiety in response to the stress of illness and hospitalization. Key nursing interventions to alleviate separation anxiety include encouraging the presence of favorite items, establishing a daily routine, providing opportunities for play, facilitating phone calls with the parents, and providing support when the child is upset.
Transition phase of labor
perineal/rectal pressure Cervix is 8-10 cm dilated and women feels the urge to urinate and poop because the increased pressure in the pelvis. descent of fetal station below the maternal ischial spines (i.e., +1 station or greater) often results in nausea and vomiting and trembling or shivering increased pain, fear, irritability, anxiety, and self-doubt. The client may require more assertive direction and emotional support during this period.
heparin-induced thrombocytopenia manifestation
petechiae, purpura
MAOI meds
phenelzine, isocarboxazid, selegiline
monoamine oxidase inhibitor (MAOI)
phenelzine, isocarboxazid, tranylcypromine Caution must be taken when a client switches from a tricyclic antidepressant to a monoamine oxidase inhibitor to avoid adverse reactions (e.g., hypertensive crisis, discontinuation syndrome). Usually, antidepressants are withdrawn gradually with a drug-free period before the new antidepressant is initiated.
Chloasma
pigmentary skin discoloration usually occurring in yellowish brown patches or spots
Proton pump inhibitors (e.g., omeprazole) are associated with increased risk of
pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis).
feeding a baby with cleft palate
point bottle down away from cleft feed every 3 to 4 hours not too frequent as it takes a lot of energy to feed. burp often feed slow over 20- 30 min. feeding too long makes baby tired.
Nicardipine (Cardene) is a prototype of nifedipine
potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs.
Sucralfate (Carafate, Sulcrate), sucker flame
prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions reduce drug efficacy. coat the stomach
Tetralogy of Fallot 4 characteristics
pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.
GCS
quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise
Glucocorticoids
raises blood sugar levels (e.g., prednisone), when taken in combination with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen, can increase the risk of gastrointestinal ulceration and bleeding. The client should report black, tarry stools (i.e., melena) to the health care provider as they could indicate gastrointestinal bleeding
Humalog (insulin lispro)
rapid 15 min onset 30 min peaks 3 hours duration must give with meals
Malignant hyperthermia (MH) is a
rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and the depolarizing muscle relaxant succinylcholine (Anatine) used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and metabolism, and dangerously high temperature (later sign). it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives had ever experienced an adverse reaction to general anesthesia, including unexplained death.
mixing regular with NPH insulin
regular first. Do not mix other insulins with lispro, glargine, or combination 70/30.
Cleansing enemas
relieve constipation or empty bowel a left lateral position with the right knee flexed. 12 in (30 cm) above the rectum gently insert 3-4 in (7.6-10 cm) into the rectum. tubing tip toward the umbilicus
Varicella (chicken pox, herpes zoster)
requires airborne precautions (and contact precautions also if open lesions are present).
lactase deficiency treatment
restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (e.g., Lactaid) to decrease symptoms . Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk.
dantrolene
reverse Malignant hyperthermia (MH) by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels.
Put on PPE in the reverse alphabetical in
reverse alphabetical in the G's, but mask comes second. Gown, mask, goggles, gloves
absolute neutrophil count is 5500/mm
should not be placed with other clients
cystic fibrosis manifestations
sinusitis barrel chest - copd pneumonia and bronchitis biliary cirrhosis pancreatic exocrine insufficiency diabetes cachexia clubbing of the fingers inspissutated stool no vas deference .
6-9 months milestones
sit up with no support start to crawl may pull up to stand move object b/t hands crude picher say mama stranger anxiety
Epstein pearls
small, white cysts found on the hard palate of newborns. These cysts are considered common findings, and they disappear a few weeks after birth.
continuous positive airway pressure (CPAP)
spontaneously breathing clients Keeps the alveoli open during inspiration and prevents alveolar collapse; used primarily as a weaning modality No ventilator breaths are delivered, but the ventilator delivers oxygen and provides monitoring and an alarm system; the respiratory pattern is determined by the client's efforts. a form of noninvasive positive pressure ventilation (NPPV) consisting of a mask and a means of blowing oxygen or air into the mask to prevent airway collapse or to help alleviate difficulty breathing
halo external fixation device
stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection. Care for the client with a halo device includes: · Cleaning pin sites with sterile solution (e.g., chlorhexidine, water) to prevent infection · Keeping the vest liner clean and dry (e.g., changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin · Placing foam inserts under pressure points to prevent pressure injury · Placing a small pillow under the client's head when supine to reduce pressure on the device · Keeping the correct-sized wrench available at all times in case of emergency Only the health care provider can adjust the pins. The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment. Educational objective: A halo external fixation device stabilizes a cervical or high thoracic fracture. The nurse should clean the pin sites with sterile solution to prevent infection, reduce pressure on the halo device (e.g., pillow under the head), keep the vest clean and dry, and avoid holding the device frame while moving the client. Pins can be adjusted only by the health care provider.
capsaicin
stimulates receptors that respond to painful heat over-the-counter analgesic that effectively relieves minor pain (e.g., osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before washing to ensure adequate absorption. The client should avoid contact with mucous membranes (e.g., nose, mouth, eyes) or skin that is not intact, as capsaicin is a component of hot peppers and can cause burning. When applying cream to other areas of the body (e.g., knee), the client should wear gloves or wash hands immediately after application. The application of heat with capsaicin is contraindicated as heat causes vasodilation, which increases medication absorption and can possibly lead to a chemical burn. Local irritation (burning, stinging, erythema) is quite common and usually subsides within the first week of regular use. If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care provider notified. Topical capsaicin is often used concurrently with acetaminophen or nonsteroidal anti-inflammatory drugs (e.g., naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (3-4 times daily) for long periods (e.g., weeks to months) to achieve the desired effect. Educational objective: The topical analgesic capsaicin relieves minor peripheral pain (e.g., osteoarthritis, neuralgia) with regular use. Local irritation (burning, stinging, erythema) is quite common. The client should wait at least 30 minutes before washing the affected area to ensure adequate absorption.
Proper care of the umbilical cord
stump facilitates healing and reduces infection and bleeding risks. The primary goal of cord care is to keep the cord stump clean and dry, which reduces infection risk. Additional teaching points regarding cord care include: · Keep the cord stump open to air when possible to allow for adequate drying. · Do not apply antiseptics (e.g., alcohol, triple dye, chlorhexidine) to the cord stump (previously common practice); current recommendations are to avoid such solutions due to the potential for skin irritation (Option 3). · Report any signs of infection (e.g., redness, purulent drainage, swelling) to the health care provider. (Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days. (Option 2) The cord usually separates spontaneously from the umbilicus 1-2 weeks after birth. Parents should be instructed not to pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications. (Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces. Educational objective: The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.
carotid endarterectomy
surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion, The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status postoperatively can be challenging, as the effects of anesthesia degrade the neurologic examination. Nurses should use the FAST acronym to assess for stroke: • Facial drooping: Numbness or droopiness on one side of the face • Arm weakness: Weakness or drifting of one arm when raised to shoulder level (Option 3) • Speech difficulties: Slurring of words, incomprehensible speech, inability to understand others • « Time: Notation of the time of symptom onset, which is critical for guiding treatment Following a carotid endarterectomy, the client should be monitored for alterations in mental status that are unexpected in the context of typical postanesthesia symptoms (eg, diminished gag reflex, altered affect, drowsiness). The FAST assessment (Facial drooping, Arm weakness or drift, Speech difficulties, Time) assists with identifying alterations that may indicate stroke.
transsphenoidal hypophysectomy
surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (Dl), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: · Decreased urine specific gravity (<1.003) (Option 5) · Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) · Hypernatremia (>145 mEq/L [145 mmol/L]) (Option 1) · Hypovolemia and potential hypotension · Polydipsia (Option 2) · Polyuria (2-20 L/day) (Option 3) Educational objective: Diabetes insipidus (Dl) is a metabolic disorder of decreased antidiuretic hormone, which is responsible for water retention in the kidneys. Dl is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity.
ileal conduit
surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine
cranial nerve IX and X injuries can impair
swallowing
The Bishop score is a
system for the assessment and rating of cervical favorability and readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥6-8 usually indicates that induction will be successful
Symptoms of hypoglycemia
tachycardia, excessive sweating (diaphoresis), light-headedness, visual disturbances · Sweating & pallor · Irritability · Tremors & weakness · Tachycardia · Drowsiness · Hunger blood glucose <70 mg/dL [3.9 mmol/L]) presents an immediate danger to the client as life-threatening neurologic impairment (e.g., lethargy, seizures, coma) can occur when the brain becomes glucose depleted. If a client with diabetes has symptoms of hypoglycemia (e.g., sweating, irritability, tremor, tachycardia, hunger), the nurse should immediately assess the client, check capillary blood glucose, and provide a simple carbohydrate snack that can be digested rapidly (e.g., juice, soft drink, candy) blood glucose should be reassessed within 30 minutes
contact isolation precautions
to prevent transmission of microorganisms between clients, including: · Placing the client in a single-client room, if possible, or in a cohort with other clients infected with C difficile (Option 3) · Wearing a single-use, disposable gown and clean gloves during all client care and discarding the equipment before leaving the room (Option 5) · Performing hand hygiene before and immediately after client care with soap and water · Using dedicated medical equipment (e.g., stethoscope, blood pressure cuff) that is not shared between clients and always remains in the client's room. When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (e.g., C difficile, anthrax). Clostridium difficile is a highly infectious bacteria requiring contact isolation precautions, including a single-client room assignment if available, disposable gowns and clean gloves, and hand hygiene with soap and water. Surgical masks are not necessary unless performing client care with the possibility of body fluid splashing.
tracheostomy tubes accidental decannulation urgent need to change a tracheostomy tube
to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (e.g., suctioning) have failed. Mucus plugs (i.e., thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect.
Amiodarone treats
treats supra ventricular and ventricular dysrhythmia.
Amitriptyline
tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure.
BIPAP involves
use of a mechanical device and facemask in a conscious client who is breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP effectiveness. Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (e.g., gag, swallow, cough), periods of apnea, and airway compromise
kava and valerian root-both
used for anxiety, insomnia, and depression—may increase central nervous system (CNS) depression when used with benzodiazepines (e.g., clonazepam). Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity
Nitroglycerin
used to reate stable angina can take up to 3 pills in 5 min call 911 if first fill does not work store in original container do not store in hot place such as car only good for 6 months after bottle is open.
Ethambutol (Myambutol)
used to treat tuberculosis out can cause ocular toxicity, resulting in vision loss and loss of red-green color discrimination. Vision acuity and color discrimination must be monitored regularly
operative vaginal birth
uses a vacuum extractor or forceps to shorten the second (pushing) stage of labor. Indications may be maternal (e.g., exhaustion, cardiac or cerebrovascular disease) or fetal (e.g., abnormal fetal heart rate, arrest of rotation). In a forceps-assisted birth, the health care provider (HCP) gently applies the blades to the sides of the fetal head and locks the handles in place. The HCP applies traction to the forceps during contractions to facilitate rotation and descent of the fetal head. The nurse should never apply fundal pressure during an operative vaginal birth because it may cause uterine rupture (Option 1). (Option 2) To avoid bladder damage, the nurse should ensure that the client has an empty bladder (e.g., catheterization) before the forceps are applied. (Option 3) Documentation should reflect birth events accurately for legal purposes and be done in a timely fashion. Birth events can happen quickly, but noting the time when forceps or a vacuum extractor is applied is essential. (Option 4) The nurse notifies the HCP when contractions are palpated so that downward/outward traction can be applied to the forceps or a vacuum extractor during the contraction, which helps facilitate the birth. In an operative vaginal birth, forceps or a vacuum extractor is used to shorten the second (pushing) stage of labor. The nurse ensures that the client's bladder is empty, monitors for contractions, and documents the time that forceps or a vacuum extractor was applied. Fundal pressure should never be applied during this procedure or labor/birth.
Calcium channel blocker cause
vasodilation fatigue dizziness fatigue othrtho hypo edema flush skin
pericarditis caused by makes it worst treatment
viral infection pleuritic chest pain that is sharp aggravated during inspiration and coughing relieved by sitting up and leaning forward friction rub (scratchy or squeaking sound) Treatment includes a combination of non-steroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine
thrush oral candidiasis
white patches, The patches are nonremovable and tend to bleed when touched. difficulty sucking or feeding due to the associated pain. antibiotic therapy or poor caregiver hand hygiene. linked to antibiotic therapy or poor caregiver hand hygiene. treatment with a fungicide (e.g., nystatin) may hasten recovery
Lactulose is administered to clients
with cirrhosis and hepatic encephalopathy to promote excretion of ammonia via fecal elimination and not solely for the treatment of constipation. The dose is adjusted to achieve 2-3 soft stools each day.
Absolute contraindications to combined hormonal contraceptives
· Active breast cancer · Migraines with aura · Uncontrolled hypertension · Active hepatitis, severe cirrhosis, liver cancer · Age ≥35 & ≥15 cigarettes/day · Ischemic heart disease, stroke · <3 weeks postpartum · Prolonged immobilization · Thrombophilia (eg, factor V Leiden, antiphospholipid antibody syndrome) · Venous thromboembolism The patch has similar contraindications as other CHCs, and some research shows that the patch may have an increased risk of thromboembolism (compared with oral contraception) due to higher serum concentrations of estrogen. A history of deep venous thrombosis (DVT) is the most concerning finding because of the additional risk of thromboembolic events when using CHCs (Option 3). (Option 1) CHCs help regulate menstrual cycles, typically reducing the amount of bleeding during menses; therefore, heavy menses is not as concerning as the client's history of DVT. (Option 2) A personal history of breast cancer or the breast cancer susceptibility gene (BRCA) is concerning because contraceptives may stimulate hormone-dependent tumor growth. The nurse should report the family history to the health care provider, but it is not more concerning than a personal history of DVT or breast cancer. (Option 4) The patch may have a higher failure rate in obese clients who are approximately >200 lb (90.7 kg) and should be avoided. The nurse should counsel the client about diet and exercise, but this is not more important than the client's history of DVT.
UAP Scope of practice
· Activities of daily living · Hygiene · Linen change · Routine, stable vital signs · Documenting input/output Positioning apply protective ointment (such as zinc oxide) perform passive range-of-motion exercises, apply protective ointment, and obtain objective data for stable clients under the direction of a registered nurse. However, UAP cannot feed clients with potential dysphagia or make evaluations about treatment effectiveness.
irrigate the wound
· Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). · Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. · Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. · Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. · Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). · Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option 4). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option 2) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option 3) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective: Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis.
signal a child's readiness for toilet training
· Ambulate to and sit on the toilet · Remain dry for several hours or through a nap · Pull clothes up and down · Understand a two-step command · Express the need to use the toilet (urge to defecate or urinate) · Imitate the toilet habits of adults or older siblings · Express an interest in toilet training Readiness for toilet training is dependent on the child's ability to voluntarily control the anal and urethral sphincters, which usually occurs at age 18-24 months. Other developmental and behavioral indicators of toilet training readiness include the child's ability to express the urge to defecate or urinate, understand simple commands, pull clothing up and down, and walk to and sit on the toilet.
Subjective (presumptive) sp
· Amenorrhea · Nausea & vomiting · Urinary frequency · Breast tenderness · Quickening · Excessive fatigue
High fall risk precaution
· Bed alarm · High fall risk signs · Room close to nurses' station · Color-coded socks & wristbands
Assessment of infants
· Before handling the infant, the nurse first observes the infant for activity level, skin color, and respiratory rate and pattern to obtain findings during a calm state (Option 4). · Auscultation is performed next while the infant is still quiet, allowing the nurse to hear sounds clearly (Option 2). · Palpation and percussion are then performed while the infant remains relatively still. This allows the nurse to accurately assess the abdomen while the abdominal muscles are relaxed. The fontanelles are also palpated while the infant is calm, as crying can cause temporary bulging (Option 5). · Traumatic procedures (e.g., examine eyes, ears, mouth) are performed near the end of the assessment after completing any procedures that require accurate observation or counting (Option 1). · Elicitation of the Moro reflex (i.e., reflexive startle and cry to a sudden dropping or jarring motion) is performed last because the infant is usually awake and moving around by this point (Option 3). Educational objective: When assessing an infant, the nurse should observe, auscultate, palpate, and then perform traumatic procedures (e.g., examine eyes, ears, mouth). Elicitation of the Moro reflex should be performed last.
Soft diet diet
· Clear and full liquids plus · Soups · Ground or finely diced meats, flaked fish · Pancakes, biscuits, muffins · Pasta, rice, mashed potatoes · Cooked or canned fruits & vegetables · Peanut butter Scrambled eggs
Clear liquids diet
· Clear fat-free broth, bouillon · Gelatin (Jello) · Popsicles · Clear fruit juices (apple, grape) · Carbonated beverages (Sprite, ginger ale) Coffee, tea
Full liquids diet
· Clear liquids plus · Strained or blended cream soups · Custards, puddings · Refined cooked cereals (oatmeal, grits) · All fruit juices Ice cream, frozen yogurt, sherbet, milkshakes
RN Scope of practice
· Clinical assessment · Initial client education · Discharge education · Clinical judgment · Initiating blood transfusion admission and discharge calling other department to give or get information / report about a client. IV meds
Positive (diagnostic)
· Fetal heartbeat heard with Doppler device · Fetal movement palpated by health care provider or visible fetal movements · Visualization of fetus by use of ultrasound
Risk factors for PPH include
· History of PPH in prior pregnancy · Uterine distension due to: o Multiple gestation o Polyhydramnios (ie, excessive amniotic fluid) o Macrosomic infant (8 lb 13 oz [4000 g]) (Option 1) · Uterine fatigue (labor lasting >24 hours) · High parity · Use of certain medications: o Magnesium sulfate o Prolonged use of oxytocin during labor o Inhaled anesthesia (ie, general anesthesia) (Option 2) Natural, unmedicated labor and birth reduces the chance of PPH. (Option 3) Labor lasting <24 hours does not increase the risk for PPH. (Option 4) A third stage of labor lasting <30 minutes does not increase the risk for PPH. Postpartum hemorrhage is defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony (i.e., "boggy" uterus) is the most common cause of early postpartum hemorrhage (occurring S24 hours after birth). Risk factors include uterine distension, uterine fatigue, high parity, and certain medications.
LPN/LVN Scope of practice
· Monitoring RN findings · Reinforcing education · Routine procedures (e.g., catheterization) · Most medication administrations · Ostomy care · Tube patency & enteral feeding · Specific assessments
Standard fall risk precaution
· Orientation to room & call light · Call light within reach · Bed in lowest position · Uncluttered room · Nonslip socks or shoes · Well-lit room · Belongings within reach
thrombolytic therapy contraindication
· Prior intracranial hemorrhage. · Structural cerebrovascular lesion (eg, arteriovenous malformation, aneurysm) · Ischemic stroke within 3 months (except within 3 hr) · Suspected aortic dissection · Active bleeding or bleeding diathesis Significant head trauma within 3 months
Objective (probable) op
· Uterine & cervical changes o Goodell sign o Chadwick sign o Hegar sign o Uterine enlargement · Braxton Hicks contractions · Ballottement · Fetal outline palpation · Uterine & funic soufflé · Skin pigmentation changes o Chloasma o Linea nigra o Areola darkening · Striae gravidarum · Positive pregnancy tests
Diabetes insipidus. (DI)
• Decreased urine specific gravity (<1.003) (Option 5) • Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) • Hypernatremia (>145 mEq/L (145 mmol/L]) (Option I) • Hypovolemia and potential hypotension › • Polydipsia (Option 2) • Polyuria (2-20 L/day) (Option 3) Educational ' objective: is a metabolic disorder of decreased. antidiuretic hormone, which. is responsible. for water retention in the kidneys. DII is often: related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, , hypovolemia,. increased! serum osmolality, and decreased urine specific gravity. DIURESE "Drain" fluid (HIGH urine output) DILUTED urine Low specific Gravity (1.005 ) DRY Inside "High & Dry" Labs HYPER osmolality (HIGH ) HYPERnatremia over 145 Na+ (HIGH ) DRINKING a lot "thirsty" DEHYDRATED Dry Mucosa & Skin DECREASED blood pressure DESMOpressin "Vasopressin" (ADH) Decrease Urine Output Death by Headache! (Low Na+) 135 or Less decreased antidiuretic hormone, which is responsible for water retention in the kidneys. Dl is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity. DRY Inside "High & Dry" Labs HYPER osmolality (HIGH ) HYPERnatremia over 145 Na+ (HIGH ) DIluted Outside "HIGH urine output ( Drains urine) LOW specific Gravity 1.005
Myocardial infarction presentation
• Described as pressure, heaviness, tightness • May radiate to jaw, arm, back, or upper abdomen • Lasts more than 30 minutes • Not improved with rest or position change • Worsens with exertion
The steps for administering a continuous enteral feeding include:
• Identify the client using 2 identifiers (e.g., first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. • Elevate the head of the bed ≥ 30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration (Option 2). • Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation (Option 5). • Check gastric residual volume. • Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration (Option 3). • Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump (Option 1) Educational objective: The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution.
fat embolus can lead to
• Respiratory distress syndrome (e.g., dyspnea, tachycardia, sudden and worsening chest pain, hypoxemia, restlessness, anxiety) • Altered mental status (e.g., confusion, memory loss) Petechial hemorrhages in the arms, chest, and/or neck Clients with pelvic and long bone injuries are at risk for fat emboli, which can occlude small vessels in the lungs, brain, and skin. Sign and symptoms include altered mental status (e.g., restlessness), chest pain, respiratory distress, and petechial hemorrhage.
beta blockers adverse contraindication
• Sinus bradycardia • Heart block • Heart Failure • Asthma • Emphysema • Hypotension Never give a beta blocker to a client with a history of asthma because it can cause bronchospasm
Assessment Findings: Pneumothorax
▪ Absent or markedly decreased breath sounds on affected side ▪ Cyanosis ▪ Decreased chest expansion unilaterally ▪ Dyspnea ▪ Hypotension ▪ Sharp chest pain ▪ Subcutaneous emphysema as evidenced by crepitus on palpation ▪ Sucking sound with open chest wound ▪ Tachycardia ▪ Tachypnea ▪ Tracheal deviation to the unaffected side with tension pneumothorax
Low-Pressure Alarm
▪ Disconnection or leak in the ventilator or in the client's airway cuff occurs. ▪ The client stops spontaneous breathing.
High-Pressure Alarm indicate
▪ Increased secretions are in the artificial airway or the client's own airway. ▪ Wheezing or bronchospasm is causing decreased airway size. ▪ The endotracheal tube is displaced. ▪ The ventilator tube is obstructed because of water or a kink in the tubing. ▪ Client coughs, gags, or bites on the oral endotracheal tube. ▪ Client is anxious or fights the ventilator.
Nursing Care Following Craniotomy
▪ Monitor vital signs and neurological status every 30 to 60 minutes. ▪ Monitor for increased intracranial pressure (ICP). ▪ Monitor for decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes, and personality changes. ▪ Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased ICP. ▪ Assess the primary health care provider's (PHCP's) prescription regarding client positioning. ▪ Avoid extreme hip or neck flexion, and maintain the head in a midline neutral position. ▪ Provide a quiet environment. ▪ Monitor the head dressing frequently for signs of drainage. ▪ Mark any area of drainage at least once each nursing shift for baseline comparison. ▪ Monitor the drain, which may be in place for 24 hours; maintain suction on the drain as prescribed. ▪ Measure drainage from the drain every 8 hours, and record the amount and color. ▪ Notify the PHCP if drainage is more than the normal amount of 30 to 50 mL per shift. ▪ Notify the PHCP immediately of excessive amounts of drainage or a saturated head dressing. ▪ Record strict measurement of hourly intake and output. ▪ Maintain fluid restriction at 1500 mL/day as prescribed.
Subdural Hematoma
▪ Subdural hematoma forms slowly and results from a venous bleed. ▪ It occurs under the dura as a result of tears in the veins crossing the subdural space.
Epidural Hematoma
▪ The most serious type of hematoma, epidural hematoma forms rapidly and results from arterial bleeding. ▪ The hematoma forms between the dura and the skull from a tear in the meningeal artery. ▪ It is often associated with temporary loss of consciousness, followed by a lucid period that then rapidly progresses to a coma. ▪ Epidural hematoma is a surgical emergency.
