NCLEX + 35 Page study guide, NCLEX UWorld
Risk factors for colorectal cancer
Chronic inflammatory bowel disease [I.B.D] Over 50 years of age FIRST RELATIVE with polyps or colorectal cancer Diet HIGH in fat and LOW in fiber
What to do if an air embolus is expected?
Clamp the tubing Turn the patient on the left side Put them in trendelenburg to [slanted with head downward] trap air in the right atrium
Continuous ambulatory peritoneal dialysis
Client performs self-dialysis 7 days a week 24 hours a day Dialysis is warmed (using heat pad), then infused and then dwell time is 4-8 hours Tubing and bag is disconnected or rolled up and worn under the clothing After the dwell time, the fluid is drained back into the bag and then the process is repeated
Client self determination act
Clients must be given info about their rights to identify written directions about the care that they wish to get in the event they become incapacitated and are unabe to make healthcare decisions Asked about advance directive on admission
Muslim culture
Cover up womans body when in the presence of a man not in her family Arrange for women staff for her care At least female nurse
Tartarazine and aspirin
Cross sensitivity, do not give together [CROSS ALLERGY]
Do not take NSAIDs while on lithium or with heart failure because NSAIDs do what?
DECREASE renal blood flow [worsen heart failure]
Long term use of PPIs can cause what?
DECREASED bone density which INCREASES the risk for fractures and can also cause c. diff
Most important way to see if diuretic therapy is working
Daily weights + decreased edema K+ and Na are not the best way
What is Menieres disease
Dilation of the membrane of the labyrinth There is recurrent attacks or vertigo and sensorineural hearing loss that can occur multiple times a week and go into remission for years at a time
What is conductive hearing loss
Disorder in the auditory canal, ear drum, or ossicles from infection, inflammation, foreign body, trauma or ear wax
Peripheral artery disease [PAD] position
Do NOT elevate [only for venous disease you will elevate legs not for arterial disease] legs above heart level Patients with peripheral artery disease [PAD] must dAngle legs below heart level
What do we do if we note bleeding after an ear procedure
Do not put pressure!! Call the HCP immediately
Screening for latex question
Do your lips swell when blowing up balloons? OR Do your hands get itchy when you put on rubber gloves?
So a patient with SIADH
Does NOT need extra fluid Needs salt [sodium] seizure precautions strict I/Os
What is sensorineural hearing loss (perceptive)
Due to a disorder of the organ of Corti or the auditory nerve caused by congenital things (mother being exposed to a communicable disease), infection, drug toxicity, trauma, Ménière's disease
Barium enema
During the test, patient is instructed to take slow deep breaths so they can retain the enema without blowing it all out Table will tilt in various positions, and the stool might be a different color for 2-3 days following, but this is not the most important information
Pulmonary embolus symptoms
Dyspnea Shortness of breath [SOB] Tachycardia Pleuritic chest pain Severe anxiety Impending doom
Cuput succedaneum
EXPECTED FINDING remember C and S for CROSSES SUTURE LINE -Edema + hematoma above periosteum that crosses suture lines -Resolves within the first week of life
Early stage of dementia vs late stage dementia
Early: impaired concentration and memory loss Late: Disorientation to person, place and time
Elevates INR/ prolonged PT
Easy bruising + increases bleeding risk because blood takes longer to clot
Position for a patient with a head injury
Elevate the head of the bed (HOB) 30 degrees to decrease ICP
What do we do as the nurse for autonomic dysreflexia
Elevate the head of the bed to 90 degree Loosen constrictive clothing Assess for bladder distention and bowel impaction (trigger!) Administer antihypertensive meds
What is expected with a lupus patient?
Elevated ESR [due to systemic inflammation] Positive anti-nuclear analysis [ANA positive if autoimmune disorder is present] Anemia Mild leukopenia Thrombocytopenia
What drugs do we give for SIADH [Syndrome of Inappropriate Anti-Diuretic Hormone]
Declomycin or diuretics
Common expected findings in peripheral arterial disease
Decrease blood supply from plaque buildup [watch for lipid levels] Lack of hair Decrease peripheral pulses Thick brittle nails Cool, dry, shiny skin Skin atrophy Toe ulcers, gangrene [necrosis]
What does the nurse do if fluid over load occurs?
Decrease the rate to a min or at KVO rate Elevate head of bed [HOB] Assess lung sounds + dependent edema of legs
When does lithium toxicity usuallly occur?
Dehydration Decreased renal function (elderly) Diet low in sodium Drug to drug interactions [NSAIDs and thiazides diuretics]
Circulatory (or fluid) overload signs
Increased blood pressure Distended jugular veins Rapid breathing Dyspnea Moist cough + crackles
Diet for a patient with abdominal aortic aneurysm [AAA]
Increased fiber and increased fluid intake so you don't have to strain when you are having a bowel movement which can increase pressure and lead to rupture of the aneurysm
Trachea deviation [mediasternal shift] signifies what
Increased pressure on one side of the lungs aka pneumothorax
Hypernatremia
Increased temp Weakness Disorientation/delusions Hypertension Tachycardia
Why do we do active assistive range of motion
Increases motion of the joint Performed by the client with the assistance of then nurse
What do we do for non-penetrating abrasions
Eye patch for 24 hours
When I see pericardial effusion and/or cardiac tamponade, I think of what?
FLUID BUILD-UP in the pericardium
14 gauge catheter
FLUIDS and DRUGS in pre hospital or emergency setting or hypovolemic shock
Any kind of shock, what do you do
FLUIDS! [0.9 sodium chloride]
How to get a client from sitting to standing
Face client and firmly grasp rib cage Push nurses knees against one of clients knees Rock client forward until they come to a standing position Pivot client to position him/her into chair (chair should be on clients strong side)
Risks for colon cancer?
Family history If you have inflammatory bowel disease [IBD], Crohns, or Ulcerative colitits Diet high in red meat Obesity Alcohol Smoking
Correct positioning for a trochanter roll
From the lateral aspect of the hip to the mid-thigh Trochanter roll is a positioning device that is placed under the greater trochanter to prevent external rotation of the hip joint and prevents the femur from rolling
Fruits and veggies that are high in potassium
Fruits: Bananas, cantelopes, oranges Veggies: Broccoli, spinach, potatoes
GTPAL system
G gravida number of times pregnant T Term babies carried to term 37 weeks or later P Preterm babies delivered from 20 weeks to 36 weeks A Abortions- pregnancy terminates before 20 weeks L Living children or babies currently living children
Botulism is what and caused from?
G.I absorption of toxin produced by clostridium botulinum from improperly canned or stored food •Found in soil and can grow in food •Look out for swollen/bulging cans [discard]
Remember for lung positioning:
GOOD LUNG UP [affected is put down for easy drainage + unaffected lung is up to facilitate breathing]
What do theh traffic signal colors mean in a peak flow meter?
GREEN [asthma is under control] there are no worsening of cough, wheezing, or trouble breathing YELLOW [means caution] symptoms are getting worse -Even after return to the green zone after use of medication, further med or change in treatment is needed -Still take meds if you return to green zone after taking rescue meds RED [needs emrgency treatment] if the level does not immediately return to yellow after taking resue meds
The delivery is oxytocin
Given through an infusion pump into a proximal port (not distal) Monitor FHR and uterine contraction pattern at least every 15 mins Monitor intake and output Continuous FHR monitoring
What does enteral mean?
Given through the G.I tract [orally or feeding tube]
Important education for celiac disease
Gluten-free diet for the rest of their lives. WHY? •Gluten damages intestines [small intestines] which are needed to function properly for nutrient absorption [increased risk for malabsorption] •These are ok to consume by a celiac patient -Rice -Corn -Potatoes •Read food labels of all processed foods because some may contain hidden gluten
Physical assessment on a child
Go from least invasive to most invasive because once the child becomes upset its hard to finish the assessment so FIRST interact with parents, then with the kid and play with them get history and weight Then auscultate [listen to heart, lungs, abdomen] Then get vitals [blood pressure, heart rate]
Hip dysplasia in 16-18 months
Gradual reduction by traction [using bilateral Bryants traction] Cast for immobilization
Diet for toddler through adolescent should be
HIGH protein and HIGH calcium Allow the toddler to pick foods to avoid an argument (we just want them to eat! Anything!)
Mnemonic to remember ventilator alarms
HOLD High alarm? Obstruction in the tube [increased secretions, kink, patient coughs/gags/bites] Low alarm? Disconnection or leak in the ventilator or patient airway cuff + Patient spontaneously stops breathing
How to remember the four defects in tetralogy of fallot
HOPS •Hypertrophy of right ventricle •Overriding aorta •Pulmonary stenosis •Septal defect
Symptoms of addisons disease?
HYPERPIGMENTATION Weight loss Muscle weakness Low blood pressure [HYPOtension] HYPOglycemia
POSITIVE Trousseua + Chvosteks signs are of what electrolyte imbalance?
HYPOcalcemia
Necrotizing enterocolitis
Happens mostly to preterm infants from underdeveloped intestines or gut Bacteria is introduced into bowel and get worse fast because compromised immunity Inflammation + ischemic necrosis of the intestine progresses and causes bowel congestion and gangrenous intestines with gas forming inside bowel wall
What is battery
Harmful or offensive touching of another person Clients can refuse medication, do not force them, even if they are psychotic
How do we prevent retinopathy of prematurity
Have experts look at the eyes in all premature babies [less than 36 weeks or weighing less than 2000g] Use minimal O2 Keep sats 95-100
Nursing interventions that decrease ICP?
Head of the bed [HOB] at 30 degrees Keep head and body midline Give stool softeners [prevent straining, which increases ICP] Suction only when necessary Provide a calm environment with dimmed lights [high risk for seizure, decrease environmental stimuli] Treat fever
Rule of nines
Head: 4.5 front 4.5 back Torso: 18 front 18 back Each arm: 4.5 front & 4.5 back (each arm is 9 total) Each leg: 9 front & 9 back (each is 18 total) genitals: 1
S&S of meningitis
Headache, fever, photophobia Nuchal rigidity Positive [Kernigs sign + Brudinskis sign] Change in LOC Seizures In infants with meningitis: -Refuses feedings -Vomiting/diarrhea -Bulging fontanelles -Vacant stare -High pitched cry
Durable power of attorney
Health care proxy chosen by client to make health care decision on clients behalf id client can no longer make decisons
Directly observed therapy
Health care worker or caregiver watches patient take every medication.This: Helps prevent infection spread Helps patient adhere to drug therapy Helps controls spread worldwide
What is a Holter monitor?
Heart monitors that we have at work Keep a diary of activities and any symptoms experienced by the patient Patient cannot bathe or shower
What suggest a client has a hiatal [diaphragmatic] hernia
Heartburn because of reflux
For adults and children over 1 year of age, how do you help someone that is choking
Heimlich maneuver [abdominal thrusts]
Gemfibrozil
Helps reduce cholesterol and triglyceride levels Must monitor liver function! AST and ALT Take 30 mins before breakfast/dinner
What is HELLP related to pregnancy?
Hemolysis Elevated Liver enzymes Low Platelet It is a severe sign of preeclampsia Symptoms may be -Right upper quadrant [RUQ] pain -N/V -Malaise
What med is given right away for malignant hyperthermia?
I.V dantrolene because it reverses the process by slowing metabolism
SIADH [Syndrome of Inappropriate Anti-Diuretic Hormone]
INCREASED antidiuretic hormone [ADH] [excessive retention of fluid] •Change in LOC •Decreased deep tendon reflexes (DTRs) •Tachycardia •Nausea, diarrhea, Vomiting •Headache
Digoxin function
INCREASES cardiac contractility but SLOWS heart rate EXCRETED BY THE KIDNEY
Increased c-reactive protein is a sign of what?
INFECTION
What lab is monitored when receiving warfarin?
INR/PT
What is expected during I.V infusion of KCL?
IRRITATION and discomfort at the site because KCL irritates the vein
What do we do as the nurse for meningitis
IV antibiotic therapy Monitor ABGs, arterial pressures, body weight, serum electrolytes, urine volume, specific gravity, osmolality Droplet precautions Prevent it! Give vaccines for those 65+ and revaccinate every 5 years Hib vaccine for infants
What do we do as the nurse for trigeminal neuralgia?
Identify and avoid what causes this Avoid rubbing of the eye Chew on the unaffected side Treatment: -Carbamazepine -Alcohol injection to the nerve -Resection of the nerve -Microvascular decompression
Korsakoff syndrome
Korsakoff syndrome CAUSES problems learning new information, inability to remember recent events and long-term memory gaps. Memory problems may be strikingly severe while other thinking and social skills are relatively unaffected. For example, individuals may seem able to carry on a coherent conversation, but moments later be unable to recall that the conversation took place or to whom they spoke Those with Korsakoff syndrome may "confabulate," or make up, information they can't remember They are not "lying" but may actually believe their invented explanations.
What is one golden sign of diabetic ketoacidosis related to breath?
Kussmaul respirations [especially that fruity smell]
What number is consididered a hypoglycemic neonate?
Less than 40 mg per deciliter Feed them right away
What is the care for acute diverticulitis?
Let the BOWEL REST and let the inflammation go DOWN [low residue, HIGH protein + calories] I.V antibiotics since bacteria may contribute to a flare up NPO I.V fluids to prevent dehydration Bed rest Posible N.G suction any procedure that increases abdominal pressure or that increases peristalsis could perforate or rupture the diverticula and should be avoided
Signs of severe dehydration in infants
Lethargy Sunken fontanel Poor feeding Tachycardia Increased Respiratory rate
Med of choice for ventricular tachycardia [V tach]
Lidocaine
What drug do we give for premature ventricular contractions PVCs
Lidocaine [premature ventricular contractions eventually turn into V tach; so this makes sense]
What do we do as the nurse during the oliguric stage
Limit fluids Diet adjustment [RESTRICT protein, sodium, and potassium] Meds as needed (Kayexalate for high K) Dialysis (hemodialysis or peritoneal)
Nystatin given for oral candidiasis is given in
Liquid suspension form Not cream because it goes inside the mouth swish it around in mouth and then swallow it
Introducing a child to table foods: 1-4 months they can have
Liquid vitamins only (A, C, D, and fluoride if indicated)
How do we know that our suctioning of an ETT was effective?
Listen to breath sounds when you are done and make sure it is clear and that there are no more adventitious breath sounds
When a mom comes in active labor, what is the first thing we do for them?
Listen to fetal heart sounds or the FHR
Instructional directive
Lists of medical treatment the client wants to omit or refuse if they become unable to make decision
Diet for prevention of stones
Low calcium Low sodium Low in oxylates [spinach, cola, tea, chocolate] No vitamin D [increases calcium absorption] Low organ meats
Signs of hypoglycemic reaction
Low glucose Shaking Sweating Pale
Juvenile idiopathic arthritis (JIA) - physical activity recommendations
Low impact weight bearing and non weight bearing exercises that involve range of motion & stretching [for example swimming, stationary bike, throwing/kicking ball, low-impact dancing, walking, yoga]
What lab values to we expect to see with adrenocortical insuffiency [Addison's disease]
Low sodium Low glucose Low fluid [dehydration] High potassium
Diet for a patient with Menieres disease
Low sodium [2000mg/day] Avoid caffeine, nicotine, and alcohol
Heatstroke
MEDICAL EMERGENCY S&S: 1. Temperature greater than or equal to 104 F (40 C) 2. Hot, dry skin 3. Hemodynamic instability [tachycardia, hypotension] 4.Altered mental status/neurologic symptoms [confusion, lethargy, coma] Treatment 1. Stabilization of ABCs 2. Rapid cooling interventions [cool water immersion, cool IV fluid infusion] Note: antipyretics are ineffective
Examples of contact precautions
MRSA +VRE + C diff + scabies
Hyperkalemia
MURDER Muscle weakness Urine [oliguria/anuria; common with kidney failure] Respiratory depression Decreased cardiac contractility ECG changes Reflexes depressed (DECREASE deep tendon reflexes)
If we suspect digoxin toxicity, what lab value should we check as a hidden sign
Magnesium could be low causing this!
Why do we do isometric exercises
Maintenance of muscle strength when the joint is immobilized Performed by the client. Alternate contraction and relaxation of the muscle without moving the joint
What is the priority when a client returns from a scleral bucking procedure?
Make sure the client is not nauseated or vomiting as this can increase intraocular pressure and mess up the surgery Scleral buckling surgery is a common way to treat retinal detachment. It is a method of closing breaks and flattening the retina
When someone has a head injury, what medication are we likely to give
Mannitol •An osmotic diuretic that decreases ICP and increase urine output •This crystallizes at room temperature so ALWAYS use a FILTER NEEDLE
Nursing interventions for necrotizing enterocolitis
Measure abdominal girth daily NPO [nothing by mouth] NG suction to DECOMPRESS stomach/intestines Parenteral hydration [I.V fluids] I.V antibiotics Place supine to avoid pressure on the abdomen Avoid rectal temperature in case perforation
Rules for crutches
Measure two fingers below axilla Client should support weight on handpick not axilla Crutches are kept 8-10 inches out to the side Elbows are flexed at 20-30 degrees Stop and rest if diaphoretic and short of breath
Symptoms of acute appendicitis
RLQ pain continuous Anorexia Nausea/Vomiting Rebound tenderness + guarding Prevent increase in intra-abdominal pressure by NOT coughing sneezing or breathing deep
When drawing up regular insulin with NPH, which order do you draw them up?
RN!! Regular before NPH
Dumping syndrome
Rapid emptying of gastric contents into small intestines Client experience: -Abdominal cramping -Nausea, vomiting -Diarrhea -Dizziness -Generalized sweating -Tachycardia
Hip dysplasia in newborn to 6 months
Reduction by manipulation •Pavlik harness: worn from 3-6 months FULL TIME •Do not remove! •Sponge bath is recommended •Check skin 2-3 times a day •Avoid lotions and powders •Gently massage under skin to stimulate circulation •Place diapers under straps •Place shirt under chest straps and knee sox under foot and leg pieces •Move child from room to room for environmental change
What is the only insulin that can be given I.V
Regular. All others must be given sub Q
Treatment of frostbite
Remove clothing/jewelry to prevent vasoconstriction Do not massage rub or squeeze affected area Immerse affected areas in warm water Provide analgesia [rewarming is painful] Elevate affected areas Let areas become dry then put loose nonadherent dressings
RSV/bronchiolitis causes what
Respiratory secretions •Use saline nose drops abd then suction the nares to remove secretions •Give fluids
Who is at risk for circulatory overload?
Respiratory, cardiac, renal or liver disease patients Older clients Very young clients
When giving a client Lithium, what do we need to remember about their diet
Restrict their sodium
3rd degree AV heart block
Results in DISASSOCIATION of atrial & ventricular contraction due to blocked electrical activity LEADS TO decreased cardiac output which is manifested with Dizziness Syncope Mental status changes HF Hypotension Bradycardia
Why do we do passive range of motion
Retention of joint range of motion and maintenance of circulation Performed by the nurse without assistance from the client
Giving aspirin to children can cuase what
Reyes syndrome
Drug of choice for treatment of TB
Rifampin
When we have appendicitis, where is the pain
Right lower quadrant or [RLQ] + Rebound tenderness
What is the only med approved for ALS?
Riluzule (Rilotek)
Signs of complications post tonsillectomy & adenoidectomy
Risk for hemorrhage up to 14 days after surgery and life-threatening airway compromise Signs of Hemorrhage: 1. Restlessness 2. Frequent swallowing or clearing of throat 3. Vomiting of blood 4. Pallor May require surgery to cauterize bleeding vessels
S&S when a client is withdrawing from heroin
Runny nose Yawning Fever Muscle and joint pain Diarrhea (A lot like S&S of the flu)
Classic symptoms of a rotator cuff injury
S &S: •shoulder pain + weakness •Severe pain on arm abduction
Parvo causes fifth disease
S&S: Slapped cheek Bright red facial rash Flu like symptoms
Preeclampsia can lead to what severe thing?
SEIZURES [eclampsia]
What can hyponatremia cause?
SEIZURES, confusion, neurologic complications institute seizure precautions
Parietal lobe [brain]
SENSATION somatic and sensory INPUT Injury of this lobe causes deficits with sensation
Order of progression from SIRS to MODS
SIRS--> sepsis --> septic shock --> MODS
In an MI,
ST elevation is seen in localized leads
Symptoms of Addisonian crisis
SUDDEN drop in blood pressure, tachycardia, hypoglycemia, abdominal pain, and weakness Treat with I.V hydrocortisone
What is a detached retina
Separation of the retina from the choroid caused by trauma, gain, diabetes or tumors Patient will see -Flashes of light, floaters -Curtain coming down Patient may be experience confusion/apprehension
How long is the GBS recovery period?
Several months to a year, normal loss of function is 10% at the end of recovery
Ipratropium
Short acting inhaled anticholinergic to promote bronchodilator
Continuous Ambulatory Peritoneal Dialysis [CAPD]
Should check weight daily Do not milk catheter, drain by gravity Eat a high protein diet as CAPD has taken out protein while flushing out the cells Use strict aseptic technique
What position is someone in for an epidural puncture
Side-lying
Process for breathing from an incentive spirometer
Sit in high fowlers or sitting Seal lips tightly to prevent air leakage inhale deeply Hold breath for 2-3 seconds Exhale slowly Breathe normal for several breaths before repeating the process Cough at the end of the session
Where should the nurse be positioned when helping a client learn to walk with a cane
Slightly behind the client on the good leg side
Test visual acuity in children
Snellen chart 10 feet away for children and 20 feet away for adults
Rhonchi
Snorous wheeze continuous, low-pitched adventitious breath sounds Similar to moaning or snoring that occur when thick secretions or foreign bodies [such as tumors] obstruct airflow in upper airways
When taking lithium, what lab value do we need to monitor
Sodium The excretion of lithium is dependent upon normal sodium levels in the body •If there is too low sodium [HYPOnatremia] that means that lithium will not be excreted and we can get lithium toxicity!
What to do FIRST with an unrestrained patient invovled in a sudden deceleration accident during emergency trauma care?
Spinal precautions are first!! [IMMOBILIZE the spine] before checking pulse AND opening their airway place cervical collar
As the nurse, what do we do for GBS patients
Steroids in acute phase Mechanical ventilation, elevate head of the bed (HOB) Suctioning Plasmapheresis treatment! High dose I.V immunoglobiluns Physical therapy and ROM Pain reducing measures Eye care Prevent complications [URI, aspiration, constipation, urinary retention]
What about if a chest tube separates from the drainage tube and becomes contaminated?
Submerge the distal end 1-2 cm below the surface of sterile water to create a water seal so that air does not get in •Keep bottle of sterile water, clamps, and antiseptic wipes at the bedside
Ovarian cancer
Subtle symptoms at first which contribute to more deaths than any other gynecologic cancer Lack of screening and vague symptoms May not be diagnosed until advanced stage
What S&S will show if it proceeds to a Myasthenia crisis
Sudden inability to swallow, speak, or maintain a patent airway
What do you need to caution a client about when taking tetracycline
Sun is HOT and skin is sensitive [photosensitivity] so wear hats and sunscreen
Position for a patient during the acute phase of a stroke
Supine with the head elevated 15-30 degrees [semi-Fowler's] Facilitates venous drainage from the brain and decreases ICP [with a stroke ICP INCREASES so patient should be placed in a semi Fowler]
How to reduce portal pressure in liver failure and esophageal varices
TIPS [trans-jugular intra-hepatic portosystemic shunt] procedure* and beta blockers [propanolol]
Instructions for taking levothyroxine
Take on EMPTY STOMACH in the morning separate from other meds Blood tests are done to determine accurate dose usually is lifelong therapy Do not take with antacid, iron, or calcium
What does a patient with Marfan syndrome look like
Tall and Thin They often have heart abnormalities so contact sports are discouraged
What do we do for a patient with glaucoma
Meds! [Prostaglandin agonists, adrenergic agonists, beta-adrenergic blockers, cholinergic agonists, carbonic anhydrase inhibitors] Surgery [laser trabeculoplasty] Avoid tight clothing Avoid use of mydriatics [Atropine]
Droplet precautions
Meningitis Haemophilius influenza type b Diphtheria Mumps Rubella Pertussis Strep group A Viral influenza wat do you need? surgical mask + private room as needed for procedures that can splash gloves, gown, goggles/shield
contact precautions
Methods of infection control that must be used for patients known or suspected to be infected with epidemiological microorganisms that can be transmitted by either direct or indirect contact.
Position for a patient in shock
Modified trendelenberg [extremities elevated 20 degrees] with the knees straight and head slightly elevated [slanted with head lower than legs]
Care of the patient with Peripheral Artery disease
Monitor peripheral pulses Good foot care Do NOT cross legs •Stop smoking •Regular exercise
Care of the patient with peripheral venous disease (varicose veins or thrombophlebitis)
Monitor peripheral pulses Thrombectomy Avoid extreme temps SCDs/tedhose/elastic stockings Bedrest 4-7 days Elevate legs Warm moist packs Anticoagulants
No weight bearing
Motorized assist device if cooperative and they have upper body strength 2 person assist with full body sling if uncooperative and/or has no upper body strength
Myopia Hyperopia Presbyopia Astigmatism
Myopia: nearsightedness [can see near things well] Hyperopia: far-sightedness [can see things far well] Presbyopia: blurry vision of near things due to age Astigmatism: Blurry vision from an uneven curving of the cornea
S&S of Menieres disease
N&V Intolerable vertigo and tinnitus Pressure / fullness in the ear Fluctuating/progressive decreased hearing on the involved side Nystagmus/headache
S&S of opioid withdrawal
N&V Restlesness Abdominal cramping
Vancomycin can cause
NEPHROTOXICIY check vancomycin -Trough levels -BUN -Creatinine
After abdominal surgery, do you expect to hear bowel sounds?
NO because postop paralytic ileus
After an amputation, should the residual limb be elevated?
NO, to prevent hip flexion contractures
Cheyne strokes breathing
NOT a good sign concerning in a TBI Tachypnea breathing followed by a gradual decrease that eventually results in apnea This breathing cycle repeats Often seen in a patient that is dying
Chest pain that occurs at rest
NOT considered stable [it is unstable angina] like for example waking up at night with chest pain
During the first 24 hours after amputation, the residual limb is
NOT elevated but can be supported by pillows elevate foot of bed Patient can be put in prone twice day for 20-30 mins
Bipolar patient comes in and is experiencing acute mania.What is the priority?
NOT risk prone behavior because physiological needs like food take priority (remember maslows) So imbalanced nutrition would be the priority
If there is a puncture wound to a person by an object, the nurse should
NOT try to remove the object Instead, the nurse should stabilize it with dressings because removal causes further trauma and bleeding
Nursing care for acute pancreatitis
NPO I.V opioids I.V fluids NG tube for suction
Salicylate
NSAID Therapeutic Level: 100-250 mcg/mL Toxic Level: >300 mcg/mL
What is Toradol?
NSAID used for inflammation and pain
How to assess for clonus?
NURSE dorsiflexes the foot with one hand and supports the leg/ankle with the other When POSITIVE clonus is shown, rhythmic jerking beats of the foot are present as the foot is released
Things to remember about Native American culture
Native americans do not rely on the clock, they used to complete their days by the sun, so they may be late to an appointment
Hyponatremia
Nausea Muscle cramps Increased intracranial pressure [ICP] Muscle twitching Convulsions •Causes CNS irritability due to swollen nerve cells
Transport techs need to know/don't need to know which info
Need to know:pertinent info to transport pt Don't need to know: exact diagnosis
Elevated bun and creatinine may indicate what?
Nephrotoxicity
Toilet training time schedule
Never begin before 18th month 2-3 years: bladder control reflex achieved 3 years: regular voiding habits established 4 years: independent bathroom activity 5 years: night time control expected
Preeclampsia
New elevated blood pressure 20 or more weeks gestation and proteinuria •HA •Visual disturbances •Facial swelling
Sleep apnea features
Nighttime: - Periods of apnea - Loud snoring - Interrupted sleep Daytime - Morning headaches - Irritability - Excessive sleepiness Other - Difficulty concentrating - Forgetfulness - Mood changes - Depression
When a woman is pregnant and having breast discomfort, do we recommend that the massage them?
No
Rate for potassium infusion
No faster than 10 MEQ per hour
For Jewish people, what do we have to remember about their diets
No meat and milk together [must be 6 hours apart, but they have two meals with dairy and one meal with meat] Meat must be Kosher [drained of blood]
When you have a colostomy, what are the restrictions of your new activities
No restrictions You can return to all normal activities after the stoma/incision is healed
Can we ever remove bucks traction weights?
No! Not without a doctors order We must reposition the client in bed with the weights still on If we take them off we are inturrupting the line of pull
Extracorporeal Shock wave therapy
Non-invasive treatment of the kidney using an acoustic pulse Teach patient to report fever, DECREASED urinary output and pain Hematuria is expected but should clear within 24 hours
Late or variable deceleration indicate what in pregnancy?
Not good and need further teaching [VEAL CHOP MINE]
Effective handoff communication components
Nurse should: 1. Provide identifying information [for example: client's name and room number] 2. Note care priorities and upcoming or outstanding tasks [for example time to replace medication infusion bag, need to perform delayed wound care and cause of delay] 3. Provide exact, pertinent information [for example medication dose, time, measurable outcomes] 4. Include multidisciplinary plans [radiology examinations, family meetings, physical therapy] 5. Relay significant client changes in a clear manner
Hep B vaccine series
One shot, then additional shots at 1 and 6 months
Describe the RH incombatibility
Only RH negative mothers have a problem if their baby is positive but they are negative
What are cataracts
Partial or total opacity of the normally transparent lens [Caused by: congenital, trauma, again, diabetes, drugs like steroid therapy, exposure to radioactivity]
Nurse finds a client slumped over in respiratory distress with low O2 Sat and visible food in throat, steps on what to do?
Position to high fowlers Oral suction Oxygenate Lung sounds Notify HCP [usually always last]
What is happening in ventricular trigeminy?
Premature ventricular contractions [PVCs] are occuring every third heartbeat
What things confirm an active TB infection?
Presence of symptoms POSITIVE sputum culture POSITIVE chest xray
What is guillen barre syndrome [GBS]?
Progressive inflammatory autoimmune response resulting in a loss of motor function symmetrically, starting from the lower extremities and working its way up. Also paresthesias and too much or too little autonomic dysfunction [hypotension, tachycardia, flushing, sweating]
What is Alzheimers disease
Progressive, irreversible, degenerative neurological disease characterized by loss of cognitive function and disturbed behavior Forgetfulness progressing to inability to recognize familiar faces, places and objects
What do we do as the nurse for bells palsy
Protect the head from cold or drafts Administer analgesics Teach isometric exercises for the facial muscles Emotional support for body image disturbance Full recovery takes 3-5 weeks
What test do we use to diagnose people with Myasthenia Gravis
Tensilon test. •Where we inject tensilon and ask you to do activities like stand up and sit down and stand up and sit down •If you get tired we inject another dose •If you can stand up again, you probably have MG •MG is susceptible to the Tensilon test
Codeine is used for
acute pain or as a cough suppressant Do NOT give to a COPD [emphysema + chronic bronchitis] patient because it causes accumilation of secretions In general, SEDATIVES like narcotics and benzodiazepines should NOT be given to COPD patients because SEDATIVES can depress the respiratory center in someone with respiratory problems and at high risk due to disease process for respiratory depression
When is the rapid response team notified?
acute significant changes in heart rate, systolic BP, RR, o2 sat, LOC, and urine output
Lithium toxicity symptoms
acute: GI disturbances: nausea, vomiting, diarrhea CNS finding can occur LATER Chronic: CNS effects: neurologic ataxia, confusion, tremors
Naegele's rule
add 9 months and 7 days to LMP [or substract 3 months and add 7 days to last menstrual period date]
What is the priority intervention for pain with sickle cell crisis and why?
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
Addisons disease-what is it?
adrenal glands NOT producing enough steroids
What is the strongest risk factor for late onset Alzeimers?
advancing age
UPPER UTI would be
affecting kidneys
Quick formula to calculate number of teeth in the first 2 years of life?
age of child in months minus 6 EQUALS expected number of teeth
What is peak expiratpry flow?
airflow out of the lungs
What does a peak flow meter measure in a person with asthma?
airflow through the lungs
Cystic fibrosis (CF) nursing priorities
airway & oxygen saturation [pneumothorax can be a complication]
Near-dorwning victim management
airway management [mechanical ventilation] warm blankets warm I.V fluids Do not necessarily need to give blood; only if blood loss has occured but not just cause of drowning
What lab levels will be seen in abnormal liver function?
albumin, ammonia, platelets, INR, and bilirubin
Treat asthma with
albuterol •SE: -N/V -Insomnia -Palpitations -Tremor
Routine contamination when hands are not visibility soiled its safe to use
alcohol sanitizer
Always remember inspection is
always done FIRST, then listening [auscultation] then palpating
If a child has an asthma exacerbation and there is no wheezing/breath sounds heard, this is
an EMERGENCY priorty because it could indicate what? lack of airflow; so this is an airway obstruction This is called "silent chest"
With a delegtaing quesiton, never pick an LPN to do something that
an UAP can do such as taking vital signs It is not an efficient use of resources
Following hip repacement, place
an abducter pillow between the patient's legs to maintain hip in straight and neutral position also do NOT bend at the hip for more than 90 deg or cross the legs or ankles
Continuous bubbling in a chest tube inicates what
an air leak in the chest tube system
Quantiferon-TB [QFT] blood test is what?
an alternative to the Mantoux test It only indicates tht the individual has been infected with TB [cannot distinguish between latent or active TB] The test is more EXPENSIVE but it ONLY requires a single visit rather than having the person coming back in 48-72 hours to have their TBT test read
If patient comes into ER and says they have the worst HeadAche of their life what could it be
an aneurysm
Metronidazole (Flagyl)
an antibiotic
Pinworm infection
anal itching thats worse at night
Chronic kidney disease can cause
anemia becase the kidneys are unable to produce erythropoietin to stimulate the production of RBCs
Bone marrow suppression can lead to what?
anemia, thrombocytopenia, and leukopenia
What meds can precipitate malignant hyperthermia?
anesthesia
What are the sartan drugs like losartan, valsartan, and candesartan
angiotension II receptor blockers used for pateitns that cannot take ACE inhibitors [reason can be the persistent cough]
"sartans"
angiotension receptor blockers like valsartan
If a sibling has autism, there is a high chance
another sibling will have it too, think of closeness of family
Nitroglycerin is what type of drug?
antianginal vasodilator that may cause a headache
Quinidine
antiarrhythmic/anti-parasite Therapeutic Level: 2-5 mcg/mL Toxic Level: >10 mcg/mL
Levofloxacin (Levaquin)
antibiotic
Gentamicin
antibiotic [renal/oto toxic] Therapeutic Level: 0.5-0.8 mcg/mL Toxic Level: >12mcg/mL
What can treat death rattle?
anticholinergic meds because they will DRY the secretions and atropine will decrease saliva production
Magnesium Sulfate
anticonvulsant Therapeutic Level: 4-8 mg/dL Toxic Level: >9mg/dL Antidote/Reversal: calcium gluconate 10% (Kalcinate)
Carbamazepine
anticonvulsant Therapeutic Level: 5-12 mcg/mL
Phenytoin
anticonvulsant used for seizures
MAOIs interact with many meds including
antidepressants SSRIs SNRIs MAOIs should not be given within 2 weeks of taking other antidepressants, SSRI, SNRI
Loperamide (Imodium)
antidiarrheal
Loratidine (claritin)
antihistamine
Orthostatic hypotension is a common side effect of most of what type of meds?
antihypertensives
Chlorhexidine gives
antimicrobial effect really quick [like 30 seconds]
Ondesetron (zofran)
antinausea
Aripiprazole (abillify)
antipsychotic for dementia
Phenytoin (Dilantin)
antiseizure
If a client complains about a staff member mistreating them ,what is the first thing the nurse does?
ask patient to describe what happened so the nurse can assess then choose a course of action
The RN can ask the UAP to apply the restraints but the RN cannot
ask the UAP to verify if they are on correctly That is the RNs job
Children should not take
aspirin as it can cause Reye syndrome especially in children with a recent viral illness It causes acute encepalopathy and hepatic dysfunction Children must instead take acetaminophen or ibuprofen
Suicidal ideations
assess if they had thoughts of self harm. find out if they have a plan and if they have one then ask about the details
After a med error happens, what should you always do first?
assess the patient
FIRST thing to do if a patient is in ventricular tachycardia?
assess them for a pulse [because they can either have a pulse or not]
If an older client is expericing acute delrium, the priority nursing action is to
assess what is causing it and then to intervene
What is the Bishop score?
assesses and rates cervical favorability and readiness for induction of labor •A score above 8 is good
Listening to lungs is part of
assessing the airway because the nurse can determine if it is open or not
Shortness of breath and high pitched expiratory wheezing are expected side effects of what
asthma
Latent vs active TB
asymptomatic/cannot spread versus symptomatic and can spread through air
At what age can infants roll
at 4 to 5 months
Borderline personality disorder
at a very high risk for suicide often make suicide threats if they feel abandonment
Placenta previa is when placenta is
at bottom touching the cervix
Phenytoin toxicity
ataxia [gait disturbance]
Incentive spirometry is important post surgery to prevent
atelectasis and expand lungs
Assessing a sleeping infant
auscultate first the palpate/percuss from head to toe then traumatic procedures like eyes, ears, mouth then moro reflex [this is the last step]
Lupus erythematous is
autoimmune disorder It is mild to severe chronic inflammation of different parts of the body like face, mucosal ulcers, pericarditis, peluritis, nephritis, arthritis, DVT
Ways to reduce dumping syndrome symptoms
avoid fluids with meals and lie down after eating
Things to note about using a walker
The nurse should be behind the client with hold of their gait belt The client should sit down by grasping the armrest on the affected side and then shift weight to the good leg and hand and then lower themselves into the chair
Hypomagnesemia
Tremors Tetany Seizures Dysrhythmias Depression Confusion Dysphagia
What are Eriksons developmental stages and the ages for each
Trust/mistrust=birth to 1 year Autonomy/Shame and doubt = 1 yr to 3 yrs Initiative/Guilt = 3 to 6 yrs Industry/Inferiority = 6 to 12 yrs Identity/ Role confusion = 12 to 20 yrs Intimacy/Isolation = 20 to 45 yrs Generativity/Stagnation = 45 to 65 yrs Integrity/Despair = 65+ yrs
If an infant if allergic to cow milk, what do we do
Try soy milk formula FIRST Then [SECOND] try a predigested formula
If someone was hurt and now is returning to the job but they are impaired forever [walk with a limp, hurt back can't lift] what do we do for them
Try to reassign them a job that is more feasible and fitting for them
What do we do as the nurse for air/pulmonary embolism
Turn patient to the LEFT side and LOWER the head of the bed
How often do we provide oral hygeine for someone with an ETT
Twice a shift
A peak flow meter
USES traffic control signals to recognize degree of asthma symptoms An asthma action plan is individulaized and developed between patient and HCP
Automated peritoneal dialysis
Uses a machine with a warming chamber for the dialysate infusion, dwell and outflow The times and volumes are preset (10 mins infusion, 10 mins dwell, 10 min outflow) and they do this for 8-10 hours
Following total hip replacement, how is hip dislocation prevented?
Using an abductor pillow to maintain hip in a straight position Don't bend hip more than 90 degree Avoid extreme internal and external rotation, tell them not to cross legs AVOID ADDUCTION and hip flexion Client supine with head of the bed elevated less than or equal to 45 degree
Med of choice for status epilepticus
Valium
vagal maneuvers examples
Valsalva Coughing Carotid massage
What is ebola
Viral hemorrhagic fever Extremely contagious High mortality rate Standard, contact, AIRBORNE, and DROPLET precautions SO for people entering an Ebola room: impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves, boot covers, apron No current meds or vaccines to prevent Prevention is key! There is a strict glove removal process when developing -Client should have AIRBORNE ISOLATION room, strict PPE use, restrict visitors, and log of people who entered the room
Croup
Viral inflammation and edema of epiglottis and larynx S&S: -Runny nose -Tachypnea -Inspiratory stridor -Barking cough
Dealing with a patient with hearing loss or deaf
Visibly gain their attention before speaking Directly face the client Put up hearing impairment sign on head of bed [HOB] or door Keep room well lighted so speakers face is well lit Direct speak to least affected ear if partial hearing loss [or speak into the ear the hears best] Speak at a NORMAL volume
S/S of digoxin toxicity
Visual changes N/V Confusion Lethargy Weakness Cardiac arrythmias
When we have a bunch of clients getting blood transfusions, all with reactions who is the most crucial to see first
Vomiting is FIRST Jugular vein distention (JVD) SECOND Itching THIRD Headache FOURTH
What is the best indicator of treatment effectiveness of antibiotics?
WBC count [DECREASES]
Prior to an EEG which diagnoses seizures:
We have these restrictions: -caffeine beverages -Stimulants or depressants •Patient must wash hair [remove oils]
What to remember when someone is in a crisis psychologically
We have to ask them what they have done in the past to cope, since this is a crisis. If it is just a normal situation, we do not focus on what has worked in the past because the past is the past
What do we need to remember about Prochlorperazine
We must draw it up in a separate syringe than all other medications It is an anti-psychotic and treats schizophrenia and anxiety as well as N&V
If we have a client who is withdrawing from alcohol, and their vital signs continue to creep up, what do we do
We need more sedation, these patients are approaching delirium tremors
Diet for a patient after an appendectomy
We need wound healing so we need high protein and high vitamin C and high calories
Osteoporosis and the elderly
We want to prevent fractures especially hip fractures Bisphosphate [example alendronate] Calcium Vitamin D supplement Encourage patients to STOP smoking and consuming alcohol Encourage patients to do weight bearing exercises to increase bone density
After having an M.I, when can sexual activity be resumed
When the client can walk up two flights of stairs or one city block with no shortness of breath [SOB] or chest pain
Glucose levels should be watched when receiving
a steroid [glucocorticoid because it causes HYPERGLUCEMIA]
What does torsades de pointes look like
a strand of DNA
Position of a patient after a laminectomy
a surgical operation to remove the back of one or more vertebrae, usually to give access to the spinal cord or to relieve pressure on nerves. Keep the body straight Pillow should be placed longitudinally between the legs to prevent adduction and spinal torque
What is an amnioinfusion?
a transvaginal infusion of a crystallid fluid to compensate for the loss of amniotic fluid [oligohydramnios or very little amniotic fluid]
What are mongolian spots?
benign discoloration bluish gray but usually fades
Gross tremors and seizures from acute alcohol withdrawal are treated with what?
benzodiazepines like lorazepam and diazepam
What are some meds that treat EPS?
benzos like "pam" drugs and benadryl
Rotate staff members with
bipolar disorder patient
Glucose levels are decreased 1 hour after
birth but gradually increases to normal 2 to 3 hrs after birth optimal is 70 to 100 but 40 or over is normal
What are common triggers of this?
bladder or rectum distention. treat the trigger
PTSD patients tend to
blame themselves Make sure to tell them it wasn't their fault
Cephalohematoma
bleed that does NOT cross suture lines
When do you not give a vaginal exam for a pregnant woman?
bleeding with unknown origin
In cystic fibrosis, pancreatic ducts are
blocked in the GI tract due to thick secretions that clog the ducts Therefore there is a deficiency in what type of enxymes? pancreatic enzymes which are given with meals
Warfarin
blocks the availibility of vitamin k and reduces risk of stroke venous thrombosis or PE; •Check PT/INR levels
How is hep B transmitted?
blood + semen + vaginal secretions "B" for body fluids
D-dimer
blood clot test [test to see if clot is present]
Before starting broad spectrum antibiotics, what must be done?
blood culture and sensitivity
What should be checked before giving erythropoietin?
blood pressure [because it causes HYPERtension]
When a patient is on methylphenidate, what do you measure
blood pressure and weight/height because it can cause Lack of appetitie leading to weight loss HYPERtension Tachycardia
For a blood transfusion, UAP can obtain
blood pressure before the transfusion begins and any time after the first 15 mins of infusion uap can also pick up blood from the blood bank
What is the trousseau sign
blood pressure cuff is inflated and the wrist spasms
UAP can carry
blood products to and from the blood bank
Wear gloves when in contact with
blood, bodily fluids, secretions, excretions, nonintact skin and mucous membranes and Wash hands in between patients and after removing gloves
Infants have a higher
body water precentage than adults so they can become dehydrated quickly with vomiting and diarrhea Severe dehydration occurs more rapidly in infants and young children
High reticulocytes inicate what
bone marrow is producing RBCs fast
Just like chemotherapy, methotrexate causes
bone marrow suppression which places patients at risk for what? infection
What kind of precautions do you need for open lesions from shingles?
both contact and airborne precautions and a negative airflow room
If children eat honey less than 1 years old this can cause
botulism
What is the battle sign?
bruising behind the ear indicates skull fracture that could cause brain injury if not treated
what is the grey-turner sign and what is it a sign of?
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
Pericardial effusion
build up of fluid between the layers of the pericaridum
What is pericardial effusion?
build-up of fluid in the pericardium
Lactated ringers [LR] is often used for
burns
Mitral valve regurgitation does what?
causes a backflow of blood from the left ventricle through the mitral valve and into the left atrium The back flow can lead to dilation of left atrium and pulmonary edema -Make sure to report any signs of heart failure
What is Sjogren's syndrome?
chronic autoimmune disorder that damages moisture producing glands Causes -Dry eyes -Dry mouth -Dry skin -Dry vagina
vitamin K is and what is it used for?
clotting factors
What does normal CSF look like/contain?
colorless and odorless a little protein, glucose, minimal wbcs, no RBCs, and no microorganisms
Diabetic ketoacidosis [DKA]
common for type 1 diabetes cardinal signs are fruity breath rapid deep respirations [Kussmaul respirations] hyperglycemia Ketosis or metabolic acidosis [caused by an intense deficit of insulin] Treatment: I.V normal saline FIRST, then I.V regular insulin, check finger-stick glucose
Clients with a cast are at risk for
compartment syndrome so they should always have neurovascular checks
What is asystole?
complete absence of ventricular electrical activity in the heart No ventricular contraction occurs client is -pulseless -apneic -unresponsive
Hepatic encephalopathy symptoms
compliction of end stage renal disease [ESRD] Build up ammonia in the blood CNS effects: lethary, confusion, slurred speech, can lead to coma watch for asterixis- flapping hand tremors
How to close a hemovac
compress to create negative suction pressure and APPLY PLUG BEFORE RELEASING THE PRESSURE
UTI and the elderly
confusion may be a sign of a UTI, but still be addressed to R/O other possible causes
What is an arteriovenous malformation [AVM]?
congenital deformity of tangled blood vessels occurring in brain USUALLY found in the brain and can cause Headaches Seizures Neurological deficits -BLOOD PRESSURE CONTROL IS CRUCUIAL -High RISK for having an intracranical bleed due to the weak vessels -ANY neurological changes like sudden severe HA, nausea, vomiting should be assessed immediately as these are symptoms of a hemorrhage -Do not perform heavy exercising as this can INCREASE blood pressure
What happens to the body in botulism?
constipation, respiratory failure and neurologic decline [muscle paralysis which is irreversible] infants usually have -Constipation -Generalized weakness -Diminished deep tendon reflexes I.V human derived botulism immuno-globulin is given ASAP to reduce severity
Shellfish allergy may carry a concurrent risk for allergic reaction to
contrast dye [iodide]
What do yo do if there is itching under a cast?
cool air from an air dryer
Practice resilience by coming up with
coping skills like deep breathing exercises
Chemical burn to the eye is an emergency- priority is what?
copious eye irrigation [water at home and NS or LR at hospital] eye must remain open
Remember when measuring fundal height, that after 20 weeks it
correlates with number of weeks pregnant. •So if you are 24 weeks pregnant, the fundal height should be 24cm above the pubis sympysis
What is the nurses priority action when she hears a sucking chest wound?
cover with petroleum gauze and tape on 3 sides
If a chest tube gets dislodged, immediately
cover with something sterile or clean if you don't have sterile What are we trying to prevent here? air from getting into the pleural cavity
What is strabismus?
cross eyes eyes don't look in the same directon at once closing one eye when viewing objects is a sign
If a patients is receiving palliative care, they can still receive
curative care too
Morphine can do what to the urine output?
decreases urine output
If a patient does have orthostatic hypotension and vitals are changing when sitting and standing, then they could be
dehydrated •Give fluids
Causes of hypernatremia in infants
dehydration [decreased oral intake, vomiting, diarrhea]
Blunt force trauma can have
delayed symptoms from a slow subdural bleed after 24 to 48 hrs it may show signs of increased ICP like LOC [which is usually the fist sign] Projectile vomiting Ataxia [loss in body movement] Unilateral pupil dilation Seizures
St Johns Wort used to treat what?
depression but interacts with many prescription meds
Radioactive iodine
destroys the thyroid gland [treats hyperthyroidism]
if a patient is on digoxin, monitor
digoxin levels as well as potassium levels [because HYPOkalemia causes digoxin toxicity]
ACE inhibitors do what main thing?
dilate blood vessels
When giving morphine or hydromorphine I.V push,
dilute slowly so it does not cause opioid induced adverse reactions like -Nausea -Itching -Flushing
Hydromoprhine IV push can be given
diluted with 5 mL NS or undiluted should be given slowly over 2 to 3 mins
Tracheostomy allow for 1 finger to fit under the ties in order to prevent
dislodgement
What is osteoarthritis?
disorder of the synovial joints [knee, hip, fingers] that causes erosion of joint cartilage and bone beneath cartilage
When starting an IV, start
distally so you can move your way up the arm if infiltration occurs or the vein blows
UAP soft wrist restraints can:
do ROM exercises reapply wrist restraints report changes in skin to nurse turn/reposition client in bed
What to do for a client with positive orthstatic vitals?`
do not complete vitals if patient feels dizzy/weak Give fluids
Important teaching for tiotropium
do not take the capsule orally even though it comes in a capsule and look slike you do. the buttom must also be pushed on the inhaler for the med to be dispersed
Drug of choice for symptomatic hypotension?
dopamine
At 6 months what should baby weigh?
double birth weight
If a patient questions a med they are gettting, just
double check yourself and go through the 6 right again
Do you tilit your head up or down during a nosebleed?
down
Which way to pull pinna for a child?
down and back
While taking lithium clients should:
drink 1-2 L of fluid daily maintain normal sodium levels have their blood drawn regularly for therapeutic levels
Influenza is transmitted how?
droplet
Pertussis and influenze precaution
droplet
Third-degree [full-thickness] burns
dry & inelastic with waxy white, leathery, or charred black color Destroy the dermis and may involve subcutaneous tissue
Peripheral Arterial Disease [PAD] Assessment Findings
due to decreased blood flow to lower extremities -Hair loss -Decreased peripheral pulses -Intermittent claudication [ischemic muscle pain] -Cool, dry, shiny skin -Thick, brittle nails -Toe ulcers + gangrene
Jaundice in a newborn
during FIRST 24 hours: jaundice is pathological related to liver problems AFTER 24 hours: physiological jaundice is related to increase amount of unconjugated bilirubin in system
UAPs CAN perform oral suction for patient
during oral care
Lumbar puncture [LP] positioning
during procedure side lying fetal knees up after procedure supine
Acute lithium toxicity presents early with what and later with what
early/acute: GI disturbances later/chronic: neurologic like ataxia, confusion, tremor, or diabetes insipidus manifestations like polyuria, polydipsia
Who to watch for while taking digoxin?
elderly and those with kidney injury because they have decreased kidney function and digoxin can build up so they must be monitored frequently
Ways to reduce ICP
elevate HOB maintain head/neck in neutral midline position give stool softener manage pain/fever cal dark quiet environment give oxygen hyperventilate before suctioning Do not suction too much [also no longer than 10 seconds]as this increases ICP
Hypothyroidism is said to cause lethargy and depression.So synthroid, the hormone replacement, is supposed to cause
elevated mood and more energy report symptoms like -High heart rate -Chest pain -Tremors as these could mean that patient is getting too much hormone repacement and it is causing symptoms of hyperthyroidism
What is the treatment for tension pneumothorax?
emergency large bore needle decompression chest tube
What are the most important adverse effects of calcium channel blockers?
end in -pine S&S: -Dizziness -Flushing -HA -Peripheral edema -Constipation
Grave's Disease/ hyperthyroidism
enlarged thyroid gland & excessive thyroid hormone secretion -Bounding rapid pulse is expected
Stress ulcers can develop in critically ill patients so what helps with this?
enterel feedings
Where should the nurse listen for a bruit in abdominal aneyurism
epigastric/periumbilical area
How often do we assess for suctioning with a vent
every 2 hours
How often do we move the ETT from one side of the mouth to the other
every 24 hrs to prevent ulcers
Emtpy a JP drain
every 4 to 12 hours or when it is 1/2 to 2/3 full, same thing as an ostomy compress the empty bulb side to side
How often should ostomy bags be changed?
every 5 to 10 days
Changing peripheral I.V tubing should occur no sooner than
every 72 hours [every 3 days]
Opiate withdrawal
everything is increased [INCREASE blood pressure, heart rate, breathing, seizures]
Symptoms of hyperthyroidism
everything is increased! like if someone is moving around a lot they would get all sweating and tired and lose weight •Anxiety/insomnia •Palpitations •Heat intolerance •Sweating •Weight loss w/out decreased appetite •Goiter •Hypertension •Hand/finger tremors •Eyeball protrusion
Narcotics like morphine can do what with obstructive sleep apnea symptoms
exacerbate them
Tetraology of fallot
exacerbation can happen when infant or child cries, becomes upset, or is feeding you immediately place them in KNEE CHEST position
Isotonic solutions [examples are 0.9% sodium chloride and lactated ringers] are given to
expand intravascular fluid volume and have the same osmolality as plasma These solutions replace fluid volume that was loss with -Vomiting and diarrhea -Burns -Traumatic injury -SHOCK
What is Guaifenesin (Mucinex)?
expectorant to facilitate mobilization of mucus
How is toxoplasmosis acquired?
exposure to infected cat feces or ingestion of undercooked meat or soil contaminated fruits/vegetables
How is hep A transmitted?
fecal-oral route
Where is amniotic fluid produced?
fetal kidney
Asterixis
flapping tremors of the hands To assess, have patient extend the arms and dorsiflex the wrist
AFTER cardiac catheterization position
flat and keep extremity straight
Delirium signs and symptoms
fluctuating acute mental status changes inattention with disorganized thinking like hallucinations altered level of consciousness and the presence of infection can cause delirium
Bounding pulses may be present in patients with
fluid overload related to hypertension
Treatment of SIADH
fluid restriction less than 1000 ml per day oral salt tablets to increase serum sodium •Hypertonic saline (3%) •Normal saline [0.9 % sodium chloride] I.V •Vasopressin receptor antagonists to decrease renal response to ADH
A patient with SIADH is going to need
fluid restrictions
Sodium intake leads to
fluid retention if you restrict sodium this leads to a decrease in water retention
While talking with a delusional patient
focus on the patient feelings and reinforce reality
Tuberculosis is curable but the medication regimen must be
followed and it takes about 6 months with unpleasant side effects
When do we give glucagon
for SEVERE hypoglycemia or if the client cannot take oral fluids
Signs of disseminated intravascular coagulation [DIC]
frank external bleeding like venipuncture site bleeding and internal bleeding like petechiae, ecchymosis, hematuria, and bloody stools, also respiratory distress from bleeding into the lungs what to do? REPLACE clotting factors + fresh frozen plasma and platelets
DASH diet
fruite/veggies/fat free/low fat dairy whole grains, fish, poltry, beans, seeds, nuts limit intake of sodium, sweets, sugary beverages, and red meats low in saturated and trans fats and rich in potassium, calcium, magnesium, fiber, and protein
SIRS
generalized inflammatory response to an infectious or noninfectious insult to the body [causes: fever, tachycardia, tachypnea]
Milking chest tubes
generally contraindicated because it messes with the pressure changes in the pleural space
copd teaching
get pneumonococcal and flu vaccine report any signs of infection
Sepsis should be treated immediately by
getting blood cultures then ANTIBIOTIC because it can lead to septic shock then multi organ dysfunction [MOD]
Phenytoin side effect
gingival hyperplasia
How to administer oral liquid med to a child?
give small amounts into the back of the cheek
If a diabetic patient shows symptoms of hypoglycemia, what does the nurse do after checking the blood glucose?
give them a carbohydrate snack!
If someone is having hypoglycemic reaction and glucose is below 70, what is the first thing to do?
give them simple carbs like orange juice or low fat milk
Which long acting insulins can you NOT mix?
glargine and detemir
Babinski sign for a child less than 1 year
great toe bends upward and smaller toes fan out. this is NORMAL
When are lithium levels considred toxic?
greater than 1.5
What is hirsutism?
happens in women where they develop male pattens of hair on the face, abdomen, chest and back CUSHING DISEASE can cause this
What is an aura?
happens right before a seizure [a warning the seizure will take place]
if injury to the spinal cord, what important precaution to take?
hard cervical collar + backboard
Cardiac catheterization
helps assess/diagnose coronary artery disease [CAD] catheter is placed in vein in leg up to heart After, a pressure dressing is applied and client is places supine with affected extremity flat for 2-3 hours If bleeding occurs, direct manual pressure is put above the puncture site peripheral pulses and pulses distal to site should be checked routinely after to make sure adequate blood flow is going to the extremities [cardiovascular check]
After a thyroidectomy, there shouldn't be swelling of the neck or increased pain. What could this indicate?
hematoma formation or increased tissue inflammation which AFFECT airway patency •This patient should be seen first
What is important after an abdominal aortic aneurysm repair?
hemodynamic stability because of graft leakage [Risk for hemorrhage is PRIORITY]
What are preventatives given before and after surgery to prevent venous thromboembolism?
heparin, enoxaparin, lovenox
Hepatic encephalopathy is caused from
high ammonia levels and elevated ammonia levels which are reflected on the patient as? Mental confusion
what is SIADH?
high antidiuretic hormone production leads to Water retention INCREASED total body water DILUTIONAL HYPONATREMIA -Signs of fluid volume overload, changes in loc, weight gain with edema, hypertension, tachycardia -SEIZURE PRECAUTIONS
HYPERcalcemia
high blood calcium level (>10.5)
Cystic fibrosis diet
high calorie, high fat, high protein
Hypovolemic patient should never be places in
high fowlers [these patients are HYPOtensive, patient should be place with head lower than upper body]
How to improve oxygenation flow?
high fowlers and take slow deep breaths
Respiratory alkalosis
high pH, LOW PaCO2
what will excess salt in diet do to BP?
higher BP
Early signs of phenytoin toxicity
horizontal nystagmus and gait unsteadiness
ACE inhibitors and angiotensin receptor blockers [ARBs] can cause
hyperkalemia
I.V iron can cause
hypersensitivity reactions
Decreased sweat production can lead to what?
hyperthermia because you are not sweating which naturally cools your body off
In dehydration the patient can.get
hypotensive and tachycardic
What does frostbite a actually mean
ice crystals form and the intracellular spaces causing peripheral vasoconstriction and reduced blood flow superficial frostbite looks: mottled, blue, or waxy yellow deeper frostibite looks: white heard and unable to sense touch and leads to gangrene
Intussusception [causes intestinal obstruction]
ileum telescopes into cecum, pain obstruction, edema, bowel ischemia, rectal bleeding [CURRANT JELLY stools]
In bacterial meningitis, what is the priority of care?
immediate antibiotics LP with csf is done to find causative organism
What does tamponade require?
immediate pericardiocentesis [to drain the fluid out of the pericardium]
What does a STAT order mean?
immediately and only once
Accidental exubation [dislodgment of Trach or ETT] is a medical emergency. if it happens, what does the nurse do?
immediately deliver rescue breaths using a bag valve mask and 100% oxygen until they can be reintubated
When is the best time to give a pregnant client that is nonimmune to MMR the vaccine?
immediately postpartum [after giving birth]
Buck's traction
immobilizes a fractured hip and reduce pain/swelling Skin/neurovascular assessments every 2-4 hrs Weights should not touch the ground Patient is supine
Buck traction
immobilizes hip and femur fractures •The weight pulls the limb into traction •The foot of the bed is elevated
Notify HCP if child temp is over 100.4 after
immunizations
Vastus lateralis for children less than 7 month is used for
immunizations
People taking corticosteroids are
immunocompromised and are prone to getting infections
Azathioprine
immunosuppressant drug causing bone marrow suppression and increases risk for infection
Hepatic encephalopathy
impaired ammonia metabolism causes cerebral edema s/s: -Change in LOC -Memory loss -Asterixis [flapping tremor] -Impaired handwriting -Hyperventilation w/ resp alkalosis Treatment: LACTULOSE traps ammnia and lowers pH, low protein, safety, rest
Where should there NOT be continuous bubbling in the chest tube drainage system?
in the air leak monitor
Inferior vena cava filter is placed where and does what?
in the femoral vein and catches blood clots from the legs from going to the lungs
Infertility
inability to conceive after unprotected intercourse for more than 12 months
Aphasia
inability to express thoughts and comprehend language
What is presbyopia?
inability to see things close up
What is hyperthyroidism?
increased T3 and T4 hormones which increases the metabolic rate
Lupus nephritis characteristics
increased creatinine and BUN abnormal urinalysis [protein, RBCs]can lead to irreversible kidney damage if not recognized early Elevated kidney tests tells us which organ is being attacked by inflammation
Glaucoma
increased intraocular pressure that can lead to Severe eye pain Reduced central vision Blurred vision Ocular redness
Dopamine
increases heart rate and increases blood pressure
Full weight bearing
independent; no assistance needed unless they are uncooperative or they are a fall risk, which is 1 person standby
What do when late decelerations is indicated in pregnancy and are they ever good>
indicate utero-placental insufficiency and URGENT
Oxytocin
induction or augmentation of labor •Should be given by an electronic infusion pump •Requires frequent mother/fetal assessment Adverse affects: maternal hypotension and water intoxication
What does a positive tuberculin skin test show?
induration [basically a white patch] surrounded by redness
Normal age for head lag
infants display head lag from birth through age 4-6 months
Once a woman's water breaks, this leaves her susceptible to what?
infection
What is a major adverse effect of TNF inhibitors like infliximab or adalimumab?
infection because they cause immunsuppression
What puts a patient at risk for preterm labor?
infection like periodontal disease
A positive reaction to a tuberculosis skin test TST indicated
infection only further testing is needed to see if TB is active therefore contagious [sputum culture required]
18 gauge catheter
infusing blood or large amounts of fluids in adults
What is the specific action of atropine?
inhibits the action of the vagus nerve [the vagus nerve slows the heart rate] This is why you do vagal nerve stimulation in hypertensive crisis ATROPINE increases heart rate
Signs of intussusception [Infants]
initial periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "currant jelly"
Lyme disease
initial symptoms: •Flu like headache •Fever •Myalgia •Fatigue •Bulls eye rash •Give ANTIBIOTICS to prevent it from spreading to heart brain or joints
Cauda equina is a medical emergency. WHY?
injury to L4 to L5 causing motor/sensory deficits from pressure on spinal nerves Acute spinal/lower back pain and bowel/bladder incontinence It's a medical emergency to prevent permanent damage
Stroke patients are at a high risk for
injury/falls because of one sided paralysis and confusion [hemiplagia]
What is Meniere disease
inner ear disorder S&S: •Vertigo •Tinnitus •Muffled hearing
Do not suction when
inserting a catheter
Metabolic syndrome- what s it?
insulin resistance syndrome
Stage 1 ulcer
intact skin non-blanchable with localized redness
Fetal alcohol syndrome causes what?
intellectual disability + developmental delay
What are some physical signs of peripheral arterial disease?
intermittent calf muscle pain rest pain hair loss decreased peripheral pulses cool dry shiny skin thick brittle nails gangrene ulcers [all of these signs + symptoms are in the extremities]
What should always be at beside for a gastric lavage?
intubation and suction supplies; it removes toxins and irrigates stomach within one hour after overdose
Symptoms of cold stress in a newborn
irritability, lethargy, decreased temp, hypoxia, bradycardia, weak suck and cry, emesis, hypoglycemia
Ipratropium
is the short acting anticholinergic used as a rescue med for COPD and asthma
When you have a cast, which type of exercises should be performed
isometric exercises Contraction of the affected muscle without movement of the joint
A patient with diabetes does not get dextrose solutions why?
it can increase blood glucose levels
A pregnant client in supine position is never really good because
it compresse the aorta and vena cava
After being found TB positive, more tests are needed to see if
it is latent TB where its noncontagious, or active TB where it is contagious through the air [AIRBORNE PRECAUTIONS]
What is the purpose of continuous bladder irrigation?
it is prescribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what does an elevated PTT mean?
it is taking your blood way too long to clot therefore this is a problem because you could bleed out; there may be a coagulation factor deficiency
What is nitroglycerin used for?
its a vasodilator that restores myocardial perfusion
Position after a vascular graft of extremity
keep extremity straight and bed rest for 24 hours
Where should NTG tabs be stores?
keep in original container stored away from light and heat sources but easily accessible
Lithium and sodium are closely related in the body so
keep their levels normal
Wilms tumor is on the
kidney presents as abnormal bulging on one side of child's abdomen DO NOT PALPATE ABDOMEN fatigue in children - kidney tumor usually occurs in children age <5 - usually discovered when caregivers note an unusual bulging/swelling on one side of abdomen
I.V iodinated contrast used for CT scan can cause
kidney injury; metformin is discontinued on the day of I.V iodine contrast exposure
Best fluid solution to give after a burn
lactated ringers [LR] because it most closely resembles blood than all of the others
What drug is going to decrease ammonia levels?
lactulose
When is stridor heard?
laryngospasm or edema of upper airway
What is "sunset eyes" in an infant a sign of?
late sign of increased intracranial pressure [ICP]/hydrocephalus
What position to place a pregnant woman in for seizure precautions?
left side
Recal irrigation and enema position
left side lying for gravity flow natural direction of the colon [SIMS]
Avoid sex with active herpes lesions and disease can still be contracted if
lesions are not present so always use a condom
What number is considered severe neutropenia?
less than 500
In postmortem care, it is ok to
let family members assist with care
Location of the phlebostatic axis [for measuring continuous arterial BP readings]
level of atria at 4th ICS 1/2 anterior/posterior diameter
Body positioning after cardiac catherterization
lie flat
After a [LP] teaching
lie flat with no pillow for at least 4 hours to increase fluid intake
Trisomy 18 and Trisomy 13
life expectancy is a few weeks after birth Discuss palliative/end of life care
When prioritizing care especially in a disaster, remember
life over limb [cut the limb to save the life]
Hemolytic uremic syndrome
life threatening complication of E. coli diarrhea
After a splenectomy, patients are subject to what?
lifelong infections MINOR infection can quickly become life threatening Report any signs of infection ASAP
How do stools look with a biliary obstruction
light gray clay colored
In continuous bladder irrigation, what should the urine look like?
light pink with no clots bladder spasms are expected
Lithium is cleared by the kidneys so a minor change in kidney function could cause
lithium toxicity
Do not take NSAIDs while on
lithium, instead use acetaminophen for pain relief
What must be checked before starting statin drugs
liver function tests because they can cause hepatotoxicity can cause muscle aches and weakness take with evening meal or at bedtime
What is trismus
locked jaw
What to wear to protect yourself from mosquitoes
long sleeve, long pants, and light colors
A porlonged QT interval is usually the result of electrolyte imbalances so what is usually the treatment?
look for electrolyte in the answer
Homonymous hemianopsia
loss in half of the visual field on the same side
symptom of macular degeneration
loss of central field of vision
What is the death rattle?
loud rattling sound when breathing in a person that is actively dying caused by increased secretions
Thrombocytopenia
low platelet count; so this increases risk for bleeding;<100,000 platelet count
Liver cirrhosis patients will have
low platelets
Ulcerative colitis diet
low residue, high protein high calorie
Heart failure patients should be on a what type of diet?
low salt, low fluid intake
heart failure, ascites, hypertension diet
low sodium (fluid overload states)
Heart failure patients must take which very important 2 actions?
low sodium diet and take medications
Magensium toxicity also causes
low urine output like urinary output less than 30 mL per hr
What is a barium enema
lower G.I series used to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, etc
Hydralazine is a vasodilator usually given to what?
lower blood pressure
The elderly tend to have
lower body temps 100.2 is febrile in an elderly patient
Radon [element] can cause
lung cancer
What is given for preeclampsia?
magnesium sulfate [anti-convulsant] to prevent seizures
Most important thing to do to prevent stroke in a patient with a ton of risk factors and hypertension
make sure they take antihypertensives
Second degree [partial thickness] burns
moist or weeping wounds with blisters and shiny, fluid-filled vesicles and moderate to severe pain
What is in the LPN scope of practice?
monitor RN findings reinforce education routine procedures like catheterization most medication administrations ostomy care tube patency and enteral feeding specific assessments
What is a major complication of RA?
morning stiffness. how to fix? take a warm shower or bath
What are some early signs of rhabdomyolysis?
muscle aches or weakness- immediately report to hcp!
Use of dantrolene
muscles spasms & malignant hyperthermia!!!
What does botulism cause?
muslce paralysis [IRREVERSIBLE]
How should I.V potassium be administered?
must be given in an infusion pump so the rate can be regulated •NOT by gravity infusion •It should also always be diluted
Ptosis [eye drooping] is common with
myesthenia gravis
Post surgical patients are usually prescrbed which prn med to help from the opioid drugs they were on
naloxone (Narcan) but it wears off in 1-2 hours so be prepared to give more than once monitor respiratory rate and give oxygen
Aortic stenosis
narrowing of orifice between left ventricle and aorta blood is NOT properly pumped to body Patients may experience passing out and shortness of breath [SOB] and sudden death That is why they should rest and not exericse before surgery
Early signs of digoxin toxicity
nausea and vomiting
What are signs of a bowel obstruction?
nausea, vomiting, abdominal distention, and dec stool production
what is myopia?
nearsightedness, have trouble seeing objects at a distance
What can a baby born to an opioid dependent mom have?
neonatal abstinence syndrome the baby experiences opiod withdrawal 24-48 hrs after birth
Vancomycin can case what 2 things
nephrotoxicity and ototoxicity
Taking folic acid during pregnancy prevents what?
neural tube defects and spina bifida
Parasthesia is an early sign of what?
neurovascular impairment
is supine positioning good for pregnant lady
no because it decreases uteroplacental blood flow and fetal oxygen
In parallel play, there is
no group involvement [child plays individually next to other children]
Can UAP tell familes and alert other departments why patient is on precautions?
no this is for RN to do
Do we massage the site after I.M shots
no!
Stridor is
noisy breathing [upper airway obstruction or laryngeal edema]
What is a magnetic resonance cholangiopancreatography
noninvasive diagnostic test to see biliary, hepatic, and pancreativ ducts via MRI •Contrast (IV gadolinium) given before contraindications of the procedure that should be assessed by nurse beforehand: -Any metal/electrical implants -Any allergic reaction to contrast -Pregnancy the contrast crosses the placenta
Early symptoms of hepatitis B?
nonspecific like -Malaise -N/V -Abdominal pain
Given what meds in hypovolemic shock [besides fluids] ?
norepinephrine + dopamine
Blood transfusions can only be run with what other fluid?
normal saline [0.9% sodium chloride]
A patient with renal or heart failure are usually not given
normal saline because this promotes fluid retention [the kidney is not function therefore extra fluid will just accumulate in the body worsening both conditions]
Local reactions like swelling and erythma, minor illness, exposure of an infectious source, and allergies to non-vaccine components are
not contraindications to immunization
Always try least restrictive before using restraint. NCLEX wants you to know this so most likely the answer is
not going to be apply restraint
If infants have cold stress, they are
not going to shiver
Addison's disease
occurs when the adrenal glands do NOT produce enough of the hormones cortisol or aldosterone; hyperpigmentation of the skin Remember this about Addison's disease, it causes: -HYPOnatremia -HYPOtension -HYPERkalemia -HYPOglycemia
Somatic delusion
of having some physical defect or disease
Pyloric stenosis is the one with
olive shaped mass on the abdomen and causes projectile vomiting
A sucking chest wound indicates what and is caused from what?
open pneumothorax, -Air is rushing in with each inspiration and fills the pleural space
Constricted pupils seen with
opioid use
Nausea and pruritis are common effects of
opioids
Basically, LPNs can give any medication that doesn't invovlve the veins right? So, what can they give?
oral, sub q, IM
Swimming pool water does not cause
otitis media It actually causes otitis externa (swimmers ear)
Gentamycin
ototoxicity
Advere reaction to gentamicin
ototoxicity and nephrotoxicity
Meds should be stored specifically how when hiding from children?
out of sight up in a cabinet and locked
A high troponin value like anything
over 0.5 for troponin I and 0.1 for troponin T indicates cardiac muscle damage
Vancomycin should be given slowly
over 60 mintes to prevent red man syndrome
Conception occurs around the time of
ovulation and is about 14 days from the beginning of the last menstrual period [LMP]
What is failure to capture on a heart rhythm?
pacemaker spikes that are not followed by QRS complexes the pacemaker may be malfunctioning related to the machine like battery or something Patient will be bradycardic and hypotensive The nurse should put on transcutaneous pacemaker pads to regulate the heart beat until the problem with the pacemaker is fixed Transcutaneous pacemaker [TP] is uncomfortable for the patient so give analgesia [painkiller]
What are some symtpoms fo osteoarthritis?
pain exacerabetd by weight bearing crepitus morning stiffness 10-15 mins decrease joint mobility and ROM
LPN can monitor
pain level
Nursing management for hemroidectomy mainly provide
pain relief and prevent constipation NSAIDs Warm sitz baths High fiber diet Lots of fluids Stool softener
A normal kidney is usually not
palpable, if it is it could indicate disease
Proton pump inhibitors examples
pantoprazole and omeprazole given for GERD, ulcer treatment and prophylaxis
Flail chest what happens?
paradoxical breathing from multiple RIB FRACTURES INSPIRATION chest moves inward and EXPIRATION chest moves outwards [it is the opposite of what should be occurring during ventilation] FRICTION RUB can puncture lung or vessels this can likely lead to hemothorax or pneumothorax
Remember with bulemia, which gland is swollen?
parotid gland
What is scanning speech?
pasues between syllables and is expected with multiple sclerosis [MS]
Jaundice in a newborn in the FIRST 24 hours is considered
pathological [ABNORMAL!]
Delusions of reference
patient believe songs newspaper articles the radio and other things are personal and significant to them
LPNs can measure
peak expiratory flow
Best indicator of moving air in an asthma patient is wha?
peak flow
Gingival hyperplasia is en expected side effect of
phenytoin Good oral hygiene can limit symptoms
Target therapy for polycythemia
phlebotomy to remove some of those RBCs
Jaundice that develops after 24 hrs is
physiologic NORMAL because their liver is still maturing but it should disappear in about a week Jaundice before or after 24 hours should still be reported to the HCP
What is suspected in a pregnant woman having painless vaginal bleeding after 20 weeks gestation?
placenta previa
Projection
placing ones own thoughts, feelings, or impulses onto someone else
what is parallel play that toddlers do?
play alongside rather than with other children
Some children may be in pain but may not show it when
playing
Chronic alcohol abusers suffer from
poor nutrition from improper diet and altered nutrient absorption Which vitamin are they specifically at RISK for deficiency in? thiamine
What does a CPAP machine do
positive pressure opens the airway that was previously cut off
If a newborn's heart rate is below 100 bpm, what does the nurse immediately do?
positive pressure ventilation
What is spironolactone and what is it used in?
potassium sparing diuretic used in liver failure, ascites, and edema to promote diuresis
Stridor is NOT good at all as it indicates
potential UPPER airway obstruction
Disaster hits and home care nurse needs to prioritize care, defintely one that needs
pre-filled insulin syringes because they could become hyperglycemic without insulin and lead to life threatening diabetic ketoacidosis
Swelling of the hands + feet + face are expected findings of what pregnant condition?
preeclampsia
How much weight you should gain during pregnancy is determined by
pregnancy BMI If you are obese, you should gain less weight during pregnancy
Warfarin should not be given during
pregnancy because it crosses the placenta and can cause fetal bleeding
If a female patient is getting radioactive iodine to treat hyperthyroidism, what should you get for her?
pregnancy test PRIOR After radioactive iodine treatment [RAI], clients will take supplemental iodine for life
Do not take ACE inhibitors if
pregnant or planning to become pregnant
whos at a high risk fr cold stress and why?
premature babies due to decreased brown adipose tissue
3rd degree AV heart block ECG changes
presents as a regular rate & rhythm with disassociated P waves and QRS complexes
Braden scale ASSESS for what?
pressure ulcer
Priority intervention for eczema
prevent scratching
When are rhonchi primarily heard?
primarily during expiration but also may be present during inspiration
Bronchioltiis
priority as it requires frequent suctioning
In priority questions, chest pain is
priority regrdless of age
When is I.V epinephrine indicated?
profound hypotension or when a patient does not repsond to I.M epinephrine and fluid resuscitation
What rises heartburn in pregnancy?
progesterone
Beneficience
promote good and do whats best for client
After feeding an infant, what does placing the infant in the side lying position do
promotes gastric emptying and reduces the risk of vomiting
If Group b streptococcus [GBS] status is unknown in a pregnant woman, always give what?
prophylactic antibiotics [35 to 37 weeks]
You should not be symptomatic of anything after a
prostatectomy
Bladder spasms are expected after a
prostatectomy with a catheter
Diverticular disease causes what?
protrusions form off the large intestine- they can become inflamed and infected causing acute diverticulitis
All chest pain is considered cardiac until
proven otherwise Need to go in to ER right away fror chest pain to get an ECG
Left-to-right cardiac shunts results
pulmonary congestion [increases pulmonary pressure, which increases risk for heart failure] Compensatory mechanisms [examples are tachycardia, diaphoresis] result from sympathetic stimulation
Acute onset dyspnea and cough with pink frothy sputum [hemotypsis] indicates what?
pulmonary edema [PE]
What to do to if pregnant client has prolapsed cord?
put client on their hands and knees in the knee-chest position
What is a central venous catheter [CVC]?
put in a "central" vein [examples of veins used subclavian, internal jugular, femoral]
What is the first thing you do with autonomic dysreflexia?
raise the head of bed [HOB] then treat the cause
How to treat acute urinary retention?
rapid comeplete bladder decompression
What is red man syndrome and why does it happen
rapid infusion of vancomycin •flushing •erythema •pruritis on face neck and chest
Acute asthma exacerbation
rapid labored respirations using accessory mmuscles
Radiation and chemo affect what type of cells first?
rapidly dividing cells like -Oral mucosa -G.I tract -Bone marrow This causes -Oral ulcerations -Nausea and vomiting Llow blood counts of RBCs, WBCs, platelets
A newly admitted client with Gillian Barr Syndrome GBS is not stable. it is unclear with the analysis when it will stop aka it could
reach the respiratory system
Reactive non-stress test versus non-reactive nonstress test
reactive nonstress test you have a baseline of 110-160/min, moderate variability and 2 or more accelerations in 20 mins and nonreactive does not meet criteria for reactivity
If asked to float to an unfamiliar unit, you can not
refuse but you can clarify the skills that you are unable to perform
Nursing interventions for pin care
regular assessment to make sure pins are not loose or showing signs of infection, notify HCP if signs of infection are present or pins are loose Neuro checks are performed at the affected extremity Clean with -hydrogen peroxide -saline -chlorhexidine
Superventricular tacycardia SVT
regular, narrow QRS complex tachycardia with heart rate at 150 to 220 per minute Stimulants like cocaine, caffeine, nicotine can cause SVT Client may experience Palpitations Dyspnea Angina I.V adenosine is treatment of choice [Mnemonic adenosine for SVT] Vagal stimulation the lines up are very narrow
So what to do with dehydrated infant?
rehydrate is PRIORITY- bolus normal saline for an infant
LOWER UTI
remember FUB Frequency, Urgency, Burning
Incentive spirometry
remember I for INHALE
If infiltration or phlebitis occur, what should the nurse do with either of these situations immediately?
remove the I.V device
If signs of phlebitis are present immediately
removel of the catheter because phlebitis can lead to clot formation [thrombophlebitis] or serious bloodstream infection [sepsis] S&S: pain, swelling, warmth at site and redness
Billroth II surgery [Gastrojejunostomy]
removes part of the stomach and shortens upper GI tract dumping syndrome is possible post-op
Additional heart sounds like S3 and S4 require
reporting to HCP to look for cardiac problems
If a central vein catheter [CVC] is occluded while trying to flush with 10 mL of NS, the first thing to do is
reposition the patient's arm and then check for tubing kinks
Treatment/Interventions - 3rd degree AV heart block
requires temporary or permanent pacing to stabilize patient [pacemaker]
With a chest tube, intermittent bubbling in the water seal chamber consistent with
respirations and it is normal
Hypoventilating can cause a buildup of carbon dioxide in the blood and can lead to
respiratory acidosis
Any condition that causes a decrease in respiratory rate is at risk for developing
respiratory acidosis [less CO2 is being blown off]
If mg toxicity is not reconized early by the DTRs, what can it lead to ?
respiratory depression + cardiac arrest
After Botox, watch for
respiratory problems like dysphagia [difficulty swallowing] and respiratory paralysis
What can cause atelectasis after surgery?
retained secretions
seeing small flashes of light is a sign of
retinal detachment
Regression
returning to a previous level of development
What is a serious complication of statin meds?
rhabdomyolysis
Rheumatoid factor [RF] is POSITIVE in clients with
rhematoid arhtiritis
When doing compressions on an infant, where do you place your fingers?
right below imaginary horizontal line between the nipples
Body positioning after liver biopsy
right side [to put pressure on the liver]
What causes pink frothy sputum in PE?
ruptured bronchial veins from the mix of blood and airway fluids
Meniere disease key to remember
safety falls -Salt restricted diet to prevent further fluid build up
Fourth-degree [full-thickness] burns
same as third-degree [dry & inelastic with waxy white, leathery, or charred black color] plus involvement of fascia, muscle, and/or bone tissue Pain is NOT major feature due to nerve damage
What type of drainage is expected after a surgical procedure?
serosanguinous [pink]
Diabetic ketoacidosis
severe form of hyperglycemia, greater than 250 mg per deciliter. Glucose can not be taken out of the bloodstream without insulin which the pancreas cannot produce The body begins to break down fat stores into ketones [this increases the acidity of the blood]
Epiglottis- what is it?
severe inflammatory obstruction caused by H. influenzae MEDICAL EMERGENCY!! Symptoms progress fast from being asymptomatic to an occluded airway Have emergency intubation available
What are the steps to deliver a dose via a metered dose inhaler MDI?
shake MDI and attach to spacer exhale completely place lips tightly around mouthpiece deliver one puff of med into spacer take a slow deep breath and hold it for 10 scds rinse mouth with water
If a pregnant women is positive for GBS, what happens?
she gets prophylactic antibiotics so that she does not pass it to her baby during labor because it can cause harmful things like pneumonia or neonatal GBS sepsis
Albuterol
short term rescue inhaler that treats reversible airway obstruction with asthma If not effective, use an inhaled corticosteroid
Remember that kids under 2 have
shorter Eustachian tubes therefore they are more prone to respiratory infections that may cause otitis media exposure to smoke, pacifiers, and drinking from a bottle when lying down are all causes of otitis media
PTT should be 1.5 to 2.0 times the control value
should not be equal to the control value
Acute cholecystitis may present with
shoulder pain
Body positioning for enema administration
sims
Enema administration position
sims
C diff room needs
single
How to relieve pain in acute pericarditis?
sit up & lean forward [orthopnea]
What is acanthosis nigricans?
skin condition patches of darkened thick skin
Cardinal physical sign of Parvo A.K.A fifth disease is what?
slapped cheek rash •Spread person to person especially with respiratory secretions
dementia characteristic
slow onset family members usually notice first gradual progressive inability to remember recent events
If there is discomfort when infusing KCL, what should the nurse do?
slow the rate don't stop it because the patient needs the potassium replacement
Undiluted morphine I.V push should be given
slowly over 4 to 5 mins
Metoprolol
slows the HR and lowers the BP
Fever and raised pustules=
smallpox
Why should a patient take diuretic in the morning and not at bedtime
so they won't have to pee a lot at night
In fibromyalgia patients feel "point tenderness" which is where
specific points on their body hurt
Transporters never need to know an exact diagnosis, but rather just
specific things like is the patient fragile
what does DOPAMINE do?
speeds up the heart rate increases cardiac contractility
A tuft of hair at base of spine in a newborn indicates what?
spina bifida
Birth defect associated with depakote during pregnancy
spina bifida
What is spina bifida
spinal cord contents protrude through vertebrae an there is a tuft of hair
How to asisst a falling client?
stand behind and let out leg for supporting them to ground
Excessive hair may be clipped but not shaved when trying to
start an I.V Shaving can cause abrasions which can introduce pathogens
What to do if evisceration happens?
stay calm and remain with patient Notify HCP Make them NPO Cover wound with saturated dressings to not dry out place in low fowlers [FLAT] with knees flexed Assess vitals every 15 minutes
Surgical wounds are re-dressed using
sterile technique remove old dressing with clean gloves and apply new dressing with sterile gloves
Epoetin is what?
stiumlates production of erthropoeitin [makes RBCs) that treats anemia in chronic kidney disease because the kdineys have a big role in blood cell production [kidney disease causes anemia because erythropoietin is not produced by the damaged kidney]
What is Docusate
stool softener
What is docusate?
stool softener
If mg toxicity occurs, what should be done?
stop infusion and give its antidote
How to measure urinary output in diapers?
subtract the weight of the diaper when dry from its weight when wet
What to do when the high pressure alarm on he MV sounds?
suction
Where in the chest tube drainage system is gentle, continuous bubbling normal?
suction control chamber •If more water is needed, add sterile water
hyperventilate [pre-oxygenate] before
suctioning
20-22 guage
sufficient for giving general I.V fluids an meds to adults [Non-urgent, general sizes]
Trimethoprim-sulfamethoxazole [Bactrim]
sulfa antibiotic
How are orthostatic vitals taken?
supine, sitting, then standing with 2 minutes between each position change
Do not stick anthing into vagina with
suspected placenta previa
When is atropine given?
symptomatic bradycardia [Increases heart rate]
Rheumatoid arthritis
systemic inflammation of the synovial joints are swollen and painful joints Usually it starts in smaller joints and affects clients ability to button clothing and difficulty completing ADLs what should you do? -Moist heat for stiffness -Range of motion [ROM] exercises -ICE on painful joints as needed -Allow periods of rest in the afternoon
Orthostatic vitals are present when what happens to systolic/diastolic BP?
systolic drops at least 20 diastolic drops at least 10 pulse usually rises about 20
Transplanted hearts are expected to be
tachycardic like 90-110
Warfrain teaching
take at same time each day Don't have a diet high in vitamin k
UAPS can assist with passive and active ROM exercises that were
taught by the nurse or PT
What is the first sign of puberty change in boys?
testicular enlargement
Knee-chest position is used for a hypoxic/cyanotic infant with
tetralogy of fallot
What does it mean when an induration is shown?
that the person has been exposed to TB Patient has developed antibodies Patient is infected with TB bacteria However, this does not tell if the infection is active or latent so further testing is required [sputum is needed to know it is active or not]
ASSESS implanted pacemakers for electrical capture of the heart rhythm but also mechanical capture of the heart rate by getting a central pulse like
the APICAL pulse this is to make sure that the pacemaker that is producing a rhythm actually corresponds with the body and giving a pulse therefore pumping blood through the body
Before ABGs are taken, what test must be performed?
the Allen's test
What is phenylketonuria PKU?
the amino acid phenylaline is unconverted causing neurological damage
What is quickening?
the awareness of fetal movement [around 16 weeks]
What are symptoms of withdrawal from opioid in infants?
the baby is HYPERSENSITIVE •Irritability •High pitched cry •Jitteriness •Sneezing •Diarrhea •Vomiting •Poor feeding •Treatment: opioid therapy like methadone or morphine
ASSESS for drugs that a pregnant client has had in the last 4 hours if they are in labor because
the baby might be born with respiratory depression [if the mom took opioids in the last 4 hours]
What does fasting do to the body?
the body goes into starvation mode Metabolism slows down and cortisol (stress hormone) increases Body breaks down muscle and converts amino acids to glucose -Fluid loss -Depletion of essential nutrients -Fatigue -HA -Dehydration -Dizziness -Muscle weakness
What is rhabdomyolysis?
the breakdown of muscle tissue releases muscle fiber contents into the blood •These substances can cause kidney damage
What is a saline lock?
the cap that goes onto an IV insertion catheter •It allows you the ability to stop giving I.V fluids and then start again at a later time without having to do another venipuncture
Orthodox jews cannot take capsules why?
the gelatin is NOT kosher (fit to be consumed)
If spine injury is suspected, do NOT use
the head tilt chin lift method as this could damage the spine further What do you use instead? Jaw thrust maneuver
Most frequet sites of bleeding in a hemophiliac are where?
the joints
What is wazy flexibility?
the patients limbs stay in the same position in which they are placed by another person
Placental abruption
the placenta prematurely detaches from the uterine wall
What does an anti-nuclear body tell us?
the presense of ANA means the body produces antibodies against its own DNA and material So this should be positive in autoimmune disorders
What is the moro reflex?
the startle reflex where the nurse holds the baby and lets it "drop" in her hands and the baby's legs and arms move up in a startle motion/crying
If the patient's INR is 2 times the control value then this is
the therapeutic effect [normal finding]
Nurses should ask clients what they think caused illness as a way to assess
their understandings and beliefs of lliness
If a 2 year old is exhibiting symptoms or other abnormal behaviors + communication then assess
their vocabulary because at age 2 kids should have a vocab of about 300 words
antisocial personality disorder
they disregard rules, hx of irresponsible behavior, and blame others for their actions. SET LIMITS with them make them aware of the rules and acceptable behaviors
Clients with alcoholism are commonly deficient in which vitamin?
thiamine
Cystic fibrosis [CF] kids have
thick secretions and lifelong respiratory infections
What is Kawasaki disease and what are he symptoms?
think of it as one big body rash •Systemic vasculitis in children presenting with more than 5 day of a fever •Conjuntivitis •Lymphadenopathy •Mucositis •Hand and foot swelling •A rash •Can cause coronary artery aneurisms •Some skin peeling •Joint pain •Irritability
Having chest pain typical of acute MI for 6 hours or less and no absolute contraindications you can then be given what
thrombolytic therapy
What is hypothyroidism?
thyroid horome deficiency, low T3 and T4 levels which decreases the metabolic rate
How to stop epistaxis
tilt the head forward and apply direct continuous pressure on the alaes (sides) for about 5-20 mins hold a cold washcloth to the bridge of nose for vasoconstriction keep child calm and quiet
What is the purpose of the water seal chamber in a chest tube>
to prevent air from flowing to the client •Up and down movement here with inspiration and expiration is normal •As lung re-expands this will decrease
During pregnancy, why are women in a hypercoaguble state?
to protect them from hemorrhage but there is a risk for DVT ambulate the patient soon after childbirth
What is the purpose of unfractioned heparin?
to slow the time it takes the blood to clot thereby keeping the current clot from getting bigger and preventing new ones from forming
What is magnesium sulfate used for?
to stop seizures during pregnancy therapeutic level is 4 to 7
while giving an enema if the patients reposrts cramping or pain, it is most likely being given
too fast What should the nurse do? stop for 30 seconds and then start at a slower rate
polycythemia
too many RBCs, WBCs, and PLATELETS leading to increased hematocrit and blood volume, thicker blood, and abnormal clotting Hematocrit is 66 is an abnormal finding
Metronidazole (Flagyl)
treatmemt for trichomoniasis Do NOT take with ALCOHOL for for 24 after completing treatment Can cause a metallic taste Cause urine to change a deep red-brown color
Carbidopa-levodopa
treats parkinson's; improves spontaneous activity seen with this disease
What is Levetiracetam (Keppra) used for?
treats seizures the preferred antiepileptic med
Oligohydramnios increases the risk for what?
umbilical cord compression and pulmonary hypoplasia [lung underdevelopment] so needs additional personnel and continuous fetal monitoring [FHR]
Sodium nitroprusside
vasodilator used in hypertensive emergencies can produce a sudden and drastic drop in blood pressure causing symptomatic hypotension monitor blood pressure closely every 5 to 10 mins
What is NTG?
vasodilator used to treat stable angina Sublingual tablet or spray Relives pain in about 3 minutes and lasts 30-40 mins RECOMMENDED dose: 1 tab or 1 spray every 5 minutes for a max of 3 doses If chest pain continues after 5 mins after first dose, call 911
Norepinephrine (Levophed)
vasopresser [increases blood pressure] used to increase -Stroke volume [SV] -Cardiac output [CO] -MAP
Kids with autism spectrum disorders are usually
visual. Do not touch them or make eye contact
Oral isoniazid [INH] interferes with what vitamin?
vitamin B6 [depletes this vitamin in the body] resulting in peripheral neuropathy If taking isoniazid you should take a vitamin B supplement
What can determine if a person with heart problems can resume sexual activity?
walking 1 block or climbing 2 flights of stairs without symptoms
Don't take aspirin/alcohol when on
warfarin
The liver is highly vascular; after a biopsy always
watch out for bleeding
Where should there be intermittent bubbling on a chest tube?
water-seal chamber
What are some reasons for venipuncture to be contraindicted in upper extremities?
weakness paralysis infection AV fistula or graft mastectomy
What is the most accurate indicator of fluid loss or gain?
weight measurements
Refeeding syndrome
what happens after a starved and severely malnourished person finally gets fed via any of the routes electrolytes distubrnaces happen and declines in phosphorus, potassium, and magnesium happen
If schizophrenia is hearing voices, alwasy assess
what those voices are saying to the patient [even if it's a delusion assess how the patient perceives the voices]
When should an ostomy bag be emptied? (when it is how full?)
when it is 1/3 full
When do *advanced directives* go into effect?
when person is unable to speak for him/herself due to either: 1. Mental Incapacity or coma [GCS score less than or equal to 7] 2. Aphasia (as soon as signed; directives can always be changed later by patient)
What are epsteins pearls?
white pearl like cysts on gum and palate that are benign and usually go away within a few weeks
What should the nurse do if the chest tube becomes separated from drainage tubing and is not contaminated?
wipe the end with antiseptic immediately reconnect it, and secure with tape
When walking upstairs use the mnemonic [up with the good and down with the bad]
with injuries and a cane and going upstairs, always hold cane on the STRONG side and move cane before moving weak leg
When does the umbilical cord detach from body?
within 2 weeks
If patients are having an ischemic stroke, they are given tissue plasminogen activator tPA to dissolve the clot. How soon must tPA be given?
within 3 to 4.5 hours of onset of symptoms
What happens in diabetic ketoacidosis?
without insulin, the body breaks down fat for fuel, resulting in ketones, polyuria, rapid respirations (kussmauls sign) DKA is serious and can lead to death
Presence of neurological change in pregnant women may indicate what?
worsening preeclampsia
If a patient has phantom limb pain after an amputation, what can the nurse do for comfort?
wrap and apply ice/heat
What are some non pharmacologic interventions that help with phantom limb pain?
wrapping the extremity or applying ice
At 12 months can in infant go fom standing to siting
yes
HIV precautions- blood borne so STANDARD PRECAUTIONS are good unless
you anticipate splashing body fluids in that case wear a gown + gloves
When giving an IM injection use which method?
z-track
Intermittent peritoneal dialysis
•4 days a week for 10 hours a day •Can be automated or manual
Ovarian cancer symptoms
•ABDOMINAL BLOATING •PELVIC PAIN OR PRESSURE •Early satiety •Abdominal, back, or leg pain •Urinary urgency/frequency G.I disturbances
What are signs of perforation?
•Abdominal pain [with shoulder tip pain] •Positive rebound tenderness •Gaurding •Abdominal distension •Boardlike/rigid abdomen
What do we do as the nurse for BPH
•Administer meds [5-alpha reductive inhibitor and alpha-blocking agents] •Suprapubic cystostomy (mini urostomy to drain bladder) •Prostatectomy [TURP, suprapubic resection through bladder, retropubic resection through abdomen] •Assess for shock and hemorrhage •Avoid long periods of sitting and strenous activity
What are some early symptoms of Increased Cranial Pressure?
•Altered LOC •Headache •Abnormal breathing •Increased blood pressure •Slow pulse [decreased heart rate] •Vomiting
Treatment for premature ventricular contraction [PVC]
•Amiodarione [potassium antidysrhythmic] •Betablockers •Procainamide [sodium antidysrhythmic]
What are the signs of Hemolytic uremic syndrome?
•Anemia [pallor] •Low platelets [petechiae and purpura] •Acute kidney injury [low urine output]
What is methotrexate?
•Antineoplastic [treat malignancies] •Immunosuppressant [lowers immunity] Uses: -Chemotherapy -Rheumatoid arthritis -Psoriasis -Abortions
Nurse actions during a seizure
•Assist them to lie down is standing/sitting, •Put them on side for patent airway •Loosen tight clothing •Give oxygen as needed •Remove objects from immediate area •Document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it) •Never put anything in mouth or restrain them since muscle contractions can occur during a seizure
Signs of phenytoin toxicity
•Ataxia •Nystagmus •Slurred speech •Decreased mentation
What to check labs while giving ace inhibitors?
•BUN/creatinine •Potassium •Blood pressure
What do we do for a patient with a detached retina
•Bedrest [don't bend forward, no excessive movements] •Area of detachment needs to be in dependent position •Surgery to reattach the retina to the choroid (gas or air bubble used to apply pressure the the retina) •No hair washing for 1 week •Avoid strenuous activity for 3 months
What are the major side effects with methotrexate?
•Bone marrow suppression •Hepatotoxicity •Fetal death
What are adverse affects of methotrexate?
•Bone marrow suppression •Hepatotoxicity •G.I irritation
Cushing's triad
•Bradycardia •Slowed respiratory rate •Widened pulse pressure
What are the 5 dangers we need to educate the public on for S&S of glaucoma
•Brow arching •Halos around lights •Blurry vision •Diminished peripheral vision •Headache or eye pain
Treatment for A Fib
•Calcium channel blockers •Digoxin •Beta blockers •CARDIOVERSON •Warfarin [anticoagulant because A.fib forms clots]
Nursing interventions for a child with ADHD in hospital
•Calm •Structured •Organized •Consistent environment •Written chart or list of daily activities
When is epinephrine given?
•Cardiac arrest •Anaphylactic reactions •Severe asthma attack
Thyroid storm
•Caused by untreated HYPERthyroidism •INCREASED temp, pulses and BP •Give hypothermia blanket, O2, PTU, potassium iodine
Signs and symptoms of air/pulmonary embolism
•Chest pain •Difficulty breathing •Tachycardia •Pale/Cyanotic •Sense of impending doom
Symptoms of active tuberculosis
•Cough •Fever/chills •Malaise •Weight loss •Night sweats •Anorexia •Fatigue •Positive T skin test •Abnormal chest xray •Transmissible [airborne]
What are normal expected findings after a colonoscopy?
•Cramping •Gas •Watery stools
Diabetes insipidus [DI]
•DECREASED antidiuretic hormone [ADH] [excessive urination] •Excessive urine output and thirst •Dehydration •Weakness We always get a urine specific gravity to tell the doctor how aggressively to treat it
Glomerulonephritis
•Damage to the glomerulus caused by an immunological action that results in proliferative and inflammatory changes within the glomeruli •Acute glomerulonephritis = Group A beta hemolytic strep infection that is somewhere else in the body (like a skin or throat strep infection) •Usually happens 10 days after the skin or throat infection
Signs of cold stress
•Decreased temp •Altered mental status •Bradycardia •Hypoxia •Weak cry
What can cause lithium toxicity in a patient taking lithium?
•Dehydration •Decreased renal function •Diet low in sodium •Drug-drug interactions like NSAIDs
Classic heart attack symptoms
•Dizziness •Sweating •Cold clammy skin •shortness of breath [SOB] •n/v •Ischemic chest pain •Pain radiating to neck, jaw, left shoulder, arms, epigastrum
How to help improve sleep
•Dont nap during day •Avoid physical activity at least 5 hours before bed 20 mins of natural sunlight •Avoid caffeine after noon •Avoid alcohol or smoking at bedtime •Relaxing activity before bed •Decrease environmental stimuli •Avoid heavy meals or large amounts of fluid at bedtime •Warm milk or small carbs before bed
Symptoms of a pleural effusion
•Dyspnea on exertion •Non-productive cough •Diminshed breath sounds •Dullness to percussion •Dec tactile fremitus
Complications of preeclampsia?
•Eclampsia [seizure] •Placental abruption [detachment of the placental from uterine wall] •HELLP [hemolysis, elevated liver enzymes, low platelet] syndrome [leads to anemia, dyspnea, jaundice, petechia, clotting disorder, thrombocytopenia]
What does the FLACC scale stand for?
•Facial grimace •Leg movement •Activity •Crying •Consolibility
Possible complications from ear surgery
•Facial nerve damage •Infection •Vertigo, tinnitus
symptoms of mononucleosis
•Fatigue •Fever •Sore throat •Splenomegaly •Hepatomegaly •Swollen lymoh nodes •Contact sports should be avoided •Caused by the epstein barr virus
Hyperparathyroidism [HIGH calcium in the blood]
•Fatigue •Muscle weakness •Renal calculi •Back/joint pain and pathological fractures Too much calcium [HIGH calcium makes you go slow]
What is placenta previa
•First and second trimester bleeding •Third trimester bleeding that is sudden, bright red, profuse and PAINLESS •This is where the placenta is implanted in the lower uterine segment usually near or over the cervical opening •No vaginal or rectal exams
Hypervolemia
•Fluid overload •Bounding pulse •Shortness of breath •Dyspnea •Rales/crackles [pulmonary edema] •Peripheral edema [dependent edema] •High blood pressure •Urine specific gravity less than 1.010 [diluted due to fluid overload]
What are some symptoms of placental abruption?
•Frequent contractions •Abdominal pain •Dark red vaginal bleeding
RSV interventions
•Give oxygen •Elevate head of the bed [HOB] •Airway suction [decrease mucus] •Give antipyretics [treat fever] •I.V fluids [to treat dehydration caused by dyspnea] CONTACT & DROPLET isolation
Signs of bulimia someone may notice
•Going to bathroom after meals •Large amonts of food disappearing •Hidden wrappers/empty food containers like sweets •Intense physical exercise •Parotid gland enlargement •Calluses on hands •Preoccupation with weight food and dieting
A child is having separation anxiety in the hospital, what are some things nurses can do to reduce the anxiety
•Have parent leave familiar objects in room •Don't leave them alone when upset •Establish daily schedule like one at home •Give child time to play
Acceptable methods of blood collection in *neonate*
•Heel stick •Venipuncture [drawing blood from vein] considered less painful and often requires fewer punctures to obtain sample, especially if larger volume is needed
high ammonia can cause what
•Hepatic encephalopathy •Confusion •Lethargy •Asterixis [hand flapping] •Coma
What do we usually see with BPH S&S
•Hesitancy [dribbling, weak urinary system] •Frequency, dysuria, urgency, nocturia •Hematuria before or after voiding •Urinary retention
Preeclampsia 2 main things:
•High blood pressure •Protein in urine •Edema [expected but not part of the criteria]
Scarlet fever symptoms
•High fever •Bright red "sandpaper" rash that begins on chest, •Strawberry tongue •Treat with penicillin
Bacterial meningitis
•High fever •Change in LOC •Nuchal rigidity •Meningeal signs [POSITIVE kernig and brudzinski signs] treat with antibiotics
Malignant hyperthermia symptoms
•High fever •Rigid jaw •Tachypnea •Tachycardia
Proper nasal spray administration
•High fowlers •Head bowed slightly forward •Occlude one nostril and put it in open one •Point tip toward side and away from center •Spray while inhaling deeply
Mnemonic to remember high vs low blood sugar
•Hot and dry? Sugar is high •Cold and clammy? Need some candy
What are early signs of bleeding into the retroperitoneal space?
•Hypotension •Back pain •Flank ecchymosis [grey turner sign] •Hematoma formation •Diminshed distal pulses
ICP vs Shock vital signs
•ICP: High BP, low pulse, low respirations •Shock: Low BP, high pulse, high respirations
After calcium gluconate, what 3 things are given to actually decrease the potassium in a hyperkalemic patient?
•IV regular insulin with dextrose [Increases in these two decreases potassium in the blood] •Sodium polystyrene sulfonate •Hemodialiysis
Hypovolemia
•Increased temp •Rapid/weak pulse •Increased respirations •Decrease blood pressure •Anxiety •Urine specific gravity greater than 1.030 [concentrated due to dehydration caused by decreased intravascular volume]
What are foods high in vitamin k?
•Leafy green veggies •Asparagus •Brocoli •Kale •Brussel sprout •Spinach
Acute hemolytic transfusion reaction
•Life threatening reaction •Develops within the first 15 mins S & S are: -Chills -Fever -Lower back pain -Tachycardia -Tachypnea -HYPOtension
Amyotrophic lateral sclerosis (ALS) typical symptoms
•Limb weakness •Dysarthria [difficulty speaking] •Dysphagia
Septic arthritis symptoms
•Localized pain •Limited ROM •Systemic infection symptoms like fever
What is tiotropium (Spiriva) and what/how is it used for?
•Long acting, 24 hour, anticholinergic inhaled med used to control COPD •Given using capsule-inhaler system where the capsule is placed in the device and a buttom is pressed to put a hole in the capsule and the powder is dispered thru the inhaler •It should NOT be used as a rescue med for example if someone has trouble breathing, that's when you would use the short acting like albuterol
Liver dysfunction abnormalities
•Low albumin •High ammonia •Elevated INR/PT •Increased bilirubin •Low platelets
If it is normal for some children to have a reaction to MMR or V vaccine 5 to 12 days after getting it symptoms like
•Low grade fever •Mild rash •Swelling/redness at injection site •Irritable, restless •Watch that their temp does not get too high because this could lead to febrile seizures •Tell them to give acetaminophen if temperature goes over 102
PKU
•Low phenylalanine diet •Specal infant formula •No meat eggs or dairy
Examples of live vaccines are:
•MMR [measles, mumps and rubella] •Varicella
Characteristics of fetal alcohol syndrome
•Microcephaly •Short eyelids [palpebral fissure] •Flat midface [cheekbones] •Smooth philtrum [between nose and upper lip] •Thin upper lip
Infant formula key points
•Never dilute or concentrate formula •Wash tops of forumla cans before opening •Unused prepare formula can be used for up to 48 hours and then discarded after •To warm prepared bottle, place in pan of hot water •Never microwave formula •Any forumula left over should be thrown out immediately when done
Myasthenia gravis clinical manifestations
•Ocular [ptosis: drooling eyelid] •Facial muscle weakness [difficulty speaking, swallowing, chewing] •Can progress to *respiratory muscles* and affect *breathing*
Noninvasive positive airway pressure ventilation [NIPPV]
•Often prescribed short-term to support gas exchange in patient with -Moderate to severe COPD exacerbations and -Acidosis [pH <7.3] -Hypercapnia [PaCO2 >45 mmHg] -Can prevent the need for tracheal intubation -Administered until underlying cause of ventilatory failure is reversed with parmacologic therapy
Symptoms of anaphylaxis
•Oral/airway swelling •Dizziness •Tachycardic •Stridor/hoarseness •Wheezing •Rash •Pruritis •Flushing •N/V Abdominal pain •Treat with IM epinephrine
Liver biopsy during and after
•Patient supine with right arm above head during after •Right side lying and pillow under puncture site This reduces risk for hemorrhage by adding pressure on the puncture site [this is why the patient lies on the right side because the liver is on the right side]
Cigarettes and pregnant can cause what things
•Perinatal loss •SIDS •Low birth weight •Premature baby
Characteristics of a basilar skull fracture
•Periorbital hematomas [raccoon eyes] •Csf fluid •Rhinorrhea •Battle sign [behind the ear bruising]
S&S of right sided heart failure
•Peripheral edema and anorexia •Distended neck veins •Polycythemia
What is abnormal after a cystoscopy
•Pink tinged urine •Frequency •Dysuria •Abdominal discomfort •Bladder spasms
Incentive spirometer use
•Piston rises with each deep inhalation •Prevents atelectasis & pneumonia in post op patients •5-10 breaths per session every hour patient is awake
Neonatal CPR positioning
•Placed on back with neck slightly extended as if sniffing a flower •A blanket or towel roll can be placed under shoulders elevating them 0.75 to 1.0 inches off mattress
In all of these conditions, breath sounds are either decreased or absent
•Pleural effusion •Pneumothorax •Emphysema •Atelectasis
Latent TB infection
•Positive TST •Negative chest xray •Asymptomatic •Non-transmissible •Steroids can convert latent to active TB
MMR is a live vaccine and live vaccines are contraindicated during what?
•Pregnant •Immunocompromised
Hip dysplasia in an older child
•Preliminary traction •Open reduction •Hip spica cast
Primary use of radioactive iodine?
•Primary treatment for nonpregnant adults with hyperthyroid disorders [Graves disease] -Radioactive iodine [RAI] damages or destroys thyroid tissue and can result in hypothyroidism •Clients need to take thyroid supplementation [levothyroxine] for life
High in sodium foods examples
•Processed meat •Cheese •Brea •Canned soup/veggies •Frozen dinners
Examples of extrapyramidal symptoms
•Pseudoparkinsonism •Dystonia
Left side heart failure symptoms
•Pulmonary edema •Dyspnea •Orthopnea •Crackles
Nursing care for patients in acute mania
•Quiet structured non stimulating environment •One on one activities instead of group •Limiting contact with other people •High protein High calories [finger foods easy to eat]
What are some symptoms that a pregnant woman has HELLP?
•RUQ pain •Nausea + vomiting •Malaise
What do we do for penetrating eye injuries (pointed or sharp objects)
•Refer to a surgeon •Cover the eye with a patch
Classic presentation of a fractured hip
•Shortened •Abducted •Externally rotated leg
Incentive spirometry steps
•Sit upright •Exhale and seal lips tight on mouthpiece •Inhale •Hold breath, then exhale
What will a child with epiglottitis present like?
•Sitting in tripod position •Be drooling •Restless •Anxious
What are some common findings 5 to 10 days after a tonsillectomy?
•Slight ear pain •Low grade fever •Bad breath
Process for a burn at home
•Soak in cool water to stop buring process •Remove clothing around burn •Cover with a clean dry cloth •Don't put any meds or anything on the wound
Signs of Epiglottitis
•Sore throat •Dysphagia [difficulty swallowing] •Drooling •Respiratory distress •Sitting up/leaning forward •An EMERGENCY- PREPARE FOR EMERGENCY AIRWAY [INTUBATION/TRACHEOSTOMY]
Interventions to prevent abdominal wound dehiscence
•Stool softeners •Antiemetics •Use abdominal binder •Monitor blood sugar to maintain tight glucose control to decrease infection risk and promote wound healing Splint the abdomen with pillow when coughing or moving
Introducing a child to table foods: 5-6 months
•Strained veggies •Strained meat
Placental abruption symptoms
•Sudden onset of dark red vaginal bleeding •Abdominal pain •Frequent uterine contractions
Symptoms of hypoglycemia
•Sweating and pallor •Irritable •Tremors/weakness •Tachycardic •Drowsiness •Hunger -If the brain becomes glucose depleted, this could cause seizures and coma
Symptoms of malignant hyperthermia
•Tachycardia •Tachypnea •Rigid jaw •High fever •It is triggered by drugs used for anesthesia Give them I.V DANTROLENE
When a patient is taking lithium, be careful when taking which medications in addition because they can increase lithium levels and lead to toxicity?
•Thiazide diuretics •NSAIDs •Antidepressants
Treatment for sinus tachycardia
•Treat underlying problem •Beta blockers •Calcium channel blockers or Cardioversion
Hypoglycemia symptoms
•Tremors •Palpitations •Anxiety •Restlessness •Sweating •Pallor
What do we do for a woman in labor who has an unreassuring FHR
•Turn to the LEFT side •Give O2 [8 to 10 L per min] •Stop the Pitocin •Increase I.V fluids (LR and NS) •Give tocolytics
What are some classic signs of DVT?
•Unilateral leg edema •Local warmth •Erythema •Low grade fever (PS a negative homan is normal)
Herpes Zoster [Shingles] characteristics
•Unilateral, linear [dermatomal distribution] •Vesicular rash [fluid filled blisters]
Signs of croup
•Upper respiratory tract symptoms •Hoarseness •Barking cough •Stridor •Respiratory distress
Oliguric [little urine] phase of acute renal failure
•Urinary output of less than 0.5 ml/kg/hr •N & V •INCREASED Serum potassium, BUN, and creatinine Increased calcium and sodium Decreased p.H [increased acidity of blood] Anemia Pulmonary edema + congestive heart failure Hypertension Albuminuria [which causes low albumin in the blood and thus leads to ascites]
Imbalances caused by vomiting or diarrhea
•Vomiting (LOSS of acid): metabolic alkalosis •Diarrhea (LOSS of base): metabolic acidosis •We use Narcan to treat (respiratory depression caused by opioid: respiratory acidosis -LOW breathing, LOW blowing off of CO2: respiratory acidosis
What do we do for conjunctivitis
•Warm, moist compress •Topical antibiotics •Hydrocortisone ophthalmic ointment Caused by virus, bacteria, and allergies
Physical findings of peripheral arterial disease
•Weak/absent peripheral pulses •Poor wound healing •Cool pallid skin •Shiny skin •Missing hair
What are symptoms of an asthma exacerbation?
•Wheezing •Coughing •Chest tightness •Dyspnea •Retractions •Cough may be the earliest sign
Characteristics of neuroleptic malignant syndrome
•fever •muscle rigidity •altered mental status •sweating •hypertension •tachycardia
Hypopokalemia can cause
•heart arrythmias •muscle cramps •weakness
What are some expected symptoms in a TBI?
•low grade constant HA •slowness in thinking •memory problems •loss of balance •poor coordination •constant exhaustion •increased sensitivity to light •heightened irritability •ALL symptoms that can last up to 6 weeks
Near drowning hypothermia
•warm I.V fluids •blankets •oxygen •weak and thready pulse
Infants that do not have a complete closure of the esophageal sphincter are therefore prone to
gastroesophageal reflux This is why they spit up after feeds How can this be reduced? Burp during and after FEEDS to get air out HOLD baby upright for 20 to 30 after feeding Feed the baby smaller and more frequent meals
What do advanced care documents include?
healthy care proxy and living will
Should bulemic patients be allowed to keep a daily diary in the hospotal?
yes, to keep track of the amount and type of food the client has eaten
Delirium
•Acute •Consciousness impaired •Fluctuating consciousness •Reversible
Chronic phase of acute renal failure
•Anemia Azotemia [uric acid in the blood] Acidosis Fluid retention Urinary output alterations
Delirium signs
•Sudden onset of fluctuating mental status changes and inattention with disorganized thinking and/or altered level of consciousness •Think of the patient that I had that was lying in bed and reaching up grabbing something in the air with her hand that was not there
Treatment for Premature atrial contraction
•Treat the underlying cause [alcohol, tobacco, caffeine]
what are common SE of immunizations?
•mild fever •soreness and redness at injection site •anorexia/fussiness in the first 24 hours
What is the normal pulse rate for a 1 year old
100-160
Hgb [Hemoglobin]
12 to 18
Fundal height [just need to memorzie this]
12 weeks: just above pubic symphysis 16 weeks: halfway between public symbiosis and umbilicus 20-22 weeks: reaches umbilicus 36 weeks: xiphoid process
Identity vs. Role Confusion
12-20 yrs Provide same age support group
What does the anterior fontanel close?
18 mon
Voluntary control over urethral and anal sphincters occurs about
18 to 24 months of age
When should quickening happen?
18-20 weeks in first time baby havers and sooner for previous moms
When do we assume a baby has developmental hip dysplasia
When the head of the femur does not fit in the acetabulum Uneven gluteal folds and uneven thigh creases Infant lays on back with legs flexed Click sound when legs are moved to abduction Delays in walking/limping with older children
Placenta previa
When the placenta covers the opening of the mothers uterus It usually presents with painless vaginal bleeding
Amlodipine + Nifedipine
calcium chennal blcokers
What is the antidote for magnesium toxicity?
calcium gluconate 10%
Calcium carbonate drug is what?
calcium supplement
Nutrients in cows milk
calcum and vitamin D NOT vitamin k, iron, or fiber
Metoclopramide
can cause tardive dyskinesia
What does magnesium toxicty cause?
central nervous system depression
What type of device would be placed in a client with sudden kidney failure requiring immediate dialysis?
central venous catheter
What is Ancef?
cephalosporin antibiotic thats active against skin flora like staff, given before and after surgery
low platelets= ICP bleeding
change in LOC
indicatrs of increased ICP
change in LOC (often the first sign), cushings triad, and pupillary changes)
Basically what 2 things do you do before and after each feeding or medication given through an NG tube?
check placement and flush tube with sterile water
RN can still delegate a task that is less than LPN for example
checking a pulse oximeter
What is the priority when giving 2 meds at the same time?
checking for drug compatibility
Acute pericarditis
chest pain worse on inspiration pericardial friction rub
The varicella zoster virus can cause what 2 things?
chicken pox and shingles
24 gauge [smallest bore or hole of needle]
children and elderly with frail veins
Peripheral Arterial Disease (PAD)
chronic, atherosclerotic disease caused by buildup of plaque in arteries
Intractible diarrhea
chronic, diarrhea that is hard to control
The trauma room after a patient should be
cleaned this is part of postmortem care aka cleaning blood from floor
Negativism
client resists instructions or attempts to be moved
General rule of thumb for engaging in sexual activity in cardiac clients
climb 2 flights of stairs without symptoms then you're good to resume sexual activities
stage 4
full thickness skin loss exposed muscle tendon or bone
Unstageable pressure ulcer
full thickness skin loss ulcer base covered by slough [yellow] and eschar [black] that needs to be removed to stage
Stage 3
full thickness skin loss with visible sub q fat
A patient with a total knee arthroplasty should be what by discharge?
fully weight bearing
I.V proton pump inhibitors are given for
gastric ulcer bleeding
Pulse assessment post abdominal aortic aneurysm [AAA] repair
-Pulses can be absent for 4-12 hours after surgery due to vasospasm -Pedal pulse decreased from baseline or absent pulse with a painful, cool, or mottled extremity can indicate presence of arterial or graft occlusion [life-threatening] [This why neuro-vascular checks are important to do]
Peripheral arterial pulses
0 absent 1+ weak 2+ normal 3+ increased, full, bounding
Hyperkalemia priority interventions
1. Administer I.V 50% dextrose + I.V regular insulin rapidly 2. If ECG changes are present, give calcium gluconate FIRST •HIGH insulin causes LOW potassium [or decreases high potassium] •LOW insulin causes HIGH potassium •HYPERkalemia=HYPOglycemia
Subjective [presumptive] signs of pregnancy
1. Amenorrhea 2. Nausea and vomiting 3. Excessive fatigue 4. urinary frequency 5. Breast tenderness 6. Quickening
Pulmonary embolism (PE) signs & symptoms
1. Anxiety/restlessness 2. Pleuritic chest pain/tightness 3. Shortness of breath 4. Tachycardia 5. Hypoxemia 6. Hemoptysis [blood in sputum]
Appropriate order of actions when client found on floor
1. Assessment of [physiological stability] ABCs 2. Assessment of injuries 3. Moving client 4. Notifications [REPORT] 5. Documentation
Disorders associated with manipulative behaviors
1. Borderline & antisocial personality disorders 2. Substance abuse problems 3. Somatic symptom disorder 4. Bipolar disorder [during manic phase]
Cognitive behavioral therapy [CBT] 5 basic components
•Education about pts disorder •Self observing and monitoring •Relaxation techniques •Cognitive restructuring •Behavioral strategies
What are some things that put patients at risk for respiratory depression?
•Elderly age •Underlying pulmonary condition •History [hx] of snoring •Obesity •Cigarette smokers •Opiate naive •Post surgery within 24 hours
Before a lumbar puncture teaching
•Empty bladder •Lateral recumbent (fetal position) or sitting •Pain may be felt radiating down the leg but should be temporary
Position for a BELOW the knee amputation
•Foot of bed elevated for the FIRST 24 hours •Position prone daily to help with hip extension
Causes of meningitis
•Infection [virus, bacterial, fungal] •Neurosurgical procedures •Basilar skull fractures •Otitis media •Mastoiditis
What sign and symptom will we see in an infant that has a mom on heroin
•Irritable •Poor sucking
Later signs of hep B?
•Jaundice •Weight loss •Clay colored stools •Thrombocytopenia [low clotting due to liver dysfunction/destruction]
Right side heart failure
•Jugular vein distention [JVD] •Hepatomegaly [enlarged liver] •Splenomegaly [enlarged spleen] •Ascites [enlarged abdomen] •Edema
Hypercalcemia
•Muscle weakness •Lack of coordination •Abdominal pain •Constipation •Pathological fractures •Confusion •Absent/DECREASED DTRs [DECREASED deep tendon reflexes] •Sedative effect on CNS •Body runs SLOW with High calcium
What are some signs of a bowel obstruction?
•Nausea, vomiting •Abdominal distention •Dec stool
For Muslim people, what do we have to remember about their diets
•No Pork •No Alcohol •No fermented fruits/veggies •Meat must be Halal [drained of blood] •Foods with special value: Figs, olives, dates, honey, milk and buttermilk
When would we hold off on a polio vaccine (IPV)
If the client is allergic to -Neomycin -Streptomycin -Polymyxin B Also remember this: "Neo Is Marrying Valery" [this mnemonic tells you what immunizations are NOT given if allergic to neomycin + streptomycin + polymyxin B] •I: IPV (inactivated polio vaccine) •M: MMR •V: varicella
Someone suffering from PTSD
has flashbakcs/nightmares of the event and their body responds with rapid heart rate and sweating They avoid reminders of the trauma like places or activities They feel detached and numb They are hyper-vigilant Cannot sleep Cannot concentrate
If the child swallowed something and is conscious and about to cough or make sounds, what should the nurse do first
have them try to cough it up, but signs of respiraotory distress require immediate intervention
Rule of thumb position for respirator and cardiac patients is with
head of the bed [HOB] elevated
Crackles - when are they heard?
heard typically only during inspiration
Cardiac tamponade
heart cannot squeeze effectively Muffled heart tones Cardiac output [CO] drops Blood pressure [HYPOtension] drops Tachycardic Jugular vein distention [JVD] Distant heart sounds Requires pericardiocentesis (draining of fluid in pericardial sac)
An S3 heart sound is a sign of what?
heart failure
Bumetanide (Bumex)
heart failure to diurese
Do not take licorice root with that medications?
heart meds
If a patient gets a transplant, they are then given immunosuppressants to
help prevent organ rejection HOWEVER, what does this make them susceptible to? infections
Droplet precautions
spiderman! -Sepsis -Scarlet fever -Streptococcal pharyngitis -Parvovirus -Pneumonia -Pertussis -Influenza -Diptheria -Epiglottitis -Rubella -Mumps -Meningitis -Mycoplasma or meningeal pneumonia -AdeNovirus [Private room and mask]
Immediately report any signs of infection after having a
splenectomy because the spleen is part of the immune system and filters the blood
New graduate RNs can be assigned
stable clients who do not require specialized skill or knowledge and can discharge them if they are stable or ones that require new teaching
Asthma
frequent cough at night
Erythropoeitin [Epogen]
stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease
Filgrastinm (Neupogen)
stimulates neutrophil production
If you are having a patient do orthostatic vitals and they become symptomatic like dizzy, you need to
stop the measurement and have them lie in bed
Coarction of the aorta
strong upper pulses and weak lower pulses
Ovarian cancer symptoms
subtle S&S: •Abdominal pain •Pelvic pain or pressure •Abdominal girth [circumference] increases •Urinary urgency/frequency •G.I disturbances
Body positioning after a lumbar puncture
supine
A UTI bacteria can ascend from the bladdder and go to
the kidney where you get pyelonephritis and have Nausea /Vomiting Fever Chills Flank pain Costovertebral angle tenderness Need prompt treatment because this could lead to sepsis
The lower the I.V catheter guage number,
the larger the bore or hole of the needle
What are vegans at risk for since they dont eat animal products?
tingling and numbness from vitamin B 12 deficiency affects the entire nervous system from peripheral nerves to spinal cord and brain
What is atropine used for?
to decrease saliva production before surgery
What is the purpose of hemoglobin?
to pick up oxygen in the lungs and carry it to the tissues
2 major purposes of amniotic fluid
to prevent cord compression and promote lung development
SIADH
too much ADH is produced causing -Water retention -Increased total body water -Dilutional HYPOnatremia -Can be caused by some central nerve disorders -ADH can sometimes be secreted by lung cancer cells
What do you do if a tooth falls
tooth death can occur in one hour so put the tooth in milk and get help
Why should you not give a baby a bottle of milk or other sugary substance to go to bed?
tooth decay
Clozapine
tretment of schizophrenia AGRANULOCYTOSIS MUST CHECK complete blood count [CBC]
At 1 year of age, what should an infant weigh?
triple their birth weight
At 12 months, an infants weight should be
tripled the birth weight
There is no cure or treatment for
trisomy 18
True or fale: antiiotics can affect INR value?
true
Glaucoma eye sees
tunnel vision
Airborne precautions
"MTV" [mnemonic to remember airborne disease] Measles Tuberculosis Varicella •Wear N95 respirator •Neg pressure room and HEPA •Clients suspected are to wear a surgical mask after triage
Late stage Alzheimer's disease - eating problems
-Inability to feed oneself -Dysphagia [difficulty swallowing]
Chronic bronchitis interventions
-Increase fluids to 2 to 3 L which helps thin secretions -Humidifier -Guaifenesin an expectorant -Abdominal breahting using huff method [sit in chair, lean forward and expel it out] -Chest physiotherapy [to break off mucus plugs to be expectorated]
Pre-blood transfusion nursing interventions
-Instruct client to void prior to starting transfusion
Symptoms of hyponatremia in infants
-Irritability + lethargy -In severe cases, hypothermia [cold intolerance] and seizure activity
Chest physiotherapy
-Parents are taught -BEFORE meals -Give supplemental pancreatic enzymes -Hungry but underweight -High protein high calorie
Correct CPR
-Place heel of hand in center of chest between nipples -Compress 2 to 2.4 inches deep -Compress at a rate of 100 to 120 compressions -30 compressions per 2 breaths
Containdications to thrombolytic [for example: Alteplase]
-Previous brain bleed -Ischemic stroke or head trauma within 3 months -Active bleeding -Cerebral aneurysm •All thrombolytics lyse the pathologic clot [a clot that causes an MI] and may lyse other clots so bleeding is a complication
What to do if patient is on oxytocin and late decels, fetal bradycardia, tachycardia, and decreased variability happen, what does the nurse do in order?
-Stop the oxcytocin right away -Put patient in side lying position -Give oxygen [8 to 10 liters via face mask] -I.V fluid bolus -Maybe give terbutaline -Notify HCP -Document
Suspected child abuse [injury patterns in nonaccidental trauma]
-Subdural & epidural hematomas -Retinal hemorrhage on fundoscopic examination* -Frenulum tears & gingival lesions -Linear type immersion burns -Long bone fractures in humerus or femur
Pre-procedure instructions for barium enema
-Take a cathartic (magnesium citrate, polythylene glycol) to empty stool from the colon -CLD day before procedure for bowel prep and to avoid dehydration [avoid red/purple liquids] -NPO 8 hours before test -Abdominal cramping may be felt during procedure
Barium enema teaching pre op
-Take a cathartic to empty stool from colon -CLD the day before for bowel prep and prevent dehydration -Avoid red or purple foo -Do not eat or drink 8 hours before test -May feel abdominal cramping during test
Teaching for PEDICULOSIS=LICE "Pediculosis capitis"
-Treatment with pediculicide [usually permethrin 1% cream] -Soak childs comb and hair accessories in boiling water for 10 minutes -May need to treat child's sibling if they share things -Use a nit comb daily for 2 weeks after treatment -Vaccum furniture, carpet, etc -Wash linens/beding in hot and dry on hot -Pets do not need to be treated as human lice does not get on animals
Abnormal findings post circumcision
-Unusual swelling with increasing redness -Odor, abnormal discharge -Excessive bleeding -Absent/decreased urine output [notify HCP if no voiding happens within 6 to 8 hours]
Teaching for an electroencephalogram [EEG]
-Wash hair before to remove oils from scalp -Avoid caffeine, stimlants, and CNS depressants before the test -Test is not painful, electrodes are just placed on the head
Circumcision care
-Washing hands before providing care -Applying petroleum jelly to glans penis at diaper changes [unless plastic ring was used] for 3 to 7 days to prevent adhering to diaper -Site typically heals within 7 to 10 days -Expect yellow exudate on penis after the first day, a normal part of healing -Use warm water [without soap] to remove urine/feces during diaper changes or at least twice daily
electroconvulsive therapy ECT
-a treatment for major depression disorder [MDD] with psychotic features or when patients are highly suicidal and are not responsing to meds and need immediate treatment to keep them safe where they can not wait for meds -ELECTRODES applied to scalp causing a brief convulsion -General anesthesia and muscle relaxant given -Common side effects after? confusion and memory loss
Conditions when rhonchi are heard
1. Bronchitis 2. Cystic fibrosis 3. Some types of pneumonia may clear with coughing or suctioning
HYPOcalcemia can result in
1. Tetany 2. Laryngeal stridor 3. Seizures 4. Cardiac dysthymia
PT
11-15 Warfarin Therapeutic Range: 1.5-2 times normal value [which ranges from 16.5 to 30]
S&S of syphillis
A papule - like lesion in the vaginal area
Anuria vs oliguria vs polyuria vs dysuria vs enuresis
Anuria = <100 ml in 24 hours (basically nothing) Oliguria = 100-400 ml in 24 hours Polyuria = >2000 ml in 24 hours (too much!) Dysuria = painful or difficult voiding Enuresis = bed wetting in a child over 5 (usually have small bladder and more common in males)
How to safely transfer a patient for the first time
Assess if they can bear weight Assess whether they are cooperative
What is Dexamethasone?
corticosteroid that reduced inflammation and cerebral edema with brain injury and tumors
What is the primary drugs to treat Addison's disease
corticosteroids
If myopathy is present, what will be very elevated?
creatinine kinase
Venturi mask
delivers a guaranteed oxygen concentration to patients with unstable COPD
Bile
made in liver and helps aid in digestion
Low platelets
petechiae + spontaneous bleeding
Which lab results are expected for a patient with severe COPD: anemia, neutropenia, polycythemia, or thrombocytopenia?
polycythemia [excessive RBC] because patient is in hypoxemic state so the body makes more RBCs to compensate
Desmopressin
treat bedwetting
Low albumin can cause what
•Fluid overload •Edema •Weight gain •ASCITES
Placenta previa symptoms
•Painless vaginal bleeding •Ultrasound shows placenta covering cervical os
Remember the 5Ps to compartment syndrome
•Paresthesia •Pain •Pressure •Palor •Pulselessness
What is the kernig sign?
•Patient lies supine •thigh is flexed at right angle •If POSITIVE, the thigh will hurts to extend
Compartment syndrome
"7 P's" 1. Parasthesia 2. Pain 3. Pressure 4. Pallor 5. Pulselessness 6. Poikilothermia (cool skin temp) 7. Paralysis never elevated if these develop
Care after an open radical prostatectomy
-Avoid anything that causes strain on the rectal area so no suppositories or enemas to NOT mess with healing of surgical area -Ways to prevent constipation [fiber, lots of water, exercise] -Do not strain with a BM
Before/after a kidney biopsy
-Discontinue ALL anti-platelet and blood thinners one week before -Type and cross match in case blood is needed -Place in prone position -Monitor vitals every 15 minutes [q15] for FIRST hour -Place patient on procedure side to put pressure -Bed rest for 24 hrs
Care of Alzheimer's patient at home
-Keyed deadbolts -Med bracelet -Remove clutter and throw rugs -Grab bars in showers/bathrooms -Household hazards removed
Teaching for ace inhibitors
-Kidney levels in the first week -CONTRAINDICATED in pregnancy -Watch foods high in potassium since can cause a mild hyperkalemia -Get out of bed slowly -Possible allergic reaction like rash or angioedema
What is homonymous hemianopsia [loss of vision on one eye]?
-Loss of one half of the field of vision on the same side in both eyes -So like a patient can only see one side of their plate -Teach them to scan with their good eye by turning their head -They are at RISK for neglecting that affected eye or not eating food placed on the side of the affected eye [the side they cannot see] -They are also at RISK for safety related injuried because they simply can not see well
A post term baby findings
-deep creases and peeling on soles of feet
Creatinine
0.6 to 1.2
Lithium therpeutic range
0.6 to 1.2
What is the fluid of choice for the rapid correction of hypotension?
0.9 sodium chloride
When calculating GTPAL, twins count as
1 in the preterm and term categories
Hemophilia Patient Education
1. Avoid medications that inhibit platelet aggregation (for example ibuprofen & aspirin) 2. Avoid IM injections [SubQ is preferred] 3. Avoid contact sports & safety hazards (non-contact activities - swimming, jogging, tennis - and use of protective equipment are preferred) 4. Dental hygiene is necesssary [soft toothbrushes should be used] 5. MedicAlert bracelets should be worn at all times
Pneumonia assessment findings
1. Crackles 2. Fever, chills, productive cough, dysnpea, and pleuritic chest pain 3. Increased vocal/tactile fremitus 4. Bronchial breath sounds in peripheral lung fields can be an early sign 5. Unequal chest expansion 6. Dullness on percussion
Testicular self-examination (TSE) instructions
1. Perform monthly on same day 2. Perform while taking a warm shower 3. Use both hands to feel each testis separately 4. Palpate each testicle gently, using the thumb and first 2 fingers 5. Check that the testicle is normally egg-shaped and moveable with a smooth surface
Nursing interventions for manipulative behaviors
1. Setting limits that are realistic, nonpunitive, and enforceable 2. Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors 3. ENFORCING all unit, hospital, or center rules 4. Ensuring CONSISTENCY from all staff members in enforcing set limits
What are normal fetal heart tones?
110-160
What is a normal newborn heart rate
110-160
Diet of a full term infant
120 cal/kg/day Human milk is ideal for FIRST 0-12 months If using formula, should be for 12 months, before going to regular cows milk
Therapeutic INR is what
2-3
Abdominal surgery and other procedures with bowel manipulation cause what for the bowels for the first 24-48 hours?
ABSENT bowel sounds!
What is Cor Pulmonale
Abnormal enlargement of the right side [right sided heart failure] of the heart as a result of disease of the lungs or the pulmonary blood vessels Choose EDEMA or jugular vein distention (JVD) if its a choice
Care of infant wearing pavlik harness
Assess skin 2-3 times daily Put shirt and socks under harness Put diapers underneath straps Leave pavlik harness on at all times Adjusting of straps should only be done by HCP, not nurse or parent
Side effects of Haldol
Galactorrhea Lactation Gynecomastia
What medical / surgical procedure can often lead to dumping syndrome
Gastrojejunostomy Have the patient lay down after eating!
Which disease should you avoid when you are pregnant?
German measles! AKA Rubella
Weight bearing and increasing mechanical stress on the bones actually
INCREASES bone density [treats osteoporosis]
When a patient has a thyroidectomy, what is MOST important to assess
If the parathyroid accidentally gets nicked during thyroidectomy surgery, there can be a DECREASE in serum calcium Must look for tingling around the mouth, toes, fingers, and also for muscular twitching
What is an external fixation
Metal device with metal scerws placed into a bone to stabilize it There is an adjustable external rod Infection with pins is a complication Antibiotics must be started right away to prevent osteomyelitis -Nurse gives sterile pin care with 1/2 strength hydrogen peroxide and normal saline OR chlorhexidine -Neurovascular assessment afterwards -With an external fixator early ambulation is key with device in place
Orienting client to the bedside unit is the job of RN or UAP?
RN
Relation of varicella/chicken pox/herpes zoster
Varicella causes [chickenpox in childhood] and then the virus goes dormant •Reactivation occurs with compromised immune system [for example aging or immunosuppression) •Can get a vaccination to prevent SHINGLES
Atrial fibrillation priority
Ventricular rate control by giving -Diltiazem -metorpolol -Digoxin These meds decrease ventricular response rate to less than 100 beats per min
Chemotherapy results in bone marrow suppression
Which means low RBCS, wbcs, and platelets
What helps minimize vertigo?
a quiet dark environment
guidelines for the pneumococcal vaccination
all adults 65 or above should get 2 pneumonococcal vaccines
Who should get the flu vaccine?
all patients 6 months old or greater unless pt has life threatening allergy to the vaccine or one of its ingredients
What to remember when introducing new foods to a baby?
allow 5 to 7 days between introduction of new food to assess for allergies
Clear and simple sentences when speaking with
an alzheimers patient
Ventricular septal defect is the same thing as atrial but the hole is
between the ventricles instead and can lead to CHF [this a-cyanotic heart defect increases pulmonary pressure or congestion and leads to heart failure] so wacth for signs of CHF like dyspnea and tachypnea
Stage 2 ulcer
blister, abrasion, shallow open ulcer red pink wound with no sloughing
Infants should not be throwing up green vomit, this could indicate what?
bowel obstruction
Laser lithotripsy
breaks down kidney stones S&S: -Burning on urination -Hematuria
Burning at the I.V site can indicate and lead to what?
can indicate phlebitis which can lead to thrombophlebitis [blood clot]
Mastitis
caused by staph [S.aureus] Frequent feeding + Appropriate latching onto breast [these two will prevent it]
Strabismus [crossed eye]
cross eyes misalignment of the eyes eyes looking in dfferent directions
Lithium toxicity occurs with
dehydration and hyponatreima SO what should you do if taking? drink lots of fluid [about 2 L per day] and get adequate salt Do not take NSAIDs or thiazide [diuretics]
Drug for fibromyalgia
duluxetene (cymbalta) It has both antidepressant and pain relieving affects its also prescribed for MDD [major depressive disorder]
Atopic dermatitis is as known as what?
eczema
A cast is place, you should instruct patient to
elevate limb above heart for the FIRST 48 hrs
When can fetal sex be determined?
end of 12 weeks
Behaviors of bulimic person
episodes of binge eating followed by self induced vomiting using enemas/laxatives intense frequent exercise
At 12 months, heat and chest circumference are
equal
In regards to delegation, the RN should
escort a disgruntled family member off the unit and not delegate this to UAP
TIPS procedure is used for what?
esophageal varices
Baseline data before an open abdominal aneuryism surg is
essential ESPECIALLY character and quality of peripheral pulses
Sickle cell crisis cause
excrutiating pain and these patients will need large dose of narcotics PCA pump is th best method with morphine or dilaudid meperedine (Demerol) is contraindicated
how to use the peak flow meter for asthma
exhale quickly and forcibly through the mouthpiece
Guaifenesin [Mucinex]
expectorant med that thins secretions to facilitate expectoration
Pressure ulcer develop how?
external pressure compressing capillaries and underlying soft tissue; occurs mainly over bony prominences
What do rales (crackles) indicate?
fluid in the lungs
Lumbar puncutre purpose is to
get a sample of CSF like for MENINGITIS You as a nurse will need an informed consent Always remember to have the patient empty the bladder PRIOR to procedure
What should nurse do before giving vancomycin?
get trough levels
When a patient is on prednisone, check
glucose levels [causes HYPERGLYCEMIA]
What is a primary component in TPN?
glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
Rice, corn, and potatoes are
gluten free and are allowed in what type of diet? gluten free diet = celiac disease patient BROW diet [Mnemonic to remember Barley, Rye, Oats, Wheat]
What will chronic pancreatitis show in stool
greasy, foamy, foul-smelling, fatty
Disaster triage
greatest good for the greatest number People with alterations in airway breathing and circulation [ABC!] who are likely to survive with timely [treat within 30 minutes] interventions are given FIRST priority [RED TAG]
If a patient being discarged is a DNR, make sure they
have a bracelet!
what are some hings that happen with myopia?
headache, dizziness, poor school performac,e eye rubbing, frequent blinking.squinting when viewing bjects from afar
What is pyrosis?
heartburn
Anaphlactic shock
hives, itching, skin rash, rapid swelling of the mouth and throat [ANGIOEDEMA] give EPINEPHRINE quick in the thigh BENADRYL can be given for hives or rash Epinephrine is the only thing that can treat anaphylaxis If you have any kind of history of severe allergic reaction then you should always carry an EPI pen.
Chronic kidney disease patients are at risk for
hyperkalemia
Cold clammy skin is a sigh of
hypoperfusion in shock
What can happen as a result of emergent catheterization from acute urinary retention?
hypotension and bradycardia
What is the desired effect of lactulose?
improve mental status [treats mental alterations caused by hepatic encephalopathy] lactulose reduces ammonia by trapping it in the gut then expelling it with a laxative
Intermediate acting [NPH]
in 4 hours
When is digoxin used?
in heart failure to increase cardiac output and in afib to reduce the heart rate
Opioid agonist-atagonist meds can be used when during labor?
in the active phase of stage 1 labor when labor contractions are well established and the cervix is dilated to at least 4 cm
What type of fluids would someone need while in hypovolemic shock?
isotonic like normal saline [0.9% sodium chloride] and lactated ringers [LR]
What type of fluids do patients in hypovolemic shock need?
isotonic solutions like NS, LR
What is the kernig sign?
leg extension on 90 degrees flexing hip causes pain and resistance
Once a nurse provides care to someone this establishes a
legal caregiver obligation + relationship with the nurse and the patient The nurse could be held negligent if the nurse does not continue the care until someone else takes over or unless they are stable
When is the only time that procedures can be performed without getting informed consent first?
lifesaving procedures
Most patients with heart failure take what kind of med
loop diuretic that ends in "ide" like furosemide, torsemide, or bumetanide
What is palliative care?
manages symptoms, provide psychosial support, coordinate care to relieve suffering and improve quality of life for patients with serious illnesses
When I see chronic kidney disease, I think of the kidneys
not producing RBCs because they cannot produce erythropoietin = ANEMIA = epoetin therapy Excessive potassium [hyperkalemia] because normal kidney function is required to rid the body of potassium
Early indicator of hypocalcemia is
numbness and tingling of the lips
How are bowel sounds determined absent
nurse listens for 2-5 mins in each quadrant
A DNR does not provide direction for
nutrition supplementation
Quality improvements should be
objective and measurable
Calf pain that relieves while at rest is what
peripheral arterial disease [intermittent claudication]
what does failing the pinprick test indicate?
peripheral neuropathy
Diffused abdominal pain and rigid abdomen could indicate what?
peritonitis
What does thromboycytopenia [low platelets] present as?
petechiae, purpura, or bleeding
Dental hygiene is required with
phenytoin
After a burn, do NOT
place ice, ointment, creams or butter just run under hot water remove clothing around burn if not stuck to skin cover with a clean dry cloth
To prevent hip fractures after leg amputation
place patient prone with hip extension for 30 mins 3 to 4 times a day
When is digoxin held in kids?
pulse less than 90
How should a person with COPD breathe?
pursed lip breathing
Back pain after catheterization could be what?
retroperitoneal bleeding [Grey Tunner sign]
Risk associated with stent placement using the femoral approach
retroperitoneal hemorrhage
Nasal cannula
short term, allows to eat and drink Delivers oxygen up to 44%
How do 8 month olds play?
solitary play by maneuvering & teething soft toys
18 guage
somewhat stable adults needing large amounts of fluid or blood [blood transfusion]
Rememebr that when delegating, the nurse can only ask for
specific assessments; something like if there are blood clot in the urine or how much urine is there, they can NOT ask the UAP to describe what the urine looks like because this involves assessment
Steps after newborn is born
stimulate •If after 30 seconds the heart rate remains less than 100 then start positive pressure ventilation [PPV] •If after 30 seconds the heart rate still reminds less than 60 after quality positive pressure ventilation [PPV] then do chest compressions and if still less 60 then give epinephrine
RN performs initial client and caregiver
teaching LPN reinforces teaching RN will also do dischagre instructions
Never clamp a chest tube during transport of a patient; what may it cause?
tension pneumothorax cuz the air has no way to escape
Persecutory [paranoid]delusion
the belief of being treated in a malicious way
What is veracity?
the duty to tell the truth
During dressing changes of a PICC line, what should a nurse check?
the external length of the PICC
Manage edema on the residual limb by using
the figure eight compression bandage
What is partial thromboplastin time (PTT)?
the time it takes your blod to clot
If there is a radiation contamination, see
the victims farthest away from the source first
Is it dangerous when someone is throwing PVCs and why?
they could go into a lethal dsrythmia
Why do opioids cause hypotension?
they dilate peripheral blood vessels. if the pt stands it can cause orthostatic hypotension
Children 3 to 6 put inappropriate causes to things that happen for example
they were bad so their knee was scraped
What is wound evisceration?
total seperation of wound layers with internal organs protruding through the wall of an incision Place them in low fowlers [FLAT] with the knees bent helps reduce the tension on the wound
Dispacement
transferring thought feelings toward one person to another Man is mad at his boss and comes home to yell at his wife
Dopamine function
treat distributive shock and maintain cardiac output
Dopamine does what?
treats hypotension caused by bradycardia [Increases cardiac output + heart rate]
What does this cause them to do?
try to regulate their self esteem
Retinoblastoma
tumor of eye usually diagnoses in children under 2 months The pupil will reflect a white color and the child will NOT have the normal RED eye reflex Radiation therapy or removal of the eye
Some symptoms of tardive dyskinesia
unusualy movements of arms, legs, face, body
Which way to pull pinna in an adult?
up and back
Black stools [melena] indicate what?
upper G.I bleeding
It is possible to have a pulse in
v-tach
Best type of oxygen delivery for a COPD patient
venturi mask
Occipital lobe [brain]
vision
What will damage to the occipital lobe cause?
visual disturbances
When are pancreative supplements taken?
with or just before every meal
What is dysarthria?
worsening ability to speak which can lead to respiratory distress
Can UAPs transfer a dead client to the morgue?
yes
Is the babinski sign present at birth?
yes but it disappears at 1 year
What are some seizure triggers?
•Excess caffeine •Alcohol •Sleep deprivation •Stress
Symptoms of RSV in infants
•Excessive mucous production •Rhinorrhea •Fever •Cough •Lethargy •Irritability •Poor feeding
Causes of kidney/ureter stones
•Obstruction and urinary stasis •Hypercalcemia •Dehydration •Immobility •Gout
Dementia
•Onset is gradual (months to years) •Consciousness intact •Progressive •Irreversible
Childhood of someone with NPD
•Sense of inferiority •Poor self esteem •Self criticism
After a cystoscopy notify HCP if there is:
•Urinary retention •Hemorrhage •Infection •Bright red blood when urinating •Blood clots •Inability to urinate [dysuria] •Fever
What do we do for styes
•Warm compresses Antibiotics I&D Caused by a staphylococcal organism
What is the brand name for valproic acid?
Depakote [anticonvulsant]
When should a baby umbilical cord fall off
1-2 weeks after birth No tub baths until them Should be drying up and getting more hard to the touch
Contraindication meds for heart failure
NSAIDS [like ibuprofen, aspirin]
Autonomy vs. Shame and Doubt
1-3 yrs Provide child with acceptable options. Let them CHOOSE [not too many option; like 2 or 3]
What is the chvostek sign
facial twitch after tapping nerve on side of head
In up to 18 months, the toes of an infant should
fan upward + out [babinki sign] and this is a normal response; after 18 months is babinki sign is abnormal, indicates neurological damage
Patients with long bone or pelvic fractures are at risk for developing what?
fat embolism
Acute pancreatitis stool
fatty and foul smelling
what ABG values indicate acute renal failure [ARF]?
low PaO2 and high PaCo2
What causes oligohydramnios?
low amniotic fluid volume caused by fetal kidney anomalies or leaking fluid through the vagina
HYPOcalcemia
low blood calcium level (<8.5)
What is osteoporosis
low bone density
kidney disorders diet
low phosphate
Ethambutol
eye exams are needed
What is polycythemia?
too many RBCs
Initiative vs. Guilt
3-6 yrs Assist parents to identify age/disease appropriate activities
Infants should be breastfed until
6 months then at 6 months infants can introduced to pureed foods [Cereal FIRST] At age 1 year or later they can have cows milk
Separation anxiety in babies
6 months to about 3 years •This is a normal reaction
What is the normal range for wet infant diapers per day?
6 to 10 great way to measure hydration status in infants
When does teeth eruption happen in infants?
6 to 10 months
When does tooth eruption occur in infants?
6 to 10 months
Normal range for wet diapers by 3-4 days of life
6 to 8 wet diapers every 24 hours
Duration of Regular
6-10 hr
Idustry vs. Inferiority
6-12 yrs Encourage child's participation in their care
WATCH our for what organ when taking acetaminophen?
LIVER
What is trismus?
LOCKJAW inablity to open the mouth due to a tonic contraction of the chewing muscles
Respiratory acidosis
LOW pH, HIGH PaCO2, normal HCO3
Metabolic acidosis
LOW pH, LOW HCO3
Obstructive sleep apnea
Lack of airflow due to the occlusion of pharynx
Symptoms of hypothyroidism "everything is slow"
Lackluster mood Bradycardia Weight gain Constipation Cold intolerance Dry/thick skin Cool, pale Brittle nails/hair Hair loss Generalized edema Fatigue Anemia Muscle/joint pain Lethargy Forgetfulness Depression Decreased libido None or little or a lot of menstrual bleeding
What med is given for encephalopathy?
Lactulose which decreases intestinal ammonia absorption [gets rid of the excessive ammonia built up in the body]
What type of syringe to we use to aspirate an NG tube
Large Barrel syringe
Signs and symptoms of a woman in labor with a baby who has an unreassuring FHR
Late decels [VEAL CHOP MINE] Fetal bradycardia Decreased variability
Where do we hear S3 , on the left side or right side of the heart in heart failure?
Left
Which 2 groups of drugs can cause problems for those with asthma?
NSAIDS and beta blockers because they can cause bronchospasm
Acute pericarditis treatment
NSAIDs and colchicine [anti-inflammatory meds]
Dysrhythmias are common after an
myocardial infarction [MI]
What does an ST elevation indicate?
myocardial infarction because one or more of the coronary arteries that supply blood to the myocardium are occluded
What is the extreme thing that happens as a result of hypothyroidism?
myxedema coma like LETHARGY mental SLUGGLISHNESS COLD INTOLERANCE coma
What should someone take with methotrexate to help with adverse affects?
folic acid supplement
What is the classic sign of a tension pneumothorax?
mediastinal shift + tracheal deviation
there are different types of POAs, like
medical and financial
Schizophrenia: Assessment
-Delusions -Tangentiality [deviating from original topic of conversation] -Waxy flexibility [tendency to remain in immobile posture]
14 guage [large bore]
for giving fluids/drugs in pre-hospital emergecy setting or for hypovolemic shock
What is the ABG most consistent with diabetic ketoacidosis?
metabolic acidosis!
Common side effects of immunizations
mild fever, redness and soreness at the injection site Apply a warm compress to the site
Autistic kids
minimal stimulation + calming environment
Hydrocdone/aceteminophen oral tablet is typically used for what type of pain?
moderate
For tuberculosis, an induration of greater than 1 indicates you have
a TB infection
Patients with A fib are usually given
a anticoagulant due to increased risk for blood clots
What is Midalozam [Versed]?
a benzodiazepine used for conscious sedation Commonly given with an opioid
Trisomy 21 [down syndrome] is normally associated with
a cardiac murmur (AV canal defect) If vital signs are stable it requires no action They may have surgery later on
Ulcerative colitis
inflammation/ulcerations in the large intestines causing urgent, frequent, bloody diarrhea, abdominal pain, anorexia, and anemia-lower GI-rectum
Meds common for an open fracture?
•Cefazolin (Ancef) •Tetanus toxoid •Toradol •Opioids
Introducing a child to table foods: 4-5 months they can have
•Cereal (usually rice cereal first) •Strained fruits next
s/s of myocardial infarction [MI]
•Chest pain •Diaphoresis •Dyspnea •Anxiety
What meds do we give for Alzheimers
•Cholinesterase inhibitors •NMDA receptor antagonists antidepressants
Introducing a child to table foods: 7-9 months:
•Chopped meat, hard breads and "finger foods", baked potato and mashed potato
What type of meds should be stopped 7 days before surgery?
•Clopidogrel •Antiplatelet •NSAIDS
What do we do for non-penetrating contusions
•Cold compresses •Analgesics
2 major clinical features of major depressive disorder
1. Depressed mood 2. Loss of interest or pleasure One of these two symptoms must be present DAILY for 2 weeks for the diagnosis to be made
Kegel exercises
Used to strengthen muscles of pelvic floor Tighten pelvic muscles for a count of 3, then relax for a count of 3. Do this lying down, sitting, and standing for a total of 45
Sucralfate
Used to treat duodenal ulcers Best results if taken on an empty stomach!
Contact Precautions
Used when germs are spread by touching Examples: C. difficile + Norovirus Minimal PPE: Gloves and Gown
Atrial septal defect (ASD)
abnormal opening between the left and right atria that causes a murmur from blood flowing in between back to the right side of the heart [increasing pulmonary pressure or congestion]
What are the 2 core symptoms of ASD? autism?
abnormalities in social interaction and communication and patterns of behavior interests and activities
HYPERnatremia
abnormally high sodium level (>145) in the blood, which helps regulate the amount of H2O in and around the cells.
HYPOnatremia
abnormally low sodium level (<135) in the blood, which helps regulate the amount of H2O in and around the cells
For all pregnant clients, weight gain in the first trimester shold be what?
about 1.1 to 4 pounds
Diuretic phase [a lot of urine output]of Acute kidney injury
urinary output of 4000-5000 ml per day Increased BUN Loss of sodium and potassium in urine Increased mental and physical activity
Gabapentin (Neurontin)
used for neuropathic pain
What are some ways iron deficiency can happen?
Diets low in iron like vegetarian Iron not being absorebd like after abdomal surgery or malabsorption syndrome Increased iron requirement Blood loss
What is transferrence?
a client unconscioulsy transfers feelings and behaviors related to a person in the clients past onto the nurse For examples: a client states that the nurse reminds them of their sister
Penicillins and cephalosporins can have
a cross sensitivity response
C section patients have
a longer recovery than vaginal birth and are in the hospital longer watch out for VBAC vaginal birth after c section because previous scaring may easily tear
If a sickle cell patient has an enlarged spleen this is
an emergency SPLENOMEGALY can lead to hypovolemic shock WHY because Most RBCs in a child with sickle cell are defective and will be destroyed
Desquamination is skin peeling and is a normal finding in
an infant, esecially those born late [post-term babies past 42 weeks]
Risperidone-what class and what is it used to treat?
antipsychotic used to treat schizophrenia and bipolar
Why is putting an I.V in the arm of a mastectomy contraindicated?
any trauma to the arm on the operative side can cause lymphedema with painful and lengthy swelling
Avoid what after open radical prostatectomy
anything that could CAUSE strain on the rectal area [give laxatives]
Postpartum psychosis-signs
appear within 2 weeks after birth include: -Hallucinations -Delusions -Paranoia -Severe mood changes -Delirium -Feelings that someone will harm baby
Potassium (K)
3.5-5
Head injury
fowlers or elevate head of bed to reduce ICP
Major depressive disorder demonstrates
•loss of appetite •weight loss •insomnia •hypersomnia •sleep disturbances
Memantine treats what?
Alzheimer's
When you think hyperkalemia, think what?
CARDIAC PROBLEMS
Parent teaching for Kawasaki disease
CHECK FOR FEVER
Metabolic alkalosis
HIGH pH and LOW HCO3
Expect heavy bleeding with
IUD
Audiogram vs tuning fork
Audiogram: quantitates the degree of hearing loss Turning fork: qualitates : the type of loss
Increased bilirubin
Jaundice Scleral icterus Itching
C. diff and scabies sanitizer is
NOT sufficient, you are going to need soap and water
What is a complication from conductive hearing loss
Meningitis
What do you NOT take tetracycline with
Milk or antacids It inhibits the med from working!
Continuous peritoneal dialysis
Automated machine used at night Final exchange is left in place for the next day and then drained at night
Frontal lobe [brain]
PERSONALITY/BEHAVIOR
Position for administration of an enema
Patient should be LEFT side laying with the knee flexed [Sims position]
Methotraxate treats what?
Rheumatoid arthritis
S&S of phlebitis
Redness in the area and red streaks
MODS
Septic shock plus multiple organ system damage (2 or more organs)
When a patient has a phobic disorder, what is the best thing to do for them
Systematic desensitization
Where is insulin produced
The beta cells of the pancreas
What med is Riluzole?
Treats for Lou Gehrig's disease also called Amyotrophic Lateral Sclerosis ALS [SLOWS progression of the disease]
Treatment for Atrial Flutter
Vagal maneuvers Adenosine [antidysrhythmic] CARDIOVERSION Ablation therapy
When is hyper-resonance percussed?
With an over inflated lung [for example asthma, emphysema] With air in pleural space [for example pneumothorax]
What does atrial flutter look like
saw tooth
Decreased hemoglobin/hematocrit levels are
normal in chronic kidney patient
Cataracts have
opaque color to the eye
SSRIs
sexual dysfunction [common side effect]
Remember NOT to choose answers with words like
"never" and "always"
Female prescribed isotretinoin (accutane) acne medication must have what
-2 negative pregnancy tests before starting [causes serious birth defects-category X] -Must use 2 forms of contraception -Enroll in a risk management program to make sure these are both being followed through
Teaching for a phenylketonuria baby
-A low phenylaline diet -Lifetime dietary restrictions -Monitor serum levels of its amino acid and is necessary but just in moderation -Infants on special formulas -Eliminate high phenylaline foods like MEAT, EGGS and MILK
Macrolide antibiotics like azithromycin, erythromycin, and clarithromycin can cause what?
-A prolonged QT interval which can lead to torsades de pointes and sudden death -Also hepatotoxicity
Normal findings after the birth of a preterm baby
-Abundant lanugo [should disappear around 36 weeks] -Smooth pink skin with visible veins [due to lack of adipose fat] -Flat areolae without palpable breast buds (areolae is palpable and raised in newborns closer to term)
How to deliver a dose via a metered dose inhaler?
-Shake MDI and attach to spacer -Exhale completely -Place lips tightly around the mouthpiece -Deliver a single puff of med into spacer -Take a slow deep breath and hold for 10 seconds -Rinse mouth with water after dose
Partial weight bearing
1 person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2 person assist with full body sling if uncooperative
BMI pregnant client should gain how much per week in the 2nd and 3rd trimestes
1 pound per week
When giving a needle IM, the needle length should be what?
1 to 1 & 1/2 inch
At what age does an infant have equal head and chest circumference?
1 year
Positive [diagnostic] signs of pregnancy
1. Fetal Heartbeat heard with doppler 2. Fetal Movement [felt by an examiner or visible] 3. Visualization of Fetus [ultrasound]
What are the 3 signs of positive [diagnostic] pregnancy?
1. Fetal heartbeat w/ doppler 2. Visualization of fetus with ultrasound 3. Fetal movement felt by the HCP
Posttransplant infections symptoms
1. Fever greater than 100.4 F (38 C) 2. Productive or dry cough 3. Changes in secretions
What modifications to take when giving CPR to a pregnant patient?
1. Perform chest compressions slightly higher on sternum 2. Displace uterus to left side
Pulmonary embolism - Nursing Priorities
1. Rapid symptom identification 2. Assessment of oxygenation [check O2 sat, sit patient up FIRST] 3. Notification of HCP
3 main categories a person with PTSD has
1. Re-experiencing the traumatic event 2. Avoiding reminders of the trauma 3. Hyper-arousal
MMR and Varicella are first given at what age?
12 to 15 mo Use this Mnemonic [MAD HPV]
Second trimester in weeks
13-26 weeks
Sodium (Na)
135-145
How soon after a blood transfusion does an acute hemolytic reaction occur?
15 mins
Ammonia level
15 to 45
Onset of Aspart
15-30 mins
Onset of Lispro
15-30 mins
Platelets
150,000-400,000 Less than 20,000 be very concerned!
Duration of Isophane (NPH)
16 hours
Phosphorus (PO4)
2.5-4.5
Intimacy vs. Isolation
20-35 yrs Provide private time with partner/family
HCO3 [bicarbonate]
22-26
Duration of Glargine [Lantus]
24 hours
Newborns should void and pass meconium within
24 hours
When will thumb sucking go away
24 months [2 years of age]
PTT
25-35 Heparin Therapeutic Range: 1.5-2 times normal value. [which ranges from 37.5 to 70]
Third trimester in weeks
27 weeks to end of pregnancy
Max time for the grieving process is
3 years
Do we aspirate the syringe when administering Heparin?
No, it can cause bruising
Normal urine output in mg/hr and mg/kg/hr
30 ml/hr 0.5-1 ml/kg/hr
What are pregnant clients tested for Group b streptococcus [GBS] ?
35-37 weeks
PaCO2
35-45
Generativity vs. Stagnation
35-65 yrs assist client with illness adaptation and home/work demands
RBC
4 million to 6 million
Age for imaginary play
4-6 [preschoolers] ❤️
Long acting [detemir & glargine]
4-9 hrs
How long does a diaphragm need to be left in the vagina after intercourse
6 hours
How much after TB injection should arm be checked?
48 to 72 hours [after 2 to 3 days]
[Parkland formula] What is the formula and actually how much is given?
4mL of lactated ringers (LR) x weight of patient in kg x % of body burned Half of the calculated parkland volume must be given in the FIRST 8 hours and the other half of parkland volume must be given in the last 16 hours
Oral warfarin is started about
5 days before a continuous heparin infusion is discontinued WHY? because this is the time it takes warfarin to reach therapeutic level
Normal weight gain in first 6 months in infants
5 to 7 oz a week
If you are doing an autologous blood donation, when can you donate to yourself
5 weeks away from your surgery up to three days before
WBC
5,000-10,000
What should the pH be when you aspirate for NG tube?
5.5 or below
Yellow ashtma
50 to 79
When inserting a catheter into a male, put it in about
7 to 9 inches Once you start to see urine drops, then advance about 1 to 2 inches more to make sure you're in bladder then inflate balloon Do NOT inflate balloon too early because it could cause urethral trauma urine could be in urethra So basically just because you are getting drops of urine into the bag does not mean you are in bladder
pH
7.35-7.45
Levothyroxine takes about
8 weeks for patient to see full therapeutic effect
Calcium (Ca)
8.5-10.5
Asthma green
80 or above of personal best
PaO2
80-100
Elbow sling placement
90 deg hand above elbow joint bottom of sling ends in middle of palm with fingers visible
Butorphanol Tartate
A narcotic pain reliever similar to morphine Monitor rate and depth of respirations
What is Bell's palsy?
A 7th cranial nerve disorder where there is an inability to close the eye, decreased corneal reflex, increased lacrimation, speech difficulty, loss of taste, distortion of one side of the face
What is acoustic neuroma
A benign tumor of the 8th cranial nerve that causes deafness (partially initially) and dizziness
What suggests that a client has an inguinal hernia
A bulge in the lower right quadrant
Glipizide is given to what type of client
A client with Type 1 diabetes where they produce none of their own insulin
What is trigeminal neuralgia?
A cranial nerve disorder where there is stabbing/burning facial pain that is excruciating and unpredictable Often will be twitching and grimacing of the facial muscles
What are some risk factors for postpartum hemorrhage?
A history of postpartum hemorrhage [PPH] Uterine distention Uterine fatigue/boggy High parity [given birth to multiple children] Certain meds
Symptoms of an aortic dissection
abrupt worst ever tearing, ripping, moving from upper to lower back epigastric pain and abdominal pain Life threatening Treatment: surgery and lowering the blood pressure which is a contributing factor
LEFT-to-RIGHT congenital heart defects
A-CYANOTIC defects 1. Patent ductus arteriosus [PDA] 2. Atrial septal defect [ASD] 3. Ventricular septal defect [VSD] Oxygenated blood from the LEFT side of the heart moves to the RIGHT side of the heart with deoxygenated blood Oxygenated blood travels systemically and does not cause cyanosis
What combination durgs are normally used to treat heart failure?
ACE inhibitor + lasix
Hyperkalemia is a side effect of
ACE inhibitors
Treatement for aspiriin poisoning
ACTIVATED CHARCOAL, and then I.V sodium bicarbonate
In terms of fetal heart rate, the only normal accelerations are
acceleration [normal-GOOD] What are the abnornal ones? variable, early, and late decelerations [VEAL CHOP MINE]
During a thyroidectomy, the parathyroid glands may be
accidentally removed because they are very small in size
Treatment for ventricular tachycardia [V-tach]
If monomorphic: give -Procainamide -Sotalol -Amiodarone If polymorphic: give -Magnesium sulfate -Isoproterenol If PULSELESS: give -CPR -Defibrillation [AED] -Epinephrine -Amiodarone
Peritoneal dialysis
for someone with insufficient renal function A catheter goes into peritoneal cavity and dialysate is infused then clamped for 30 mins then it is unclamped for the dialysate to drain via gravity
If a child is suddenly in distress and can not speak what should you suspect
foreign body aspiraion
What are the priorities of care for suspected placenta abrupto?
monitor mom for fluid status and fetal heart tones [FHR] because it can cause maternal hemorrhage and/or fetal oxygen supply interruption
Oligohydramnios [very little amniotic fluid] requires
more personnel in the room for delivery
Major complication of rheumatoid arthritis is
morning stiffness take a warm shower or bath upon wakening
Dilaudid is 5 to 10 times the strength of
morphine
What does lead poisoning cause?
neurological and motor impairment
Gestational diabetes
new onset of elevated blood pressure at 20 or more weeks without proteinuria
What is preeclampsia?
new onset of hypertension PLUS proteinuria after 20 weeks gestation
When a patient says something like "Someone is trying to kill me tonight" what do you do
Don't go along with their delusion like you support it [persecutory hallucinations] Just acknowledge how they are feeling and move on. Say something like "It must be frightening to think someone is trying to kill you"
When a mom chooses to bottle feed, what do we need to recommend for her
Don't use a breast pump because your body will think that you need to continue to produce milk The milk will subside on its own in 5-7 days
Cardiac cath
Done via artery Arterial bleed can lead to shock and death if not treated quick Knee are kept flat after procedure to not dislodge clot should not be bleeding at puncture site -This means no clot formed then
Advanced age and pregnant increases risk of what?
Down syndrome baby
Teaching when on lithium
Drink 1 to 2 L of fluid daily Blood levels checked periodically Get adequate sodium
Patient with the Flu precautions
Droplet 3 ft away when coughing or sneezing Place mask on patient when transporting
Once we start mag on a pregnant client with hypertension, what do we do
Assess for their deep tendon reflexes [DTR]
APETOMAN
APETM aortic, pulmonary, erbs point, tricuspid valve, mitral valve
Med of choice for CHF
Ace inhibitor "pril"
What will increase the absorption of iron
Acidic foods! Take with orange juice
As the nurse, what do we do for myasthenia gravis
Administer meds before eating [anti cholinesterase, corticosteroids, immunosuppressants] Optimal eye care [to prevent and help diplopia] Maintain optimal mobility Avoid things that precipitate myasthenia crisis [infections, stress, neomycin/streptomycin, surgery]
Where do we get pulses for CPR in an adult and infant
Adult: Neck [sternoceidomastoid] or carotid Infant: Arm [Brachial]
When does "stormy" behavior onset?
Age 11
Bladder scanner residual urine volume to report
Amount that is less than 100 mL; this indicates urinary retention
Two types of glaucoma
Angle closure: sudden onset, emergency from allergy, vasomotor problems, and emotional disturbances Open angle: blockage of aqueous humor flow from trauma, tumors, hemorrhage, aging
Skin cancer mnemonic ABCDE what does it stand for?
Asymmetrical Border irregularity Color changes Diameter more than the size of a pencil eraser Evolving or changing in any way
Med of choice for Asystole
Atropine
What do we give for bradycardia
Atropine
Treatment for sinus bradycardia
Atropine or possible pacemaker
Clozapine
Atypical antipsychotic used to treat schizophrenia
How to prevent hemorrhage after a tonsillectomy
Avoid clearing the throat •Blowing the nose •Coughing
Albumin is the same normal value as
potassium [3.5 to 5]
What drug is given with furosemide to prevent electrolyte imbalances?
potassium chloride
Spironolactone
potassium sparing diuretic
Bronchiolitis [caused by RSV]
Droplet isolation S&S: -Low grade fever -Tachypnea -Wheezing [lower respiratory obstruction] -Poor feeding
Expected side effects of lithium
Drowsiness Weight gain Dry mouth GI upset
ace inhibitors side effects
Dry cough Orthostatic hypotension Hyperkalemia Angioedema
Anticholinergic effects
Dry mouth and constipation
First degree [superficial] burns
Dry with blanchable redness Usually only epidermis is damaged
Clients with ESRD are unable to excrete which electrolyte?
potassium; so they should eat a diet low in potassium
Corticosteroids and surgery
During the few weeks leading up to surgery, we need to increase the dose of corticosteroids because surgery requires more Nurse must monitor for side effects of too much corticosteroids
What 2 races have a high incidence of getting a cough from ace inhibitors?
BLACKS + asians
KIDNEY and LIVER biopsy [both organs are highly vascularized] what to watch out for
BLEEDING!
Beta blockers major side effects
Bradycardia Bronchospasm [watch out for asthma + COPD patients; make sure cardio-selective] Hypotension Depression Impotence
Signs of heart failure
Dyspnea Orthopnea Weight gain Cough Fatigue
Proton pump inhibitors can increase the risk of
C-diff
Soap and water hand hygiene is used for
C. diff + scabies
What is acute otitis media
Ear infection in the middle of the ear from a pathogenic organism [bacteria or virus]
Amoxicillan can cause what super infection?
C.diff watch out for a fever and abdominal pain that develops with diarrhea
Hypocalcemia
CATS Convulsions Arrythmias Tetany Spasms Stridor
Hypoparathyrodism (LOW calcium in the blood)
CATS: -Convulsions -Arrythmias -Tetany -Spasms -Stridor Too little calcium [the body goes out of control]
What is the standard treatment for overdose?
CHARCOAL [but it is ineffective for lithium, iron, and alcohol]
Diet for adolescent
Caloric, protein and calcium is HIGH! For adolescent girls that are menstruating, we need to increase their iron Must have high minerals and high vitamins
When walking with a cane, what is the sequence of steps
Cane first Then weak foot then good foot
Muffled heart tones are heard in?
Cardiac tamponade
Theophylline toxicity presents as what symptoms?
Central nervous stuff- HA Insomnia Seizures GI disturbances Cardiac toxicity
what is CVP and what does it monitor?
Central venous pressure measuring right ventricular preload and reflects fluid volume status •Connect it to the proximal port to pressure monitoring system Normal range 2-8
Central sleep apnea
Cessation of airflow and respiratory movements
Post-procedure instructions for barium enema
Chalky white stool until barium passes Take a laxative like milk of magnesia to help expel barium Drink plenty of fluids to promote hydration and eat a high fiber diet
What must we do after an endoscopy
Check the gag reflex
When someone has a permanent pacemaker, what is something that we have to be sure they do
Check their pulse for a full one minute every day at the same time of day
Methotrexate
Chemotherapy/Immunosuppressant Toxic Level: >10 mcmol over 24 hours
Myocardial infarction symptoms
Chest pain Dizziness Sweating Shortness of breath [SOB] N/V Pain radiation to neck, jaw, left shoulder, arms and epigastrium
What is a positive sweat test significant for
Child has cystitis fibrosis [CF] Child will need replacement of enzymes, high calorie, high protein diet
What is Duchenne muscular dystrophy?
Childhood form of MD X linked recessive Lack protein called dystrophin for proper muscle stabliizing Muscle of proximal lower extremities are affected first They do the gower sign to help them stand Remove clutter to prevent falls
What is Raynauds phenomenon
Chronic connective tissue disease that causes inflammation, fibroids, and sclerosis of the skin and vital organs Pain and color changes of the extremities when exposed to the cold Arterial peripheral vascular disease
RN scope of practice
Clinical assessment Initial client education Discharge education Clinical judgement Initiating blood transfusion
What do we do for people with strabismus
Close good eye to strengthen bad eye Eye exercises Surgery on rectus muscle of eye
ARBs and ACE inhibitors are contraindicated in
pregnancy
What are some common side effects of anticholinergics?
Constipation Urinary retention Flushing Dry mouth Heat intolerance
What could be causing insufficient outflow in peritoneum dialysis [PD] and what to do?
Constipation could be the cause Assess bowel pattern and give stool softener Assess for abdominal distention and constipation Check tubing for kinks Reposition client to side lying or walk with them Keep drainage bag below abdomen
Rubella titer is contraindicated in
pregnancy
Pertussis [whooping cough] symptoms
Cough lasting 2 weeks or more with one or more of the following: -Violent, spasmodic cough/paroxysms of cough -Inspiratory whooping sound -Coughing up thick mucus plug sometimes followed by vomiting [post-tussive emesis]
Client identifiers
First and last name Medical record number DOB
What do we do as nurses for cystitis
Get a clean catch for testing Encourage 3000ml of fluid a day Give cranberry juice / urinary acidifiers Void every 2-3 hours Teach females to void after intercourse and to wipe from front to back
Rationalization
I did poorly on the test because the questions were hard
Simple face mask
delivers higher concentration than cannula about 40 to 60% Can be used if hypoxemia does not resolve
What is the first line treatet for kawasaki disease?
I.V immunoglobulin and aspirin to prevent the aneurism
What is the FIRST line of treatment for torsades de pointes?
I.V magnesium
Never give potassium via which routes?
I.V push Intramuscular [IM] Subcut
Parenteral?
I.V route
What should all intoxicated patients be given?
I.V thiamine before or with I.V glucose
Delirium vs Dementia
dementia has a slow onset usually with normal attention
What is the pavlik harness used to treat
DDH in kids •It keeps kids legs bent and spread apart
Raising the head of bed [HOB] causes BP to do what?
DECREASE
Beta blockers like the lols do what
DECREASE heart rate [cause bradycardia] and decrease cardiac workload
In some patients with COPD, a too high level of inspired oxygen can
DEPRESS the respiratory drive to breathe causing alveolar hypoventilation Removing supplemental oxygen like a cannula may actually increase the reading
If a patient cannot ingest a simple oral carb during a HYPOglycemic reaction, they are given
DEXTROSE [D50] or glucagon [IM injection] but these can cause rebound hypoglycemia by stimulating more insulin release from the body in response to increased glucose levels
What happens in peritoneal dialysis?
DIALYSATE is infused into the abdominal cavity and the tubing is clapmed to allow the dialysate to dwell [the dialysate stays in the abdomen for several hours] after the dwell time, tubing is unclamped and the fluid drains out
Lmbar puncture positioning
DURING: side lying AFTER: supine
What best detects fluid gain/retention in an infant
Daily weights
Thyroid replacement can give symptoms of hyperthyroidism like
Diarrhea Weight loss Palpitations Tachycardia Sweating Heat intolerance
If a patient is in a hypertensive crisis, give them
I.V vasodilators but remember to lower BP slowly to prevent it from dropping too rapidly and causing organ damage from decreased perfusion
What is the most important med to give for anaphylactic shock?
IM epinephrine
When do we hold potassium
Do NOT give potassium without adequate urine output "No Pee, No K"
Heart failure patient have trouble breathing, what to do first?
Elevate HOB
Position of a patient with Bucks traction
Elevate the foot of the bed for counter traction
What are lab results that support a vaso-occlusive crisis [pain crisis] in sickle cell patients?
Elevated reticulocytes Elevated bilirubin Anemia [Hgb <10 g/dL]
Normal amount of drainage in first 24 hours following surgery
depends on type of procedure performed, but about 80-120 mL/hour of serosanguineous or sanguineous drainge* can be expected
Symptoms of acromegaly [overproduction of growth hormone]
Enlarged face Enlarged hands + feet Enlarged organs like tongue, spleen, kidney, thyroid Hypertension •Heart failure •Joint pain •Skin changes •HYPERglycemia
What is benign prostatic hypertrophy
Enlargement of the prostate gland that causes urinary flow obstruction, incontinence, and possible infection [caused by urinary stasis]
In delegation, nurses must take patients where there is...
Evaluation Assessment Teaching Do not delegate what you can EAT
Additional calories needed for a pregnant woman, and then for a lactating woman
Extra 300/day for a pregnant woman Extra 500/day for a lactating woman
What do we do for a patient with cataracts
Extracapsular extraction [cutting through anterior capsule /more superficial/exposes opaque lens] Intracapsular extraction [removal of entire lens/more radical/easier for us, more harmful to client] Then implant a new lens
What do we do as a nurse for glomerulonephritis
Give meds to treat the infection Treat volume overload and hypertension Give: -Antibiotics [if bacterial infection] -Corticosteroids [to treat inflammation] -Antihypertensives [to treat HYPERtension] -Immunosuppresives [to lower body immunity from attacking glomeruli] -Diuretics [to decrease fluid overload] •Restrict sodium intake •Daily weights •Assess I&O and serum potassium •Bed rest
What do we do if the parenteral nutrition needs to be stopped immediately or the new feeding bag is not ready on the unit
Hang D10% so we can keep the patients sugars in check and they don't suddenly go hypoglycemic
What is the causitive agent of fifth disease?
Human parvovirus
What drug is used to treat skin and athritic manisfestaions of Lupus
Hydroxychloroquine When taking this med, make sure to have an eye appointment every 6 to 12 months Take with food
When administering anti-psychotics, what do we need to monitor for?
Hypotension Ask them to sit and stand while you take their BP two times to make sure they aren't hypotensive before you give the med
Classic symptoms of neurogenic shock
Hypotension Bradycardia Pink + dry skin
Hypermagnesemia
Hypotension Facial Flushing Muscle weakness Absent/DECREASED DTRs [DECREASED deep tendon reflexes] Shallow respirations Emergency •Sedative effects on the CNS Too much magnesium, SLOWS you down!
Signs/symptoms of cardiac tamponade
Hypotension [heart is not contracting effectively, SO cardiac output drops] Muffled or distant heart tones Jugular vein distention [JVD] Dyspnea Tachypnea Tachycardia Weak thready pulses
What route is the best way to give burn victim meds?
I.V
What do we do as the nurse for neuroleptic malignant syndrome
Immediately withdraw [stop] anti-psychotic meds [like Haldol] Control hyperthermia [cooling measures, antipyretic] Hydration Give Dantroline and Bromocriptine
What is an EARLY symptom of hepatic encephalopathy
Impaired thought process and forgetfulness
When is S3 a normal sound
In C.H.F it is normal, but NOT in M.I
When does a depressed client have the highest level of functioning and activity
In the morning hours right after they wake up [sunlight has a positive effect on depressed people]
What to remember about feeding an infant with Tetralogy of Fallot
Increase the size of the hole in the bottle so the infant can get as much nutrition as possible. Do feedings every 3 hours Feed the infant soon after awakening so the infant doesn't cry [prevent crying because it tires them more due to disease process]
What is the FIRST thing we do when a patient has constipation
Increase their fresh fruits, veggies, and cereal Asking for a stool softener or laxative is a last resort
Meningitis causes
Infections (viral, bacteria, fungal) Neurosurgical procedure, basilar-skull fracture Otitis media, mastoiditis
Cystitis
Inflammation of the bladder S&S -Urinary frequency -Burning on urination -Cloudy/foul smelling odor
What is keratitis and what do we do for it
Inflammation of the cornea Antibiotics Warm compresses Steroids, except with Herpes Simplex
What is uveitis and what do we do for it
Inflammation of the iris, ciliary body, and choroid Warm compresses Dark glasses Antibiotics, analgesis, sedatives
Pyelonephritis
Inflammation of the kidney caused by a bacteria S&S -Chills -Fever -Malaise -Flank pain -Urinary frequency -Dysuria -CVA -Tenderness
What is a chalazion and what do we do for it?
Inflammatory cyst leading to a duct obstruction Must I&D
What contains live vaccines?
Influenza nasal spray [ONLY the intra-nasal form] MMR Varicella
What is the main cause of asthma
Inhaled allergens like animal dander, mold, pollen, and dust
How do 10-12 month olds play?
Interactive games [like peek-a-boo, pat-a-cake]
3 classic symptoms of intusseception
Intermittent severe abdominal cramp pain Sausage shaped mass Currant jelly stools •The baby will experience these: Inconsolable crying Drawing up knees to chest Vomiting
Why is tea a problem in graves disease
It is a stimulant and in graves disease your body is already in hyperactive hyper metabolism mode
For what diseases do we use droplet precautions
Think SPIDERMAN S:sepsis S:scarlet fever S: streptococcal pharyngitis P:Parvovirus B19 P:Pneumonia P:Pertussis I:Influenza Type B D: Diptheria (pharyngeal) E: Epiglottitis R: Rubella M:mumps M:Meningitis M:Mycoplasm or meningeal pneumonia An: Adenovirus
What meds are used in black people with heart failure
Isosorbide (nitrate) and hydralazine
Hantavirus
It is a disease from rodents/rodent droppings that can cause -Hematuria -Hematemesis -Bleeding gums
Sepsis
presence of infection along with systemic manifestations of infection
Liver is very vascular- after a biopsy
It is priority to assess for bleeding
When someone has a spinal cord injury, what is very important
Keeping the spine in alignment. •Prevent flexion or hyperextension!
Drug of choice for treatment of candidasis
Ketoconazole [antifungal]
Position for a mom with a prolapsed cord
Knee-chest position or trendelenburg
What do we do as the nurse to prevent thrombus formation
Leg exercises: flexion, extension of toes for 5 mins every hour
S&S of a hemolytic reaction [blood transfusion reaction]
Low back pain Fever Bach ache Hypotension Chills
Why do we do active range of motion
Maintains mobility of joint and increases muscle strength Performed by client without assistance
Drug of choice for trichromonias, I.B.D, and intestinal amebiasis
Metronidazole
Pleurisy
Manifests with pleural friction rub which is loud, rough rubbing or grating sound heard throughout •Inspiration & expiration cause the pleural surfaces to rub against together
What is Ketarolac?
NSAID analgesic used for short term pain relief- usage should not exceed 5 days due to -Kidney injury -GI ulcers -Bleeding
Symptoms of serotonin syndrome
Mild [shivering and diarrhea] Sever [muscle rigidity, fever, seizures] Also tachycardia and hypertension Also agitation/restlessness
What do we do as the nurse for kidney stones
Monitor I&O and temp Avoid over hydration and under hydration Strain the urine and check the PH Give analgesics
Hypokalemia
Muscle weakness Dysrhythmias Increase K intake [INCREASE raisins, bananas, apricots, oranges, beans, potatos, carrots, celery]
What is Myasthenia Gravis
Muscular weakness produced by repeated movements •Disappears when the patient rests •No problems with CNS or PNS just random •We see -Diplopia [double vision] -Ptosis [drooping of eyelid] -Impaired speech -Dysphagia [difficulty swallowing] -Respiratory distress
What is the brudzinski sign?
Neck flexion and exhibits pain and hip/knee flexion
Examples of isotonic solutions?
Normal saline Lactated ringers
Main two signs of meningitis
Nuchal ridigity Photophobia
What patient needs Fluvoxamine
OCD Side effect dry mouth
Itching and nausea are adverse effects of giving
OPIOID benadryl and zofran can provide antihistamine and antiemetic relief respectively
Phases of acute kidney injury
Oliguric Diuretic Chronic
Position during internal radiation
On bedrest while the implant is in place
Position for an infant with a cleft lip
On their back or in an infant seat to prevent trauma to the suture line. If feeding, hold in an upright position
How are late decelerations corrected?
Oxygen by face mask [8 to 10 liters per minute] Reposition left side Stop oxytocin if on it I.V fluid bolus [to increase perfusion to placenta + fetus] Give tocolytic like terbutaline or magnesium sulfate
How do toddlers play?
PARALLEL PLAY right alongside eachother but not with each other
Position of a patient after cataract surgery
Patient should sleep on the UNAFFECTED side and have a night shield for 1 to 4 weeks
testicular self examination
Perform monthly and on same day Perform while after taking warm shower because temp will relax scrotal tissue and make testis hang lower in scrotum Use both hands to feel each testis separately Palpate gently using thumb and first 2 fingers
What do we do if a patient has decreased LOC during tube feeding
Position the patient on the RIGHT side [this increases gastric emptying] and RAISE the head of the bed to at least 30 degrees [this prevents aspiration]
What drug do we use for Diabetes insipidus [DI]
Pitressin
Expected term newborn findings
Plantar creases up entire sole Presence of babinski Epstein's pearls
Babinski sign for child more than 1 year and an adult
Plantar flexion Normal toe flexion [no babinski]
DECREASED breath sounds on left side or right side of the lung could indicate what
Pleural effusion Pneumothorax Atelectasis If these occur and breath sounds decrease is because that side of the lung is collapsing due to disruption of the pleural space or alveoli
S&S dehydration
Poor skin turgor Dry mucous membranes Tachycardia Orthostatic hypotension Weakness Lethargy
Common proton pump inhibitors PPIs
Prazoles: omeprazole, lansoprazole, etc
What do we do as the nurse for acoustic neuroma
Pre and post op care for posterior fossa craniotomy Assist with turning of the neck for comfort measures Treatment: surgical removal of tumor
How long to GBS symptoms last for?
Progresses for 10 days and then last for 10 days
Why do we do active resistive range of motion
Provision of resistance to increase muscle strength 5 lb weights or bags may be used Performed by the client against manual or mechanical resistance
1st line treatment for Myasthenia Gravis
Pyridostigmine
Renal arteriogram
Radiologic test performed to visualize renal blood vessels to detect abnormalities [renal artery stenosis or aneurysm] Contrast medium is injected into femoral artery [check for iodide or shellfish allergy] Client should increase fluid intake after procedure to flush dye out of body Increased urinary output is an expected finding
Goals for IBS
Reduce diarrhea or constipation Abdominal pain Stress Manage with diet Meds Exercise Stress reduction
What is the nursing care focus opioid dependent newborns?
Reduce stimulation Promote nutrition and comfort
What do we do when a baby has club foot
Reposition the foot to normal position every 4 hour Casts and splints correct the deformity if placed early (change casts every few days for the first 1-2 weeks and then every 1-2 weeks after that) Surgery is usually required for older children
What usually causes delayed postpartum hemorrhage?
Retained placental fragments
Decerebrate posturing (toes point down and amrs/legs straight out) is a sign of
Severe brain damages
Protective factors for SIDS
Sleep supine [infants must sleep on their backs] Breastfeeding Pacifier during sleep Up to date vaccines Appropriate clothing like sleep sack Firm mattress Remove loose items from bed like pillows toys blankets [choke hazards] Do not let them sleep in parent room
Remember the SIRS continuum
Starts with inflammatory response [this includes fever, tachycardia, tachypnea] Then when an infectious source is identified, this is considered SEPSIS When the patient remains hypotensive despite 2 liters of fluids being given, this is called septic shock SHOCK + 2 or more organ systems damaged is called multi organ damage syndrome [MODS]
When you have medication-induced Cushing syndrome, what is causing this
Steroids! they need to be tapered off! Never stop them automatically even when you are having a bad reaction because you can die from acute adrenal insufficiency
Positive orthostatic vital signs are present when
Systolic BP DROPS by at least 20 OR Diastolic BP DROPS by at least 10 Pulses usually RISES about 20
what does TORCH stand for?
T: toxoplasmosis O: other like parvo- b 19 + varicella zoster R: rubella C: cytomeglovirus H: herpes
Cystic fibrosis
THICK MUCUS, lungs become clogged with mucus The mucus eventually harbors bacteria and they have recurrent respiratory infections Chest physiotherapy is used
Hypocalcemia is a potential complication of
THYROIDECTOMY The parathyroid glands that regulate calcium are sometimes removed accidentally during thyroidectomy because they are so small WATCH patient for signs of hypocalcemia like POSITIVE trousseau and Chvostek signs Give calcium gluconate to increase serum calcium
Correct way to cough and deep breathe
Take 3 deep breaths, hold your incision, and cough
Position for a patient with a continuous bladder irrigation [CBI]
The catheter is taped to the patients leg so the leg should be kept straight, but there are no other positioning limitations
Sleep apnea syndrome
The client snores loudly, stops breathing for 10 seconds or more and then awakens abruptly with a loud snort (multiple times throughout the night) Often in older, overweight men, elderly, and people with thick necks, smokers
Encourage patients with PTSD to talk about
The experience and discuss the trauma at their own pace The point is to be able to talk about it without experiencing high levels of anxiety Help them decide what causes triggers and identify how they cope
What is strabismus
The eyes do not function as a unit because there is an imbalance of extra ocular muscles
How do we diagnose Menieres disease
Weber and Rinne test C.T scan
Poor thiamine consumption can lead to
Wernicke encepalopathy
Insulin with a fetus right after birth
The fetus produces insulin to match the mother during pregnancy (which is high). When the baby comes out, it is still producing a lot of insulin which can cause HYPOglycemia Must MONITOR for hypoglycemia
What can thiamine deficiency lead to?
Wernicke encephalopathy
What can inadequate thiamine lead to?
Wernicke encephalopathy S&S: Altered mental status Oculomotor dysfunction Ataxia [loss of coordination] Seizures
When are we going to administer an anti anxiety
When a client is restless and has an increased heart rate
What is abruptio placentae
The premature separation of the placenta which leads to hemorrhage. •Biggest concern is fluid volume deficit related to bleeding
What is the Somogyi effect?
When blood glucose levels drop too low in the middle of the night, the body tries to compensate by rebounding into hyperglycemia, so you think you are high blood sugars in the morning when it is all just a FACADE!
Tobramycin
Therapeutic Level: 5-10 mcg/mL Toxic Level: >12 mcg/mL
What are mongolian spots and are they normal?
They are bluish discoloration of the skin on newborns seen on darker skinned newborns on the back or butt They usually fade over 1-2 yrs of life Nurse should measure and document because they look like bruises They are normal
When undergoing a transplant, what do we need to remind visitors of
They cannot be in the room for the first 72 hours
What is the primary problem for a client diagnosed with schizophrenia
They have difficulty forming relationships
What do we need to remember about potassium and people on "-pril" meds
They want low potassium! No bananas, no salt substitutes, etc ACE inhibitors + ARBs INCREASE POTASSIUM levels when combined with other meds that do the same. Risk for HYPERkalemia
Signs of developmental dysplasia of the hip?
Thigh folds Laxity of the hip joint
Autonomic dysrefexia [hyperreflexia]
Throbbing headache from uncontrolled hypertension Nausea Blurred vision Sweating and skin flushing above level of injury
What are the contraindications for giving tPA?
Thrombocytopenia Coagulation disorders Major surgery within the last 14 days
S&S of a preschooler who overdosed on aspirin
Tinnitus and gastric distress
What do we need to teach the client about Menineres disease
To slow down their body movements as jerking or sudden movements can cause an attack Need to lie down when an attack occurs If driving, pull over and stop the car
Side effects of albuterol and other beta 2 agonists
Tremor Tachycardia Palpitations Restlessness Hypokalemia
How can pregnant women avoid heartburn?
Upright position after meals Small frequent meals Keep HOB elevated Drink smaller amounts of fluid while eating Eliminate dietary trigger like cffeien, chocolate, fried/fatty foods, spciy foods , peppermint Do not take Alka seltzer while pregnant
IVPB Potassium Chloride [KCl] route & method
Use: treatment of hypokalemia Infusion rate: should not exceed 10 mEq/hr Give via infusion pump
Positive Pressure Ventilation (PPV)
Used most commonly in acute respiratory failure causes increased intrathoracic pressure: leads to reduced venous return, ventricular preload and cardiac output, which results in hypotension-effect is greater in presence of hypovolemia [such as hemorrhage, hypovolemic shock] and decreased venous tone [such as septic shock, neurogenic shock]
Stress incontinence teaching
Void every 2 hours while awake Void every 4 hours at night Perform kegel exercise to strengthen pelvic floor muscles
When can we give TPA [Thrombolytics] in an M.I
Within 6 hours
What must be done after ng tube placement?
X-ray to confirm location
If you are having a bad reaction to a DtAP vaccine, when will you see the side effects
You will see a low-grade fever and it will be about 48 hours after the injection
Clamping a chest tube should NOT happen for longer than
a minute and only if perscribed by the HCP
Always suction pharynx [throat] first in
a newborn
Goal to reduce ICP is to
reduce metabolic demands
What is sodium polystyrene sulfonate?
reduces potassium levels
Gallstone surgery may have
referred pain
After thyroidectomy watch out for what
respirtory distress from neck compressing [due to swelling from edema at the surgical site]
What is akathisia?
restlessness with inability to sit still
Diet for chronic kidney disease
restrict fluids, sodium, potassium, and phosphorus
Low residue diet may be used for
acute diverticulitis but high fiber for future episodes
Wheezing indicates what in a respiratory issue?
an obstructive process like -Asthma -COPD [emphysema + chronic bronchitis]
Late signs of digoxin toxicity
arrhythmias
What is significant about Guillain Barr Syndrome GBS?
ascending symmetricl paralysis
Reaction formation
behaving in a manner or expressing a feeling opposite of ones true feelings
With a balloon tamponade tube, what should always be kept at the bedside?
scissors
Ultra sound is done around 36 weeks to
see location of placenta
In acute pericarditis, an ST elevtion is
seen in almost all leads
People with narcissistic personality disorder try to maintain what?
self esteem
Septic shock
sepsis induced HYPOtension despite adequate fluid resuscitation
Patient with chronic venous insufficiency should not
clip their own toenails
What are wheezes?
continuous, high pitched musical adventitious sounds caused by air movement through narrow bronchi and bronchioles
What is the Allen's test?
determines patency of the ulnar artery •Patient makes a fist and radial and ulnar arteries are occluded •Patient opens fist and pallor is shown on hand from non-blood flow •Nurse releases pressure on arteries and blood flow is returned to hand •Allens test should be positive and if negative, another artery should be used
Antihypertensives are held the morning before
dialysis [this is because dialysis causes HYPOtension]
Take pulse and withold which med if less than 60?
digoxin
How to give morphine I.V push
dilute and give slowly over 3-5 mins
What does nonmaleficience mean?
do no harm
What can cause pseudohyperkalemia?
hemolysis or clotting during the blood draw
Acute angle closure glaucoma requires
immediate medical intervention!
Ptosis means injury to what nerve
oculomotor nerve [cranial nerve III]
What is fremitus?
palpable vibration on the chest wall when talking
Tochanter rolls
prevent legs from turing outwards
what does excess salt cause?
retention of water
Morphine is typically used for what type of pain?
severe
Delirium tremors
severe alcohol withdrawal symptoms like -Shaking -Confusion -Hallucinations
When is atropine given?
severe bradycardia it will speed up heart rate!
Albuterol
short acting and immediate bronchodilation
Vitamin K would lower INR why
the more clotting factors, the faster it would take the blood to clot so the lower the INR
What is countertransferrence?
the nurse unknowingly displaces feelings and behaviors in the nurses past onto the client
PCA pumps have a running I.V line attached to deliver a flush each time a dose of the pca is delivered, this is to make sure
the patient gets all of the pain med and thus has adequate pain control
Position for a detatched retina
•Area of detachment should be in the dependent position
Trust vs. Mistrust
0-1 yr Teach parents to meet infant's physical and social needs
Dystonia
*abnormal muscle movements* of the *face, neck, and trunk* caused by *sustained muscular contractions* (eg *torticollis, oculogyric crisis, opisthotonos*)
Why is a post op C section patient at high risk for pulmonary embolism?
-Abdominal C section -Engorged BVS from hypercoagubility of blood and venous stasis from being in the operating table -Immobility due to surgery [C-section is a major surgery] -Postpartum hypercoagubility state because the body makes a lot more blood to prepare for blood loss during birth
What is an amniotomy?
-Artificial rupture of the membranes (AROM) -Induces labor -Watch for cord prolapse -Assess fetal heart rate -Assess characteristics of amniotic fluid -Once membranes ruptured this increases the risk for infection -Check patients temp every 2 hours after rupturing -Assist client to an upright position after the procedure
If patient has a chest tube and all of the sudden the dainage stops, what are some interventions?
-Assess lung sounds [because it could be that the lungs have re-expanded which is amazing news and there is no more drainage) -Reposition patient [could be occluded from draining by patient/remember good lung UP and bad lung DOWN to drain OUT] -Get them to cough and deep breathe
Causes of hyponatremia in infants
-Can result from *water intoxication* when formula is diluted to "stretch feeding" -Can also result from *ingestion of plain water*
Immediate client care for basilar skull fracture
-Cervical spine immobilization -Close neurologic monitoring -Support of ABCs
What are some indicators that a child is ready for toilet training?
-Child can express the need to pee or poo -Can understand commands, communicate, and follow directions -Can pull up and down clothing [but not necessarily dressed and undressed themselves] -Walk to and sit on toilet for about 5 to 8 mins without crying or gettting up -Remain dry for several hours through a nap
Examples of cost-effective care
-Considering inside of sterile glove wrapper as a small sterile field -Donning clean, rather than sterile gloves to remove client's dressing
Sleep apnea interventions
-Continuous positive airway pressure [CPAP] device at night -Limiting alcohol intake at bedtime -Weight loss and exercise -Avoiding sedating medications [examples: benzodiazepines, sedating antidepressants, antihistamines, opiates]
Care of anorexic patient
-Determine pt daily calorie requirement -Monitor weight at same time every day with same scale, same amount of clothes on -Limit exercise initially bc they are obsessed -Reflecting with the patient on triggers -Do not encourage a log of food because this contributes to patient's obsession with food
Sjogren's Syndrome symptoms
-Dry eyes [xerophthalmia] can lead to corneal ulcerations -Dry mouth [xerostomia] can lead to dental caries and oral thrush -Dry skin & rashes -Chronic dry cough -Vaginal dryness & painful intercourse
Nursing care for NG tube feeding
-Elevate head of bed [HOB] during and after -Check gastric residual every 4 hours with continuous feeding or BEFORE each intermittent feeding/medication giving -Flush tube before and after bolus feedings -Aspirate but return contents to stomach -Check for excessive residual volume [if more than 100 mL notify doctor, hold feeding] -Start feeding after getting residual volume less than 100 ml -Gastric ph should be acidic or less than 5
Barium enema post op teaching
-Expect chalky white stool (this is the contrast) -Take a laxative MIlk of Magnesia to expel stool -Drink plenty of fluids and eat high fiber foods
Sjogren's syndrome Treatment & Patient Education
-Eye drops -Wearing goggles -Sugar free gum and/or artificial saliva -Regular dental appointments for dental caries -lubricants [such as KY Jelly] -Sip of water frequently -Use lukewarm water and mild soap when showering -Humidifiers to maintain adequate humidity [mainly at night]
Earlier stage Alzheimer's disease eating problems
-Forgetting that meal was consumed due to short-term memory loss -Anorexia & weight loss secondary to depression &/or recognition of disease
Middle stage Alzheimer's disease - eating problems
-Forgetting to eat at all -Not recognizing sensations* of hunger or thirst -Forgetting how to use utensils -Consuming nonfood items -Refusing to eat -Restlessness: inability to sit long enough to consume a meal
How does the nurse prevent refeeding syndrome?
-Get baseline electrolytes -By Initiating nutrition support cautiously with hypo caloric feedings -Closely monitor electrolytes -By increasing caloric intake gradually
Postpartum psychosis - risk factors
-History bipolar disorder -Previous discontinuation of mood-stabilizing medications [such as lithium]
Umbilical cord care after birth
-Keep it clean and let it dry to open air [do not put dipare over it] -Do not put alcohol on it, just soap + water to clean -Report signs of infection such as REDNESS SWELLING PUS coming from the umbilical cord [but remember the normal yellow crust that should form] The cord is cut after birth and a little remains there The cord will shrivel and turn black in a few days and will fall off by itself in a 1 to 2 weeks Teach parents and caregivers to NOT mess with it or pull it off
Strategies to prevent accidental drug overdoses in children
-Keep medications out of sight in a locked drawer or cabinet -Put them away after each use
Peripheral Arterial Disease [PAD] Home Management Instructions
-Lower extremities below heart when sitting and lying down [DANGLE for Peripheral Arterial disease] -Engage in moderate exercise [for example 30 to 45 minute walk, twice daily) -Perform daily skin care, including application of lotion to prevents skin breakdown from dry skin -Maintain mild warmth [lightweight blankets, socks) but never use heating pads -STOP SMOKING! -AVOID tight clothes and stress - Take prescribed medications [such vasodilators + antiplatelets]
Steps for putting in an NG tube
-Measure, mark, and lube -Tell client to extend neck back -Insert tube just passed nasopharynx -Tell client to flex neck forward and swallow -Advance tube to the marked point -Verify placement of tube [X-ray] and anchor to nose
COPD exacerbation nursing monitoring
-Most important for nurse to monitor mental status frequently and report changes [like restlessness, decreased LOC, somnolence, difficult arousal, confusion] to HCP because this may indicate increased CO2 retention & worsening hypercapnia -Altered mental status poses greatest threat to survival of a COPD patient because it can lead to •Decreased protective reflexes [like gag, swallow, cough reflexes] •Periods of apnea •Airway compromise
Hypercalcemia [Low calcium causes everything to run slow] signs and symptoms
-Muscular weakness -CONSTIPATION -DEPRESSED deep tendon reflexes [DTR] -Anorexia -Nausea/vomiting -Polyuria [excessive urination] + Polydipsia [extreme thirst] -Dehydration -Flank pain [kidney involvement due to stone] -Calcium stones -Deep bone pain [pathological fractures] -Hypertension When you think hypercalcemia, think hyper-parathyroidism
ECT patient teaching
-NPO for 6 to 8 hrs before procedure -Anesthesia and muscle relaxant given before; patient will be unconscious during procedure -No driving after procedure -There will be temporary memory loss and confusion in immediate recovery period -Discontinue anticonvulsants because the treatment induces a seizure
Airborne precautions diseases & equipment
-Negative pressure isolation room Disease acronym [airing MTV]: - Measels - TB - Varicella zoster (chicken pox) infections
Signs & Symptoms of hypernatremia in infants
-Neurological symptoms [restlessness, seizures] -On history indicates adequate oral intake & signs of fluid overload [facial edema] not dehydration
Long term corticosteroid treatment
-Never abruptly discontinue; this could lead to addisonian crisis -Report any signs of infection immediately because this usually can cause immunosuppression and can even mask signs of infection -Watch for signs of HYPERglycemia -Cataracts is a SIDE EFFECT [eye checkups every year are recommended] -Never take on an empty stomach
Patient teaching for IBS
-No gas producing foods [such as bananas cabbage onions] caffeine, alcohol, honey, high fructose corn syrup, and other G.I disturbing foods like spices, hot food/drink, dairy, fatty foods -Gradually increase fiber intake -Generally tolerated well are protein, bread, and bland food
Pertussis management & treatment
-Oral antibiotics -Droplet precautions -Supportive measures [humidified oxygenation and oral fluids]
Patient care for acute manic episode
-Reduce environment stimuli -Calm quiet low lit -Limiting person contact -ONE on ONE- not group activities -Structured scheudle of activities to keep focus -Physical activities one on one to relieve energy -High protein high calorie finger foods -SET LIMITS
Pursed lip breathing instruction
-Regular practice [for example 5-10 min 4 times a day] 1. Relax neck & shoulders 2. Inhale 2 seconds through nose while mouth closed 3. Exhale 4 seconds [or twice as long as inhalation] through pursed lips
diverticular disease dviverticulitis
-Sac like protrusions off the large intestine [colon] asymptomatic usually and patient is not aware until this pouch becomes infected or inflammed which is then called diverticulitis -What can the patient do? Prevent constipation which may cause diverticula to become inflamed -High fiber diet -Daily intake 8 glasses water -Daily exercise -DECREASE red meats and foods high in fat BEFORE diverticulitis INCREASE FIBER + fluids but once diverticulitis is present patient needs to be on a low residue diet
Acute pericarditis assessment
-Sharp pleuritic chest pain -Aggravated on inspiration and coughing -Assessment shows pericardial friction rub
What can lead to recurrent otitis media?
-Smoking around child -Regular pacifier use -Drinking from a bottle while lying down -Lack of immunizations
Some facts about cystic fibrosis
-Sticky thick respiratory secretions -Chronic cough -At risk for recurrent lung infections -Reduced pulse ox but 90% requires immediate intervention -Can cough up blood sputum [hemoptysis] -Lose weight -Fecal retention/impaction
When is using an indwelling catheter appropriate?
-Urinary obstruction or retention -The need of strict I/Os in crtically ill patients -Peri op [during surgery] like urologic procedures, prolonged surgeries, or when I.V fluids or diuertics are given during surgery -Prolonged immobilization when bed rest is necessary -To improve end of life comfort -To promote healing of an open perineal or sacral wound in incontinent patients
Bilevel positive airway pressure [BIPAP] device
-Used in conscious client who is breathing spontaneously -Delivers oxygen to lungs and removes CO2
Criteria for diagnosis of IBS
-recurrent abdominal pain + discomfort 3 or more days a month for 3 months At least 2 of these -improvement with bowel movement, change in frequency of stool, or change in form of stool
Neonatal heel stick
-used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders [for example: congenital hypothyroidism + phenylketonuria]
Children under what age should not be given honey?
1 year
When does the Babinski reflex disappear
1 year
Clinical Manifestations of Right-to-Left congenital heart defects
1. Clubbing of fingertips associated with chronic hypoxia 2. Cyanosis evident shortly after birth and during periods of physical exertion [bluish skin color]
Expected number of stools per day in patient on lactulose
2-3 soft stools per day
Hepatitis is diagnosed when liver enzymes are
2-3 times the normal value [elevated ALT + AST]
Short acting [regular] insulin peak
2-5 hrs
Aortic
2nd ICS
Pulmonic
2nd ICS
How to calculate MAP?
2x diastolic + systolic all divided by 3
What number of weeks is considered term?
37 weeks of gestation
Erbs point
3rd ICS
Tricuspid
5th ICS
Mitral AKA apex
5th ICS at midclavicular line
How many diapers for a full term infant
6-8 wet diapers and one stool daily
What is normal MAP
60 or more
Pneumonia vaccine
65 and older need 2 vaccines
How long does an M.R.I ususally last for
90 minutes
Normal O2 Sat for test purposes is
95% to 100% and if under 95% this is hypoxemia
in pregnancy, pts are considered anemic when hemoglobin drops below what?
<11
Mastitis
= postpartum breast infection from clogged milk ducts [poor latch] NOT draining properly -Symptoms: Fever Breast pain Breast inflammation + redness - Treatment: 1. antistaphylococcal antibiotics [dicloxacillin or cephalexin] and analgesics like ibuprofen] 2. Frequent continued breastfeeding [every 2-3 hours] 3. Increase oral fluid intake 4. Wear soft cup bras to encourage milk flow
Refractory hypoxemia
=inability to improve oxygenation with increases in oxygen concentration hallmark of acute respiratory distress syndrome [ARDS]-progressive form of acute respiratory failure that has high mortality rate
What is the blood loss amount to be considered postpartum hemorrhage (PPH)?
>500 ml after vaginal birth >1000 ml after c-section
What is retinopathy of prematurity
A cause of blindness in premature infants because when they are premature, we slam them with O2, but this is much of the cause as to why the retinal vessels constrict; this leads to blindness
Avoid I.M or venipncture when the platelet count is below what?
50,000 cells
Platelets [at least afte chemo] are not considered urgent until below what?
50,000 platelets
What is acute RLQ pain, N/V, and a high WBC count most likely?
APPENDICITIS It's an EMERGENCY surgery because the appendix could rupture If the appendix ruptures, the pain will subside temporarily [until peritonitis + sepsis develops]
Which heart meds cannot be given during pregnancy?
ARBs and ACE inhibitors
Since a client post op is coming off anesthesia, they are at risk for
ASPIRATION due to their altered level of consciousness [LOC] Nausea post op should be a priority
Temporal lobe
AUDITORY input cannot understand visual or written language
What to avoid with Sjögren's syndrome
AVOID -Decongestants can cause further dryness -Oral irritants* (eg coffee, alcohol, nicotine found in cigarettes) -Acidic drinks -Low-humidity environments [such as centrally heated houses, airplanes]
What is glaucoma
Abnormal INCREASE in intraocular pressure leading to visual disabilities and blindness •Cloudy, blurry vision or loss of vision •Artificial lights have rainbows or halos around them •DECREASE in peripheral vision
What scale do we use to detect the presence of tradeoff dyskinesia
Abnormal Involuntary Movement Scale (AIMS)
If someone has a gastric ulcer, when are they going to experience the most pain
About 30 mins to one hours after eating
If you have a cervical cancer radium implant in, how long do you need to abstain from sex and tampons for?
About 6 weeks, whenever your followup with your primary care physician is
Fall risk factors
Above age 60 Previous fall Bowel/bladder incontinence or urinary frequency Sedatives, diuretics, ntihypertensives, CNS drugs unsteady gait Weakness, limited mobility HYPOtension Visual/auditory impairments Dementia Tubes Med equipment SCDs Restraints
What is typically seen in a retinoblastoma?
Absence of red reflex •The pupil reflects a white color
When does a child have an actual concept of death
Age 9
how to calculate the # of teeth a child should have in the first 24 months?
Age of child in months minus 6
Patient with measles precautions
Airborne and negative pressure room N95 respirators
First level priority problems
Airway Breathing Circulation & cardiac [become first priority in cardiac arrest] Vital signs
What is the best lab value to look at for long term nutritional status
Albumin
Contraindication to administering the flu vaccine
Allergy to eggs An allergy to eggs should also be reported before receiving "eggs Make Me Rise Very happy INside" •M,M,R: MMR •V: varicella •IN: influenza
Second level priority problems
Altered mental status Acute pain Untreated medical problems (like hyperglycemia in client with diabetes) Chronic pain Acute elimination problems Abnormal lab results Risk for infection Safety
Aluminum hydrozide
Antacid Take it one hour after meals
What is Amphotericin B?
Anti-fungal med used to treat systemic fungal infections severe adverse reactions like HYPOtension, fever, chills, and nephrotoxicity
What do we do as the nurse for otitis media
Antibiotics (organism specific) Antihistamines for allergies Nasal decongestants Ventilatory tubes [inserted in the eustachian tube for continuous ventilation] Tympanoplasty [reconstruction of the ossicles and tympanic membrane] Myringotomy [incision to tympanic membrane to relieve pressure and release purulent drainage;no water allowed in ear]
What is imipramine
Antidepressant and nerve pain medication Side effects include: -Fever -Dry mouth -Vomiting/diarrhea -Fatigue -Sore throat
Acetaminophen (Tylenol)
Antidote/Reversal: acetylcysteine (Muscomyst) Toxic Level: >250mcg/mL
What meds are we giving to someone with Menieres disease
Antihistamines Anti emetics Antivertigo Diruetics
What volume of chest tube drainage should be reported to HCP
Any thing greater than 100 mL/hr
What do we do for patients with rheumatoid arthritis
Apply heat and do ROM exercises This REDUCES swelling, INCREASES circulation and DECREASES stiffness while preserving joint mobility
Use of aspirin during pregnancy
Aspiring can cause fetal hemorrhage, do not use this during pregnancy [it is contraindicated]
What do we do as the nurse for sleep apnea syndrome
Avoid alcohol and meds that depress the upper airway Talk about weight loss and diet CPAP or BiPAP Surgery Low flow O2 Position [fixing devices are used to prevent subluxation of the neck and tongue obstruction]
In leukemia, bone marrow activity is depressed and so what does this result in
BLOOD CANCER Infection [low WBC] Low RBC production= anemia Decreased making of platelets= bleeding [thrombocytopenia]
Signs of preeclampsia
BP greater than 140/90 Proteinuria greater than 300 mg of protein in urine in 24 hours Headache Visual changes 2+ pitting edema
Beta blockers, calcium channel blockers, and digoxin can all cause
BRADYCARIA [Mnemonic Be a Cautious Detective] WITHHOLD beta blockers, calcium channel blockers or digoxin if heart rate is below -60 for adults -70 for children -90 for infants This is a general rule but check your hospital/nursing policy + procedures
Remember BETA blocker cause
BRADYcardia
Where is gluten found?
BROW [Do not give to celiac patients/gluten free ONLY] •Barley •Rye •Oats •Wheat
How do we diagnose benign prostatic hypertrophy?
BUN and creatinine PSA [Prostate specific antigen][should be less than 4mg per mL] Transabdominal/transrectal ultrasound Prostate biopsy
What labs to check before giving digoxin?
BUN and creatinine because this drug is mostly excreted by the kidney
Which foods may cause a latex-food syndrome in patients with a latex allergy?
Bananas Avocados Tomatoes Kiwi Potatoes Peaches Grapes Apricots
If there is a low potassium level, why do we need to hold the digoxin
Because hypokalemia can lead to dig toxicity •We have to call the HCP and ask for a potassium supplement before giving the dig
Glucose levels during and after pregnancy
Because of hormone levels and a baby in you, glucose rises during pregnancy Glucose will drop after delivery
What do we as nurses do for Pyelonephritis
Bedrest during the acute phase Antibiotic therapy, antiseptics, analgesics Encourage fluid intake of 3000ml per day
Red asthma
Below 500 [medical alert]
pH of gastric contents should be:
Between 1 and 4
When we are admitting a psych patient, what type of admission history do we need to get
Biopsychosocial so we are encompassing all of them, not just a psych approach
When a client with parkinsons is experiencing extrapyramidal side effects, which med should we administer
Biperiden
Signs of complications after a prostatectomy
Bleeding Passing blood clots A decrease in urinary stream Urinary retention Symptoms of a UTI ALL these should al be reported
What do you closely monitor when giving furosemide?
Blood pressure Potassium BUN Creatinine
What is an advantage of having an insulin pump?
Blood sugar does not go way up and way down Sugar level will stay at a more steady rate You still have to test your blood sugar when you have this
Symptoms of hypothyroidism
Bradycardia Dry skin Weight gain
Drugs for stones
Broad spectrum antibiotics Thiazide diuretics Allopurinol Vitamin B6 (pyridoxine)
Aminophylline
Bronchodilator
Terbutaline
Bronchodilator and anti-contraction [tocolytic] Used to stop contractions in preterm labor and delay the process Side effects are •Maternal and fetal tachycardia •Tremors •Nervousness •Headache •Pulmonary edema
What are the 2 signs the nurse does to check for meningitis?
Brudzinski + Kernig
Post extracorpeal shock wave lithotripsy for kidney stones instructions
Bruising on back or abdomen is normal Increase fluid to flush out fragments Ambulate to remove fragments Blood in urine is normal
Examples of proton pump inhibitors (PPIs)
"prazoles" omeprazole, lansoprazole, pantoprazole
Fifth disease
"slapped face" Distinct red rash on cheeks It's on communicable before the onset of symptoms Spreads via respiratory
Parkland formula for burns
% BSA x weight (kg) x 4 Give half calculated volume of fluid in FIRST 8 hours Give the remaining half of the volume calculated the LAST 16 hours
Factors contributing to female infertility
1. Hormonal dysfunction [PCOS] with anovulatory cycles 2. High or low BMI [normal: 18.5-24.9 kg/m2] 3. Maternal age >35 4. Endometriosis 5. Recurrent infections [chlamydia + PID]
Signs of depression in adolescents
1. Hypersomnolence [always sleeping] or insomnia; napping during daily activities 2. Low self-esteem; withdrawal from previously enjoyable activities 3. Outbursts or angry, aggressive, or delinquent behavior (eg vandalism, absenteeism) inappropriate sexual behavior 4. Weight gain or loss; increased food intake or lack of interest in eating
First trimester in weeks
1-12 weeks
Onset of Isophane [NPH]
1-2 hr
Drugs contraindicated in patients with HYPERkalemia
1. ACE inhibitors [-prils] 2. Angiotension 2 (ARBs)[-sartan] 3. Potassium-sparing diuretics
UAP scope of practice
1. ADLs 2. Hygiene 3. Linen change 4. Routine, stable vital signs 5. Documenting input/output 6. Positioning
Diet of a premature infant
100-200 kcal/kg/day Need more sodium, calcium, and protein than full term infants Supplements: Vitamin A, C, D, and iron. Sometimes Vitamin E Vitamin K to prevent clotting problems
Risk factors for cervical cancer
1. Infection with high-risk HPV strains 2. History of sexually transmitted diseases 3. Early onset of sexual activity 4. Multiple or high-risk sexual partners 5. Immunosuppression 6. Oral contraceptive use 7. Low SES 8. Tobacco use
Steps for suctioning an endotracheal tube (ETT)
1. Perform hand hygiene and don clean gloves 2. Suction oropharynx and perform oral care 3. Ensure that the system is connected to appropriate wall suction [less than 120 mm Hg] 4. Hyperoxygenate the lungs [100% FiO2] 5. Advance catheter into trachea until resistance is met. Do not suction while advancing the catheter 6. Gently remove catheter while suctioning and rotating it. Do not suction for more than 10 seconds 7. Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times Document procedure when complete 8. Resume oxygenation and ventilation settings as prescribed
Infant formula teaching
1. Keep parts of bottles as clean as possible [boil or wash in dishwasher] 2. Wash the top of can before opening 3. Keep unused prepared formula or cans in refrigerator after opening but discard after 48 hours -but throw away formula that infant left in bottle 4. Never microwave but instead can be placed in pan of hot water to warm it, then test temp on inner wrist. should be lukewarm 5. Never dilute or concentrate formula
Safety promotion for client with moderate Alzheimer's disease
1. Keyed deadbolts and close supervision 2. Medical identification/location devices 3. Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns 4. Household hazards [gas applicanes, rugs, toxic chemicals] are removed to prevent injury 5. Grab bars installed in showers and tubs
LPN scope of practice
1. Monitoring RN findings 2. Reinforcing education 3. Routine procedures [like catheterization, med administration expect med that goes through vein] 4. Most med administration 5. Ostomy care 6. Tube patency and enteral feeding [NG, GT] 7. Specific assessments [like lung, bowel, neuro-vascular checks]
What is monitored carefully after an abdominal aortic aneurysm (AAA) repair?
1. PULSES [examples: femoral, posterior tibial, dorsalis pedis] SKIN COLOR and TEMPERATURE of lower extremities 2. Renal status so things like BUN, CREATININE,* and urinary output [any less than 30 mL per hour is bad] reason for checking kidney is that blood is temporarily cut off the kidney to repair the AAA. So monitoring the kidney is essential
Things that UAP are allowed to do
1. Passive/active ROM exercises 2. Transport body to the morgue 3. Pick up something from pharmacy 4. Measurement of vital signs 5. Fingerstick glucose testing 6. Personal hygiene & skin care 7. Oral care 8. Measurement of urine output
Steps for preparing sterile field for a wet-to-damp dressing change
1. Perform hand hygiene 2. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze 3. Hold the inverted opened gauze package 6 inches (15cm) above waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto sterile field 4.Place the sterile dressings on the sterile field 2 inches (5 cm) from the edge*; the 1 inch (1.25cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces 5. Use sterile normal saline from a recapped bottle that was opened less than 24 hours ago
SBAR Communication Framekwork Components
1. S = Situation - what prompted the communication [what changes occurred] 2. B = Background - pertinent information, relevant history, vital signs 3. A = Assessment - nurse's assessment of the situation [when* & *what changes occurred] 4. R = Recommendation - request for prescription or action from HCP
Neonatal heel stick proper technique
1. Select location on the medial or lateral side of the outer aspect of the heel 2. Warm the heel for several minutes with warm towel compress or approved single-use instant heat pack 3. cleanse intended puncture site with alcohol 4. Sucrose + nonnutritive sucking on a pacifier may reduce pain 5. Use an automatic lancet
Acute hemolytic transfusion reaction - Nursing Interventions
1. Stop transfusion immediately and disconnect tubing at catheter hub 2. Maintain IV access with normal saline using new tubing to prevent HYPOtension & vascular collapse 3. Notify HCP & blood bank 4. Monitor vital signs 5. Recheck labels, numbers and client's blood type 6. Treat symptoms according to HCP's prescription 7. Collect blood and urine samples to evaluate for hemolysis 8. Return blood & tubing set to blood bank for additional testing 9. Complete necessary facility paperwork to document reaction
Situations that nurses must legally report
1. Suspected abuse 2.Suspicious deaths - medical examiners has legal authority & obligation to perform an autopsy independent of family wishes when deaths are suspected to be result of crime, trauma, or suicide 3. Impaired or intoxicated health care professionals regardless of their position
Clinical Manifestations of left-to-right cardiac shunts
1. Tachypnea [hyperventilation] 2. Tachycardia, even at rest [fast heart rate] 3. Diaphoresis [sweating] during feeding or exertion 4. Heart murmur or extra heart sounds [S3] 5. Signs of congestive heart failure 6. Increased metabolic rate with poor weight gain
Objective [probable] signs of pregnancy
1. Uterine/cervical changes -Goodell sign -Chadwick sign -Hegar sign -Uterine enlargement 2. Braxton hicks contractions 3. Ballottement 4. Fetal outline palpation 5. Uterine & funic souffle 6. Skin pigmentation changes -Chloasma -Linea nigra -Areola darkening 7. Striae gravidarum 8. Positive pregnancy tests
Written consents - Nurse's Role
1. Witness that consent was signed voluntarily 2. That patient was competent at time of signing 3. Documenting in medical records after signature obtained with date/time of signature
What medications interact with grapefruit?
1. calcium channel blockers [diltiazem, nifedipine, verapamil] 2. statins [anti-cholesterol meds] 3. SSRIs [antidepressants]
Conditions of being ineligible to leave AMA
1. danger to self or others 2. lack of consciousness 3. Altered consciousness 4. Mental illness 5. Being under chemical influence 6. Court decision
With CO poisoning, what should be the nurses primary action?
100% oxygen at 15ml via non-rebreather mask
Therapeutic PTT
1.5-2 times normal reference of 25-35 seconds so if on heparin expected normal is about 37 to 70 seconds
How many cm is the complete dilation to birth?
10 cm
Normal vancomycin level
10 to 20
Onset of Glulisine
10-15 mins
Dumping syndrome
10-30 mins after eating you get diarrhea and rapid gastric emptying Patient should lay down after eating to delay gastric emptying time, Patient should NOT drink 1 hour before, during, or 2 hours after meals [similar to the antacid rule do not drink fluids 1 hour before or 2 hours after meals] Patient should eat smaller meals more frequently
Med of choice for supraventricular tachycardia [SVT]
Adenosine
What is the priority for a patient with sickle cell crisis
Adequate hydration
A chest tube and catheter should both be placed
below chest and bladder
What does the posterior fontanel close?
2 months
Heparin and warfarin are given simultaneously until the INR reaches
2 to 3, and then the heparin can be discontinued and warfarin continued
Heparin has a short duration like
2 to 6 hours so if it is not being infused, the aPTT level will go back to the control value So check for infiltration [med going into tissue instead of into vein] if the lab studies show aPTT at the control value despite heparin administration
Normal range for wet diapers first 48 hours of life
2 to 6 wet diapers every 24 hours
What is the normal force of the pulse on the scale
2+
What number is the normal, expected deep tendon reflex?
2+
When does the grasp reflex disappear
3 months for palmar 8 months for plantar
What are the criteria for Metabolic syndrome?
3 or more of the following: Increased waist circumference High blood pressure 130/85 Triglyceride level over 150 HDL below 40 or 50 Fasting glucose levels above 100 mnemonic: We Better Think High Glucose
Normal weight gain in an infant from age 6 to 12 months
3 to 5 oz a week
Glasgow coma scale ranges from
3-15; 3 being worst 15 being best condition [8 or below in a coma]
Onset of Glargine [Lantus]
3-4 hr
When does the Moro reflex disappear
3-4 months
When does the Tonic Neck reflex disappear
3-4 months
Duration of Aspart
3-5 hours
Duration of Glulisine
3-5 hours
Duration of Lispro
3-6 hours
Measure NG tube
From nose tip, to earlobe, down to the xiphoid process
Normal albumin level
3.5 to 5.0;function of albumin keeps fluid from leaking out of vessels; low albumin causes pitting edema + ascites
Normal respiratory rate for a neonate?
30 to 60 breaths per minute
Normal newborn respiratory rate
30-60 glucose levels are normally decreased 1 hour after birth
Onset of Regular
30-60 min
Rapid acting insulin peak [aspart, lispro, glulisine]
30mins-3 hours
Normal newborn head circumference
32 to 37 cm
Average head circumference of a newborn
32-36 cm
Tetraology of fallot is the one with
4 issues It is cyanotic There is tet spell where kids will squat down to breathe better Clubbing of fingers + irritabilty expected
How to calculate the parkland formula
4 mL lactated ringers x surface areas that was burned % x weight in kg then divide by 2 because patient should receive the FIRST half of fluid volume in the FIRST 8 hours the other half of the volume calculated is given in the LAST 16 hours [making a total of a 24 hour of fluid resuscitation in a burned patient]
Introduction of solid food usually happens at how many months?
4 to 6 months of age
What are the key signs of refeeding syndrome?
PPM rapid decline in phosphorus, potasium, magnesium Fluid overload
Gout
A high level of uric acid that leads to joint deterioration Put on a low purine diet [no fish or organ meats] You do not need rest and activity and exercise like you do in RA and osteoarthritis, you just need to manage the pain
What is an ewald tube
A large orogastric tube that is designed for rapid lavage and often causes gagging and vomiting Always have suction equpiment at the bedside
What is aluminum hydroxide gel
A medication to prevent epigastric pain. Take it one hour after a meal to neutralize stomach acids Contains sodium so check if the patient is on a restricted sodium diet!
Pseudoparkinsonism
A medication-induced temporary constellation of symptoms associated with Parkinson's disease, signs of -Masklike face -Shuffling gait -Rigidity -Resting tremor -Psychomotor retardation [bradykinesia]
Describe an electromyography
A noninvasive procedure that takes about 30 minutes. Electrodes are attached to the legs and impulse transmission is measured
What is a flourescin angiography
A series of photographs taken that show details of the circulation of the eye The clients eyes are dilated with mydriatic eyedrops [dilatory drops] before the exam and patient has to protect their eyes from the sun AFTER the exam
If an african american needs a blood pressure med, which are we likely to prescribe
A thiazide diuretic NOT a beta blocker or an ACE inhibitor (pril)
Anti diuretic hormone
ADH is a hormone made by the hypothalamus in the brain and stored in the posterior pituitary gland. It tells your kidneys how much water to conserve. ADH constantly regulates and balances the amount of water in your blood.
offer 2 choices with
ADHD
if patient is in respiratory distress what do you assess first?
AIRWAY
Heparin is measured thru what levels?
PTT
Warning signs of cancer
CAUTION
Cystic fibrosis
CF is genetic bronchodilators before chest physiotherapy- to remove secretions that cause ineffective airway clearance Diet high in fat calories, proteins + high fluids Pancreatic enzyme supplements with all meals and snacks Recurrent respiratory infections
About eczema
CHRONIC skin disroder with Prurititis Erythema Skin dryness -Goal: DO NOT SCRATCH [this leads to more infections] -Alleviate the itching and keep skin hydrated -Moisturize, Keep nails short Patient with eczema should NOT wear wool or rough fabrics, gloves or cotton stockings over the hands
First test to show evidence of an MI
CK MB (appears in 3-6 hours) Then Troponin (appears in 4-12 hours)
What happens when carbon monoxide enters the body relating to hemoglobin?
CO displaces oxygen from HGB causing hypoxia that is NOT REFLECTED BY A PULSE OXIMETER the pulse oximeter can not differentiate between carbo-hemoglobin and oxy-hemoglobin SO, their pulse oximeter may relfect normal findings, yet severe hypoxia may be present
Autonomic dysreflexia
COMMON in people wwith spinal injuries T6 or higher It causes: -Severe hypertension -Throbbing headache -Sweating above level of injury -Bradycardia -Goose bumps -Flushing
What is exopthalmos?
COMPLICATION of hyperthyroidism from Graves disease Keep eyes moist and protected
Treatment for ventricular fibrillation [V fib]
CPR
how to treat asystole?
CPR Initiate advanced cardiac life support Give epinephrine and/or vasopressin Place an airway
What does a DNR exactly mean to withhold?
CPR + other lifesaving measures
If 20 to 40 of KCL are needed to be given, use a
CVAD rather than a peripheral vein
RIGHT-to-LEFT congenital heart defects
CYANOTIC defects or decreased pulmonary circulation 1. Tetralogy of Fallot 2. Transposition of the Great Vessels
Difference between Enteral nutrition and Parenteral nutrition
Enteral goes to the stomach via G-tube or something Parenteral goes through the vein straight into the cells
How often do we need to rinse and change a bag of continuous tube feeding
Every 4 hours to minimize the growth of organisms
Cardiac cath position
Femoral approach Bed rest 4 to 6 hrs Client can turn from side to side Keep extremity straight Head of bed is no higher than 30 degree
PTSD characteristics in people
Flashbacks of the traumatic event Persistent angry, fearful mood Difficulty concentrating Feeling detached from others
What do we do as the nurse during the diuretic phase
Fluids need to be replaced Diet adjustment [high carb, restrict protein, potassium and sodium] Replace potassium Dialysis (hemodialysis or peritoneal)
What is the antidote used for benzodiazepams?
Flumazenil (Romazicon)
What is a tilt table and what is it used for
For weight bearing on long bones to prevent de-calcification and bone weakess Use elastic stockings to prevent postural hypotension Board can gradually be tilted in 5-10 degree increments BP needs to be checked during procedure
Majority of cases of Epiglottitis are caused by what?
HiB [Haemophilus inflanzae type B] •most cases are prevented by standard vaccinations
Diet for someone with glomerulonephritis
High calorie, low Protein
How to fix acute renal failure [ARF] immediately?
High concentrations of O2
Body positioning for paracentesis
High fowlers
When a baby has increased ICP, what S&S will they display?
High pitched cry
How to use a cane
Hold cane in the OPPOSITE hand of the affected extremity Advance the cane with the affected/hurt extremity Lean on the cane when advancing the good leg
What is the brudzinski sign?
bending of neck causes flexion of knee and hip
What are the 4 categories for triaging?
Immediate [red tag] life threatening injuries with good prognosis once treated [patients have 30 minutes] Delayed [yellow] injuries requiring treatment within hours [patients have 30 minutes to 2 hours] Minimal [green tag] injuries requiring treatment within a few days [walking wounded] Expectant [black tag] extensive injuries, poor prognosis regardless of treatment
What lab value do we need to be aware of prior to a liver biopsy
PTT [prothrombin time/RISK for bleeding]
Time frame for checking pedal pulses when coming back from a cardiac catheterization
PULSES need to be checked immediately •And then every 15 minutes for the FIRST few hours
Hypercapnia
PaCO2 >45 mmHg
Manifestations of OsteoArthritis
Pain exacerbated by weight bearing Crepitus Morning stiffness Decreased joint mobility and range of motion Atrophy of the muscles
Cystoscope
Inserted through urethra to directly visualize bladder wall and urethra. May cause slight burning sensation with voiding for a day or two
Side effects of albuterol
Insomnia N/V Palpitations (from tachycardia) Tremor
Symptomatic bradycardia will present like what?
Pale Cool skin Hypotension [drop in cardiac output due to drop in heart rate] Weakness Confusion Dyspnea Chest pain Syncope
Autonomic dysreflexia can happen in someone with
a spinal cord injury [SCI] at or above T6
What can long term steroid therapy cause
OSTEOPOROSIS + PATHOLOGICAL FRACTURES + muscle wasting
What is topical capsaicin cream (Zostrix)?
OTC analgesic that relived minor pain like osteoarthritis special instrution: wait 30 mins after massaging cream into hands before washing
What to know about an electrical encephalogram [EEG]
Painless test that records electrical activity of the brain Wash hair before test to remove oils RESTRICT tranquilizer meds and stimulants 24-48 hours befit [example of stimulants include coffee, tea, smoking, soda] Instructed to stay awake late the night before so they can sleep through the test Maybe hyperventilate 3-4 times before the exam
gastric lavage "stomach pumped"
Orogastric tube removes toxins and irrigates stomach Rarely performed unless overdose could be lethal and if it can be done within ONE HOUR of the overdose NOT done a lot because of high RISK for aspiration or esophageal/gastric perforation Intubation/suction should always be at bedside elevate HOB or put patient on side Use large bore
Is reactive nonstress test positive or negative?
POSITIVE
Lactated ringers contains what electrolyte?
POTASSIUM
What patients are considered immunosuppressed?
Patient on -Steroids/chemo -HIV positive -New post op -Multiple chronic co morbidities -Splenectomy -Diabetes -Very young/elderly
Catatonic schizophrenia
Patient remians in a fixed stupor and refuses to move about or do adls, remaining mute, bizarre postures -Patient is unable to meet thier basic needs for adequate fluid and food intake and are at risk for dehydration and malnutrition
Which MAOIs are used to treat depression
Pirates who say "arrrrr" take MAOIs when they are depressed Parnate [Tranylcypromine] Nardil [Phenylzine] Marplan [Isocarboxazid] and then Selegeline (Emsam) Or the Depressed pirates too a ship to PANAMA Parnate Nardil Marplan
How to get a client to sit on the side of the bed
Place hands under knees and shoulders of client Have client push elbow into bed, while at the same time the nurse lifts the clients shoulders with one arm and swings the legs around with the other arm
Patients with Alzheimer's (and other forms of dementia) may wander or get lost so its important to take precautions in the home like
Place locks above or below eye level because they lose their peripheral vision Put alarms on doors Disguise the doors Childproof doorknobs You want to take precautions to PREVENT them actually leaving
What to do if you need to use an aed on a child but there are only adult pads available not kids
Place one on front and one on back to "sandwhich" the heart Just make sure they don't touch
How do we properly instill eardrops
Put the affected ear up Pull the ear up and back for an adult [older than 3] Pull the ear down and back for children under 3
If you have carpal tunnel, what exercise do we recommend for you
Put the back of your hands together and bend both wrists at the same time
RACE for FIRES in a hospital
R: rescue any patient in immediate danger and move them to safety A: alarm [sound the alarm] C: confine fire by closing all doors to all rooms E: extinguish fire with extinguisher
During disaster triage, what do red, yellow, green and black mean ?
RED [life threatening] significant impairment to the ABC and patient will likely survive if treated within 30 minutes YELLOW can wait 30 minimum to 2 hours [examples bone piercing through skin] GREEN [walking wounded] can wait more than 2 hours to receive care BLACK [expected to die, do nothing] TRAFFIC LIGHT Mnemonic [Red FIRST, YELLOW second, GREEN third can GO, BLACK broken traffic light say GOOD BYE]
During instillation and dwell time of peritoneal dialysis, what are clients closely monitored [PRIORITY] for?
RESPIRATORY DISTRESS from -infusing too quickly -overfilling the abdomen -fluid entering the thoracic cavity
With injury to T1-T6 what do we most need to worry about
RESPIRATORY function!
AFTER a liver biopsy positioning
RIGHT SIDE [on affected side] lying to put pressure on liver to stop bleeding
S&S of Neuroleptic Malignant Syndrome
Think of S&S You get HOT [hyper-pyrexia] You get STIFF [increased muscle tone] You get sweaty [diaphoresis] BP, Pulse and Resp INCREASE Patient starts to drool!
Why is throwing up green vomit an emergency?
This is indicitaive of bile ad could mean its a bowel obstruction
HYPOmagnesia causes
a prolonged QT interval which leads to torsades de pointes [lethal + shockable AED]
What is the Simian crease and what is it seen in?
a single transverse crease across the entire palm of the hand; seen in down syndrome
What is uterine atony?
a soft boggy poorly contracted uterus and most commonly causes early PPH
Orders and re-evaluation for wrist restraints
Wrist restraints need to be re-evaluated every 4 hours and a new order for a wrist restraint needs to be obtained every 4 hours
Even after the diagnosis of a DVT, is walking suggested?
YES [AMBULATION]
Is aspirin contraindicated in children and why?
YES bc they can get Reye syndrome
Is it okay to instill 30 ml of air into the stomach before aspirating fluid out of an NG tube?
Yes
What is important to tell the patient before a PET scan
You must empty your bladder before this test
What is creatinine clearance
a measure of glomerular function and an indicator for renal disease progression it is a 24 HOUR URINE COLLECTION. •The test must be started again if all urine in the 24 hours period is not collected when the test begins, the first urine is taken and thrown away
What does an absent babinski or weak reflex indicate?
a neurological deficit
Sinus tachycardia has
a normal looking rhythm with a P wave and QRS complex, but it is just really fast
No lasix to what kind of patient
a pneumonia patient with fine crackles because the patient crackles are not from heart failure or edema
The use of radioactive iodine is contraindicated in
a pregnant client ALL females should be tested before
What kind of environment do autistic kids need?
a private calming one with minimal stimulation
Amoxicillan is the standard treatment for
acute otitis media •If symptoms don't mprove within 48-72 hours, the client should return for further assessment basically if antibiotics are not treating the infection, this may mean your body is resistant to the antibiotic and you need a different one in order to treat the infection
What lab is monitored when receiving unfractioned heparin?
aPTT
What does a pulsating mass in peri umbilical area with back pain indicate?
abdominal aneuryism
What is a pleural effusion?
abnomral collection of fluid greater than 15 to 20 mL in the pleural space between parietal and visceral This prevents the lung ffrom expanding fully Results in: -Decreased lung volume -Atelectasis -Ineffective gas exchange
Age when head lag is abnormal finding
abnormal = remaining after age 6 months often associated with cerebral palsy or autism
A client with a normal pre-pregnancy weight should gain a total of
about 25 to 35 during the whole pregnancy
what is the earliest sign of magnesium toxicty
absent or decreased deep tendon reflexes [DTR] (normal 2+) DTR should be assessed during magnesium infusion
Patients with chlamydia should
abstain from sex for one week after starting treatment and partners must be treated
Which patients should Lactated Ringers not be given to?
acute kidney injury [AKI] or chronic kidney disease [Why? because potassium must be excreted properly from the body in order to give LR]
LDL (bad) cholesterol level is ok if
below 100
What foods to think when you see latex allergy
bananas, avocados, tomatoes [BAT]
What are some foods that are high in potassium?
bananas, strawberries, legumes, green leafy veggies, potatoes, carrots, tomatoes, melons, avocados, whole grains, most fish, beef, pork
here is a PICC line inserted into?
basilic or cephalic veins which go into the superior vena cava
In Arab culture, a man is not allowed to
be alone with a woman other than his wife
After an ABK amputation, the residual limb really should not
be elevated but maybe only in the FIRST 24 hrS definitely NOT after 24 hours
If patient has pertussiss infection, family members should
be treated
normal triglycerides
below 150 mg/dL
Why does tension pneumothorax cause hypotension?
because the HEART and GREAT VESSELS are compressed/shifted and cardiac output is reduced it is LIFE THREATENING
Why is V-fib more lethal than V-tach?
becuase there is no pulse with V-fib No pulse calls for immediate CPR and defibrillation [shockable by AED]
Atrial pacemaker spikes before P waves and ventricular pacemaker spikes
before QRS complexes
An atrial pacemaker shows a spike when?
before the P wave
Bronchiolitits
begins with upper respiratory symptoms like rhinorrhea/congestion and then goes to lower respiratory symptoms like tachypnea, cough and weezing
Delirium in older adults causes
behavior changes and confusion that require assessment by the nurse They have acute onset and are usually REVERSIBLE often caused by -Meds -Infection -Hypoxia
Tet spell where they become cyanotic
baby will SQUAT! knee to chest
If a child under 1 years of age is choking, what do you do
back blows and chest thrusts
What temp means hypothermia?
below 95
In a hypothermic patient, make sure to put them on
cardiac monitor and anticipate defibrillation [AED/shocking] because they can easily go into V fib The myocardim becomes cold and PRONE to dysrhythmias
Pericarditis can lead to
cardiac tamponade
X linked recessive
carried by females and affects males
Take slow deep breaths during
catheter insertion, do not hold breath tell patient to hold breath when changing caps or tubing during a CL dressing change to prevent air embolus
what are TORCH infections
cause fetal abnormalities in pregnant women
What is clonus?
cause is neurological; it is rhythmic muscle spasms
Clients with hypertension should NOT take decongestants why?
decongestants can contain a vasoconstrictor and exacerbate hypertension
Be careful giving too much oxytocin why
can lead to -Uterine tachysystole -Decreased placental perfusion -Fetal distress •This is why it is given via an infusion pump so there are no med errors
Why do we monitor intake and output during oxytocin infusion?
can lead to water intoxication
What is troponin
cardiac marker used to detect an MI
Nifedipine (Procardia) is what?
calcium channel blocker antihypertensive don't give if hypotensive
What is nifedipine?
calcium channel blocker antihypertensive. do not give if bp on the lower end range
What drugs is kept at bedside when getting magnesium sulfate to reverse the event of megnesium toxicity?
calcium gluconate 10%
What is given to hyperkalemia patients to stabilize the myocardium?
calcium gluconate 10%
EpiPen delivery
can be delivered through clothing in the out thigh hold for 10 scds so all med goes in then massage the thigh for 10 more scds
What does atropine treat?
can decrease saliva and also used for bradycardia [to increase heart rate]
How often and where is growth hormone replacement given to a child?
daily sub q injections tretment is most successful when it begins early in a child's life, as soon as growth delays are noted; it stops when bone growth finishes or when parents decide
What is the most accurate indicator of fluid loss or gain?
daily weight
Ventricular bigemy must be assessed rapidly because it can lead to what?
deadly arrythmias like v-tach or v-fib
What is presbyopia?
decrease in ability to see objects close up
Autopsies are typically required when?
death by suicide, homicide, accident, or within 24 hours of admission to facility In these cases consent from family is not required when required dont remove any tubes or lines from deceased patient
What are some iron rich foods?
meats- beef, lamb, liver chicken, pork shellfish- oysters, clams, shrimp eggs, green leafy veggies, broccoli, dried fruits, dried beans, brown rice, oatmeal eating foods rich in vitamin c like citrus fruits potatoes and tomatoes and also orange juice can enhance the absorption of iron
Isotretinoin
med for severe acne a HUGE teratogenic!! Derived from vitamin A Do not take extra vitamin A as this could cause TOXICITY -Required to enter risk management plan and also use 2 forms of birth control -Can not give blood while on it because some could still be in blood
Bulging fontanel signifies
meningitis
The herb black cohosh is used for
menopausal hot flashes
The positive babinski is normal in children
under 1 [positive means big toe moves up and other toes fan out]
Characteristics of herpes zoster
unilateral linear pattern of fluid filled blisters patients report pain and itching
How to go up and down stairs with a cane
up with the good, down with the bad Going up: Step up on the good extremity, then place the cane and affected extremity on the step Going down: Step down on the bad extremity with the cane, and follow with the good leg
What does coffee ground emesis indicate?
upper G.I bleeding
Positioning for paracentesis
upright semi or high fowler
Position during a thoracentesis
upright sitting position on side of bed, leaning forward over bedside table, arms on pillows
Nursing precautions when administering peritoneal dialysis
use sterile technique when spiking and attaching bags of dialysate to the PD catheter
Non rebreather
used in EMERGENCIES Delivers high concentrations of oxygen up to 90% to 95%
What is a barium enema aka lower GI series?
uses fluroscopy to visualize the colon outlined by contrast to detect abnormalities like polyps, ulcers, tumors, and diverticula
What is the gower sign?
uses ones hands to rise from sqaut to a chair
As far as for ostomies, any gray or paleness to the area of the stoma is
usually priority because this indicates lack tissue perfusion which can to necrosis of stoma
What antibiotic is used for c.diff?
vancomycin
What is the purpose of norepinephrine?
vasoconstriction and improved contractility/output
I.V hydralazine for hypertensive emergency
vasodilator goal is to slowly drop blood pressure but not too fast
Five Rights of Medication Administration
1. Right Client 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time
Five Rights of Delegation
1. Right Person 2. Right Task 3. Right Circumstance 4. Right Direction and Communication 5. Right Supervision and Evaluation
Urine Specific Gravity
1.01-1.025 High gravity means urine is concentrated Low gravity means urine is dilute
Magnesium (Mg)
1.5-2.5
BUN
10 to 20
Hct [hematocrit]
36% to 50%
Integrity vs. Despair
65+ yrs Encourage use of personal items when not at home
Addison disease vs Cushings disease
Addison's disease: down down down up down [Low Aldosterone] •HYPOnatremia •HYPOtension •Low blood volume •HYPERkalemia •HYPOglycemia Cushing disease: up up up down up [High Aldosterone] •HYPERnatremia •HYPERtension •HIGH blood volume •HYPOkalemia •HYPERglycemia
Iron
Antidote/Reversal: deferoxamine (Desferal)
Curare
Antidote/Reversal: edrophonium (Tensilon)
Ethylene Poisoning
Antidote/Reversal: fomepizole (Antizol)
Cyanide poisoning treatment
Antidote/Reversal: methylene blue
Lead
Antidote/Reversal: succimer (Chemet)
APGAR
Appearance [color all pink =2, pink and blue=1 blue/pale=0] Pulse [>100=2, <100=1] Grimace [cough=2 grimace=1] Activity [flexed=2 flaccid=1 limp=0] Respirations [strong cry=2 weak cry=1 No cry=0]
What position is the patient in AFTER a lumbar puncture (and also oil-based myelogram)
Have the patient flat on his or her back to prevent CSF from leaking out and prevent a headache
TPN Total Parenteral Nutrition
Hypertonic Solution Given via PICC line, tunneled catheter Prepared daily by pharmacy Use Sterile Asepsis for dressing change Check blood glucose every 4-6 hours Change bag every 24 hours
INR
Less than 2 Warfarin Therapeutic Range: 2-3
Cholesterol
Less than 200
Position of a patient after a thyroidectomy
Low or semi-fowlers •Support the head, neck, and shoulders •Have a tracheostomy at the bedside [in case of an emergency]
For what diseases do we use contact precautions
MRS.WEE M:multi drug resistant organism R: Respiratory infection [such as RSV] S: Skin infections [such as varicella, zoster, cutaneous diptheria, herpes simplex, impetigo, pediculosis, scabies] W:wound infection E: Enteric infection [C.diff] E: eye infection [pink eye or conjunctivitis]
For what diseases do we use airborne precautions
My [Measles] Chicken [chicken pox or varicella] Hez [herpes zoster or shingles] TB [TB]
Airborne Precautions
Needed to prevent transmission from particles so small the can float in the air and travel long distances. Examples: chickenpox, measles, Tuberculosis, SARS Minimal PPE: Well fitting mask [N95]!!!! *Use respirator mask for TB and SARS **Negative Pressure room
Position of a patient after a myringotomy
Position the patient on the side of the AFFECTED ear after surgery to allow for drainage of secretions This procedure is surgical incision into the eardrum [tympanic membrane] to relieve pressure or drain fluid
When implementing droplet precautions, what do we have to do
Private room or cohort them with a client with the same infection Wear a mask Door may remain open
When implementing airborne precautions, what do we have to do
Private, negative pressure room Must wear mask Can cohort with patient who has same organism, but not if they have different organisms Place mask on client when they are being transported
Position for a patient with peritoneal dialysis when the outflow is inadequate
Turn the patient from side to side BEFORE checking the tube for kinking
Droplet Precautions
Used to prevent contact with mucus and other secretions from nose, sinuses, throat, airway, and lungs. Use when contact will be within 3 ft or less Examples: infulenza, mumps, pertussis Minimal PPE: Mask
Standard Precautions
When handling blood, bodily fluid, bodily tissue, mucous membranes, open skin PPE: depends on type of exposure (minimal is nothing)
Amitriptyline
antidepressant + nerve pain med Toxic Level: >500 ng/ML
Position of a patient after total hip replacement
•Do not sleep on the operated side •No flexing the hip more than 45-60 degrees •Don't elevate the head of bed (HOB) more than 45 degrees •Keep the hip abducted by separating legs with a pillow or abductor
Position for an ABOVE the knee amputation
•Elevate for the first 24 hours on a pillow •Position prone daily to help with hip extension
Position if the patient has autonomic dysreflexia/hyperreflexia
•Place the client in a sitting position (elevate the HOB to 90) -FIRST before any other implementation Signs &Symptoms include: •Extreme hypertension •Pounding headache •Profuse sweating •Nasal congestion •Goose flesh •Bradycardia
Position of an infant with spina bifida
•Prone [on their belly] •So their sac does NOT rupture
