Saunder's Comprehensive NCLEX Review

Antianginal meds

- Isosorbide dinitrate - Isosorbide mononitrate - Nitroglycerin, sublingual - Nitroglycerin, translingual - Nitroglycerin, transdermal patches - Nitroglycerin ointment - IV nitroglycerin priority nursing actions for chest pain in a hospitalized client with cardiac disease: 1. quickly assess the client, specifically characteristics of pain, HR, rhythm, and BP 2. administer a nitroglycerin tablet sublingually 3. stay with the client 4. reassess in 5 minutes 5. administer another nitroglycerin tablet sublingually if pain is not relieved and the BP is stable 6. reassess in 5 minutes 7. administer a third nitroglycerin tablet sublingually if pain is not relieved and the BP is stable 8. reassess in 5 minutes; contact the PHCP if the third nitroglycerin tablet does not relieve the pain 9. document the event, actions taken, and the client's response to the treatment Nitrates: - produce vasodilation, decrease preload and afterload, and reduce myocardial O2 consumption. - contraindicated in the client with significant hypotension, IICP, or severe anemia and in those taking meds to treat erectile dysfunction - should be used with caution with severe renal or hepatic disease - avoid abrupt withdrawal of long-acting preparations to prevent the rebound effect of severe pain from MI adverse effects: - headache - orthostatic hypotension - dizziness, weakness - faintness - flushing or pallor - dry mouth - reflex tachycardia sublingual medications: 1. monitor vitals 2. offer sips of water before giving, because dryness may inhibit medication absorption 3. instruct the client to place under the tongue and leave until fully dissolved 4. instruct the client not to swallow the med 5. instruct the at-home client to take 1 tablet for pain and to immediately call 911 if the pain is not relieved; in the hospitalized client, 1 tablet is administered every 5 minutes for up to 3 doses and the PHCP is notified immediately if pain is not relieved following the 3 doses. (the BP is checked before each administration) 6. inform the client that a stinging or burning sensation may indicate the tablet is fresh 7. instruct the client to store the med in a dark, tightly closed bottle 8. instruct the client to take acetaminophen for a headache trans-lingual meds (spray): 1. instruct the client to direct the pray against the oral mucosa 2. instruct the client to avoid inhaling the spray sustained-release meds: 1. instruct the client to swallow and not chew or crush the med transdermal patch: 1. instruct the client to apply the patch to a hairless area, using a new patch for a different site each day 2. as prescribed, instruct the client to remove the patch after 12-14 hours, allowing 10-12 "patch-free" hours each day to prevent tolerance topical ointments: 1. instruct the client to remove the ointment on the skin from the previous dose 2. instruct the client to squeeze a ribbon of ointment of the prescribed length onto the applicator or dose-metered paper 3. instruct the client to spread the ointment over a 2.5-3.5 inch area and cover with a plastic wrap, using the chest, back, abdomen, upper arm, or anterior thigh (avoid hairy areas) 4. instruct the client to rotate sites and to avoid touching the ointment when applying patches and ointments: 1. wear gloves when applying 2. do not apply on the chest in the area of defibrillator-cardioverter pad placement, because skin burns can result if the pads need to be used **instruct the client using nitroglycerin tablets to check the expiration date on the medication bottle, because expiration may occur within 6 months of getting the med. The tablets will not relieve chest pain if they have expired**

Poison Ivy, Poison Oak, and Poison Sumac

- a dermatitis that develops from contact with poison ivy, oak, or sumac plants assessment: - papulovesicular lesions - severe pruritus interventions: 1. cleans the skin of plant oils immediately 2. apply cool, wet compresses to relieve itching 3. apply topical products to relieve the itching and discomfort 4. topical or oral glucocorticoids may be prescribed for severe reactions Poison Ivy treatment: - treatment of lesions includes calamine lotion and commercial products that soothe lesions, compresses and solutions that are astringent and antiseptic, and / or colloidal baths with oatmeal to relieve discomfort. - topical corticosteroids are effective in preventing or reducing inflammation - oral corticosteroids may be prescribed for severe reactions, and an antihistamine such as diphenhydramine may be prescribed.

bronchopulmonary dysplasia in newborn

- affects newborns who have experienced respiratory failure or who have been O2 dependent for more than 28 days. - X-ray findings are abnormal, indicating areas of overinflation and atelectasis assessment: - tachypnea - tachycardia - retractions - nasal flaring - labored breathing - crackles and decreased air movement - occasional expiratory wheezing interventions: - monitor airway and cardiopulmonary function; provide O2 therapy - fluid restriction may be prescribed - meds include surfactant at birth, bronchodilators, and possible diuretics and corticosteroids

Pediatric immune problems and infectious diseases: Roseola (Exanthema Subitum)

- agent: human herpesvirus type 6 - incubation period: 5-15 days - communicable period: unknown, thought to be from febrile period to time rash first appears - source: unknown - transmission: unknown - assessment: sudden high fever lasting 3-5 days followed by a rash with rose-pink macules that blanch with pressure, and febrile seizures may occur. rash appears several hours to 2 days after the fever and lasts 1-2 days. - interventions: supportive

Ulcerative colitis

- an ulcerative and inflammatory disease of the bowel that results in poor absorption of nutrients - commonly begins in the rectum and spreads upwards towards the cecum - the colon becomes edematous and may develop bleeding lesions and ulcers; the ulcers may lead to perforation - scar tissue develops and causes loss of elasticity and loss of the ability to absorb nutrients - colitis is characterized by various periods of remissions and exacerbations - acute ulcerative colitis results in vascular congestion, hemorrhage, edema, and ulceration of the bowel mucosa - chronic ulcerative colitis causes muscular hypertrophy, fat deposits, and fibrous tissue with bowel thickening, shortening, and narrowing assessment: - anorexia - weight loss - malaise - abdominal tenderness and cramping - severe diarrhea that may contain blood and mucus - malnutrition, dehydration, and electrolyte imbalances - anemia - vitamin K deficiency interventions: 1. acute phase: maintain NPO status and administer fluids and electrolytes IV or by parenteral nutrition as prescribed 2. restrict activity to reduce metabolism 3. monitor bowel sounds and for abdominal tenderness and cramping 4. monitor stools, noting color, consistency, and the presence or absence of blood 5. monitor for bowel perforation, peritonitis, and hemorrhage 6. following the acute phase, the diet progresses from clear liquids to a low-fiber diet as tolerated 7. instruct the client about diet. usually a low-fiber diet is prescribed during an exacerbation episode, in addition, a high-protein diet with vitamin and iron supplements are prescribed 8. instruct the client to avoid gas-forming foods, milk products, and foods such as whole-wheat, grains, nuts, raw fruits and veggies, pepper, alcohol, and caffeine-containing products. 9. instruct the client to avoid smoking 10. administer meds as prescribed, which may include a combination of meds such as salicylate compounds, corticosteroids, immunosuppressants, and antidiarrheals surgical interventions: 1. performed in extreme cases if medical interventions are unsuccessful 2. minimally invasive procedures are considered as a surgical option if the client is a candidate; clients who are obese, have has previous abdominal surgeries, or have adhesions may not be candidates 3. minimally invasive procedures can include laparoscopic procedures, robotic-assisted surgery, and natural orifice transluminal endoscopic surgery 4. restorative proctolectomy with ileal pouch-anal anastomosis allows for bowel continence, may be performed through laparoscopic procedure, involves a 2-stage procedure that includes removal of the colon and most of the rectum, and the anus and anal sphincter remain intact. an internal pouch known as a reservoir is created using the small intestine and connected to the anus, followed by a creation of a temporary ileostomy through the abdominal skin to allow healing of the internal pouch and all anastomosis sites. the second surgical procedure is performed within 1-2 months and the ileostomy is closed. 5. total proctocolectomy with permanent ileostomy: performed if the client is not a candidate for the other surgery or if the client prefers this procedure. the procedure involves the removal of the entire colon, the end of the terminal ileum forms the stoma or ostomy, which is located in the RLQ. pre-op interventions: 1. consult with the enterostomal therapist to help identify optimal placement of the ostomy 2. instruct the client on dietary restrictions, the client may need to follow a low-fiber diet for 1-2 days before surgery 3. parenteral antibiotics are given 1 hour before the surgical opening 4. address body image concerns and allow the client to express concerns; a visit from an ostomate may be helpful to the client post-op interventions: 1. a pouch system with a skin barrier is usually placed on the stoma post-operatively, if the pouch system is not covering the stoma a petroleum gauze dressing is placed over the stoma as prescribed to keep it moist, followed by a dry sterile dressing 2. monitor the stoma for size, unusual bleeding, or necrotic tissue 3. monitor for color changes in the stoma 4. note that normal stoma color is pink to bright red and shiny, indicating high vascularity 5. note that a pale pink stoma indicates low Hgb and Hct levels and a purple-black stoma indicates compromised circulation, requiring PHCP notification 6. assess the functioning of the ostomy 7. expect the stool to be liquid in the immediate post-op period but becomes more solid depending on the area of creation; ascending colon is liquid, transverse colon is loose to semiformed, and descending colon is close to normal 8. monitor the pouch system for proper fit and signs of leakage; the pouch is emptied when it is 1/3 full 9. fecal matter should not be allowed to remain on the skin, skin assessment and care are a priority 10. monitor for dehydration and electrolyte imbalance 11. administer analgesics and antibiotics are prescribed 12. instruct the client to avoid foods that cause excess gas formation and odor. 13. instruct the client about stoma care and irrigations as prescribed 14. instruct the client that normal activities may be resumed when approved by the PHCP

signs of illness or infection in the older client

- anorexia - apathy - changes in functional status - altered mental status including delirium - tachypnea - hyperglycemia - dyspnea - falling - fatigue - incontinence - self-neglect - SOB - BP below baseline

small for gestational age

- at or below the 10th percentile on the intrauterine growth curve assessment: - fetal distress - decreased or increased body temp - physical abnormalities - hypoglycemia - signs of polycythemia (increase in the # of RBCs) are ruddy appearance, cyanosis, jaundice - signs of infection - signs of aspiration of meconium interventions: - maintain airway and cardiopulmonary function - maintain body temp - observe for signs of respiratory distress - monitor for infection and initiate measures to prevent sepsis - monitor for hypoglycemia - initiate early feedings and monitor for signs of aspiration

Glucocorticoids (corticosteroids)

- beclomethasone - budesonide - ciclesonide - flunisolide - fluticasone proprionate - mometasone furoate - trimcinolone acetonide - prednisone - prednisolone - act as anti-inflammatory agents and reduce edema of the airways, are used to treat asthma and other respiratory problems

Pediatric eye, ear, and throat problems: allergic rhinitis

- condition when children are sensitized to environmental allergens assessment: - itchy and watery eyes, runny nose, itchy throat - may be a history of atopic disease - dark circles under the eyes, roughening of the conjunctiva, pale nasal mucosa, clear nasal drainage, nasal polyps, fluid in the middle ear, roughening of the posterior pharynx, wheezes, rhonchi, eczema, hives, and angioedema interventions: - kids should be tested for environmental allergies, food allergies, atopic dermatitis, and asthma - avoid triggers, administer antihistamines, nasal corticosteroids, and inhalers

Acetaminophen

- contraindicated in clients with hepatic or renal disease, alcoholism, or hypersensitivity - assess the client for a history of liver dysfunction - monitor for signs of hepatic damage (nausea, vomiting, diarrhea, and abdominal pain) - monitor liver function parameters - self-medication should not continue for longer than 10 days in an adult and 5 days in a child because of high risk for hepatotoxicity - antidote to acetaminophen is acetylcysteine

Asian americans beliefs related to end-of life care

- family usually make decisions about care and often do not tell the client about their problem or diagnosis - dying at home may be considered bad luck with some ethnic groups - organ donation may not be allowed in some ethnic groups

positive signs (diagnostic) of pregnancy

- fetal heart rate detected by electronic device at 10-20 weeks - active fetal movements palpable by examiner - outline of fetus by radiography or ultrasonography

Pediatric respiratory problems: cystic fibrosis

- is a chronic multi-system disorder characterized by a dysfunction of the exocrine gland - the mucus produced by the exocrine gland is abnormally thick, tenacious, copious, and causes obstruction of the small passageways of the affected organs, particularly in the respiratory, GI, and reproductive systems - common symptoms are associated with pancreatic enzyme deficiency and pancreatic fibrosis caused by duct blockage, progressive chronic lung disease as a result of infection, and sweat gland dysfunction resulting in increased sodium and chloride sweat concentrations. - an increase in sodium and chloride in sweat and saliva for the basis of the diagnostic test, called the sweat chloride test - cystic fibrosis is a progressive and incurable disorder, respiratory failure is a common cause of death, and organ transplants may be an option to increase survival rates - respiratory system: - symptoms are produced by the stagnation of mucus in the airway, leading to bacterial colonization and destruction in the lung tissue - emphysema and atelectasis occur as the airways become increasingly obstructed - chronic hypoxemia causes contraction and hypertrophy of the muscle fibers in pulmonary arterioles and arteries, leading to pulmonary HTN and eventual cor pulmonale. - pneumothorax and hemoptysis occur as the disease progresses - other respiratory symptoms are wheezing, dyspnea, cyanosis, clubbing of fingers and toes, barrel chest, and repeated episodes of bronchitis and pneumothorax - GI system: - meconium ileus in the newborn is the earliest sign - intestinal obstruction caused by thick intestinal secretions can occur, and cause pain, abdominal distention, nausea, and vomiting. - stools are frothy and foul-smelling - deficiency in the fat-soluble vitamins A, D, E, and K result in bruising, bleeding, and anemia - malnutrition and failure to thrive is a concern - hypo-albuminemia due to diminished absorption of protein causes generalized swelling - rectal prolapse can result from the large, bulky stools and increased intra-abdominal pressure - pancreatic fibrosis can occur and places the child at risk for diabetes - integumentary system: - abnormally high amount of sodium and chloride in sweat - infants may taste salty when kissed - dehydration and electrolyte imbalances can occur, especially during hyperthermic conditions - reproductive system: - can delay puberty in girls - can inhibit fertility by highly viscous cervical solutions which act as a plug and block sperm entry - males are usually sterile caused by the blockage of the vas deferens by abnormal secretions or by failure of normal development of duct structures diagnostic tests: - sweat chloride test is + - newborn screening of mutant genes and immuno-reactive trypsinogen analysis - chest ray shows atelectasis and obstructive emphysema - pulmonary function tests show abnormal small airway function - a 72-hour stool sample is collected to check the fat or enzyme content or both interventions: - respiratory system - 1. goals of treatment include preventing and treating pulmonary infection by improving aeration, removing secretions, and administering antibiotics 2. monitor RR and status 3. chest physiotherapy on awakening and in the evening but not right before or after a meal 4. a flutter mucus clearance device is a small, hand-held plastic pipe with a stainless steel ball in the middle that facilitates the removal of mucus and may be prescribed 5. hand-held percussors or a special vest device that provides high frequency chest wall oscillation may help loosen secretions 6. a positive expiratory pressure mask may be used to force secretions to the upper airway for expectoration 7. teach the child huffing, which is the forced expiration technique to mobilize secretions for expectoration 8. bronchodilator meds by aerosol may be prescribed; the meds open the bronchi for easier expectoration and is administered before chest physiotherapy when the child has reactive airway disease and is wheezing. meds that decrease the viscosity of mucus may also help 9. a physical exercise program should sim to stimulate mucus expectoration and establish an effective breathing pattern should be instituted 10. aerosolized or IV antibiotics may be prescribed; IV antibiotics may be administered at home through a central venous access device 11. O2 may be prescribed during acute episodes, monitor closely for O2 narcosis; signs include fatigue, numbness and tingling of extremities, nausea, vomiting, malaise, and substernal distress; because a child with cystic fibrosis may have CO2 retention 12. lung transplantation may be an option - GI system - 1. give a high-calorie, high-protein diet that is well-balanced to meet energy expenditure and growth needs, and multivitamins ADE and K are also administered. 2. monitor weight and for failure to thrive 3. monitor stool patterns are for signs of intestinal obstruction 4. goal for pancreatic insufficiency is to replace pancreatic enzymes, which are administered within 30 mins of eating, and are given with all meals and snacks 5. the amount of pancreatic enzymes given depend on the PHCP's preferences and are tapered to achieve normal growth and a decrease in the # of stools to 2-3 a day 6. enteric-coated pancreatic enzymes should not be crushed or chewed, capsules can be taken apart, and the contents sprinkled on food 7. monitor for constipation, intestinal obstruction, and rectal prolapse 8. monitor for signs of GERD, place the infant in an upright position after eating - additional interventions - 1. monitor glucose levels and for signs of DM 2. ensure adequate salt intake and fluids that supply electrolytes 3. monitor bone growth in the child 4. monitor for retinopathy or neuropathy 5. provide emotional support to parents and child 6. teach the parent and child about the care involved and encourage independence in the child - home care - - educate the parent and child about all aspects of care for the disorder - inform the parents and child about the signs of complications and actions to take, and that follow-up care is critical - instruct the parents to ensure the child receives immunizations - inform the child and parents about the cystic fibrosis foundation

pediatric hematological problems: Aplastic anemia

- is a deficiency of circulating RBCs and all other blood elements, resulting from the arrested development of cells within the bone marrow; pancytopenia, a deficiency of RBCs, leukocytes, and thrombocytes occurs

Sucralfate

- is a gastric protectant that creates a protective barrier against acid and pepsin - administered orally, should be taken on an empty stomach - can cause constipation - may impede absorption of warfarin sodium, phenytoin, theophylline, digoxin, and some antibiotics; should be given at least 2 hours apart from these meds

Esophageal cancer

- is a malignancy found in the esophageal mucosa, formed by squamous cell carcinoma or adenocarcinoma - cause is unknown - major risk factors are smoking, alcohol consumption, chronic reflux, Barrett's esophagus, and vitamin deficiencies - complications are dysphagia, painful swallowing, malaise, and loss of appetite - the goal of treatment is to inhibit tumor growth and maintain nutrition assessment: - dysphagia - odynophagia - epigastric or sternal pain interventions: 1. monitor nutritional status, including daily weight, I&O, and calories consumed 2. instruct the client about diet changes that make eating easier and less painful 3. prepare the client for chemo and radiation as prescribed 4. prepare the client for surgical resection of the tumor as prescribed

Pancrelipase

- is a pancreatic enzyme replacement used to supplement or replace pancreatic enzymes and improve the nutritional status and reduce the amount of fatty stools (a deficiency of pancreatic enzymes can compromise digestion, especially the digestion of fats) - should be taken with all meals and snacks - adverse effects are abdominal cramps or pain, nausea, vomiting, and diarrhea - products that contain calcium carbonate or magnesium hydroxide interfere with the action of these meds

Metoclopramide

- is a prokinetic agent that stimulates motility of the upper GI tract and increases the rate of gastric emptying without stimulating GI secretions - use to treat GERD and paralytic ileus - may cause restlessness, drowsiness, extrapyramidal reactions, dizziness, insomnia, and headache - usually is given 30 minutes before meals and at bedtime - contraindicated in clients with sensitivity, and mechanical obstruction, perforation, or GI hemorrhage - can precipitate HTN crisis in clients with pheochromocytoma - safety during pregnancy has not been established - can cause parkinsonian reactions; if these occur, the med will be discontinued by the HCP - anticholinergics such as atropine and opioid analgesics such as morphine antagonize the effects of metoclopramide - alcohol, sedatives, cyclosporine, and tranquilizers produce an additive effect

Chronic kidney disease (CKD)

- is a slow, progressive, irreversible loss in kidney function with a GFR less than or equal to 60 mL/minute for 3+ months. - it occurs in stages (with loss of 75% of functioning nephrons, the client becomes symptomatic) and eventually results in uremia or end-stage kidney disease (with a loss of 90-95% of functioning nephrons) - hypervolemia can occur because of the kidneys inability to excrete sodium and water, hypovolemia can occur because of the kidneys inability to conserve sodium and water. ** CKD affects all body systems and may require dialysis or kidney transplantation to maintain life ** primary causes: - may follow AKI - DM and other metabolic disorders - HTN - chronic kidney obstruction - recurrent infections - renal artery occlusion - autoimmune disorders assessment: - assess body systems for the manifestations of CKD - assess psychological changes, which could include emotional liability, withdrawal, depression, anxiety, denial, dependence-independence conflict, changes in body image, and suicidal behavior interventions: 1. same as the interventions for AKI 2. administer a prescribed diet, which is usually a moderate protein(to increase the workload of the kidneys), and high-carb, low-potassium, and low-phosphorus 3. provide oral care to prevent stomatitis and reduce discomfort from mouth sores 4. provide skin care to prevent pruritus 5. teach the client about fluid and dietary restrictions and the importance of daily weights 6. provide support to promote acceptance of the chronic illness and prepare the client for long-term dialysis or transplantation, or explain to the client about their choice to decline dialysis or transplantation; for the elderly client provide information that kidney function is declining and in time may reach end-stage renal disease and require dialysis; encourage healthy lifestyle and discuss choices special problems in kidney disease and interventions: 1. activity intolerance and insomnia: - fatigue results from anemia and buildup of wastes from the diseased kidneys - provide adequate rest periods - teach the client to plan activities to prevent fatigue - mild CNS depressants can be prescribed to promote rest 2. anemia: - results from the decreased secretion of erythropoietin by damaged nephrons, resulting in decreased production of RBCs - monitor for decreased Hgb and Hct levels - administer hematopoietics such as epoetin alfa or darbepoetin alfa, as prescribed to promote maturity of the RBCs - administer folic acid as prescribed - administer iron orally as prescribed but not at the same time as phosphate binders - administer stool softeners as prescribed because iron m,ay cause constipation - note that oral iron is not well-absorbed by the GI tract in CKD and causes nausea and vomiting; parenteral iron may be used if iron deficiencies persist - administer blood transfusions; prescribed only when necessary such as in acute blood loss or symptomatic anemia - blood transfusions can also cause the development of antibodies against human tissues, which can make matching for an organ transplant difficult 3. GI bleeding: - urea is broken down by the GI tract into ammonia which irritates the GI mucosa and causes ulceration and bleeding - monitor for decreased Hgb and Hct levels - monitor stools for occult blood - avoid administering acetylsalicylic acid, because it is excreted by the kidneys; if administered, aspirin toxicity can occur and prolong the bleeding time **place the client with kidney disease on continuous telemetry; the client can develop hyperkalemia, increasing their risk for dysrhythmias** 4. hyperkalemia: - monitor vitals for HTN or hypotension, and monitor apical pulse rate; an irregular HR can indicate dysrhythmias - monitor the serum K+ level; an elevated K+ level can cause decreased CO, heart blocks, fibrillation, or asystole - provide a low K+ diet - administer electrolyte-binding and electrolyte-excreting meds such as oral or rectal sodium polystyrene sulfonate as prescribed to lower the serum K+ level - administer prescribed meds: 50% dextrose and regular insulin IV may be prescribed to shift K+ into the cells; calcium gluconate IV may be prescribed to reduce myocardial irritability from hyperkalemia, and sodium bicarb IV may be prescribed to correct acidosis - administer prescribed loop diuretics to excrete K+ - avoid K+-retaining meds such as spironolactone or triamterene because these meds will increase the K+ level - prepare the client for peritoneal dialysis or hemodialysis as prescribed 5. hypermegnesemia: - results from decreased renal excretion of magnesium - monitor for cardiac manifestations like bradycardia, peripheral vasodilation, and hypotension - monitor for CNS changes like lethargy or drowsiness - monitor neuromuscular manifestations such as reduced or absent tendon reflexes or weak or absent voluntary skeletal muscle contractions - administer loop diuretics as prescribed to excrete magnesium - administer calcium as prescribed for cardiac problems - avoid administering meds that have magnesium, such as antacids, or certain enemas, and laxatives - during severe Mg elevations, avoid foods that are high in Mg 6. hyperphosphatemia: - as the phosphorus level rises, the calcium level drops; this leads to the stimulation of parathyroid hormone, causing bone demineralization - treatment is aimed at lowering the serum phosphorus level - administer phosphate binders as prescribed with meals to lower serum phosphate levels - administer laxatives as prescribed because phosphate binders cause constipation - teach the client about the need to limit the intake of food high in phosphorus 7. HTN: - caused by failure of the kidneys to maintain BP homeostasis - monitor vitals for elevated BP - maintain fluid and Na+ restrictions as prescribed - administer diuretics and antihypertensives as prescribed 8. hypervolemia: - monitor vitals for an elevated BP - monitor I&O and daily weights for signs of fluid retention - monitor for periorbital, sacral, and peripheral edema - monitor the serum electrolyte levels - monitor for HTN and notify the PHCP if there are sustained elevations - monitor for signs of HF and pulmonary edema like restlessness, heightened anxiety, tachycardia, dyspnea, basilar lung crackles, and blood-tinges sputum; notify the PHCP immediately if these occur - maintain fluid restriction - avoid administering large amounts of IV fluids - administer diuretics as prescribed - teach the client to maintain a low-sodium diet - teach the client to avoid OTC meds without consulting the PHCP 9. hypocalcemia: - results from a high phosphorus level and the inability of the kidneys to activate vitamin D - the absence of vitamin D causes poor calcium absorption from the GI tract - monitor the serum calcium level - administer calcium supplements as prescribed - administer activated vitamin D as prescribed 10. hypovolemia: - monitor vitals for hypotension and tachycardia - monitor for decreasing I&O and a reduction in the daily weight - monitor for dehydration - monitor electrolyte levels - provide replacement therapy based on the electrolyte levels 11. infection: - the client is at an increased risk for infection because of their suppressed immune system, dialysis access site, and possible malnutrition - monitor for signs of infection - avoid urinary catheters when possible, if used provide catheter care per agency protocol - provide strict asepsis with urinary catheter insertion and other invasive procedures - instruct the client to avoid fatigue and avoid people with infection - administer antibiotics as prescribed, monitor for nephrotoxic effects 12. metabolic acidosis: - the kidneys are unable to excrete hydrogen ions or manufacture bicarb, resulting in acidosis - administer alkalizers like sodium bicarb as prescribed - note that clients with CKD adjust to low bicarb levels and as a result do not become acutely ill 13. muscle cramps: - result from electrolyte imbalance and uremia - monitor serum electrolyte levels - administer electrolyte replacements and meds to control muscle cramps as prescribed - administer heat and massage as prescribed 14. neurological changes: - the buildup of active particles and fluids causes changes in the brain cells and leads to confusion and impairment in decision-making ability - peripheral neuropathy results from the effects of uremia on peripheral nerves - monitor the LOC and for confusion - monitor for restless leg syndrome which is also common during dialysis treatment - teach the client to examine areas of decreased sensation for signs of injury 15. Ocular irritation: - calcium deposits in the conjunctivae cause burning and watering of the eyes - administer meds to control the calcium and phosphate levels as prescribed - administer lubricating eye drops - protect the client from injury 16. potential for injury: - the client is at risk for fractures caused by alterations in the absorption of calcium, excretion of phosphate, and vitamin D metabolism - provide for a safe environment - avoid injury; tissue breakdown causes increased serum K+ levels 17. pruritus: - to rid the body of excess wastes urate crystals are excreted through the skin, causing pruritus - the deposit of urate crystals (uremic frost) occurs in advanced stages of CKD - monitor for skin breakdown, rash, and uremic frost - provide meticulous skin care and oral hygiene avoid the use of soaps - administer antihistamines and antipruritics as prescribed to relieve itching - teach the client to keep their nails trimmed to prevent local infection from scratching 18. psychosocial problems: - listen to the client's concerns to determine how the client is handling the situation - allow them time to mourn the loss of their kidney function - with client permission, include the family members in discussing the client's concerns - provide education about treatment options and support the client's decision; elderly clients with CKD may progress slowly towards end-stage-kidney-disease or require dialysis, and clients may decide on no treatment and opt for end-of-life care - offer info about support groups

Cycloserine

- is a second-line med to treat TB - used when resistance to other TB meds is expected - use of alcohol or ethionamide increases the risk of seizures - use caution in clients with a seizure disorder, depression, severe anxiety, psychosis, or renal insufficiency in clients who use alcohol - adverse effects: hypersensitivity, CNS reactions, neurotoxicity, seizures, HF, headache, vertigo, altered LOC, irritability, nervousness, anxiety, confusion, mood changes, depression, and thoughts of suicide interventions: 1. monitor LOC 2. monitor for changes in mental status or thought processes 3. monitor renal and hepatic function tests 4. monitor serum med level to avoid the risk f neurotoxicity; the peak concentration, measured 2 hours after dosing, should be 25-35 mcg/mL client education: 1. take the med after meals to prevent GI upset 2. report signs of a rash or signs of CNS toxicity 3. avoid driving or performing tasks that require alertness until the reaction to the med has been determined 4. about the need for monitoring serum med levels weekly, as prescribed

Episiotomy

- is an incision made into the perineum to enlarge the vaginal outlet and facilitate birth - use of the procedure has declined dramatically in recent years - check the episiotomy site, institute measures to relieve pain, provide ice packs for the first 24 hours, instruct the client on the use of an ice pack for the first 24 hours and then sitz baths after, apply analgesic spray or ointment as prescribed, provides perineal care using clean technique, instruct the client on proper care of the incision, instruct the client to dry the perineal area from the front to back and to blot the area rather than wipe it, instruct the client to shower rather than take a bath, apply a perineal pad without touching the incision surface of the pad, and report any bleeding or discharge from the episiotomy site to the PHCP

Hydromorphone

- is an opioid analgesic - primary concern is respiratory depression - other effects include drowsiness, dizziness, and orthostatic hypotension - monitor vitals, especially RR and BP

Pediatric respiratory problems: asthma

- is chronic inflammatory disease of the airways - mast cell release of histamine caused by exposure to an allergen causes bronchospasm and obstruction - status asthmaticus is the most severe form of asthma. is a medical emergency because the attack is unresponsive to beta-agonist therapy, and can result in respiratory failure and death assessment: - child has episodes of dyspnea, wheezing, breathlessness, chest tightness, and cough - acute asthma attacks are episodes of worsening sob, cough, wheezing, chest tightness, bronchospasm, mucosal edema, mucus plugging, and air is occluded/trapped behind narrowed airways causing hypoxemia - just before the attack the child may have itching, irritability, restlessness, headache, or feel tired - respiratory symptoms include hacking and an irritable non-productive cough - once secretions accumulate the cough may produce a frothy clear sputum - retractions - coarse and loud breath sounds, coarse rhonchi, wheezing, and prolonged expirations - cyanosis - diaphoresis - short, broken phrases when talking - younger children may assume the tripod position - an exercise-induced attack has manifestations cough, sob, chest pain or tightness, wheezing, and endurance problems can occur with exercise - severe spasm or obstruction: breath sounds and wheezing cannot be heard and cough is ineffective - ventilatory failure and aphasia: sob with air movement in the chest restricted to the point of absent breath sounds is noted and accompanied by an increased RR interventions: 1. assess airway patency and respiratory status 2. administer humidified O2 by nasal cannula or face mask 3. administer quick-relief (rescue) meds 4. initiate an IV 5. prepare the child for a chest radiograph and fiberoptic nasal laryngectomy if prescribed 6. prepare to obtain a blood sample for determining ABGs if prescribed - Medications: - quick-relief (rescue) meds include short acting beta2 agonists, anticholinergics, and corticosteroids. - meds for long-term control = inhaled corticosteroids, anti-allergy meds, nonsteroidal anti-inflammatory drugs, long-acting B2 agonists, leukotriene modifiers, and monoclonal antibodies - nebulizer, metered-dose inhaler: may be used to give meds, if used to give a corticosteroid a spacer is used to prevent yeast infections in the child's mouth; the spacer prevents the med from spraying directly into the child's mouth, which can lead to irritation and possibly infection (thrush) in the mouth. - the child's growth patterns need to be monitored when using corticosteroids - chest physiotherapy: - includes breathing exercises and physical training that strengthens the respiratory muscles and produces more efficient breathing patterns. is not recommended during an acute exacerbation. - allergen control: - testing may be done to identify allergens - teach the child and parents about measures to prevent and reduce exposure to allergens - home care measures: - eliminate environmental allergens - avoid cold temps - avoid exposure to people with respiratory infections - recognize early symptoms of an asthma attack - know how to use a nebulizer, MDI, or peak expiratory flow meter (PEF) - the PEF measures how fast air comes out of the lungs after exhaling forcefully and inhaling fully - monitor the peak expiratory flow rate at home; a decrease may indicate an infection or exacerbation - clean devices used to administer the meds - encourage adequate rest, sleep, and a well-balanced diet - get adequate intake of fluids - develop an exercise program - cough effectively - keep immunizations up to date - inform care takers and school of asthma condition - allow the child to take control of self-care

external fetal monitoring

- is non-invasive - is performed with a tocotransducer or Doppler ultrasonic transducer - Leopold's maneuvers are performed to determine on which side the fetal back is located, and the ultrasound transducer is placed over this area - the tocotransducer is placed over the fundus where contractions feel the strongest - the client's preferred position is lying on her side to increase perfusion

Induction of labor

- is the deliberate initiation of uterine contractions that stimulates labor - is accomplished by infusion of oxytocin - obtain a baseline tracing of uterine contractions and FHR - increase the IV dosage of oxytocin as prescribed only after assessing contractions, FHR, and maternal BP and pulse - do not increase the rate of oxytocin when the desired pattern of contractions is obtained (frequency of 2-3 minutes lasting 60 seconds) ** an oxytocin infusion is discontinued if uterine contraction frequency is less than 2 minutes or duration is longer than 90 seconds, or if fetal distress is noted

Osmotic diuretics

- magnesium hydroxide - magnesium citrate - sodium phosphates - polyethylene glycol and electrolytes - lactulose - attract water to the large intestine to produce bulk and stimulate peristalsis ** the client receiving a laxative need to increase fluids to prevent dehydration **

Laryngeal cancer

- malignant tumor of the larynx - presents as malignant ulcerations with underlying infiltration and is spread by local extension to adjacent structures in the throat and neck and by the lymphatic system - diagnosis is made by a laryngoscopy and biopsy. a laryngoscopy allows for evaluation of the throat and biopsy of tissues. chest radiography, CT, and MRI are used for staging. - risk factors are cigarette smoking combined with alcohol use, exposure to environmental pollutants, and exposure to radiation. assessment: - hoarseness - painless neck mass - feeling a lump in the throat - burning sensation in the throat - dysphagia - change in voice quality - dyspnea - weight loss - hemoptysis (coughing up blood) - foul breath odor interventions: 1. place in fowler's position 2. monitor respiratory status and signs of aspiration 3. administer O2, respiratory treatments, and analgesics as prescribed 4. provide activity as tolerated 5. provide nutritional support by parenteral nutrition, NG tube feedings, or gastrostomy or jejunostomy tubes as prescribed 6. encourage clients to stop smoking and drinking alcohol to increase the effectiveness of the treatment non-surgical interventions: 1 radiation and chemo surgical interventions: 1. the goal is to remove the cancer while preserving as much normal function as possible 2. types of resection include cordal stripping, cordectomy, partial laryngectomy, and total laryngectomy 3. a tracheostomy is used with a total laryngectomy, the airway is permanent and is called a laryngectomy stoma pre-op interventions: 1. discuss care of the airway, alternative methods of communication, the critical care environment, and nutritional support 2. encourage the client to express feelings about changes in body image and loss of voice 3. describe the rehab program and information about the trache and suctioning post-op interventions: 1. monitor vitals, respiratory status, airway patency, pulse ox, and provide frequent suctioning to remove bloody secretions 2. place the client in high-fowler's position 3. maintain mechanical ventilator support or a trache collar with humidification as prescribed 4. maintain surgical drains in the neck area if present 5. observe for hemorrhage and edema in the neck 6. monitor IV fluids or parenteral nutrition until nutrition is administered by an NG tube, gastrostomy, or jejunostomy tube 7. provide oral hygiene 8. assess gag and cough reflexes and the ability to swallow 9. increase activity as tolerated 10. assess the color, amount, and consistency of sputum 11. provide consultation with speech and language pathologist as prescribed 12. reinforced methods of communication decided pre-op 13. prepare the client for rehab and speech therapy 14. provide stoma and laryngectomy care: - protect the neck from injury - instruct the client on how to clean the incision and provide stoma care - instruct the client to wear a stoma guard to shield it - demonstrate how to prevent debris from entering the stoma - advise the client to wear loose-fitting, high-collared clothing to hide the stoma - avoid swimming, showering, and using aresol sprays - teach the client to use a clean suctioning technique - advise the client to increase humidity in the home - increase fluids to 3,000 mL/day - avoid exposure to people with infections - alternate rest with activity - instruct the client in ROM exercises for the arms, shoulder, and neck as prescribed - advise the client to wear a Medic-alert bracelet

protestant beliefs related to end-of life care

- no last rites are provided - prayers are given to offer comfort and support

Myocardial infarction

- occurs when myocardial tissue is abruptly and severely deprived of O2 - ischemia can lead to necrosis of myocardial tissue if blood flow is not restored - infarction does not occur instantly but evolves over several hours - obvious physical changes do not occur in the heart until 6 hours after the infarction, when the area appears blue and swollen - after 48 hours, the infarct turns gray, with yellow streaks developing as neutrophils invade the tissue - by 8-10 days after infarction, granulation tissue forms - over 2-3 months, the necrotic tissue develops into a scar, scar tissue permanently changes the size and shape of the ventricle - not all clients experience the classic symptoms of an MI - women may experience atypical discomfort, SOB, or fatigue and often present with non-ST elevation MI or T-wave inversion - an older client may experience SOB, pulmonary edema, dizziness, altered mental status, or dysrhythmias risk factors: - atherosclerosis - coronary artery disease - elevated cholesterol levels - smoking - HTN - obesity - physical inactivity - impaired glucose tolerance - stress diagnostic studies: - troponin levels rise within 3 hours and remain elevated for 7-10 days - total CK level: rises within 6 hours after the onset of action and peaks within 18 hours after damage and death of cardiac tissue - CK-MB isoenzyme: peak elevation occurs 18 hours after the onset of chest pain and returns to normal 48-72 hours later - myoglobin: levels rise within 2 hours after cell death, with rapid decline in the level after 7 hours - WBC: an elevated WBC count appears on the 2nd day after a MI, and lasts up to 1 week. - ECG: shows ST segment elevation, T wave inversion, or an abnormal Q wave. hours to days after the MI, ST and T wave changes return to normal, but the Q wave usually stays abnormal permanently - cardiac catheterization: may be done emergently to determine the extent and location of obstructions of the coronary arteries; this allows for use of PCTA and restoration of blood low to the myocardium diagnostic tests after the acute stage: - exercise tolerance test or stress test to assess for ECG changes and ischemia and to evaluate for medical therapy or to identify clients who need invasive therapy - Thallium scans to assess for ischemia or necrotic muscle tissue - multigated cardiac blood pool imaging scans may be used to evaluate left ventricular function - if not done urgently, cardiac catheterization to determine the coronary artery obstructions will be done after the client is stabilized assessment: - pain: the client may experience crushing substernal pain, it may radiate to the jaw, back, and left arm, it may occur without cause especially early in the morning, pain is unrelieved by rest or nitroglycerin and is only relieved by opioids, and may last 30+ minutes. - nausea and vomiting - diaphoresis - dyspnea - dysrhythmias - feelings of fear and anxiety, impending doom - pallor, cyanosis, coolness of extremities complications of MI: - dysrhythmias - HF - pulmonary edema - cardiogenic shock - thrombophlebitis - mitral valve insufficiency - postinfarction angina - ventricular rupture - Dressler's syndrome: a combination of pericarditis, pericardial effusion, and pleural effusion, which can occur several weeks to months following a MI interventions: 1. acute stage: **pain relief increases O2 supply to the myocardium, administer morphine as a priority in managing pain in the client having a MI** - obtain a description of the chest discomfort - administer O2 and institute pain relief measures (morphine, nitroglycerin as prescribed) - assess vitals and cardiovascular status and maintain cardiac monitoring - assess RR and breath sounds for signs of HF, as indicated by the presence of crackles or wheezes or dependent edema - ensure bed rest and place the client in a semi-fowler's position to enhance comfort and tissue O2, stay with the client - establish IV access - obtain a 12-lead ECG - monitor lab values monitor for cardiac dysrhythmias, because tachycardia and PVCs frequently occur in the first few hours after MI; administer anti-dysrhythmias as prescribed - administer thrombolytic therapy, which may be prescribed within the first 6 hours of the coronary event if cardiac catheterization is not going to be done emergently; monitor for signs of bleeding if the client is receiving thrombolytic therapy - assess distal peripheral pulses and skin temp because poor CO may be identified by cool diaphoretic skin and diminished or absent peripheral pulses - monitor the BP often after the administration of meds; if the systolic pressure is lower than 100 or 25 lower than the previous reading, lower the HOB and notify the PHCP - administer beta blockers as prescribed to slow the HR and increase myocardial perfusion while reducing the force of myocardial contraction - provide reassurance to the client and family interventions following the acute episode: - maintain bedrest as prescribed - allow the client to stand to void or use a bedside commode if prescribed - provide ROM exercises to prevent thrombus formation and maintain muscle strength - progress to gangling legs at the side of the bed or out of bed to the chair for 30 mins 3x a day if prescribed - progress to ambulation in the client's room and to the bathroom and then in the hallway 3x a day - monitor for complications - administer ACE inhibitors, Angiotensin-2 receptor blockers, CCBs, aspirin, thienopyridines, and lipid-lowering agents as prescribed - encourage the client to verbalize feelings regarding the MI - cardiac rehabilitation: process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life within the limitations of heart disease

Supine hypotension (vena cava syndrome)

- occurs when the venous return to the heart is impaired by the weight of the uterus on the vena cava. - the syndrome results in partial occlusion of the vena cava and aorta and in reduced cardiac return, cardiac output, and BP - assess for pallor, faintness, dizziness, breathlessness, tachycardia, hypotension, sweating, cool and damp skin, and fetal distress. - interventions: position the client on her side to shift the weight of the fetus off the vena cava until the client's signs and symptoms subside and the vitals stabilize, and monitor vitals and FHR. ** to prevent supine hypotension, avoid the supine position, position the client by placing a pillow or a wedge under the client's hip to displace the gravid uterus off the vena cava **

Standard precautions

- practiced with all clients regardless of what they are diagnosed with - include hand washing, using gloves, hand washing after removal of gloves, and the use of masks, eyewear, and gowns when appropriate.

Antilipemic medications

- reduce serum cholesterol, triglyceride, and LDL levels - when cholesterol, triglyceride, and LDL levels are elevated the client is at risk for coronary artery disease - in many cases diet alone will not lower blood lipid levels, therefore antilipemic meds will be prescribed Bile sequestrants: - colsevelam - colestipol - cholestyramine - binds with acids in the intestines which prevents reabsorption of cholesterol - should not be used as the only therapy in clients with elevated triglyceride levels because they may raise triglyceride levels adverse effects: - constipation - GI disturbances (heartburn, nausea, belching, and bloating) interventions: 1. cholestyramine comes in a gritty powder that must be mixed thoroughly in juice or water before administration 2. monitor the client for early signs of peptic ulcer such as nausea and abdominal discomfort followed by abdominal pain and distention. 3. instruct the client that the med must be taken with food and sufficient fluids HMG-CoA reductase inhibitors: - atorvastatin - fluvastatin - lovastatin - pitavastatin - pravastatin - rosuvastatin - simvastatin - lovastatin is highly-protein bound and should not be administered with anticoagulants - lovastatin should not be administered with gemfibrozil - administer lovastatin with caution to the client taking immunosuppressive meds adverse effects: - nausea - diarrhea or constipation - abdominal pain or cramps - flatulence - dizziness - headache - blurred vision - rash - pruritus - elevated liver enzyme levels - muscle cramps and fatigue interventions: 1. monitor serum liver enzyme levels 2. instruct the client to have an annual eye exam, because the meds can cause cataract formation 3. if lovastatin is not effective in lowering the lipid level after 3 months, it should be discontinued **instruct the client who is taking antilipemic meds to report any unexplained muscular pain to the PHCP immediately** other antilipemic meds: - cholecystramine - colesevelam - colestipol - ezetimibe - lomitapide - fenofibrate - gemfibrozil - nicotinic acid - gemfibrozil should not be taken with anti-coagulants because they compete for protein sites; if the client is taking an anticoagulant, the anticoagulant dose should be reduced during antilipemic therapy and the INR should be monitored closely - do not administer gemfibrozil with HMG-CoA reductase inhibitors, because it increases the risk for myositis, myalgias, and rhabdomyolysis - fish oil supplements have been associated with a decreased risk for cardiovascular heart disease; plant stanol and sterol esters and cholestin have been associated with reducing cholesterol levels interventions: 1. monitor vitals 2. monitor liver enzyme levels 3. monitor serum cholesterol and triglyceride levels 4. instruct the client that it will take several weeks before the lipid levels decline 5. instruct the client to restrict intake of fats, cholesterol, carbohydrates, and alcohol 6. instruct the client to follow an exercise program 7. instruct the client to have an annual eye exam and to report changes in vision 8. instruct the client with DM who is taking gemfibrozil to monitor blood glucose levels regularly 9. instruct the client to increase fluid intake 10. nicotinic acid has numerous side and adverse effects, including GI disturbances, flushing of the skin, elevated liver enzyme levels, hyperglycemia, and hyperuricemia 11. instruct the client that taking aspirin or non-steroidal anti-inflammatory drugs 30 mins before nicotinic acid may assist in reducing the side effect of cutaneous flushing 12. instruct the client to take nicotinic acid with meals to reduce GI discomfort

Nutritional guidelines for pregnancy

- should gain an average of 25 - 35 lbs. - increase of 300 calories a day - increase of 500 calories a day is needed during lactation - a diet high in folic acid or folic acid supplements are needed to prevent neural tube defects and orofacial clefts in the fetus - at least 8 - 10 glasses of water are needed

hispanic beliefs related to end-of life care

- the family makes decisions and may choose to withhold the diagnosis from the client - extended family members are often involved in end of life care - several family members may be at a dying client's bedside - vocal expression of grief and mourning is acceptable and respected - members may refuse procedures that alter the body, such as an autopsy - dying at home may be considered bad luck

Pediatric GI Problems: Esophageal Atresia and Tracheoesophageal Fistula

- this is when the esophagus terminated before it reaches the stomach ending in a blind pouch, or a fistula is present and forms an unnatural connection with the trachea. - the condition causes oral intake to enter the lungs or a large amount of air to enter the stomach, presenting a risk of coughing and choking. severe abdominal distention can also occur. - aspiration pneumonia and severe respiratory distress may occur, and death is likely without surgery - treatment is with maintenance of airway, prevention of aspiration pneumonia, gastric or blind pouch decompression, supportive therapy, and surgical repair assessment: - frothy saliva, excessive drooling - coughing, chocking, cyanosis - regurgitation and vomiting - abdominal distention - increased respiratory distress during and after feeding pre-op interventions: 1. infant is placed in a warmer and humidified O2 is administered 2. maintain NPO 3. maintain IV fluids as prescribed 4. monitor respiratory status closely 5. suction accumulated secretions 6. maintain a supine position at least 30 degrees upright to facilitate drainage and prevent aspiration of gastric secretions 7. keep the blind pouch empty of secretions by intermittent or continuous suction as prescribed; monitor its patency closely, because clogging from mucous can occur easily 8. if a gastrostomy tube is inserted, it may be left open so that air entering the stomach through the fistula can escape, minimizing the risk of regurgitation of gastric contents into the trachea 9. broad-spectrum antibiotics may be prescribed because of the high risk for aspiration pneumonia post-op interventions: 1. monitor vitals and respiratory status 2. maintain IV fluids, antibiotics, and parenteral nutrition as prescribed 3. monitor strict I&O 4. monitor daily weight, assess for dehydration and fluid overload 5. assess for signs of pain 6. maintain chest tube if present 7. inspect the surgical site for signs and symptoms of infection 8. monitor for anastomotic leaks as evidenced by purulent drainage from the chest tube, increased temp, and increased WBC count 9. if a gastrostomy tube is present, it is usually attached to a gravity drainage until the infant can tolerate feedings and the anastomosis is healed (usually by post-op day 5 - 7), then feedings are prescribed 10. before oral feedings and removal of the chest tube, prepare for an esophagogram as prescribed to check the integrity of the esophageal anastomosis 11. before feeding, elevate the gastrostomy tube and secure it above the level of the stomach to allow gastric secretions to pass to the duodenum and swallowed air to escape through the open gastrostomy tube 12. administer oral feedings with sterile water, followed by frequent small feedings of formula as prescribed 13. assess the cervical esophagostomy site if present for redness, breakdown, or exudate; remove accumulated drainage frequently, and apply protective ointment, barrier dressing, or a collection device as prescribed 14. provide non-nutritive sucking using a pacifier for infants who remain NPO for extended periods, unless the infant is unable to handle secretions 15. instruct the parents in the techniques of suctioning, gastrostomy tube care and feedings, and skin site care as appropriate 16. instruct the parents to identify behaviors that indicate the need for suctioning, signs of respiratory distress, and signs of a constricted esophagus (indicated by poor feeding, dysphagia, drooling, coughing, and regurgitated undigested food).

Pediatric metabolic and endocrine problems: diabetes

- type 1 DM: characterized by the destruction of pancreatic beta cells, which produce insulin, and results in absolute insulin deficiency - type 2 DM: arises due to insulin resistance in which the body fails to use insulin properly, combined with relative insulin deficiency - diagnosis is based on classic symptoms and an elevated blood glucose level preventing type 2 diabetes in childhood: - drink water instead of sugary beverages - eat more fruits and vegetables - limit fast foods - make healthy snacks - have 60 mins a day of activity - limit screen time to 60 minutes a day - warning signs include: increased thirst, increased night-time urination, blurry vision, and unusual fatigue assessment: - polyuria, polydipsia, polyphagia - hyperglycemia - weight loss - unexplained fatigue or lethargy - headaches - occasional bed wetting in a toilet trained child - vaginitis in adolescent girls - fruity breath - dehydration - blurred vision - slow wound healing - changes in LOC long-term effects: - failure to grow at a normal rate - delayed maturation - recurrent infections - neuropathy - cardiovascular disease - retinal microvascular disease - renal microvascular disease complications: - hypoglycemia - hyperglycemia - diabetic ketoacidosis - coma - hypokalemia - hyperkalemia - microvascular changes - cardiovascular changes diet: - 3 balanced meals per day at regularly scheduled intervals, plus a mid-afternoon and bedtime snack, a consistent intake of prescribed fats, protein, and carbs, concentrated sweets are discouraged and fat is reduced to 30% or less. - parents and children should carry a source of glucose with them to treat hypoglycemia if it occurs - allow the child to participate in making food choices to provide a sense of control - they don't need any special types f foods or supplements. only regular healthy nutrition and sufficient calories to meet their daily needs. exercise: - instruct the child on dietary adjustments while exercising - extra food needs to be consumed for increased activity, usually 10-15 g of carbs for every 30-45 mins of activity - instruct the child to monitor blood glucose levels before exercising - plan an appropriate exercise regimen with the child, taking their developmental stage into account insulin: - diluted insulin may be needed for some infants to provide small enough doses to avoid hypoglycemia, diluted insulin should be labeled clearly to avoid dosage errors - lab evaluation of glycosylated hemoglobin (HgbA1c) should be performed every 3 months. the reference interval for HgbA1c is <6% - illness, infection, and stress increase the need for insulin, and insulin should not be withheld during illness infection or stress because hyperglycemia and ketoacidosis can result - when the child is NPO for a surgical procedure, verify with the PHCP the need to withhold the morning insulin, and when food fluids and insulin are to be resumed. - instruct the child and parents in the administration of insulin, and to recognize symptoms of hyperglycemia and hypoglycemia - instruct the parents in the administration of glucagon IM or sub Q if the child has a hypoglucemia reaction and is unable to consume anything orally - instruct the parents and child to always have a spare bottle of insulin available - advise the parents to wear a medical alert bracelet indicating the type and daily insulin dosage prescribed for the child blood glucose monitoring: - is more accurate than urine testing - instruct the child and parents about the proper procedure for blood glucose monitoring, and that it must be done precisely to get accurate results - stress the importance of hand washing before and after performing the procedure to prevent infection - stress the importance of following the manufacture's instructions on the blood glucose monitoring device - instruct the child and parents to calibrate the monitor as instructed by the manufacturer - instruct the child and parents to check the expiration date on the test strips used for blood glucose monitoring - instruct the child and parents that if the results do not seem reasonable, they should re-read the instructions, re-assess technique, check the expiration date of the test strips, and perform the procedure again to verify the results urine testing: - instruct the parents and child for the procedure for urine testing for ketones and glucose - teach the child that second voided urine specimens are the most accurate - the presence of ketones may indicate impending ketoacidosis hypoglycemia: - is a blood glucose level less than 70 - results from too much insulin, not enough food, or excessive activity - signs include headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around the mouth, and anxiety interventions: - if possible, confirm hypoglycemia with a blood glucose reading - administer glucose immediately, rapid-releasing glucose is followed by complex carbohydrate and protein such as a slide of bread or a peanut butter cracker - give an extra snack if the next meal is not planned for more than 30 minutes or if activity is planned - if the child becomes unconscious, squeeze cake frosting or glucose paste into the gums and retest the blood glucose level in 15 minutes, if the reading remains low, administer additional glucose - if the child remains unconscious, the administration of glucagon may be necessary - in the hospital, prepare to administer dextrose IV if the child is unable to consume an oral glucose tablet hyperglycemia: - is an elevated blood glucose level above 200 - signs include polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, and syncope interventions: - instruct the PHCP when the following occur: blood glucose levels remain elevated above 200, moderate or high ketonuria is present, child is unable to take food or fluids, child vomits more than once, or illness persists. diabetic ketoacidosis: - is a life-threatening condition - hyperglycemia that progresses to metabolic acidosis occurs - develops over several hours to days - blood glucose level is greater than 300 and urine and serum ketone tests are positive - signs are those of hyperglycemia, Kussmaul's respirations, acetone or fruity breath odor, increasing lethargy, and decreasing LOC. - interventions: - restore circulating blood volume, and protect against cerebral, coronary, or renal hypoperfusion - correct dehydration with IV infusions of normal saline - correct hyperglycemia with IV regular insulin - monitor vitals, urine output, and mental status closely - correct acidosis and electrolyte imbalances as prescribed - administer O2 as prescribed - monitor blood glucose levels frequently - monitor K+ levels closely because when the child receives insulin to reduce the blood glucose level, the serum K+ level decreases, and K+ replacement may be required - the child should be voiding adequately before administering K+, if the child does not have adequate output, hyperkalemia may result - monitor the child closely for signs of fluid overload - IV dextrose is added as prescribed when the blood glucose reaches an appropriate level - treat the cause of hyperglycemia

Bites and stings

1. brown recluse spider bites: - bite can cause a skin lesion, a necrotic wound, or systemic effects fro the toxin - application of ice decreases enzyme activity of the venom and limits tissue necrosis; should be done immediately and intermittently for up to 4 days after the bits - topical antiseptics and antibiotics may be necessary if the sits becomes infected 2. black widow spider bite: - bite causes a small red papule - venom causes neurotoxicity - ice is applied immediately to inhibit the action of the neurotoxin - systemic toxicity can occur, and the victim may require supportive therapy in the hospital 3. tarantula bite: - bite causes swelling, redness, numbness, lymph inflammation, and pain at the bite site - the tarantula launches its barbed hairs which can penetrate the skin and eyes of the victim, producing a severe inflammatory reaction - tarantula hairs are removed as soon as possible, using sticky tape to pull hairs from the skin, and the skin is thoroughly irrigated; saline irrigations are used for eye exposure - the involved extremity is elevated and immobilized to reduce pain and swelling - anti-histamines and topical or systemic corticosteroids may be prescribed, tetanus prophylaxis is necessary 4. scorpion stings: - scorpions inject venom through a stinging apparatus on their tail - most stings cause local pain, inflammation, and mild systemic reactions that are treated with analgesics, wound care, and supportive treatment - the bark scorpion can inflict a severe and potentially fatal systemic response, especially in small kids and the elderly; their venom is neurotoxic, the victim should be taken to the ED and an anti-venom is administered 5. Bees and wasps: - stings usually cause a wheal and flare reaction - emergency care involves quick removal of the stinger and application of an ice pack - the stinger is removed by gently scraping or brushing it off with the edge of a needle, and tweezers are not used due to the risk of puncturing the venom sac - if the victim is allergic, a severe allergic response can occur and immediate care is required - people who are allergic should carry epinephrine for self-injecting and should seek medical attention after injecting it 6. snake bites: - some snakes are venomous and can cause a severe systemic reaction in victims - the victim should be moved to a safe area and rest to decrease the circulation of the venom, the extremity is immobilized and kept below the heart level - constricting clothing and jewelry are removed before swelling occurs - keep the victim warm and do not let them consume alcoholic or caffeinated drinks because they increase the absorption of the venom - if unable to seek medical attention right away, apply a constricting band proximal to the wound to slow the venom circulation, monitor the circulation often and loosen it if edema occurs - the wound is not incised or sucked and ice is not applied to the wound - ED care is needed, an anti-venom may be given along with supportive care - contact the poison control center for bites

Serosanguineous drainage

pink colored due to the presence of a small amount of blood cells mixed with serous drainage, occurs as a normal part of the healing process

The process of labor

- 4 major factors (4 Ps) interact during normal childbirth. they are powers, passageway, passenger, and psyche. - Powers: are uterine contractions. they are the forces acting to expel the fetus. - effacement: shortening and thinning of the cervix during the first stage of labor - dilation: enlargement of the cervix during the first stage of labor - also includes the pushing efforts of the mother during the second stage of labor - passageway: the mother's bony pelvis and the soft tissues of the cervix, pelvic floor, vagina, and external opening to the vagina. - passenger: the fetus, membranes, and placenta - psyche: a woman's emotional structure that can determine her entire response to labor and influence physiological and psychological functioning; the mother may experience anxiety or fear. - attitude: is the relationship of the fetal body parts to one another. normal attitude is flexion, in which the fetal back is rounded, the head is forward on the chest, and the arms and legs are folded in against the body. - lie: is the relationship of the spine of the fetus and the spine of the mother. - longitudinal or vertical lie: the fetal spine is parallel to the mother's spine and the fetus is in the cephalic or breech position. - transverse or horizontal lie: the fetal spine is perpendicular or at a right angle to the mother's spine. the presenting part is the shoulder and delivery by C-section is necessary. - presentation: portion of the fetus that enters the pelvic inlet first. - cephalic is head first, is the most common presentation, and has 4 variations: vertex, military, brow, and face. - breech is buttocks first, delivery by C-section may be required, three variations are frank, full, and footling - shoulder is when the fetus is in a transverse lie, or the arm, back, abdomen, or side could present. if the fetus doesn't spontaneously rotate or if it's impossible to turn the fetus manually, a C-section may be needed. - presenting part: the specific fetal structure lying nearest to the cervix - position: the relationship of assigned area of the presenting part to the maternal pelvis - station: is the measurement of the progress of descent in cm above or below the midplane from the presenting part to the ischial spine. station 0 means it's at the ischial spine, minus station means its above the ischial spine, plus station is below the ischial spine, and engagement is when the widest diameter of the presenting part has passed the inlet, corresponds to a 0 station.

Risk conditions related to pregnancy: Hydatidiform mole

- A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta. Women appear to be pregnant, but the uterus enlarges much more rapidly than in a normal pregnancy. Most women have severe nausea and vomiting, vaginal bleeding, and very high blood pressure. - assessment findings: fetal HR not detectable, vaginal bleeding, signs of preeclampsia before the 20th week of gestation; fundal height greater than expected for expected due date; elevated HCG levels; and characteristic snowstorm pattern seen on ultrasound. - interventions: prepare the client for uterine evacuation; evacuation of the mole is done by vacuum aspiration, oxytocin may be administered after evacuation to contract the uterus; monitor for post-procedure hemorrhage and infection; tissue is sent to the lab for evaluation, and follow-up is needed to detect changes suggestive of malignancy; HCG levels are monitored every 1-2 weeks until normal pre-pregnancy levels are attained, levels are checked every 1-2 months for 1 year; and instruct the client and her partner about birth control measures so that pregnancy can be prevented during the 1-year follow-up period.

Loop diuretics

- Bumetanide - ethacrynic acid - furosemide - torsemide - are anti-hypertensive meds that inhibit sodium and chloride reabsorption from the loop of henle and the distal tubule - loop diuretics have little effect on the blood glucose level, however, they cause depletion of water and electrolytes, increased uric acid levels, and the excretion of calcium - loop diuretics are more potent than thiazide diuretics, causing rapid diuresis, and thus, decreasing vascular fluid volume, cardiac output, and BP - are used for HTN, pulmonary edema, edema associated with HF, hypercalcemia, and renal disease - use loop diuretics with caution in the client taking digoxin or lithium and in the client taking aminoglycosides, anticoagulants, corticosteroids, or amphotericin B adverse effects: - hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia - thrombocytopenia - hyperuricemia - orthostatic hypotension - rash - ototoxicity and deafness - thiamine deficiency - dehydration interventions: 1. monitor vitals 2. monitor weight 3. monitor urine output 4. monitor electrolytes, glucose, calcium, BUN, creatine, and uric acid levels 5. check peripheral extremities for edema 6. monitor for signs of digoxin or lithium toxicity if the client is taking these medications 7. instruct the client to take the medication in the morning to avoid nocturia and sleep interruption 8. instruct the client on how to record the BP 9. instruct the client to eat foods high in K+ 10. instruct the client on how to take K+ supplements if prescribed 11. instruct the client to take the med with food to prevent GI upset 12. instruct the client to change positions slowly to prevent orthostatic hypotension 13. instruct the client to use sunscreen when in direct sunlight because of increased photosensitivity 14. instruct the client with DM to have the blood glucose levels checked periodically 15. monitor electrolytes, calcium, magnesium, BUN, creatinine, and uric acid levels 16. administer IV furosemide slowly over 1-2 minutes, because hearing loss can occur if injected rapidly

Magnesium sulfate

- CNS depressant and anti-seizure medication - causes smooth muscle relaxation - antidote is calcium gluconate - used to stop preterm labor and preventing or controlling seizures in preeclamptic or eclamptic clients adverse effects and contraindications: - can cause respiratory depression, depressed reflexes, flushing, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. - continuous IV infusion increases the risk of magnesium toxicity in the newborn - may be prescribed for the first 12-24 hours postpartum if the mother has preeclampsia - high doses can cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. - the med is contraindicated in clients with heart block, myocardial damage, or kidney failure - used in caution with clients who have a kidney impairment interventions: - monitor maternal vitals every 30-60 minutes - assess renal function and ECG - monitor mag levels every 6 hours or if toxicity is noted, the target range for a tcoclytic agent is 4-7.5 - always administer by an IV monitoring device - keep calcium gluconate readily accessible - monitor deep tendon reflexes every hour - patellar reflex must be present and RR needs to be at least 12 per minute before each parenteral dose - monitor I&O hourly

Hypocalcemia

- Ca2+ level less than 9.0 - assessment findings: Cardiovascular: decreased HR, hypotension, diminished peripheral pulses Respiratory: not directly affected, however, respiratory failure or arrest can develop from decreased respiratory movement because of muscle tetany or seizures neuromuscular: - irritable skeletal muscles: twitches, cramps, tetany, seizures - painful muscle spasms in the calf or foot during periods of inactivity - paresthesias followed by numbness in the lips, nose, tongue, ears, or limbs - positive Trousseau's and Chvosek's signs - hyperactive deep tendon reflexes - anxiety, irritability GI: - increased motility, hyperactive bowel sounds - cramping, diarrhea ECG changes: - prolonged ST interval - prolonged QT interval

Hypercalcemia

- Ca2+ level over 10.5 - assessment findings: Cardiovascular: - increased HR in the early phase, bradycardia that can lead to cardiac arrest in the late phase - bounding peripheral pulses Respiratory: - ineffective respiratory movement due to skeletal muscle weakness Neuromuscular: - profound muscle weakness - diminished or absent deep tendon reflexes - disorientation, lethargy, coma GI: - decreased motility, hypoactive bowel sounds - anorexia, nausea, abdominal distension, diarrhea ECG changes: - shortened ST segment - widened T wave - heart block

Cushing's syndrome and Cushing's disease (hypercorticolism)

- Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol from the adrenal cortex or from the administration of glucocorticoids in large amounts for several weeks or longer - ACTH secreting tumors can cause Cushing's syndrome also - Cushing's disease is a metabolic disorder characterized by abnormally increased secretion of cortisol, caused by increased amounts of ACTH secreted by the pituitary gland assessment: - generalized muscle wasting and weakness - moon face (swelling in your face that makes it rounder), buffalo hump (lump of fat that develops at the top of the back between the shoulders) - truncal obesity with thin extremities, supraclavicular fat pads, weight gain - hirsutism (muscular characteristics in females) - hyperglycemia, hypernatremia - hypokalemia, hypocalcemia - HTN - fragile skin that bruises easily, reddish-purple striae on the abdomen and upper thighs interventions: 1. monitor vitals, I&O, weight, lab values especially WBCs, serum glucose, sodium, K+, and Ca2+ 2. prepare the client for radiation as prescribed if the condition is due to a pituitary adenoma 3. administer chemo as prescribed for inoperable adrenal tumors 4. prepare the client for removal of the pituitary tumor if the condition results from increased pituitary secretion of ACTH 5. prepare the client for an adrenalectomy if the condition results from an adrenal adenoma; glucocorticoid replacement may be needed following adrenalectomy 6. clients requiring lifelong glucocorticoid replacement following adrenalectomy should get instructions from their PHCPs about increasing their dose during times of stress 7. assess for and protect against post-op thrombus formation; Cushing's syndrome predisposes thromboemboli 8. allow the client to discuss feelings related to body appearance 9. instruct the client about the need to wear a medi-alert bracelet

Risk conditions related to pregnancy: Disseminated intravascular coagulation (DIC)

- DIC is a maternal condition in which the clotting cascade is activated, resulting in the formation of clots. the rapid and excessive formation of clots causes the platelets and clotting factors to be depleted, this results in bleeding and the potential for vascular occlusion of organs. - Predisposing conditions for DIC: abruptio placentae, amniotic fluid embolism, gestational HTN, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, and severe postpartum hemorrhage and blood loss. - assessment may show uncontrolled bleeding; bruising, petechiae, and ecchymosis; presence of blood in stool; hematuria, hematemesis, or vaginal bleeding; signs of shock; decreased fibrinogen level, platelet count, and hematocrit level; and increased prothrombin time and partial thromboplastin time, clotting time, and fibrin degradation products. - interventions include remove the underlying cause; monitor vitals, assess for bleeding and signs of shock; prepare for O2 therapy, volume replacement, blood component therapy, and possibly heparin therapy; monitor for complications associated with fluid and blood replacement and heparin therapy; and monitor urine output and maintain at least 30 mL per hour because renal failure is a complication of DIC.

Medications to control diarrhea

- Diphenoxylate with atropine sulfate - loperamide - bismuth subsalicylate - bulk-forming meds - anticholinergics antispasmodics (dicyclomine, glycopyrrolate) - identify and treat the underlying cause, treat dehydration, replace fluids and electrolytes, relieve abdominal discomfort and cramping, and reduce the passage of stool - opioids: are effective anti-diarrheal meds that decrease intestinal motility and peristalsis. when poison, infections, or bacterial toxins are the cause of the diarrhea, opioids worsen the condition by delaying the elimination of the toxin.

Enoxaparin or Rivaroxaban (low-molecular weight heparins)

- Enoxaparin or Rivaroxaban have the same mechanism of action and use as heparin but are not inter-changeable with heparin, they have longer half-lives than heparin does. interventions: 1. administer enoxaparin only to the recumbent (lying down) client by subcutaneous injection into the abdominal wall; do not expel the air bubble from the pre-filled syringe or aspirate during injection 2. rivaroxaban is taken PO 1x a day 3. monitor the results of the Anti-Xa assay (the # of heparins in plasma); the therapeutic range for anticoagulation is 0.5-1.2 IU/mL; observe for bleeding. 4. the antidote to low-molecular weight heparins is protamine sulfate

Eryipelas and Cellulitis

- Erysipelas is an acute, superficial, rapidly-spreading inflammation of the dermis and lymphatics caused by group A streptococcus, which can enter the tissue by an abrasion, bite, trauma, or wound - Cellulitis is an infection of the dermis and underlying hypo-dermis, the causative agent is usually group A streptococcus or staphylococcus aureus assessment: - pain and tenderness - erythema and warmth - edema - fever interventions: 1. promote rest of the affected area 2. apply warm compresses as prescribed to promote circulation, decrease discomfort, decrease erythema, and decrease edema 3. apply antibacterial dressings, ointments, or gels as prescribed 4. administer antibiotics as prescribed for infection, obtain a wound culture of the areas before initiating antibiotics

Food sources of vitamins

- Folic acid: green leafy veggies, liver, beef, fish, legumes, grapefruit, oranges - Niacin: meats, poultry, fish, beans, peanuts, grains - Vitamin B1 (Thiamine): pork, nuts, whole-grain cereals, legumes - Vitamin C: citrus fruits, tomatoes, broccoli, cabbage - Vitamin A: liver, egg yolk, whole milk, green or orange veggies, fruits - Vitamin D: fortified milk, fish oils, cereals - Vitamin E: veggie oils, green leafy veggies, cereals, apricots, apples, peaches - Vitamin K: green leafy veggies, cauliflower, cabbage

Treatment for irritable bowel syndrome (IBS)

- IBS is a GI disorder that is characterized by crampy abdominal pain accompanied by constipation, diarrhea, or both - pharm treatment depends on if the client has constipation or diarrhea treatment for constipation-predominant IBS: - bulk-forming laxatives, usually taken with meals with a full glass of water. - Lubiprostone: chloride channel activator that increases fluid in the intestines to promote bowel elimination, and needs to be taken with food and water. - Linaclotidine: stimulates receptors in the intestines to promote bowel transit time, taken daily 30 minutes before breakfast treatment for diarrhea-predominant IBS: - alosetron: a selective serotonin receptor antagonist, can cause adverse effects such as constipation, impaction, bowel obstruction, perforation of the bowel, and ischemic colitis. a strict risk management regimen must be followed, including monitoring for adverse effects, reporting them, and immediate discontinuation of the med if they arise.

Anticholinergics

- Ipratropium - Tiotropium - Aclidinium - Umeclidinium - inhaled meds that improve lung function by blocking muscarinic receptors in the bronchi, which prevents broncho-constriction - effective for treating COPD, allergy-induced asthma, and allergy-induced bronchospasm - side effects are dry mouth and irritation of the pharynx, sucking on sugarless candy will help relieve symptoms - systemic anticholinergic effects rarely occur but can include increased intra-ocular pressure, blurred vision, tachycardia, cardiovascular events, urinary retention, and constipation. ** the client with a peanut allergy should not take certain ipratropium products because they contain soy lecithin, which is in the same plant family as peanuts

Hyperkalemia

- K+ level over 5.0 Assessment findings: Cardiovascular: - slow, weak, irregular heart rate - decreased bp - dysrhythmias Respiratory: - profound weakness of respiratory muscles leading to respiratory failure Neuromuscular: - early stage: muscle twitches, cramps, paresthesias - late stage: profound weakness, flaccid paralysis in arms and legs followed by trunk, head, and respiratory muscles GI: - increased motility - hyperactive bowel sounds - diarrhea ECG changes: - tall peaked T waves - flat P waves - widened QRS complexes - prolonged PR interval Causes: acute kidney injury or chronic kidney disease, Addison's disease, dehydration, diabetic ketoacidosis, excessive dietary or IV intake of potassium, massive tissue destruction, or metabolic acidosis

Methicillin-Resistant Staphylococcus Aureus (MRSA)

- MRSA can be community-acquired such as through sports when skin-to-skin contact occurs and sharing of equipment occurs. it can also be hospital-acquired, such as when a surgical site infection occurs - infection can range from mild to severe - it can present as folliculitis - is a superficial infection of the follicle caused by Staphylococcus aureus and presents as a raised red rash and pustules - it can also present as furuncles - which occur deep in the follicle and present as large painful raised bumps that may or may not have a pustule - if MRSA infects the blood, sepsis organ damage or death can occur assessment: - a culture and sensitivity test of the skin or wound confirms the presence of MRSA and leads to choice of appropriate antibiotic therapy interventions: 1. maintain standard precautions and contact precautions 2. monitor the client closely for signs of further infection, which may result in systemic illness or organ damage 3. administer antibiotics as prescribed

Hypermagnesemia

- Mg level above 2.6 - assessment findings: Cardiovascular: - bradycardia - dysrhythmias - cardiac arrest if severe - hypotension Respiratory: - respiratory insufficiency when the skeletal muscles of respiration are involved Neuromuscular: - diminished or absent deep tendon reflexes - skeletal muscle weakness CNS: - drowsiness and lethargy that progresses to coma ECG changes: - prolonged PR interval - widened QRS complexes

Hypomagnesemia

- Mg level less than 1.8 - assessment findings: Cardiovascular: - tachycardia - HTN Respiratory: - shallow respirations Neuromuscular: - twitches, paresthesias - positive Trousseau's and Chvosek's signs - hyperreflexia - tetany, seizures CNS: - irritability - confusion ECG changes: - tall T waves - depressed ST segments

Nonopioid analgesics: Nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin

- NSAIDs include ibuprofen, naproxen, and more. - contraindicated in clients with gastric irritation, ulcer disease, or allergy to medication. - bleeding is a concern, NSAIDs can amplify the effects of anticoagulants - take PO doses with milk or a snack to reduce gastric irritation - hypoglycemia may result for the client taking ibuprofen with an oral antidiabetic agnt - ibuprofen with a CCB causes a high risk of toxicity - side effects of NSAIDs = gastric irritation, hypotension, sodium and water retention, blood dyscrasias, dizziness, tinnitus, and pruritus

Hyponatremia

- Na+ level less than 135 Assessment findings: Cardiovascular: - rapid pulse rate Respiratory: - shallow, ineffective respiratory movement is a late manifestation Neuromuscular: - generalized skeletal muscle weakness that is worse in extremities - diminished deep tendon reflexes CNS: - headache - personality changes - confusion - seizures - coma GI: - increased motility and hyperactive bowel sounds - nausea - abdominal cramping and diarrhea Renal: - increased urinary output - decreased urine specific gravity integumentary: - dry mucous membranes Causes: Addison's disease, decreased dietary intake of sodium, diabetic ketoacidosis, diuretic therapy, excessive loss from the GI tract, excessive sweating, or water intoxication

Hypernatremia

- Na+ level over 145 Assessment findings: - pulmonary edema - altered cerebral function* - extreme thirst - decreased urinary output - dry, flushed skin - dry and sticky tongue and mucous membranes - increased urine specific gravity - early stage: spontaneous muscle twitches, irregular muscle contractions - late stage: skeletal muscle weakness, deep tendon reflexes diminished or absent Causes: dehydration, impaired renal function, increased dietary or IV sodium intake, primary aldosteronism, or use of corticosteroid therapy

Pediatric GI problems: abdominal wall defects

- Omphalocele = herniation of the abdominal contents through the umbilical ring, usually with an intact peritoneal sac. - the protrusion is covered by a translucent sac that may contain bowel or other abdominal organs - rupture of the sac results in evisceration of the abdominal contents - immediately after birth, the sac is covered with sterile gauze soaked in normal saline to prevent drying of abdominal contents; a layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss - monitor vitals frequently (every 2-4 hours) - pre-op: maintain NPO, administer IV fluids as prescribed to maintain hydration and electrolyte balance, monitor for signs of infection, and handle the infant carefully to prevent rupture of the sac - post-op: control pain, prevent infection, maintain fluid and electrolyte balance, and ensure adequate nutrition - Gastroschisis: occurs when the herniation of the intestine is lateral to the umbilical ring - no membrane covers the exposed bowel - the exposed bowel is covered loosely in saline-soaked pads, and the abdomen is loosely wrapped in a plastic drape or an agency-approved drape, wrapping directly around the exposed bowel is contraindicated because if the exposed bowel expands, the wrapping could cause pressure and necrosis - pre-op: care is similar to that for omphalocele, surgery is performed within several hours after birth because no membrane is covering the sac - post-op: most infants develop prolonged ileus, require mechanical ventilation, and need parenteral nutrition

Pediatric musculoskeletal problems: Fractures

- a break in continuity of the bone as a result of trauma, twisting, or bone decalcification - fractures in kids usually occur as a result of increased mobility and inadequate or immature motor and cognitive skills, they may result from bone or trauma diseases such as congenital bone disease or bone tumors - fractures in infancy are rare and warrant further investigation to rule out the possibility of child abuse to identify bone structure defects assessment: - pain or tenderness over the involved area - obvious deformity - edema - ecchymosis - muscle spasm - loss of function - crepitation initial care of a fracture: 1. assess extent of injury and immobilize the affected extremity check to neurovascular status of the extremity 2. if a compound fracture exists, cover the wound with a sterile dressing 3. elevate the injured extremity if appropriate 4. apply cold to the injured area 5. continue to monitor neurovascular status 6. transport to the nearest ED 1. reduction: is storing bone to proper alignment - closed reduction: accomplished by manual alignment of the fragments, followed by immobilization - open reduction: surgical insertion of internal fixation devices, such as rods, wires, or pins, that help maintain alignment while healing occurs 2. retention: is application of traction or a cast to maintain alignment until healing occurs 3. traction: - russell skin traction: used to stabilize a fractured femur before surgery, similar to Buck's traction but provides a double pull using a knee sling that pulls at the knee and foot - balanced suspension: used with skin or skeletal traction to approximate fractures of the femur, tibia, or fibula. balanced suspension is produced by a counterforce other than the child. Provide pin care if pins are used with the skeletal traction. - 90-degree-90-degree traction: the lower leg is supported by a boot cast or a calf sling. a skeletal steinmann pin or kirschner wire is placed in the distal fragment of the femur, allowing 90-degree flexion at the hip and the knee - interventions for traction: - maintain correct amount of weight as prescribed - ensure that weights hang freely - check all ropes for fraying and all knots for tightness, be sure that the ropes are approximately tracking in the grooves of the pulley wheels - monitor neurovascular status of the involved extremity - protect the skin from breakdown - monitor for signs and symptoms of complications of immobilization, such as constipation, skin breakdown, lung congestion, renal complications, and disuse syndrome of unaffected extremities - provide therapeutic and diversional play 4. Casts: made of plaster or fiberglass to provide immobilization of bone and joints after a fracture or injury. fractures of the hip or knee may require a spica cast - interventions: - examine the cast for pressure areas - ensure that no rough casting materials remains in contact with the skin, petal the cast edges with waterproof adhesive tape as needed to ensure a smooth cast edge - if a hip spica cast is placed, the cast edges around the perineum and buttocks may need to be taped with waterproof tape - monitor the extremity for circulatory impairment, such as a pain greater than that expected for this type of injury, edema, rubor, pallor, numbness and tingling, coolness, decreased sensation or mobility, or diminished pulse - notify the PHCP if circulatory impairment occurs - prepare for bivalving or cutting the cast if circulatory impairment occurs, prepare for emergency fasciotomy if cast removal does not improve the neuro-circulatory compromise - instruct parents and the child not to stick objects down the cast - keep the cast clean and dry - perform isometric exercises to prevent muscle atrophy

Cirrhosis

- a chronic, progressive disease of the liver characterized by degeneration and destruction of hepatocytes - repeated destruction of hepatic cells causes the formation of scar tissue - cirrhosis has many causes, and is due to chronic damage and injury to liver cells, the most common are chronic hepatitis C, alcoholism, non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis complications: 1. portal hypertension: a persistent increase in the pressure of the portal vein that develops as a result of obstruction of flow. 2. ascites: accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries. capillary congestion leads to plasma leaking directly from the liver surface and portal vein. 3. bleeding esophageal varices: fragile, thin-walled, distended esophageal veins that become irritated and rupture. 4. coagulation defects: decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble vitamins, and without vitamin K and clotting factors, the client is prone to bleeding. 5. jaundice: occurs because the liver is unable to metabolize bilirubin and because the edema, fibrosis, and scarring of the hepatic ducts interfere with normal bile and bilirubin secretion. 6. portal systemic encephalopathy: is end-stage hepatic failure characterized by altered LOC, neurological symptoms, impaired thinking, and neuromuscular disturbances. they are caused by the failure of the liver to detoxify neurotoxic agents such as ammonia. 7. hepatorenal syndrome: is progressive renal failure associated with hepatic failure. is characterized by a sudden decrease in urinary output, elevated BUN and creatinine levels, decreased urine sodium excretion, and increased urine osmolarity. interventions: 1. elevate the HOB to minimize SOB 2. if ascites and edema are absent and the client does not exhibit signs of impending coma, a high-protein diet supplemented with vitamins is prescribed 3. provide supplemental vitamins B, A, C, K, folic acid, and thiamine as prescribed 4. restrict sodium and fluid intake as prescribed 5. initiate enteral feedings or parenteral nutrition as prescribed 6. administer diuretics to treat ascites as prescribed 7. monitor I&O and electrolyte balance 8. weight client and measure abdominal girth daily 9. monitor LOC and assess for pre-come state characterized by tremors and delirium 10. monitor for asterixis, which is a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. This motor disorder is characterized by an inability to maintain a position, which is demonstrated by jerking movements of the outstretched hands when bent upward at the wrist. 11. monitor for fetor hepaticus, which occurs when your breath has a strong, musty smell. It's a sign that your liver is having trouble doing its job of filtering out toxic substances, usually due to severe liver disease. As a result, sulfur substances end up in your bloodstream and can make their way to your lungs. 12. maintain gastric intubation to assess bleeding. Gastric intubation is the process of passing a NG tube through the nose or mouth into the stomach or small intestine for diagnostic or treatment purposes. 13. Maintain esophagogastric balloon tamponade to control bleeding varices if prescribed. Esophagogastric balloon tamponade is a procedure in which a balloon is inflated within the esophagus and stomach to apply pressure on bleeding blood vessels, compress the vessels, and stop the bleeding. 14. administer blood products as prescribed 15. monitor coagulation therapy results, and administer vitamin K if prescribed 16. administer antacids if prescribed 17. administer lactulose as prescribed; which decreases the pH of the bowel, decreases production of ammonia by bacteria in the bowel, and facilitates the excretion of ammonia. 18. administer antibiotics as prescribed to inhibit protein synthesis in bacteria and decrease the production of ammonia 19. avoid meds like opioids, sedatives, and barbiturates and any hepatotoxic meds or substances 20. instruct the client about the importance of not consuming alcohol 21. prepare the client for paracentesis to remove abdominal fluid 22. prepare the client for surgical shunting procedures if prescribed to divert fluid from ascites into the venous system

Pediatric musculoskeletal problems: Legg-Calve-Perthes Disease

- a condition affecting the hip where the femur and pelvis meet in the joint - blood supply is temporarily interrupted to the head of the femur and the bone dies and stops growing assessment: - limping - pain or stiffness in the hip, groin, thigh, or knee - limited ROM in the affected joint interventions: 1. physical therapy, stretching exercises 2. use of crutches to avoid bearing weight on the affected hip 3. bed rest and traction if pain is severe 4. casting to keep the femoral head in its socket 5. use of a nighttime brace 6. hip replacement surgery

Pediatric metabolic and endocrine problems: obesity

- a condition where excess body fat negatively impacts the health and well-being of a child - BMI is a screening tool used to measure obesity - BMI is a person's body weight in Kg divided by the square of a person's height in meters - overweight is being above the 85th percentile, obese is being over the 95th percentile effects of obesity: 1. can lead to physical, social, and emotional health problems later in life 2. asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors leading to heart disease such as hyperlipidemia can occur 3. a child who is obese is more likely to be obese as an adult

Pediatric renal and genitourinary problems: bladder exstrophy

- a congenital anomaly characterized by extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall - the cause is unknown - the condition can include defects of the abdominal wall, bladder, genitals, pelvic bones, rectum, and anus - children with this will have vesicoureteral reflux, in which the urine back flows through the ureters through the kidneys - treated with surgical procedures that repair the affected organs, muscles, and bones - initial surgery for closure of the abdominal defect should occur within the first few days of life - the goal of subsequent surgeries is to reconstruct the bladder and genitalia and enable the child to achieve urinary continence assessment: - exposed bladder mucous and epispadius in males - defects of the abdominal wall - vesicoureteral reflux - defects of the rectum and anus interventions: - monitor urinary output - monitor for signs of UTI or wound infection - maintain the integrity of the exposed bladder mucosa - prevent the bladder tissue from drying while allowing the drainage of urine until surgical closure is performed. - monitor lab values and urinalysis to assess renal function - administer antibiotics as prescribed - provide emotional support to the parents, and encourage verbalization of their fears and concerns

Vacuum extraction

- a cup-like suction device is applied to the fetal head to facilitate extraction - suction is used to assist in delivery of the fetal head - traction is applied during uterine contractions until descent of the fetal head is achieved - the suction device should not be kept in place any longer than 25 minutes - monitor FHR frequently, fetal monitoring should be used - assess infant at birth and throughout the postpartum period for signs of cerebral trauma - monitor for developing cephalhematoma - caput succedaneum (swollen head) is normal and should resolve in 24 hours

Aplastic anemia

- a deficiency of circulating RBCs and all other blood elements, due to the arrested development of the cells in the bone marrow. it can be primary or secondary. - several causes are chronic exposure to myelotoxic agents, viruses, and infections, auto-immune disorders, and allergic states. - diagnosis is determined by a bone marrow aspiration - therapeutic management focuses on restoring function to the bone marrow and involves immunosuppressive therapy and bone marrow transplantation assessment: - pancytopenia (deficiency of RBCs and all other blood elements) - petechiae, purpura, bleeding, pallor, weakness, tachycardia, and fatigue interventions: 1. prepare the client for a bone marrow transplant if planned 2. administer immunosuppressive meds as prescribed 3. administer colony stimulating factors to enhance production of bone marrow as prescribed 4. corticosteroids and cyclosporine may be prescribed 5. administer blood transfusions if prescribed and monitor for transfusion reactions

Chronic obstructive pulmonary disease (COPD)

- a disease state characterized by an airflow obstruction - chronic bronchitis and emphysema are progressive lung diseases that fall under the general category of COPD - chronic bronchitis is a condition in which the bronchial tubes become inflamed and excessive mucus production occurs as a result of irritants or injury - emphysema is a condition in which the air sacs in the lungs are damaged and enlarged resulting in hyperinflation and breathlessness - progressive airflow limitation occurs, associated with an abnormal inflammatory response of the lungs that are not completely reversible - COPD leads to pulmonary insufficiency, pulmonary HTN, and cor pulmonale. assessment: - cough - exertional dyspnea - wheezing and crackles - sputum production - weight loss - barrel chest - use of accessory muscles for breathing - prolonged expiration - orthopnea - cardiac dysrhythmias - congestion and hyperinflation seen on chest x-ray - ABG levels that indicate respiratory acidosis and hypoxemia - pulmonary function tests that demonstrate decreased vital capacity interventions: 1. monitor vitals 2. administer a concentration of O2 based on ABG values and O2 saturation by pulse oximeter as prescribed 3. monitor pulse ox 4. provide respiratory treatments and CPT 5. instruct the client in diaphragmatic or abdominal breathing techniques, which increase airway pressure and keep air passages open, promoting max CO2 expiration 6. record the color, amount, and consistency of sputum 7. suction the client's lungs if needed to clear the airway and prevent infection 8. monitor weight 9. encourage small, frequent meals to maintain nutrition and prevent dysphagia 10. provide a high-calorie, high-protein diet with supplements 11. encourage fluid intake up to 3000 mL/day to keep secretions thin, unless contraindicated 12. place the client in fowler's position and leaning forward to aid with breathing 13. allow activity as tolerated 14. administer bronchodilators as prescribed, and instruct the client in the use of oral and inhalant meds 15. administer corticosteroids as prescribed for exacerbations 16. administer mucolytics as prescribed to thin secretions 17. administer antibiotics for infection as prescribed client education: 1. adhere to activity limitations, alternating rest periods with activity 2. avoid eating gas-producing foods, spicy foods, and extremely hot or cold foods 3. avoid exposure to people with infections and avoid crowds 4. avoid extremes in temperatures 5. avoid fireplaces, pets, feather pillows, and other environmental allergens 6. avoid powerful odors 7. meet nutritional requirements 8. receive immunizations as recommended 9. recognize the signs and symptoms of respiratory infection and hypoxia 10. stop smoking 11. use meds and inhalers as prescribed 12. use O2 therapy as prescribed 13. use pursed-lip and diaphragmatic or abdominal breathing 14. when dusting, use a wet cloth

Pediatric metabolic and endocrine problems: fever

- a fever in an infant less than 1 month old is a medical emergency, the pediatric specialist should be contacted right away if this occurs - normal temp range for a child is 97.5 - 98.6, 100.4 is considered to be a fever - assessment findings include: flushed skin, warm to touch, diaphoresis, chills, and restlessness or lethargy. interventions: - monitor vitals - remove excess clothing and blankets, reduce the room temp, and increase the air circulation; also apply a cool compress to the forehead if appropriate - administer a sponge bath with tepid water for 20-30 minutes and gently squeeze water from a facecloth over the back and chest. recheck the temp 30 mins after the bath. - administer antipyretics such as ibuprofen as prescribed - aspirin should not be administered unless specifically prescribed because of the risk of Reye's syndrome - recheck the temp 30-60 mins after the antipyretic is administered - provide adequate fluids - monitor for signs and symptoms of dehydration and electrolyte imbalances and monitor lab values - instruct parents how to check the temps, how to medicate the child safely, and when to call the PHCP

Acute Respiratory Distress Syndrome (ARDS)

- a form of acute respiratory failure that occurs as a complication caused by a diffuse lung injury or critical illness and leads to extravascular lung fluid - the major site of injury is the alveolar capillary membrane - the interstitial edema causes compression and obliteration of the terminal airways and leads to reduced lung volume and compliance - the ABG levels show respiratory acidosis and hypoxemia that do not respond to an increased % of O2 - the chest x-ray shows bilateral interstitial and alveolar infiltrates; interstitial edema may not be noted until there is a 30% increase in fluid content - causes include sepsis, fluid overload, shock, trauma, neurological injuries, burns, DIC, drug ingestion, aspiration, and inhalation of toxins assessment: - tachypnea - dyspnea - decreased breath sounds - deteriorating ABG levels - hypoxemia despite high concentrations of delivered O2 - decreased pulmonary compliance - pulmonary infiltrates interventions: 1. identify and treat the cause of acute respiratory distress syndrome 2. administer O2 as prescribed 3. place the client in fowler's position 4. restrict fluid intake as prescribed 5. provide respiratory treatments as prescribed 6. administer diuretics, anticoagulants, or corticosteroids as prescribed 7. prepare the client for intubation and mechanical ventilation using PEEP

Pediatric cardiovascular problems: hyperlipidemia

- a high level of lipids can predispose a child to heart disease - any child with hyperlipidemia is likely to have it later in life, and it pre-disposes them to cardiac events - if they have abnormal lab values they should be referred to a cardiologist - treatment focuses on lifestyle modification and behavior changes lab values for lipids for kids age 2-19: - total cholesterol should be less than 170, 170-199 is borderline high, and 200+ is high. - LDL cholesterol should be less than 110, 110-129 is borderline, and 130+ is high - HDL cholesterol should be >45, 40-45 is borderline low, and <40 is low - triglycerides should be less than 100 for kids aged 9 and younger, and less than 130 for kids aged 10+

Folate deficiency anemia

- a macrolytic anemia where RBCs are larger than normal and are oval shaped due to lack of intake of folate. folate acid is needed for dna synthesis, and for RBC formation and maturation. - common causes are dietary insufficiency, malabsorption syndromes like celiac disease, chron's disease, or small bowel resection, meds like anti-seizure meds that decrease the absorption of folate, a condition like pregnancy that increases the need for folate, chronic alcoholism, or chronic hemodialysis. assessment: - dyspepsia - smooth, beefy red tongue - pallor, fatigue, and weakness - tinnitus - tachycardia interventions: 1. encourage the client to eat foods rich in folic acid like green leafy veggies, meat, liver, fish, legumes, peanuts, OJ, and avocado 2. administer folic acid as prescribed

Multiple myeloma

- a malignant proliferation of plasma cells within the bone - excessive numbers of abnormal plasma cells invade the bone marrow and destroy bone, invasion of lymph nodes, spleen, and liver also occurs - the abnormal plasma cells make an abnormal antibody found in the blood or urine - multiple myeloma causes decreased production of immunoglobulin and antibodies and increased levels of uric acid and calcium which can lead to kidney failure - the disease typically develops slowly and the cause is unknown assessment: - bone pain in the ribs, spine, and pelvis - weakness and fatigue - recurrent infections - anemia - urinalysis shows Bence jones proteinuria and elevated serum protein level - osteoporosis (bone loss and development of fractures) - thrombocytopenia and leukopenia - elevated calcium and uric acid levels - kidney failure - spinal cord compression and paraplegia - bone marrow aspiration shows an abnormal # of immature plasma cells interventions: 1. administer chemo as prescribed 2. provide supportive care to control symptoms and prevent complications, especially bone fractures, hypercalcemia, kidney failure, and infections 3. maintain neutropenic and bleeding precautions as needed 4. monitor for signs of bleeding, infection, and skeletal fractures 5. encourage 2 L of fluids a day to offset potential problems associated with hypercalcemia, hyperuricemia, and proteinuria, and encourage additional fluids as indicated and tolerated 6. monitor for signs of kidney failure; collect 24-hour urine as prescribed 7. encourage ambulation to prevent renal problems and to slow down bone resorption 8. administer IV fluids and diuretics as prescribed to increase renal excretion of calcium 9. administer blood transfusions for anemia 10. administer analgesics for pain 11. administer antibiotics for infection 12. prepare the client for local radiation therapy 13. instruct the client in home care measures and the signs and symptoms of infection 14. administer bisphosphonate meds as prescribed to slow bone damage and reduce pain and risk of fractures

Steven's-Johnson-Syndrome

- a med-induced skin reaction that occurs through an immunological response, common causative meds are antibiotics, anti-seizure meds, and NSAIDs - similar to toxic epidural necrolysis, another med-induced skin reaction that results in diffuse erythema and large blister formation on the skin and mucous membranes - may be mild or severe, and may cause vesicles, erosions, and crusts on the skin. if severe, a systemic reaction occurs that involves the respiratory system, renal system, and eyes, resulting in blindness, and it can be fatal. initial clinical manifestations are flu-like symptoms and erythema of the skin and mucous membranes. serious systemic complications and symptoms occur when the ulcerations involve the larynx, bronchi, and esophagus - most commonly occurs in clients with impaired immune systems - treatment includes immediate discontinuation of the medication causing the syndrome, antibiotics, corticosteroids, and supportive therapy may be necessary.

Fludrocortisone acetate

- a mineralocorticoid which enhance the reabsorption of sodium and chloride and promote the excretion of K+ and hydrogen from the renal tubules, helping maintain fluid and electrolyte balance - used for replacement therapy in adrenal insufficiency and Addison's disease side effects: - sodium and water retention, edema, HTN - hypokalemia - hypocalcemia - osteoporosis, compression fractures - weight gain - HF interventions: 1. monitor vitals 2. monitor I&O, weight, and for edema 3. monitor electrolyte and calcium levels 4. instruct the client to take med with food or milk 5. instruct the client to eat a high-K+ diet 6. instruct the client to report signs of illness; to notify the PHCP if low bp, weakness, cramping, palpitations, or changes in mental status occur; and to wear a medi-alert bracelet * instruct client not to stop taking the med abruptly, because this can cause adrenal insufficiency)

Hypertension

- a normal BP is a systolic under 120 and a diastolic under 80. - stage 1 HTN is a systolic in the 130s and a diastolic in the 80s - stage 2 HTN is a systolic in the 140s and a diastolic at least 90 - the higher measure, either systolic or diastolic will determine the classification. - HTN is a major risk factor for coronary, cerebral, renal, and peripheral vascular disease - the disease is initially asymptomatic - the goals of treatment include reduction of the BP and preventing or lessening the extent of organ damage - non-pharmacological interventions like lifestyle changes are prescribed initially, if the client cannot control their BP then in 1-3 months the client may be prescribed pharmacological intervention. - risk factors = aging, family history, African American race, obesity, smoking, stress, excessive alcohol, hyperlipidemia, and increased intake of salt or caffeine - secondary HTN: occurs as a result of other disorders, treatment depends on the cause and the organs involved, precipitating factors or conditions are cardiovascular disorders, renal disorders, endocrine system disorders, pregnancy, or certain meds. assessment: - may be asymptomatic - headache - visual disturbances - dizziness - chest pain - tinnitus - flushed face - epistaxis (nosebleeds) interventions: 1. the goals are to reduce BP and prevent or lessen the extent of organ damage. 2. question the client regarding the signs and symptoms of HTN 3. obtain the BP at least 2 times on both arms when the client is supine and standing 4. compare the BP with prior documentations 5. determine family history of HTN 6. identify current meds 7. obtain weight 8. evaluate dietary patterns and sodium intake 9. assess for visual changes or retinal damage 10. assess for cardiovascular changes such as distended neck veins, increased HR, and dysrhythmias 11. evaluate X-ray for heart enlargement 12. assess the neurological system 13. evaluate renal function 14. evaluate results of diagnostic and lab studies non-pharmacological interventions: 1. weight reduction or maintenance of ideal weight 2. dietary sodium restriction to 2g daily as prescribed 3. moderate intake of alcohol and caffeine-containing products 4. initiation of a regular exercise program 5. avoidance of smoking 6. relaxation techniques and biofeedback therapy 7. elimination of unnecessary meds that may contribute to the HTN pharmacological interventions: 1. medication therapy is individualized for each client, and the selection of the medications is based on factors age, presence of co-existing conditions, severity of the HTN, and the client's preferences client education for HTN: 1. describe the importance of adherence with the treatment plan 2. describe the disease process, explaining that symptoms usually do not develop until organs have suffered damage 3. initiate and assist the client in a regular exercise plan, avoiding heavy weight-lifting and isometric exercises 4. emphasize the importance of beginning the exercise program gradually 5. encourage the client to express feelings about daily stress 6. assist the client in finding ways to reduce stress 7. teach relaxation techniques 8. instruct the client in how to incorporate relaxation techniques into their daily living 9. instruct the client and family in ways to reduce BP 10. instruct the client to maintain a diary of BP readings 11. emphasize the importance of lifelong medications 12. instruct the client and family about dietary restrictions, which may include sodium, fat, calories, and cholesterol 13. instruct the client in how to shop for and prepare low-sodium meals 14. provide a list of products that contain sodium 15. instruct the client to read labels of products to determine sodium content, focusing on substances listed as sodium, NaCl, or MSG 16. instruct the client to bake, roast, or boil foods, and to avoid using salt to prepare foods and season foods 17. instruct the client that fresh foods are the best to consume, and to avoid canned foods 18. instruct the client that if uncomfortable side effects occur, to contact the PHCP or cardiologist and not to stop the medication 19. instruct the client to avoid OTC medications 20. stress the importance of follow-up care

Peptic ulcer disease

- a peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus in portions accessible to gastric secretions; erosion may extend through the muscle - the ulcer may be referred to as a gastric, duodenal, or esophageal depending on its location - the most common are gastric and duodenal ulcers gastric ulcers: - involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach - predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs, alcohol, history of gastritis, family history of gastric ulcers, or an infection with H. pylori - complications include hemorrhage, perforation, and pyloric obstruction assessment: - gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30-60 minutes after a meal, and food ingestion accentuates the pain. - hematemesis (vomiting blood) is more common than melena (feces with blood) interventions: 1. monitor vitals and for signs of bleeding 2. administer small, frequent bland feedings during the active phase 3. administer H2 receptor antagonists or proton pump inhibitors as prescribed to decrease the secretion of gastric acid 4. administer antacids as prescribed to neutralize gastric secretions 5. administer anticholinergics as prescribed to reduce gastric motility 6. administer mucosal barrier protectants as prescribed 1 hour before each meal 7. administer prostaglandins as prescribed for their protective and anti-secretory actions client education: - avoid consuming alcohol and substances that contain caffeine or chocolate - avoid smoking - avoid aspirin or NSAIDs - obtain adequate rest and reduce stress interventions during active bleeding: 1. monitor vitals closely 2. assess for dehydration, hypovolemic shock, sepsis, and respiratory insufficiency 3. maintain NPO status and administer IV fluid replacement as prescribed; monitor I&O 4. monitor Hgb and Hct 5. administer blood transfusions as prescribed 6. prepare to assist with administering meds as prescribed to induce vasoconstriction and reduce bleeding surgical interventions: 1. total gastrectomy: removal of the stomach with attachment of the esophagus to the jejunum or duodenum 2. vagotomy: surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach 3. gastric resection: removal of the lower half of the stomach and usually includes a vagotomy 4. gastroduodenostomy: partial gastrectomy, with the remaining segment anastomosed to the duodenum 5. gastrojejunostomy: partial gastrectomy, with the remaining segment anastomosed to the jejunum 6. pyloroplasty: enlargement of the pylorus to prevent or decrease pyloric obstruction, enhancing gastric emptying post-op interventions: 1. monitor vitals 2. place in a fowler's position for comfort and to promote drainage 3. administer fluids and electrolyte replacement as prescribed, monitor I&O 4. assess bowel sounds 5. monitor NG suction as prescribed 6. maintain NPO status as prescribed for 1 to 3 days until peristalsis returns 7. progress the diet from NPO to sips of clear water to 6 small bland meals a day, as prescribed when bowel sounds return 8. monitor for post-op complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency ** following gastric surgery, do not irrigate or remove the NG tube unless specifically prescribed because of the risk for disruption of the gastric sutures. Monitor closely to ensure proper functioning of the NG tube to prevent strain on the anastomosis site. contact the surgeon if the tube is not functioning properly ** Duodenal ulcers: - is a break in the mucosa of the duodenum - risk factors are infection with H.pylori, alcohol intake, smoking, stress, caffeine, and the use of aspirin, corticosteroids, and NSAIDs - complications include bleeding, perforation, gastric outlet obstruction, and intractable disease assessment: - burning pain in mid-epigastric area 1.5-3 hours after a meal and during the night (often wakes up the client) - melena is more common than hematemesis - pain is often relieved by the ingestion of food interventions: 1. monitor vitals 2. instruct the client on a bland diet with small, frequent meals 3. provide rest 4. encourage cessation of smoking 5. instruct the client to avoid alcohol intake, caffeine, and the use of aspirin, corticosteroids, NSAIDs 6. administer meds to treat H. pylori and antacids to neutralize acid secretions as prescribed 7. administer H2 receptor antagonists or proton pump inhibitors as prescribed to block the secretion of acid surgical interventions: - surgery is only performed if the ulcer is unresponsive to meds or if hemorrhage, obstruction, or perforation occurs Dumping syndrome: - is the rapid emptying of the gastric contents into the small intestine that occurs after a gastric resection assessment: - symptoms occur 30 mins after eating - nausea, vomiting - feelings of abdominal fullness and cramping - diarrhea - palpitations and tachycardia - perspiration - weakness and dizziness - borborygmi (loud gurgling sounds resulting from bowel hyper-motility) client education: - avoid sugar, salt, and milk - eat a high-protein, high-fat, and low-carb diet - eat small meals and avoid consuming fluids with meals - lie down after meals - take anti-spasmodic meds as prescribed to delay gastric emptying

cardiac tamponade

- a pericardial effusion occurs when the space between the parietal and visceral layers of the pericardium fills with fluid - pericardial effusion places the client at risk for cardiac tamponade, an accumulation of fluid in the pericardial cavity - tamponade restricts ventricular filling, and CO drops ** acute cardiac tamponade can occur when small volumes (20-50 mL) of fluid accumulate rapidly in the pericardium ** assessment: - pulse paradoxus - increased CVP - jugular venous distention with clear lungs - distant, muffled heart sounds - decreased CO - narrowing pulse pressure interventions: 1. the client needs to be placed in a critical care unit for hemodynamic monitoring 2. administer fluids IV as prescribed to manage decreased CO 3. prepare the client for X-ray or ECG 4. prepare the client for pericardiocentesis to withdraw pericardial fluid if prescribed 5. monitor for recurrence of tamponade following pericardiocentesis 6. if the client experiences recurrent tamponade or recurrent effusions or develops adhesions from chronic pericarditis, a portion or all of the pericardium may be removed to allow adequate ventricular filling and contraction

catholic and orthodox beliefs related to end-of life care

- a priest anoints the sick - other sacraments before death include reconciliation and Holy communication

mormon beliefs related to end-of life care

- a sacrament may be given if the client requests it

Buddhism beliefs related to end-of life care

- a shrine to Buddha may be placed in the client's room - time for meditation at the shrine is important and should be respected - clients may refuse medications that may alter their awareness - after death, a monk may recite prayers for 1 hour - consider organ donation and consider it an act of mercy

Pediatric musculoskeletal problems: Idiopathic scoliosis

- a spinal deformity that usually involves a lateral curvature, spinal rotation involving in rib asymmetry, and hypokyphosis of the thorax - it is usually diagnosed during the preadolescent growth spurt and screenings are important when growth spurts occur - surgical (spinal fusion) and nonsurgical (bracing) interventions are used, the type of treatment depends on the degree of the curvatures, the age of the child, the amount of growth that is yet anticipated, and any underlying disease processes - long-term monitoring is essential to detect any progression of the curve assessment: - asymmetry of the ribs and flanks is noted when the child bends forwards at the waist and hangs the arms down to their feet (Adam's test) - hip height, rib positioning, and shoulder height are asymmetrical, leg length discrepancy is also apparent - radiographs are obtained to confirm the diagnosis interventions: 1. monitor the progression of the curvatures 2. prepare the child and parent for the use of a brace if prescribed 3. prepare the child and parents for surgery (spinal fusion, placement of internal instrumentation systems) if prescribed post-op interventions: 1. maintain proper alignment, avoiding twisting movements 2. logroll the child when turning to maintain alignment 3. assess extremities for adequate neurovascular status 4. encourage coughing, deep breathing, and use of incentive spirometry 5. assess pain and administer prescribed analgesics 6. monitor for incontinence 7. monitor for signs and symptoms of infection 8. monitor for superior mesenteric artery syndrome (caused by mechanical changes in the position of the child's abdominal contents during surgery) and notify the PHCP if it occurs; symptoms include emesis and abdominal distention similar to what occurs with intestinal obstruction or paralytic ileus 9. instruct in activity restrictions 10. instruct the child how to roll from a side lying position to a sitting position, and assist with ambulation 11. address a potential body image disturbance when formulating a plan of nursing care

pleural friction rub

- a superficial, low-pitched, coarse rubbing or crating sound. sounds like 2 surfaces rubbing together. heard throughout inspiration and expiration. loudest over the anterolateral surface. not cleared by cough. - heard in people with inflammation of the pleural surfaces

Lymphoma: Hodgkin's disease

- abnormal proliferation of lymphocytes - Hodgkin's disease is a malignancy of the lymph nodes that originate in a single lymph node or in a chain of lymph nodes - metastasis occurs to other lymph structures and eventually to non-lymph structures - the disease usually involves lymph nodes, tonsils, spleen, and bone marrow and is characterized by the presence of Reed-Sternberg cells in the nodes - possible causes are viral infections, clients treated with combination chemo for Hodgkin's disease have a greater risk of developing acute leukemia and non-Hodgkin's lymphoma, among other secondary malignancies. - prognosis depends on the stage of the disease assessment: - fever - malaise, fatigue, weakness - night sweats - loss of appetite and significant weight loss - anemia and thrombocytopenia - enlarged lymph nodes, spleen, and liver - positive biopsy of lymph nodes with cervical nodes often affected first - presence of Reed-sternberg cells in the nodes - positive CT scan of the liver and spleen interventions: 1. for early stages (1 and 2), without mediastinal node involvement, the treatment of choice is extensive external radiation of the involved lymph node regions 2. with stages 3 and 4, radiation and multi-agent chemo are used 3. monitor for side affects related to chemo and radiation 4. monitor for signs of infection and bleeding 5. maintain infection and bleeding precautions 6. discuss the possibility of sterility with the client receiving chemo or radiation, and inform the client of fertility options such as sperm banking

pneumothorax

- accumulation of atmospheric air in the pleural space which results in a rise of intrathoracic pressure and reduced vital capacity, or the greatest amount of air expelled from the lungs after taking a deep breath - the loss of negative intrapleural pressure results in collapse of the lung - a spontaneous pneumothorax occurs with the rupture of pulmonary bleb, or small air-containing spaces deep in the lungs - an open pneumothorax occurs when an opening through the chest wall allows the entrance of positive atmospheric air pressure into the pleural space - a tension pneumothorax occurs from a blunt chest injury or from mechanical ventilation with PEEP when a buildup of positive pressure occurs in the pleural space assessment: - absent or decreased breath sounds on affected side - cyanosis - decreased chest expansion unilaterally - dyspnea - hypotension - sharp chest pain - subcutaneous emphysema evidenced by crepitus on palpation - sucking sound with open chest wound - tachycardia - tachypnea - tracheal deviation to the unaffected side with tension pneumothorax interventions: 1. diagnosis of pneumothorax is made by chest x-ray 2. apply a non-porous dressing over an open chest wound 3. administer O2 as prescribed 4. place the client in Fowler's position 5. prepare for chest tube placement, which will remain in place until the lung has expanded fully 6. monitor the chest tube drainage system 7. monitor for subcutaneous emphysema ** clients with a respiratory disorder should be positioned with the HOB elevated **

necrotizing enterocolitis (NEC) in the newborn

- acute inflammatory disease of the GI tract, usually occurs 4-10 days after birth and is frequently seen in preterm newborns assessment: - increased abdominal girth, decreased or absent bowel sounds, bowel loop distention, vomiting, bile-stained emesis, abdominal tenderness, and occult blood in stool prevention: - withhold feedings for 24-48 hours for infants believed to have suffered birth asphyxia. breast milk is the preferred nutrient after this time period - the use of probiotics with enteral feedings and breast milk has shown evidence of prevention - administration of corticosteroids to the mother prior to birth promote early gut closure and maturation of gut mucosa interventions: - hold oral feedings - insert oral gastric tube to decompress the abdomen - administer IV antibiotics and IV fluids to correct any imbalances - surgery if indicated

Myocarditis

- acute or chronic inflammation of the myocardium as a result of pericarditis, systemic infection, or allergic response assessment: - fever - dyspnea - tachycardia - chest pain - pericardial friction rub - gallop rhythm - murmur that sounds like fluid passing an obstruction - pulsus alternans (beat-to-beat variability of the arterial pressure waveform on the ECG) - signs of HF interventions: 1. assist the client to a position of comfort, such as sitting up and leaning forward 2. administer O2 as prescribed 3. administer analgesics, salicylates, and NSAIDs as prescribed to reduce fever and pain 4. administer digoxin as prescribed 5. administer antidysrhythmics as prescribed 6. administer antibiotics as prescribed to treat the causative organism 7. monitor for complications, which can include thrombus, HF, and cardiomyopathy

Pediatric immune problems and infectious diseases: Pertussis (whooping cough)

- agent: Bordetella pertussis - incubation period: 5-21 days - communicable period: greatest during the catarrhal stage (when respiratory secretions are discharged) - source: discharge from the respiratory tract of the infected person - transmission: direct contact or droplet spread from infected person, indirect contact with freshly contaminated articles assessment: - symptoms of respiratory infection followed by increased severity of cough, with a loud whooping inspiration - many experience cyanosis, respiratory distress, and tongue protrusion - listlessness, irritability, and anorexia interventions: - isolate the child during the catarrhal stage, if the child is hospitalized, institute airborne, droplet, and contact precautions - administer antimicrobial therapy as prescribed - reduce environmental factors that cause coughing spasms - ensure adequate hydration and nutrition - provide suction and humidified O2 if needed - monitor cardiopulmonary status and pulse ox - infants do not receive maternal immunity to pertussis, the tetanus-diptheria-acellular-pertussis (Tdap) vaccine should be administered to women in the postpartum period and those in close contact with the infant to prevent the spread of pertussis to infants

Pediatric immune problems and infectious diseases: Rocky mountain spotted fever

- agent: Rickettsia Rickettsii - incubation: 2-14 days - source: tick from a mammal, usually from dogs and wild rodents - transmission: bite of infected tick assessment: - fever, malaise, anorexia, vomiting, headache, myalgia - maculopapular or petechial rash primarily on the extremities (ankles and wrists) but may spread to other areas, usually to the palms and soles. interventions: - provide vigorous supportive care - administer antibiotics as prescribed - teach the child and parent about protection from tick bites

Pediatric immune problems and infectious diseases: Rubella (German Measles)

- agent: Rubella virus - incubation period: 14-21 days - communicable period: from 7 days before to 5 days after the rash appears - source: nasopharyngeal secretions, also in blood, stool, and urine - transmission: airborne or direct contact with infectious droplets, transmitted indirectly by articles freshly contaminated with nasopharyngeal secretions, feces, or urine, and transplacental. - assessment: low-grade fever, malaise, pinkish-red maculopapular rash that begins on the face and spreads to the entire body within 1-3 days. Petechiae (red, pinpoint spots) may occur on the soft palate. - interventions: use airborne, droplet, and contact precautions if the child is hospitalized, provide supportive treatment. isolate the infected child from pregnant women.

Pediatric immune problems and infectious diseases: Chickenpox (varicella)

- agent: Varicella-zoster (VCZ) virus - incubation period: 13-17 days - communicable period: from 1-2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed - source: respiratory tract secretions of infected person, skin lesions - transmission: direct contact, airborne, droplet, and contaminated objects - assessment: slight fever, malaise, and anorexia are followed by a macular rash that first appears on the trunk and scalp and moves to the face and extremities. lesions become pustules, begin to dry, and develop a crust. lesions may appear on the mucous membranes of the mouth, genital area, and rectal area - interventions: - ensure strict isolation in then hospital - at home, isolate the child until the vesicles have dried - an anti-viral agent may have been used to treat varicella infections in susceptible immunocompromised people to decrease the # of lesions, shorten the duration of the fever, and decrease the itching, lethargy, and anorexia. - the use of the VCZ immune globulin in IV immune globulin is recommended for kids who are immunocompromised, who have no previous history of varicella, and who are likely to contract the disease and have complications as a result. - provide supportive care

Pediatric immune problems and infectious diseases: Diptheria

- agent: corynebacterium diptheriae - incubation period: 2-5 days - communicable period: variable, until virulent bacilli are no longer present (usually 2-4 weeks) - source: discharge from the mucous membrane of the nose and nasopharynx, skin, and other lesions of the infected person - transmission: direct contact with infected person, carrier, or contaminated articles assessment: - low-grade fever, malaise, sore throat - foul-smelling, mucopurulent nasal drainage - dense pseudomembrane formation in the throat that may interfere with eating, drinking, and breathing - lymphadenitis, neck edema, "bull neck" interventions: - ensure strict isolation for the hospitalized child - administer diptheria anti-toxin as prescribed - provide bed rest - administer antibiotics as prescribed - provide suction and humidified O2 as needed - provide tracheostomy care if a trache is necessary

Pediatric immune problems and infectious diseases: Poliomyelitis

- agent: enteroviruses - incubation period: 7-14 days - communicable period: unknown, the virus is present in the throat and feces shortly after the infection and persists for about 1 week in the throat and for 4-6 weeks in the feces - source: oropharyngeal secretions and feces of the infected person - transmission: direct contact with the infected person, fecal-oral and oropharyngeal routes assessment: - fever, malaise, anorexia, nausea, headache, and sore throat - abdominal pain followed by soreness and stiffness of the trunk, neck, and limbs that may progress to CNS paralysis interventions: - enteric and contact precautions - supportive treatment - bed rest - monitoring for respiratory paralysis - physical therapy

Pediatric immune problems and infectious diseases: Infectious Mononucleosis

- agent: epstein-barr virus - incubation period: 4-6 weeks - communicable period: unknown - source: oral secretions - transmission: direct intimate contact assessment: - fever, malaise, headache, fatigue, nausea, abdominal pain, sore throat, enlarged red tonsils - lymohadenopathy and hepatosplenomegaly - discrete macular rash most prominent over the trunk may occur interventions: - provide supportive care - monitor for signs of splenic rupture (abdominal pain, LUQ pain, and left shoulder pain)

Pediatric immune problems and infectious diseases: Scarlet Fever

- agent: group A B-hemolytic streptococci - incubation period: 1-7 days - communicable period: about 10 days during the incubation period and clinical illness, during the first 2 weeks of the carrier stage, although may persist for months - source: nasopharyngeal secretions of the infected persons and carriers - transmission: direct contact with infected person or droplet spread, indirectly by contact with contaminated articles, ingestion of contaminated milk, or other foods assessment: - abrupt high fever, flushed cheeks, vomiting, headache, enlarged lymph nodes, malaise, abdominal pain - a red, fine sandpaper-like rash develops in the axilla, groin, and neck that spreads to cover the entire body except the face - red blanches with pressure, pink or red lines of petechiae are noted in areas of deep creases and folds of the joints - desquamation, sheet-like sloughing of the skin on palms and soles appears by weeks 1-3 - the tongue is initially coated with a white, furry covering with red projecting papillae, by the third to fifth day the white coat sloughs off, leaving a red swollen tongue - tonsils are reddened, edematous, and covered with exudate - pharynx is edematous and beefy red interventions: - institute contact and airborne precautions until 24 hours after initiation of antibiotics - provide supportive therapy - provide bed rest - encourage fluid intake

Pediatric immune problems and infectious diseases: Erythema Infectiosum (Fifth disease)

- agent: human parvovirus B19 - incubation period: 4-14 days, can be up to 20 - communicable period: uncertain but before the onset of symptoms in most kids - source: infected person - transmission: unknown, possibly respiratory secretions and blood assessment: - before rash: asymptomatic or mild fever, malaise, headache, or runny nose - stages of rash: 1. erythema of face (slapped0cheek appearance) develops and disappears by 1-4 days 2. about 1 day after the rash appears on the face, maculopapular red spots appear, symmetrically distributed on the extremities, the rash progresses from proximal to distal surfaces ad may last a week or more 3. the rash subsides but may reappear if the skin becomes irritated by the sun, heat, cold, exercise, or friction interventions: - child is not usually hospitalized - pregnant women should avoid infected person - provide supportive care - administer antipyretics, analgesics, and anti-inflammatory meds as prescribed

Pediatric immune problems and infectious diseases: Mumps

- agent: paramyxovirus - incubation period: 14-21 days - communicable period: immediately before and after parotid gland swelling begins - source: saliva of infected person and possibly urine - transmission: direct contact or droplet spread from an infected person - assessment: fever, headache and malaise, anorexia, jaw or ear pain aggravated by chewing, followed by parotid gland swelling. Orchitis or oophoritis may occur, deafness may occur, and aseptic meningitis may occur interventions: - institute airborne, droplet, and contact precautions - provide bed rest until parotid gland swelling subsides - avoid foods that require chewing - apply hot or cold compresses as prescribed to the neck - apply warmth and local support with snug-fitting underpants to relieve orchitis - monitor for aseptic meningitis

Pediatric immune problems and infectious diseases: Rubeola (Measles)

- agent: paramyxovirus - incubation: 10-20 days - communicable period: 4 days before to 5 days after rash appears, usually during the early stage of the disease - source: respiratory tract secretions, blood, or urine of an affected person - transmission: airborne particles or direct contact with infectious droplets, transplacental assessment: - fever - malaise - coryza, cough, conjunctivitis - rash appears as red, erythematous maculopapular eruption starting at the face and spreading down to the feet, blanches easily with pressure and gradually turns a brownish color - Koplik's spots: small red spots with a bluish white center and a red base, located at the buccal mucosa and lasts 3 days interventions: 1. use airborne, droplet, and contact precautions if the child is hospitalized 2. restrict the child to quiet activities and bed rest 3. use a cool mist vaporizer for cough and coryza 4. dim lights if photophobia is present 5. administer antipyretics for fever 6. administer vitamin A supplements as prescribed

Pediatric immune problems and infectious diseases: Community-associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA)

- agent: staphylococcus aureus - is resistant to methicillin, usually occurs in people who are healthy - people at risk include athletes, prisoners, day care centers, military personnel, those who use IV drugs, people living in crowded places, people with poor hygiene and who use contaminated items, people who get tattoos, and people with a compromised immune system - transmission: person contact, contaminated items, or through infection or a pre-existing cut or wound not protected by a dressing - the bacteria can enter the blood and cause sepsis, cellulitis, endocarditis, osteomyelitis, septic arthritis, toxic shock syndrome, pneumonia, organ failure, and death prevention: - frequent hand washing, strict aseptic technique - avoid sharing personal items - regular cleaning or shared equipment - cleaning a cut or wound thoroughly - ensure tattoo or body piercing facilities adhere to strict guidelines for preventing infection assessment: - appearance of skin infection; red swollen area, warmth around the skin, drainage, pain, and fever - symptoms of a more serious infection include chest pain, cough, fatigue, chills, fever, malaise, headache, muscle aches, SOB, and rash interventions: - assess skin lesions - prepare to drain the infected skin site and culture the wound and wound drainage - prepare to get blood cultures, sputum and urine cultures - prepare to give antibiotics - educate the child and family about the causes and modes of transmission, signs and symptoms, and importance of treatment measures prescribed

Bronchodilators

- albuterol - arformoterol - formoterol - levalbuterol - salmeterol - theophylline - aminophylline - relax the smooth muscle of the bronchi and dilate the airways making air exchange and respirations easier for the client. - are used to treat acute bronchospasm, asthma, bronchitis, restrictive airway diseases, and reactive airway diseases - contraindicated with people who have hypersensitivity, peptic ulcer disease, severe cardiac disease and dysrhythmias, hyperthyroidism, or uncontrolled seizure disorder. - used with caution in clients with HTN, DM, or narrow-angle glaucoma - Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and phenytoin, and should be a last-line med. - Theophylline and a B2-adrenergic agonist administered together can cause cardiac dysrhythmias - beta blockers, cimetidine, and erythromycin increase the effects of theophylline - adverse effects: palpitations and tachycardia, dysrhythmias, restlessness, nervousness, tremors, anorexia, nausea, vomiting, headaches, dizziness, hyperglycemia, mouth dryness and throat irritation with inhalers, and tolerance and paradoxical bronchoconstriction with inhalers interventions: 1. assess lung sounds 2. monitor for cardiac dysrhythmias 3. assess for cough, wheezing, decreased breath sounds, and sputum production 4. monitor for restlessness and confusion 5. provide adequate hydration 6. administer the med at regular intervals around the clock to maintain a sustained therapeutic level 7. administer oral meds with or after meals to decrease GI irritation 8. monitor for a therapeutic serum level of theophylline (10-20) 9. IV administered theophylline preparations should be administered slowly and always by an infusion pump client education: 1. not to rush enteric-coated or sustained release tablets or capsules 2. to avoid caffeine 3. about the side and adverse effects of bronchodilators 4. how to monitor the pulse and to report any abnormalities to the PCHP 5. how to use an inhaler, spacer, or nebulizer, and how to monitor the amount of medication remaining in an inhaler canister 6. the importance of smoking cessation and information regarding support resources 7. to monitor blood glucose levels if diabetes mellitus is a coexisting condition 8. to wear a Medi-alert bracelet especially if the client has asthma ** theophylline toxicity is likely to occur when the level is above 20, early signs of toxicity include restlessness, nervousness, tremors, palpitations, and tachycardia **

Hiatal hernia

- also called an esophageal or diaphragmatic hernia - a portion of the stomach herniates through the diaphragm and into the thorax - herniation results from weakening of the muscles of the diaphragm and is aggravated by factors that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting - complications include ulceration, hemorrhage, regurgitation, and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis, and mediastinitis assessment: - heartburn - regurgitation or vomiting - dysphagia - feeling of fullness interventions: 1. medical and surgical management are similar to those for gastroesophageal reflux disease 2. provide small frequent meals and limit the amount of fluids taken with meals 3. advise the client not to recline for 1 hour after eating 4. avoid anticholinergics which delay stomach emptying

Pediatric cardiovascular problems: Kawasaki disease

- also called muco-cutaneous lymph node syndrome, is an acute systemic inflammatory illness - cause is unknown but may be associated with infection - cardiac involvement is the most serious complication, aneurysms can develop assessment: - acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of cervical lymph nodes - subacute stage: cracking lips and fissures, desquamation of the skin and tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis - covalescent stage: child appears normal but signs of inflammation may be present interventions: 1. monitor temp frequently 2. assess heart sounds, rate, and rhythm 3. assess extremities for edema, redness, and desquamation 4. examine eyes for conjuctivitis 5. monitor mucus membranes for inflammation 6. monitor strict I&O 7. administer soft foods and liquids that are not too hot or cold 8. weigh child daily 9. provide passive ROM exercises to facilitate joint movement 10. administer acetylsalicylic acid as prescribed for its antipyretic and antiplatelet effects 11. administer immunoglobulin IV as prescribed to reduce the duration of the fever and the incidence of coronary artery lesions and aneurysms, IV immunoglobulin is a blood product as use blood precautions when administering 12. parent education

Pediatric eye, ear, and throat problems: Conjuctivitis

- also called pink eye, is an inflammation of the conjunctiva - is usually caused by an allergy, infection, or trauma - types are viral, bacterial, or allergic; bacterial or viral are very contagious assessment: - itching, burning, or scratchy eyelids - redness, edema, discharge interventions: - viral conjunctivitis: the infection will usually resolve in 7-14 days, in some cases may take 2-3 weeks. anti-viral meds may be prescribed to treat more serious forms - bacterial conjunctivitis: mild cases may improve without antibiotic treatment, an antibiotic may be prescribed to shorten the length of infection, reduce complications, or reduce the spread to others. - allergic conjunctivitis: remove the allergen from the environment, allergy meds and eyedrops like a topical histamine and vasoconstrictors may be prescribed - general interventions: - the PHCP needs to be contacted regarding attending school and contact with others - instruct the child and parent about the administration of the prescribed meds - instruct in infection control measures such as good hand washing and not sharing towels - instruct the child to avoid rubbing the eye to prevent injury - instruct a child wearing contacts to stop and obtain new lenses to eliminate the chance of reinfection - instruct an adolescent that eye makeup should be discarded and replaced

opioid antagonists

- alvimopan - methylnaltrexone - naloxone - naltrexone - reverses respiratory depression in clients with opioid overdose - avoid its use for non-opioid respiratory depression - recurrence of respiratory depression can occur if duration of opiate exceeds duration of opioid antagonist - this med may be prescribed for clients at risk of an opioid overdose - adverse effects: nausea, vomiting, tremors, sweating, increased BP, tachycardia interventions: 1. assess vitals, especially respirations 2. for IV administration, the dose is titrated every 2-5 minutes as prescribed 3. have O2 and resuscitative equipment available during administration

potassium-sparing (retaining) diuretics

- amiloride hydrochloride - eplerenone - spironolactone - triamterene - K+-sparing diuretics are antihypertensive meds that act on the distal tubule to promote sodium and water excretion and potassium retention - used for edema and HTN, to increase urine output, and to treat fluid retention and overload associated with HF, ascites resulting from cirrhosis or nephrotic syndrome, and diuretic-induced hypokalemia - contraindicated in severe kidney or hepatic disease and in severe hyperkalemia - should be used with cation in clients with DM, taking antihypertensives or lithium, or taking ACE inhibitors or K+ supplements, because hyperkalemia can result **the primary concern with administering K+-sparing diuretics is hyperkalemia** adverse effects: 1. hyperkalemia 2. nausea, vomiting, diarrhea 3. rash 4. dizziness, weakness 5. headache 6. dry mouth 7. photosensitivity 8. anemia 9. thrombocytopenia interventions: 1. monitor vitals 2. monitor urine output 3. monitor for signs and symptoms of hyperkalemia, such as nausea, diarrhea, abdominal cramps, tachycardia followed by bradycardia, tall peaked T waves on the ECG, and oliguria (production of abnormally small amounts of urine) 4. monitor for a K+ level greater than 5 which indicates hyperkalemia 5. instruct the client to avoid foods high in K+ 6. instruct the client to avoid exposure to direct sunlight 7. instruct the client to monitor for signs of hyperkalemia (do the same as the prefix, except for the HR and urine output) 8. instruct the client to avoid salt substitutes because they have K+ 9. instruct the client to take the med with or after meals to decrease GI irritation

antibiotics used as 2nd-line drugs for TB

- aminoglycoside antibiotics or fluoroquinolones are given with at least 1 other anti-TB med - bactericidal and interfere with protein synthesis in susceptible microorganisms - GI disturbances are the most common side effects - fluoroquinolones are not recommended for use in kids - contraindicated in clients with hypersensitivity, meuromuscular disorders, or 8th cranial nerve damage - used with caution in the older client, in neonates because of renal insufficiency and immaturity, and in young infants because it may cause CNS depression - the risk of toxicity increases if its taken with other aminoglycosides or with other nephrotoxicity or ototoxicity-producing meds - adverse effects: hypersensitivity, pain and irritation at the injection site, nephrotoxicity is indicated by increased BUN and serum creatinine levels, ototoxicity is indicated by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing - neurotoxicity is indicated by headache, dizziness, lethargy, tremors, and visual disturbances, and super-infections interventions: 1. assess for hypersensitivity 2. monitor for ototoxic, neurotoxic, and nephrotoxic reactions 3. monitor liver and renal test results 4. obtain baseline audiometric test and repeat every 1-2 months, because the med impairs the 8th cranial nerve, assess acuteness of hearing, monitor for visual changes, assess hydration status and maintain adequate hydration during therapy, monitor I&O, assess urianalysis, monitor for superinfection client education: notify the PHCP if hearing loss, changes in vision, or urinary problems occur

Calcium Channel Blockers (CCBs)

- amlodipine - clevidipine - diltiazem - cardizem - felodipine - isradipine - nicardipine - nifedipine - nimodipine - nisoldipine - verapamil - they all end in "dipine" except diltiazem, cardizem, and verapamil. Remember "Pam is dippin' at the zem" - CCBs decrease cardiac contractility (have a negative inotropic effect by relaxing smooth muscle) and decrease the workload of the heart, decreasing the need for O2. - promote vasodilation of the coronary and peripheral vessels - are used for angina, dysrhythmias, or HTN - should be used with caution in the client with HF, bradycardia, or AV block adverse effect: - bradycardia - hypotension - reflex tachycardia as a result of the hypotension - headache - dizziness, lightheadedness - fatigue - peripheral edema - constipation - flushing of the skin - changes in liver and kidney function interventions: 1. monitor vitals 2. monitor for signs of HF 3. monitor liver enzyme levels 4. monitor kidney function tests 5. instruct the client not to discontinue the med 6. instruct the client in how to check their pulse 7. instruct the client to notify the PHCP if dizziness or fainting occurs 8. instruct the client not to crush or chew sustained-release tablets

Basics of electrocardiography (ECG)

- an ECG reflects the electrical activity of cardiac cells and records electrical activity at a speed of 25 mm/second. - an ECG strip consists of horizontal lines representing seconds and vertical lines representing voltage. - each small square is 0.04 seconds - each large square is 0.20 seconds - the P wave represents atrial depolarization - the PR interval represents the time it taken an impulse to travel from the atria through the atrioventricular node, bundle of His, and bundle branches to the Purkinje fibers - normal PR interval duration is 0.12 to 0.20 seconds - the PR interval is measured from the beginning of the P wave to the end of the PR segment - the QRS complex represents ventricular depolarization and is usually 0.04 to 0.10 seconds - the ST segment represents early ventricular repolarization - the T wave represents ventricular repolarization and ventricular diastole - the U wave may follow the T wave and a prominent U wave may indicate an electrolyte abnormality, such as hypokalemia - the QT interval represents refractory time, or the time it takes for ventricular depolarization and repolarization - the QT interval is measured from the beginning of the QRS complex to the end of the T wave - the QT interval is normally 0.32 to 0.4 seconds but may vary

Thyroid storm

- an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism - it can be caused by manipulation of the thyroid gland during surgery and the release of thyroid hormone in the blood, or severe infection and stress - anti-thyroid meds, beta-blockers, glucocorticoids, and iodides may be administered to the client before thyroid surgery to prevent its occurrence assessment: - fever - tachycardia - systolic HTN - nausea, vomiting, diarrhea - agitation, tremors, anxiety - irritability, restlessness, confusion, seizures (as condition worsens) - delirium and coma interventions: 1. maintain a patent airway and adequate ventilation 2. administer anti-thyroid meds, iodides, propranolol, and glucocorticoids as prescribed 3. monitor vitals 4. monitor for cardiac dysrhythmias 5. administer nonsalicylate antipyretics as prescribed 6. use a cooling blanket to decrease temp as prescribed

Risk conditions related to pregnancy: ectopic pregnancy

- an ectopic pregnancy is the implantation of the fertilized ovum outside of the uterine cavity - assessment may show a missed period, abdominal pain, vaginal spotting or bleeding that is dark red or brown, and when it ruptures increased pain, referred shoulder pain, and signs of shock. - interventions include: obtain assessment data and vitals; monitor for bleeding and initiate measures to prevent rupture and shock; methotrexate, a folic acid antagonist, may be prescribed to inhibit cell division in the developing embryo; prepare the client for laparotomy and removal of the pregnancy and tube or repair of the tube; and administer antibiotics, and Rho immune globulin as prescribed for Rh negative women.

Pediatric neurological and cognitive problems: Hydrocephalus

- an imbalance of CSF absorption or production caused by malformation, tumors, hemorrhage, infections, or trauma - results in head enlargement and IICP assessment: - infants: increased head circumference; thin, widely spread bones of the head that make a cracked-pot sound on percussion; anterior fontanel tense, bulging, and non-pulsating, sutures will separate prior to fontanel bulging; dilated scalp veins; frontal bossing; and "sun setting" eyes - child: behavior changes like irritability and lethargy; headache upon awakening; nausea and vomiting; ataxia; nystagmus; late signs are high shrill cry and seizures surgical interventions: 1. the goal of surgical treatment is to prevent further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where is can be reabsorbed 2. shunt revision may be needed as the child grows pre-op interventions: 1. monitor I&O, give small frequent feedings as tolerated until made NPO 2. reposition the head often and use special devices like an egg crate mattress under the head to prevent pressure sores 3. prepare the child and family for diagnostic procedures and surgery post-op interventions: 1. monitor vitals and neurological status 2. position the child on the un-operated side to prevent pressure on the shunt valve 3. keep the child flat if prescribed to avoid rapid reduction of intracranial fluid 4. observe for IICP and if it occurs elevate the HOB to 15-30 degrees 5. measure head circumference 6. monitor for signs of infection and assess dressing for drainage 7. monitor I&O 8. provide comfort measures and give meds as prescribed 9. instruct parents on how to recognize shunt infection or malfunction 10. in an infant: irritability, loud cry, lethargy, and feeding difficulties may indicate shunt malfunction or infection 11. in a toddler: headache and a lack of appetite are the earliest signs of shunt malfunction 12. in older children: alteration of LOC is an indication of shunt malfunction

methyltestosterone and other testosterone preparations

- androgens used to replace deficit hormones or to treat hormone-sensitive disorders - can cause bleeding if the client is taking oral anticoagulants - can caused decreased serum glucose, reducing insulin requirements for the client with DM - hepatotoxic meds are avoided with the use of androgens because of the risk of additive damage to the liver - androgens ate usually avoided in men with known prostate or breast carcinoma, because they can stimulate the growth of these tumors side effects: - masculine secondary sexual characteristics - bladder irritation and UTIs - breast tenderness - gynecomastia (enlargement or swelling of breast tissue in males) - priapism (prolonged erection of the penis) - menstrual irregularities - virilism (development of male characteristics) - sodium and water retention with edema - nausea, vomiting, diarrhea - acne - changes in libido - hepatotoxicity, jaundice - hypercalcemia interventions: 1. monitor: vitals, edema, weight gain, and skin changes 2. assess mental status and neurological function 3. assess for signs of liver dysfunction (RUQ pain and abdominal pain, malaise, fever, jaundice, and pruritus) 4. assess for the development of secondary sex characteristics 5. instruct the client to take meds with a meal or a snack 6. instruct the client to notify the HCP if priapism or fluid retention occurs 7. instruct women to use a non-hormonal contraceptive while on therapy 8. for women, monitor menstrual irregularities and decreased breast size

methimazole, proplthiouracil, and potassium iodide and strong iodine solution

- antithyroid medications that inhibit the synthesis of thyroid hormone - are used for hyperthyroidism or Grave's disease - adverse effects: nausea and vomiting, diarrhea, drowsiness, headache, fever, hypersensitivity with rash, agranulocytosis with leukopenia and thrombocytopenia, alopecia and hyperpigmentation, toxic levels cause hypothyroidism, and iodism is characterized by vomiting, abdominal pain, metallic or brassy taste, rash, and sore gums and salivary glands

Pediatric GI Problems: cleft lip and cleft palate

- are congenital anomalies that result from failure of soft tissue or bony structure to fuse during embryonic development - the defects involve abnormal opening is the lip and palate that are apparent at birth - causes include hereditary and environmental factors, exposure to radiation or rubella virus, chromosome abnormalities, family history, maternal smoking, and teratogenic factors like meds taken during pregnancy. - prenatal supplementation of folic acid is important to decrease the risk - closure of the cleft lip occurs before closure of the cleft palate, usually is performed at 3-6 months - cleft palate repair is usually performed around 1 year of age - a child with a cleft palate is at risk for developing otitis media, which can result in hearing loss - assessment: - cleft lip cab range from a slight notch to a complete separation from the floor of the nose - cleft palate can include nasal distortion, midline or bilateral cleft, and variable extension from the uvula and soft and hard palate - interventions: - assess the ability to suck, swallow, and handle normal secretions and breathe without distress - assess fluid and calorie intake daily - monitor daily weight - modify feeding techniques, plan to use special feeding techniques, obturators, and special nipples and feeders - hold the infant in an upright position and direct the formula to the back and side of the mouth to prevent aspiration - feed small amounts gradually and burp frequently - keep suction equipment and a bulb syringe at the bedside - teach the parents special feeding / suctioning techniques - teach the parents the ESSR method of feeding: Enlarge the nipple, Stimulate the sucking reflex, Swallow, Rest to allow the infant to finish swallowing - encourage parents to express their feelings about the disorder - encourage parental bonding with the infant, including holding the infant and calling them by name - post-op interventions: - cleft lip repair: - provide lip protection, a metal appliance or adhesive strips may be taped securely to the cheeks to prevent trauma to the suture line - avoid positioning the infant on the side of their repair or in the prone position - keep the surgical site clean and dry - apply antibiotic ointment to the site as prescribed - elbow restraints should be used to keep the infant from injuring or traumatizing the surgical site - monitor for signs of infection at the site - cleft palate repair: - feedings are resumed - oral packing may be secured to the palate and is usually removed in 2-3 days - instruct the parents to avoid placing anything in the child's mouth that is harsh and could disrupt the site - soft elbow or jacket restraint may be used to keep the infant from touching the site - avoid oral suction - provide analgesics for pain as prescribed - instruct the parents in feeding techniques and how to care for the site - instruct parents to monitor for signs of infection at the site - encourage parents to hold the child - initiate appropriate referrals to dental or speech therapy

Apgar scoring system

- assess each of the five items to be scored and add the points to determine the newborn's total score. - The newborn's Apgar score is routinely assessed and recorded at 1 minute and 5 minutes after birth, and may be repeated if the score is low. - the 5 vital indicators of Apgar scoring: 1. heart rate: absent = 0 points < 100 bpm = 1 point > or = 100 bpm = 2 points 2. RR and effort: absent = 0 points slow, irregular breathing, or weak cry = 1 point good rate and effort, vigorous cry = 2 points 3. Muscle tone: flaccid / limp = 0 points minimal flexion of extremities = 1 point good flexion, active motion = 2 points 4. reflex irritability: no response = 0 points minimal response, grimace to suction or to gentle slap on soles = 1 point responds promptly with cry or active movement = 2 points 5. skin color: pallor or cyanosis = 0 points body skin color normal, extremities blue = 1 point body and extremity skin color normal = 2 points Apgar score interventions: - Score 8-10 = no intervention needed - Score 4-7 = stimulate; rub newborn's back, administer O2, and re-score at specific intervals - Score 0-3 = newborn requires full resuscitation, re-score at specific intervals

Measures to prevent falls

- assess the client's risk for falling, use the agency fall risk assessment scale - assign the client at risk for falling to a room near the nurse's station - alert all personnel to the client's risk for falling, use agency fall risk alert procedures and methods as necessary - assess the client frequently - orient the client to physical surroundings - instruct the client to seek assistance when getting up - explain the use of the nurse call system - use safety devices such as floor pads, and bed or chair alarms - keep the bed in the lowest position with side rails adjusted to a safe position - lock all beds, wheelchairs, and stretchers - keep client's personal items within their reach - eliminate clutter and obstacles in their client's room - provide adequate lighting - reduce bathroom hazards - maintain the client's toileting schedule throughout the day

Risk conditions related to pregnancy: cardiac disease

- assessment will show signs and symptoms of cardiac decompensation (cough and respiratory congestion, dyspnea and fatigue, palpations and tachycardia, peripheral edema, and chest pain), signs of respiratory infection, and signs of heart failure and pulmonary edema. - interventions: monitor vitals, FHR, and condition of the fetus; limit physical activities and stress the need for rest; monitor for signs of cardiac stress like cough, fatigue, dyspnea, chest pain, and tachycardia, also monitor for signs of heart failure and pulmonary edema; encourage adequate nutrition to prevent anemia which would worsen the cardiac status, also a low-sodium diet may be prescribed to prevent fluid retention and heart failure; avoid excessive weight gain; during labor, prepare to monitor vitals frequently and place the client on a cardiac monitor and on an external fetal monitor; maintain bed rest with the client lying on her side with the head and shoulders elevated; administer O2 as prescribed; manage pain early in labor, cardiology clearance may be needed for an epidural, spinal, or general anesthesia agent; and use controlled pushing efforts to decrease cardiac stress.

Fetal distress

- assessment: - fetal HR less than 10 or over 160 - meconium-stained amniotic fluid - fetal hypoactivity or hyperactivity - progressive decrease in baseline variability - severe variable decelerations - late decelerations - interventions: - discontinue oxytocin if infusing - place the client in a lateral position - administer 8-10 L/min of O2 by face mask - administer IV fluids - monitor maternal and fetal status ** in the event of fetal distress, prepare the client for emergency C-section delivery**

Intrauterine fetal demise

- assessment: - loss of fetal movement - absence of fetal heart tones - screen for DIC because it's a complication of intrauterine fetal demise - low Hg and Hct, low platelet count, prolonged bleeding and clotting time - bleeding from puncture sites could indicate DIC - interventions: - encourage the client and her family to verbalize feelings, provide emotional support - incorporate religious, spiritual, and cultural health care beliefs and practices into the plan of care - allow the client choices regarding labor and delivery - administer IV fluids, medications, and blood and blood products as prescribed if DIC occurs

Pediatric neurological and cognitive problems: Seizure disorders

- assessment: - obtain info from parents about the time of onset, precipitating events, and behavior before and after the seizure - determine the child's history of seizures - ask the child about the presence of an aura (warning sign of an impending seizure) - monitor for apnea and cyanosis - post-seizure the child may appear sleepy and disoriented seizure precautions: - raise side rails when child is sleeping or resting - pad side rails and other hard objects - place waterproof mattress on bed or crib - instruct child to wear medical identification - instruct child in precautions to take during potentially hazardous activities - instruct child to swim with a companion - instruct child to use protective helmet and padding when riding a bike, etc - alert all caregivers of special precautions interventions: 1. ensure airway patency 2. have suction equipment and O2 available 3. time the seizure episode 4. if the child is standing or sitting, ease the child down to the floor and place them in a side-lying position 5. place a pillow or folded blanket under the child's head 6. loosen restrictive clothing 7. remove eyeglasses if present 8. clear the area of hazards or hard objects 9. allow the seizure to proceed, do not interfere 10. if vomiting occurs turn the child to one side 11. do not restrain them, put anything in their mouth, or give liquids 12. prepare to give meds as prescribed 13. remain with the child until they fully recover 14. observe for incontinence 15. document the occurrence

Glucocorticoids

- betamethasone - cortisone acetate - dexamethasone - hydrocortisone - methylprednisolone - prednisolone - prednisone - triamcinolone - affect glucose, protein, and bone metabolism; alter the normal immune response and suppress inflammation; and produce anti-inflammatory, anti-allergic, and anti-stress effects. - they are used as a replacement in adrenal insufficiency, and are used for their anti-inflammatory and immunosuppressant effects in the treatment of several non-endocrine disorders. adverse effects: - adrenal insufficiency - hyperglycemia - hypokalemia - hypocalcemia, osteoporosis - sodium and fluid retention - weight gain and edema - mood swings - moon face, buffalo hump, truncal obesity - increased susceptibility to infection and masking the signs of infection - cataracts - hirsutism, acne, fragile skin, bruising - growth retardation in kids - GI irritation, peptic ulcer, pancreatitis - seizures - psychosis contraindications and cautions: - contraindicated with clients who have hypersensitivity, psychosis, or fungal infections - caution with clients with DM - extreme caution for clients with infections - increases potency of meds taken concurrently - use of K+-losing diuretics causes hypokalemia - dexamethasone decreases the effects of oral anticoagulants and antidiabetic meds - barbituates, phenytoin, and rifampin decrease effectiveness of prednisone interventions: 1. monitor: vitals, electrolyte and glucose levels, for hypokalemia and hyperglycemia, I&O, weight, for edema, HTN, and older adults for signs of increased osteoporosis. 2. assess medical history for glaucoma, cataracts, peptic ulcer, mental health disorders, or DM 3. assess for changes in muscle strength 4. prepare a schedule as needed for the client, with info on short-term tapered doses 5. instruct the client it is best to take meds in the morning with food or milk 6. the client should eat foods high in K+ 7. avoid people with infections 8. inform PHCPs of med regimen 9. report signs and symptoms of Cushing's syndrome (moon face, puffy eyelids, edema in the feet, increased bruising, dizziness, bleeding, and menstrual irregularities) 10. note the client may need additional doses during periods of stress 11. instruct the client not to stop the med abruptly, because it can cause severe adrenal insufficiency 12. consult with PHCP before getting vaccinations, because live virus vaccines should not be administered 13. wear a medi-alert bracelet

Stimulant laxatives

- bisacodyl - senna - stimulate motility of the large intestine

Intraventricular hemorrhage in the newborn

- bleeding within the ventricles of the brain - risk factors are prematurity, respiratory distress syndrome, trauma, and asphyxia assessment: - diminished or absent moro reflex, lethargy, apnea, poor feeding, high-pitched shrill cry, and seizure activity interventions: - supportive treatment

hypoglycemia

- blood glucose level below 70 - may be caused by too much insulin, too little food, or too much activity - show the client to carry fast-acting simple carbohydrates with them assessment: - mild: hunger, nervousness, palpitations, sweating, tachycardia, tremor - moderate: confusion, double vision, drowsiness, emotional changes, headache, impaired coordination, inability to concentrate, irrational or combative behavior, lightheadedness, numbness in the lips or tongue, and slurred speech - severe: difficulty arousing, disoriented behavior, LOC, or seizures interventions: 1. check blood glucose level 2. give fast-acting carb if below 70 3. check level again in 15 mins 4. if still under 70 give more carbs 5. recheck in 15 mins, if still under 70 give more carbs 6. recheck level in 15 mins, if its still under 70 administer 25-50 mL of 50% dextrose IV, or 1 mg of glucagon subcutaneously or IM if no IV available 7. after the blood glucose level is restored, give the client a snack that includes a complex carb and a protein 8. document the client's complaints, actions taken, and outcome 9. explore the precipitating cause of hypoglycemia with the client 10. if the client is experiencing altered LOC, bypass oral treatment and start with the injectable glucagon or the 50% dextrose.

Risk conditions related to pregnancy: HTN

- blood pressure elevations can lead to preeclampsia and then eclampsia. - Types of HTN: - Normal: less than 120/80 - elevated: systolic between 120 and 129 and diastolic less than 80 - stage 1 HTN: systolic between 130 - 139 and diastolic between 80 - 89 - stage 2 HTN: systolic at least 140 and diastolic at least 90 - chronic HTN: HTN that is present before pregnancy or that occurs in the 1st half (1st 20 weeks) of pregnancy - gestational HTN: BP elevation that first occurs in the 2nd half of pregnancy, it usually resolves after birth, but may increase the risk of developing HTN in the future. - preeclampsia: usually occurs in the 2nd half of pregnancy, typically in the 3rd trimester. it can also occur in the postpartum period. - eclampsia: seizures occurring in pregnancy and linked to high BP. - women who have preeclampsia, especially those who also delivered pre-term, are at increased risk later in life for developing cardiovascular disease and kidney disease, including heart attack, stroke, and high BP. - having preeclampsia once increases the chance of having it again in a future pregnancy. - HELLP syndrome can also result (Hemolysis, Elevated liver enzymes, and Low platelet count). In this condition, RBCs are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain. HELLP syndrome is a medical emergency, the mother can die or have lifelong health problems as a result. - assessment of preeclampsia: persistent HTN, swelling of the face or hands, headache, changes in sight, pain in the upper abdomen or shoulder, nausea and vomiting in the 2nd trimester of pregnancy, sudden weight gain, and difficulty breathing. - preeclampsia BP: greater or equal to 140/90 on two occasions at least 4 hours apart after 20 weeks gestation a woman with a previously normal BP. - preeclampsia with severe features BP: persistent elevation and greater than or equal to BP of 160/110 on 2 occasions more than 2 hours apart while on bedrest. - risk factors for preeclampsia: previous preeclampsia or gestational HTN, previous placental abruption, previous fetal demise, primigravida, family history of preeclampsia, 40+ years of age, african american ethnicity, more than 1 fetus, history of chronic HTN or kidney disease, having a medical condition related to cardiac or kidneys, BMI over 26, metabolic syndrome, in vitro fertilization, or a previous complication of labor. - complications of HTN: abruptio placentae, DIC, fetal growth restriction, preeclampsia and eclampsia, intracranial hemorrhage or hematoma, HELLP syndrome, oligohydraminos, placental insufficiency, the need for preterm delivery or C-section, or maternal or fetal death. - interventions for HTN / preeclampsia: monitor BP and weight throughout pregnancy, weekly or biweekly HC appointments, may have to deliver early, monitor fetal activity and fetal growth, encourage rest and lie in lateral position, administer BP meds as prescribed but BP should not lower too quickly because placental perfusion could be compromised, provide adequate fluids, monitor I&O, monitor for changes in neurological status which may indicate seizure, monitor deep tendon reflexes, monitor for HELLP syndrome, evaluate renal function studies, mag sulfate may be prescribed to prevent seizures and may need to be continued for 1-2 days postpartum, monitor for signs of magnesium toxicity (flushing, sweating, hypotension, depressed deep tendon reflexes, decreased urine output, and CNS depression including respiratory depression), may need to administer calcium gluconate, corticosteroids may be prescribed to promote fetal lung maturity, and prepare the client for delivery. - eclampsia assessment: seizures - eclampsia interventions: remain with the client and call for help, ensure an open airway, turn the client on her side and give O2 by face mask up to 8-10 L/minute, monitor FHR, administer meds as prescribed, after the seizure has ended insert an oral airway and suction the client's mouth as needed, prepare for delivery of the fetus after stabilization of the client if warranted, and document the occurrence, the client's response, and the outcome.

Postterm newborn

- born after 42 weeks of gestation assessment: - hypoglycemia - dry and cracked skin without lanugo - long nails - a lot of hair - long and thin body - wasting of fat and muscle in extremities - meconium staining may be present on nails and umbilical cord interventions: - provide normal newborn care - monitor for hypoglycemia - maintain newborn's temp - monitor for meconium aspiration

Antihistamines

- brompheniramine - cetirizine - chlorpheniramine - clemastine - cyproheptadine - desloratadine - dimenhydrinate - diphenhydramine - fexofenadine - levocetirizine - loratadine - olopatadine - prevent a histamine response by binding to their receptor spots and blocking them - prevent constriction of smooth muscle - decrease nasopharyngeal, GI, and bronchial secretions - used for the common cold, rhinitis, nausea and vomiting, motion sickness, urticaria (allergic rash), and as a sleep aid - can cause CNS depression if taken with alcohol, opioids, hypnotics, or barbiturates - use with caution in clients with COPD because they have a drying effect - Diphenhydramine has an anti-cholinergic effect and should be avoided in clients with narrow-angle glaucoma - adverse effects: drowsiness and fatigue, dizziness, urinary retention, blurred vision, wheezing, constipation, dry mouth, GI irritation, hypotension, hearing disturbances, photosensitivity, nervousness and irritability, confusion, and nightmares interventions: 1. monitor for signs of urinary dysfunction 2. administer with food or milk 3. avoid sub Q injection, and administer by IM in a large muscle if the IM route is prescribed client education: 1. avoid hazardous activities, alcohol, and other CNS depressants 2. if the med is being taken for motion sickness, take it 30 minutes before the event and then before meals and at bedtime during the event if prescribed 3. suck on hard candy or ice chips for dry mouth

Pediatric respiratory problems: Bronchiolitis and RSV

- bronchiolitis is inflammation of the bronchioles that cause production of thick mucus that occludes bronchiole tubes and small bronchi - RSV causes an acute viral infection and is a common cause of bronchiolitis - RSV is highly communicable and is usually transferred by droplets or by direct contact with respiratory secretions - RSV occurs in the fall, winter, and spring - at risk kids are those who are immunocomprimised or who have a chronic or disabling condition - identification of the virus is by testing nasal or nasopharyngeal secretions - prevention is by encouraging breast feeding, avoiding tobacco, using good hand washing - administer the antibody palivizumab to high-risk infants. assessment: - initial manifestations: rhinorhea, eye or ear drainage, pharyngitis, coughing, sneezing, wheezing, and intermittent fever - manifestations as disease progresses: increased coughing and wheezing, signs of air hunger, tachypnea and retractions, and periods of cyanosis - manifestations in severe illness: tachypnea of 70+ breaths a minute, decreased breath sounds and poor O2 exchange, listlessness, and apneic episodes interventions: 1. interventions are aimed at treating symptoms and include airway maintenance, cool humidified air O2, adequate fluid intake, and meds. 2. a child with RSV should have an isolated room 3. nurses caring for the child with RSV should not care for other high-risk kids 4. use contact, droplet, and standard precautions and good hand-washing techniques 5. monitor airway status and maintain a patent airway 6. position the client at a 30-40 degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm 7. provide cool- humidified O2 8. monitor pulse ox 9. encourage fluids 10. periodic suctioning may be needed if nasal secretions are copious, use of a bulb syringe for suctioning infants may be effective, suctioning should be done before feedings to promote comfort and adequate intake 11. antiviral meds may be given 12. cough suppressants are given with caution because they reduce the clearance of respiratory secretions

Food sources of minerals

- calcium: cheese, collard greens, milk and soy milk, sardines, tofu, yogurt - iron: breads, cereals, dark green veggies, dried fruits, egg yolk, legumes, liver meats - magnesium: almonds, avocado, canned white tuna, cauliflower, green leafy veggies, milk, peanut butter, peas, pork, beef, chicken, potatoes, raisins, soybeans, yogurt - potassium: avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, pork, beef, veal, potatoes, raisins, spinach, strawberries, tomatoes - sodium: bacon, butter, canned foods, cheese, pork, hot dogs, ketchup, lunch meat, milk, mustard, processed/snack foods, soy sauce, table salt, bread

Pediatric eye, ear, and throat problems: strabismus

- called "squint" or "cross-eye" - eyes are not aligned because of a lack or coordination of the extraocular muscles - results from muscle imbalance or paralysis of extraocular muscles, or a congenital defect - ambylopia = reduced visual acuity; may occur if not treated early, because the brain receives two messages as a result of the nonparallel vision axes - permanent loss of vision can occur if not treated early - this condition is considered normal in a young infant, should not be present after age 4 months - treatment depends on the cause assessment: - crossed eyes - squinting, tilts head or closes one eye to see - loss of binocular vision - impairment of depth perception - frequent headaches - diplopia, photophobia interventions: - corrective lenses may be indicated - instruct the parents regarding patching (occlusion therapy) of good eye to strengthen the weaker eye - prepare for surgery of realign the weak muscles as prescribed if non-surgical interventions are unsuccessful - instruct the parents about the need for follow-up visits

Fetal alcohol syndrome disorders (FASDs)

- can cause cognitive and physical delays - FAS is the most severe of the FASDs, other disorders included are alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) assessment: - facial changes: short palpebral fissures, hypoplastic philtrum, short upturned nose, flat midface, thin upper lip, low nasal bridge - abnormal palmar creases - respiratory distress - congenital heart disorders - irritability and hypersensitivity to stimuli - tremors - poor feeding - seizures interventions: - monitor for respiratory distress - position the newborn on the side to facilitate drainage of secretions - initiate seizure precautions - keep resuscitation equipment at the bedside - monitor for hypoglycemia - assess suck and swallow reflex - administer small feedings and burp well - suction as needed - monitor I&O - monitor weight and head circumference - decrease environmental stimuli - make referral to local early intervention system

Jehovah's witnesses beliefs related to end-of life care

- cannot receive a blood transfusion - believe the soul cannot live after the body has died

b-adrenergic blockers (beta blockers)

- carvedilol - labetalol - nadolol - pindolol - propranolol - sotalol - acebutolol - atenolol - betaxolol - bisoprolol - esmolol - metoprolol - they all end in LOL... remember "get people to lower their blood pressure? LOL" - inhibit response to b-adrenergic stimulation, thus decreasing the CO - they block the release of catecholamines, epinephrine, and norepinephrine decreasing the HR and BP; they also decrease the workload of the heart and decrease O2 demands - used for angina, dysrhythmias, HTN, migraine headaches, prevention of MI, and glaucoma - b-adrenergic blockers are contraindicated in the client with asthma, bradycardia, HF (with exceptions), severe renal or hepatic disease, hyperthyroidism, or stroke; carvedilol, metoprolol, and bisoprolol have been approved for the use of HF once the client has been stabilized with ACE inhibitors and diuretic therapy. - use with caution in the client with DM because the med can mask symptoms of hypoglycemia - also use with caution with the client taking anti-HTN meds adverse effect: - bradycardia - bronchospasm - hypotension - weakness, fatigue - nausea, vomiting - dizziness - hyperglycemia - agranulocytosis - behavioral or psychotic response - depression - nightmares interventions: 1. monitor vitals 2. withhold the med if the pulse or BP is not within prescribed parameters 3. withhold for signs of HF or worsening HF 4. assess for respiratory distress and for signs of wheezing or dyspnea 5. instruct the client to report dizziness, lightheadedness, or nasal congestion 6. instruct the client not to stop taking the med because rebound HTN or tachycardia, or an anginal attack can occur 7. advise the client taking insulin that these meds can mask signs of hypoglycemia such as tachycardia and nervousness 8. instruct the client taking insulin to monitor their blood glucose level 9. instruct the client in how to take their pulse and BP 10. instruct the client to change positions slowly to prevent orthostatic hypotension 11. instruct the client to avoid OTC medications, especially cold medications and nasal decongestants.

Pediatric respiratory problems: Tuberculosis

- caused by a bacteria - drug-resistant strains can occur due to non-compliance with therapeutic regimen - is spread by inhalation or droplets - increased incidence in low-income areas, non-white racial or ethnic groups, and first-generation immigrants from endemic countries assessment: - may be asymptomatic, or may develop symptoms like malaise, fever, cough, weight loss, anorexia, and lymphadenopathy - specific symptoms related to the site of infection like the lungs, brain or bone may be present - with illness progression asymmetrical expansion of the lungs, decreased breath sounds, crackles, and dullness to percussion develop - tuberculin skin test (TST) or Mantoux test are used to diagnose - test produces a positive result 2-10 weeks after initial infection - test determines whether a child has been infected and has developed a sensitivity to the bacteria, not if the child is actively infected - the child will always react + after having the illness - Tb testing should not be done at the same time as a measles immunization - sputum culture - a definitive diagnosis is made by showing the presence of the bacteria on the culture - chest X-rays are supplemental to the culture but cannot alone diagnose a + result interventions: 1. a 9-month course of isoniazid may be prescribed to prevent a latent infection from progressing to clinically active Tb, and to prevent initial infection in kids in high-risk situations. A 12-month course may be prescribed for a child who has HIV 2. recommendation for a child with clinically active Tb may include combination administration of isoniazid, rifampin, and pyrazinamide daily for 2 months, and then isoniazid and rifampin twice weekly for 4 months 3. inform the parents and child that bodily fluids, including urine, may turn an orange-red color with some Tb medications 4. directly observed therapy may be necessary for some kids 5. place kids with an active Tb disease who are contagious on respiratory isolation until meds have been initiated, sputum cultures show a diminished # of organisms, and cough is improving; this includes use of fitted N95 masks or N100 respirator masks for the nurse caring for the child. 6. stress the importance of adequate rest and diet 7. instruct the child and family about measures to prevent the transmission of Tb 8. case finding and follow-up with known contacts is crucial to decrease the # of cases of individuals with active Tb

Actinic Keratoses

- caused by chronic exposure to the sun and appears as rough, scaly, red, or brown lesions that usually are found on the face, scalp, arms, and backs of the hands - lesions are considered pre-malignant and there is risk for slow progression of squamous cell carcinoma - treatment includes medication, excision, cryotherapy, curettage, and laser therapy

Occupational lung disease

- caused by exposure or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, and allergens; can result in acute reversible effects of chronic lung disease - common disease classifications include occupational asthma pneumoconiosis (silicosis or coal miner's black lung disease), diffuse interstitial fibrosis (asbestosis, talcosis, berylliosis), or extrinsic allergic alveolitis (farmer's lung, bird fancier's lung, or machine operator's lung) assessment: - manifestations depend on the type of disease and respiratory symptoms interventions: 1. prevention through the use of respiratory protective devices 2. treatment is based on the symptoms experienced by the client

Pediatric neurological and cognitive problems: Neural tube defects

- caused by failure of the tube to close during embryonic development - folic acid is recommended during childbearing years and pregnancy to reduce the occurrence of these conditions - associated defects include sensorimotor disturbance, dislocated hips, clubfoot, and hydrocephalus - defect closure is performed soon after birth - types: - spina bifida occulta - closed neural tube defect - meningocele - myelomeningocele assessment: - depends on the spinal cord involvement - visible spinal defect - flaccid paralysis of the legs - altered bladder and bowel function - hip and joint deformities - hydrocephalus interventions: 1. evaluate the sac and measure the lesions 2. perform a neurological assessment 3. monitor for IICP 4. measure head circumference and assess for anterior fontanel bulging 5. protect the sac; cover the site with a sterile moist (normal saline) non-adherent dressing as prescribed 6. change the dressing on a regular schedule or whenever it becomes soiled because of risk of infection, diapering may be contraindicated until the defect is repaired 7. use aseptic technique to prevent infection 8. assess the sac for redness, drainage, abrasions, irritation, and signs of infection 9. early signs of infection are fever, irritability, lethargy, and nuchal rigidity 10. place prone to minimize tension on the sac and the risk of trauma, turn the head to 1 side for feeding 11. assess for physical impairments like hip and joint deformities 12. prepare the child and family for surgery 13. administer antibiotics post-op to prevent infection 14. educate the parents and child about long-term home care: - positioning, feeding, skin-care, and ROM exercises - starting a bladder elimination program and performing clean intermittent catheterization if needed - administering anti-spasmodics that act on the smooth muscle of the bladder to increase bladder capacity and improve continence - implement a bowel program, including a high-fiber diet, increased fluids, and suppositories as needed - the child has a high risk of latex allergy and rubber allergy because of the frequent exposure of latex during implementation of care measures

Hypoparathyroidism

- caused by hyposecretion of parathyroid hormone by the parathyroid gland. - can occur after thyroidectomy due to removal of parathyroid tissue assessment: - hypocalcemia and hyperphosphatemia - numbness and tingling in the face - muscle cramps and cramps in the abdomen or extremities - positive Trousseau's sign (twitching of the facial muscles in response to tapping over the area of the facial nerve) or Chvosek's sign (same thing) - signs of overt tetany (bronchospasm, laryngospasm, carpopedal spasm, dysphagia, photophobia, dysrhythmias, and seizures) - hypotension - anxiety, irritability, depression interventions: 1. monitor vitals 2. monitor for signs of hypocalcemia and tetany 3. initiate seizure precautions 4. place a trache set, O2, and suction at bedside 5. prepare to give IV calcium gluconate for hypocalcemia 6. provide a high-calcium, low-phosphorous diet 7. instruct the client to administer calcium supplements as prescribed 8. instruct the client to administer vitamin D supplements as prescribed to enhance the absorption of calcium from the GI tract 9. instruct the client in the use of thiazide diuretics if prescribed, to protect the kidney if vitamin D is also taken 10. instruct the client in the administration of phosphate binders as prescribed to promote the excretion of phosphate through the GI tract 11. instruct the client to wear a medi-alert bracelet

Pediatric neurological and cognitive problems: Cerebral palsy

- characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system assessment: - extreme irritability and crying - feeding difficulties - abnormal motor performance - alterations of muscle tone, stiff and rigid arms and legs - delayed developmental milestones - reflexes in infancy last longer than they should - abnormal posturing interventions: 1. the goal of treatment is early recognition and interventions to maximize the child's abilities 2. physical therapy, occupational therapy, speech therapy, education, and recreation 3. assess the child's developmental level and intelligence 4. encourage early intervention and participation in school programs 5. prepare for using mobile devices to help prevent or reduce deformities 6. encourage communication and interaction with the child based on their developmental level, not just based on their age 7. provide a safe environment by reducing sharp objects, using a protective helmet if the child falls a lot, and implement seizure precautions if needed 8. provide safe, appropriate toys for the child 9. position the child upright after meals 10. meds may be prescribed to relieve muscle spasms, which can cause intense pain, and anti-seizure meds may also be prescribed 11. provide the parents with info about the disorder and treatment plan, and encourage support groups for them

Thiazide diuretics

- chlorothiazide - chlorthalidone - hydrochlorothiazide - indapamide - metolazone - thiazide diuretics are antihypertensive meds that increase sodium and water excretion by inhibiting sodium reabsorption in the distal tubule of the kidney - used for HTN and peripheral edema - not effective for immediate diuresis - used in clients with normal renal function; contraindicated in clients with renal failure - thiazide diuretics should be used in caution in the client taking lithium, because lithium toxicity can occur, and in the client taking digoxin, corticosteroids, or hypoglycemia meds. adverse effects: - hypercalcemia, hyperglycemia, hyperuricemia (increased uric acid) - hypokalemia, hyponatremia - hypovolemia - hypotension - rashes - photosensitivity - dehydration interventions: 1. monitor vitals 2. monitor weight 3. monitor urine output 4. monitor electrolytes, glucose, calcium, BUN, creatine, and uric acid levels 5. check peripheral extremities for edema 6. monitor for signs of digoxin or lithium toxicity if the client is taking these medications 7. instruct the client to take the medication in the morning to avoid nocturia and sleep interruption 8. instruct the client on how to record the BP 9. instruct the client to eat foods high in K+ 10. instruct the client on how to take K+ supplements if prescribed 11. instruct the client to take the med with food to prevent GI upset 12. instruct the client to change positions slowly to prevent orthostatic hypotension 13. instruct the client to use sunscreen when in direct sunlight because of increased photosensitivity 14. instruct the client with DM to have the blood glucose levels checked periodically

Diabetic retinopathy

- chronic and progressive impairment of the retinal circulation that eventually causes hemorrhage - permanent vision changes and blindness can occur - the client has difficulty with carrying out the daily tasks of blood glucose testing and insulin injections assessment: - a change in vision is caused by the rupture of small micro-aneurysms in retinal blood vessels - blurred vision results from macular edema - sudden loss of vision results from retinal detachment - cataracts result from lens opacity interventions: 1. maintain safety 2. early prevention by the control of HTN and blood glucose levels 3. photocoagulation (laser therapy) may be done to remove hemorrhagic tissue to decrease scarring and prevent progression of the disease progress 4. virectomy may be done to remove vitreous hemorrhages and thus decrease tension on the retina, preventing detachment 5. cataract removal with lens implantation improves vision

peripheral arterial disease

- chronic disorder in which partial or total arterial occlusion deprives the lower extremities of O2 and nutrients - tissue damage occurs below the level of the arterial occlusion - atherosclerosis is the most common cause of peripheral arterial disease assessment: - intermittent claudication (pain in the muscles resulting from inadequate blood supply) - rest pain, characterized by numbness, burning, or aching in the distal portion of the lower extremities which awakens the client at night and is relieved by placing the extremity and is relieved by placing the extremity in a dependent position - lower back or buttock discomfort - loss of hair and dry scaly skin on the lower extremities - thickened toenails - cold and gray blue-color of skin in the lower extremities - elevational pallor and dependent rubor in the lower extremities - decreased or absent peripheral pulses - signs of arterial ulcer formation occurring on or between the toes or on the upper aspect of the foot that are characterized as painful - BP measurements at the thigh, calf, and ankle are lower than the brachial pressure interventions: ** the client with PAD is instructed to elevate the feet at rest but to refrain from elevating them above the level of the heart because extreme elevation shows arterial blood flow to the feet. In severe cases of peripheral arterial disease, clients with edema may sleep with the affected limb hanging from the bed, or they may sit upright (without leg elevation) in the chair for comfort) 1. assess pain 2. monitor the extremities for color, motion, sensation, and pulses 3. obtain BP measurements 4. assess for signs of ulcer formation or signs of gangrene 5. assist in developing an individualized exercise program, which is initiated gradually and increased slowly to improve arterial flow through the development of collateral circulation 6. instruct the client to walk to the point of claudication pain, stop and rest, and then walk a little further 7. instruct the client with peripheral arterial disease to avoid crossing the legs which interferes with blood flow 8. instruct the client to avoid exposure to cold (causes vasoconstriction) to the extremities and to wear socks or insulates shoes for warmth at all times 9. instruct the client never to apply direct heat to the limb, because the limb has decreased sensitivity and it can cause burning. 10. instruct the client to inspect the skin on the extremities daily, and to report any signs of skin breakdown. 11. instruct the client to avoid tobacco and caffeine because of their vasoconstrictive effects 12. instruct the client to use hemorheological and antiplatelet meds as prescribed

asthma

- chronic inflammatory disorder of the airways that causes varying degrees of obstruction in the airways - marked by airway inflammation and hyper-responsiveness to a variety of stimuli or triggers - causes recurrent episodes of wheezing, chest tightness, breathlessness, and coughing associated with airflow obstruction that may resolve spontaneously; it is often reversible with treatment - severity is classified based on the clinical features before treatment - status asthmaticus is a severe life-threatening asthma episode that is refractory to treatment and may result in pneumothorax, acute cor pulmonale, or respiratory arrest ** silent breath sounds are associated with acute asthma exacerbation, may indicate impending respiratory failure due to diffuse bronchospasm, and is a life-threatening condition assessment: - restlessness - wheezing or crackles - absent or diminished lung sounds - hyperresonance - use of accessory muscles for breathing - tachypnea with hyperventilation - prolonged exhalation - tachycardia - pulsus paradoxus - diaphoresis - cyanosis - decreased O2 saturation - pulmonary function test that demonstrates decreased airflow rates interventions: 1. monitor vitals 2. monitor pulse oximetry 3. monitor peak flow 4. during an acute asthma episode, provide interventions to assist with breathing: - position the client in a high-fowler's position or sitting to aid in breathing - administer O2 as prescribed - stay with the client to decrease anxiety - administer bronchodilators as prescribed - record the color, amount, and consistency of sputum, if any - administer corticosteroids as prescribed - administer magnesium sulfate as prescribed - auscultate lung sounds before, during, and after treatment client education: - on the intermittent nature and symptoms and need for long-term management - to identify possible triggers and measures to prevent episodes - on the administration of meds and proper management - about developing an asthma action plan with the PHCP and what to do if an episode occurs

centrally acting sympatholytics (adrenergic blockers)

- clonidine - guanfacine - methyldopa - stimulate a-receptors in the CNS to inhibit vasoconstriction, reducing peripheral resistance - used to treat HTN - contraindicated in impaired liver function adverse effects: 1. sodium and water retention 2. edema 3. drowsiness, dizziness 4. dry mouth 5. hypotension 6. bradycardia 7. impotence 8. depression interventions: 1. monitor vitals 2. instruct the client not to discontinue the med, because abrupt withdrawal can lead to severe rebound hypertension 3. monitor liver function tests

Bile acid sequestrants

- colesevelam - colestipol - cholestyramine - act by absorbing and combining with intestinal bile salts, which are then secreted in the feces, preventing intestinal reabsorption. - used to treat increased cholesterol in adults, biliary obstruction, and pruritus associated with biliary disease - with powdered forms, taste and palatability are often reasons for noncompliance and can be improved by the use of flavored products or mixing the meds with various juices - adverse effects are nausea, bloating, constipation, fecal impaction, and intestinal obstruction - stool softeners and other sources of fiber can be used to abate the GI side effects ** should be used cautiously in clients with suspected bile obstruction or severe constipation because they can worsen these conditions **

Empyema

- collection of pus in the pleural cavity - the fluid is thick, opaque, and foul-smelling - the most common cause is pulmonary infection and lung abscess caused by thoracic surgery or chest trauma, in which bacteria are introduced directly into the pleural space - treatment focuses on treating the infection, emptying the empyema cavity, re-expanding the lung, and controlling the infection assessment: - recent febrile illness or trauma - chest pain - cough - dyspnea - anorexia and weight loss - malaise - fever and chills - night sweats - pleural exudate on the chest X-ray interventions: 1. monitor breath sounds 2. place the client in a semi-Fowler's or high-Fowler's position 3. encourage coughing and deep breathing 4. administer antibiotics as prescribed 5. instruct the client to splint the chest as needed 6. assist with thoracentesis or chest tube insertion to promote drainage and lung expansion 7. if marked pleural thickening occurs, prepare the client for discortication (a medical procedure involving the surgical removal of the surface layer, membrane, or fibrous cover of an organ), if prescribed; this surgical procedure involves the removal of the restrictive mass of fibrin and inflammatory cells.

Hepatitis D

- common in the mediterranean and middle eastern areas - it occurs with hepatitis B and causes infection only if there is an active hepatitis B infection - it intensifies the symptoms of hepatitis B - transmission is the same for hepatitis B, and is primarily contact with blood - prevention of HB prevents HD - high-risk people are those who are IVDA, receive hemodialysis, and receive frequent blood transfusions. - incubation period is 7-8 weeks - determining the presence of the HD antigen early in the course of the infection and detection of anti-HD antibodies later in the disease are diagnostic testing for HD. - complications are chronic liver disease and fulminant hepatitis - prevented by preventing hep B

Pediatric GI Problems: Intestinal parasites

- common ones in kids are Giardiasis and Pinworms - Giardiasis is caused by protozoa and is prevalent among kids in crowded environments - Pinworms are universally present in temperate climate zones and are easily transmitted in crowded environments assessment of Giardiasis: - diarrhea and vomiting - anorexia - failure to thrive - abdominal cramps with intermittent loose stools and constipation - steatorrhea (fat in feces) - stool specimens from 3+ collections are used for diagnosis assessment of Pinworms: - intense peri-anal itching - irritability, restlessness - poor sleeping - bed wetting interventions for Giardiasis: - meds that kill the parasites may be prescribed, meds are not usually prescribed for kids under 2 - caregivers should wash hands meticulously - provide education to family and caregivers regarding sanitary practices interventions for Pinworms: - perform a visual inspection of the anus with a flashlight 2-3 hours after sleep - tape test is most common diagnostic test - educate the family and caregivers regarding the tape test; a loop of transparent tape is placed against the child's peri-anal area, it's removed in the morning and placed in a glass jar or plastic bag and transported to the lab for analysis - meds that kill them may be prescribed, not usually given to kids under 2 - the med regimen may be repeated in 2 weeks to prevent infection - all members of the family are treated for infection - teach the family and caregivers the importance of meticulous hand washing and about washing all clothes and bed linens in hot water

Hyperparathyroidism

- condition caused by hypersecretion of parathyroid hormone (PTH) by the parathyroid gland assessment: - hypercalcemia and hypophosphatemia - fatigue and muscle weakness - skeletal pain and tenderness - bone deformities resulting in fractures - anorexia, nausea, vomiting, epigastric pain - weight loss - constipation - HTN - dysrhythmias - renal stones interventions: 1. monitor vitals 2. monitor for dysrhythmias 3. monitor I&O and for signs of renal stones 4. monitor for skeletal pain; move the client slowly and carefully 5. encourage fluids 6. administer furosemide as prescribed to lower calcium levels 7. administer IV NS to maintain hydration 8. administer phosphates as prescribed which interfere with calcium reabsorption 9. administer calcitonin as prescribed to decrease skeletal calcium release and increase renal excretion of calcium 10. administer oral or IV biophosphonates as prescribed to inhibit bone resorption 11. monitor calcium and phosphorus levels 12. prepare the client for a parathyroidectomy as prescribed 13. encourage a high-fiber, moderate calcium diet 14. emphasize the importance of an exercise program avoiding prolonged inactivity

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

- condition of hyper-functioning of the posterior pituitary gland in which excess ADH is released, but not in response to the body's need for it. - causes are trauma, stroke, malignancies, meds, or stress - the syndrome results in increased intravascular volume, water intoxication, and dilutional hyponatremia. - it may cause cerebral edema and the client is at risk for seizures assessment: - signs of fluid volume overload - changes in LOC and mental status - weight gain without edema - HTN - tachycardia - anorexia, nausea, vomiting - hyponatremia - low urinary output and concentrated urine interventions: 1. monitor vitals, cardiac, and neurological status 2. provide a safe environment 3. monitor for signs of IICP 4. implement seizure precautions 5. elevate the HOB to a max of 10 degrees to promote venous return and decrease baroreceptor-induced ADH release 6. monitor I&O and obtain daily weight 7. monitor fluid and electrolyte balance 8. monitor serum and urine osmolality 9. restrict fluid intake as prescribed 10. administer IV fluids (Usually NS or hypertonic saline) as prescribed, monitor IV fluids carefully because of the risk for fluid volume overload 11. loop diuretics may be prescribed to promote diuresis, but only if serum sodium is 125 at least; potassium replacement may be needed if loop diuretics are prescribed 12. vasopressin antagonists may be prescribed to decrease the renal response to ADH

Pediatric renal and genitourinary problems: epispadias and hypospadias

- congenital defects involving abnormal placement of the urethral orifice of the penis - can lead to bacteria easily entering the urine assessment: - epispadias: the urethral orifice is located on the dorsal surface of the penis, the condition often occurs with exstrophy of the bladder - hypospadias: the urethral orifice is located below the glans penis along the ventral surface surgical interventions: - surgery is done between 6 and 12 months old - circumcision is not performed post-op interventions: - the child has a pressure dressing and has some kind of urinary diversion or a urinary stent while the meatus is healing - monitor vitals - encourage fluid intake to maintain adequate output and maintain patency of a stent if one was used - monitor I&O and urine for cloudiness or a foul odor - notify the surgeon if there is no urinary output for 1 hour, because this may indicate kinks in the urinary diversion or stent or obstruction by sediment - provide meds for pain or anticholinergics to relieve bladder spasms as prescribed - administer antibiotics as prescribed - instruct parents in the care of a child who has a urinary diversion or stent - instruct parents to avoid giving the child a tub bath until the stent is removed - instruct parents about fluid intake, med administration, signs and symptoms of infection, and need for follow-up for dressing removal after surgery as prescribed

Pediatric GI Problems: constipation and encopresis

- constipation is the infrequent and difficult passage of dry, hard stools - encopresis is constipation with fecal incontinence; children often complain that soiling is involuntary and occurs without warning - if the child does not have a neurological or anatomical disorder, encopresis is usually the result of fecal impaction and an enlarged rectum caused by chronic constipation. constipation assessment: - abdominal pain and cramping without distention - palpable moveable fecal mass - normal or decreased bowel sounds - malaise and headache - anorexia, nausea, and vomiting encopresis assessment: - evidence of soiling of clothing - scratching or rubbing of the anal area - fecal odor - social withdrawal interventions: - maintain a diet high in fiber and fluids to promote bowel elimination - monitor treatment regimen for severe encopresis for 3-6 months - decrease sugar and milk intake - administer enemas as prescribed until impaction is cleared - monitor for hyper-natremia or hyper-phosphatemia when administering repeated enemas - signs of hyper-natremia = increased thirst, dry sticky mucous membranes, flushed skin, increased temp, nausea and vomiting, increased temp, nausea and vomiting, oliguria, and lethargy - signs of hyper-phosphatemia = tetany, muscle weakness, dysrhythmias, and hypotension - administer stool softeners or laxatives as prescribed - encourage the child to sit on the toilet for 5-10 minutes approximately 20-30 minutes after breakfast and dinner to assist with defecation

Betamethasone and dexamethasone

- corticosteroids that increase the production of surfactant to accelerate fetal lung maturity and reduce the incidence of severity of respiratory distress syndrome. - used for a client in preterm labor between 28 and 32 weeks gestation and whose labor can be inhibited for 48 hours without causing harm. adverse effects and contraindications: - may decrease the mother's resistance to infection - pulmonary edema secondary to sodium and fluid retention can occur - elevated blood glucose levels can occur in a client with diabetes interventions: - monitor maternal vital signs, lungs sounds, and chck for edema - monitor the mother for signs of infection - monitor WBC count - monitor blood glucose levels - administer by deep IM injection

Cesarean delivery

- delivery of the fetus through transabdominal, low-segment incision of the uterus - preoperative interventions: prepare the mother and partner, obtain informed consent, ensure pre-op diagnostic tests are done including Rh factor determination, prepare to insert an IV line and an indwelling urinary catheter, prepare the abdomen as prescribed, monitor the mother and fetus continuously, provide emotional support, and administer pre-op meds as prescribed - post-op interventions: monitor vitals, perform a fundal assessment and evaluate incision, provide pain relief, encourage turning, coughing, and deep breathing, encourage ambulation, encourage bonding and attachment with newborn, provide psychological support, monitor for signs of infection and bleeding, burning and pain on urination may indicate bladder infection, a tender uterus and foul-smelling lochia may indicate endometritis, a productive cough or chills may indicate pneumonia, and pain, redness, or edema of an extremity may indicate thrombophlebitis

Diabetic neuropathy

- deterioration of the nervous system throughout the body - complications include the development of non-healing ulcers of the feet, gastric paresis, and erectile dysfunction classifications: 1. focal neuropathy or mono-neuropathy: - involves a single nerve or group of nerves, most often are cranial nerves 3 (oculomotor) and 6 (abducens), resulting in diplopia 2. sensory or peripheral neuropathy: - affects distal portion of nerves usually in the lower extremities 3. autonomic neuropathy: - symptoms vary according to the organ system involved 4. cardiovascular neuropathy: - cardiac denervation syndrome: when the heart does not respond to changes in oxygen needs; and orthostatic hypotension occur. 5. pupillary neuropathy: - pupil does not dilate in response to decreased light 6. gastric neuropathy: - decreased gastric emptying (gastroparesis) 7. urinary neuropathy: - neurogenic bladder (lack of bladder control) 8. skin: - decreased sweating 9. adrenal: - hypoglycemia unawareness 10. reproductive: - impotence in males, painful intercourse in females assessment: - findings depend on the classification - decreased or absent reflexes - decreased sensation to vibration or light touch - pain, aching, or burning in lower extremities - poor peripheral pulses - skin breakdown or signs of infection - weakness or loss of sensation in cranial nerves 3, 4, 5, and 6 (oculomotor, trochlear, trigeminal, abducens) - dizziness and postural hypotension - nausea and vomiting - diarrhea or constipation - incontinence - dyspareunia - impotence - hypoglycemic unawareness interventions: 1. early prevention by controlling HTN and blood glucose levels 2. careful foot care to prevent trauma 3. administer meds for pain relief as prescribed 4. initiate bladder training programs 5. instruct on the use of estrogen-containing lubricants for women with dyspareunia 6. prepare the male with impotence for penile injections or other possible treatments as prescribed 7. prepare for surgical decompression of compression lesions related to the cranial nerves as prescribed

direct-acting arteriolar vasodilators

- diazoxide - fenoldopam - hydralazine - nirtoglycerin - sodium nitroprusside - direct-acting vasodilators relax the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation; causing the BP to drop and the sodium and water to be retained resulting in peripheral edema (diuretics may be given to decrease the edema). - direct-acting vasodilators promote an increase in blood flow to the brain and kidneys - these meds are used in the client with moderate to severe HTN and for acute hypertensive emergencies adverse effects: - hypotension - reflex tachycardia caused by vasodilation and the drop in BP - palpitations - edema - dizziness - headaches - nasal congestion - GI bleeding - neurological symptoms - confusion - with sodium nitroprusside, cyanide toxicity and thiocyanate toxicity can occur interventions: 1. monitor vitals, especially BP 2. sodium nitroprusside: - monitor cyanide and thiocyanate levels - protect from the light because the med decomposes - when administering, the solution must be covered by a dark bag provided by the manufacturer and is stable for 24 hours - discard the med if it is red, green, or blue **vasodilators cause orthostatic hypotension; instruct the client about safety measures when taking these meds, such as when rising from a sitting position slowly**

Esophageal varices

- dilated and tortuous veins in the submucosa of the esophagus - caused by portal hypertension, often associated with liver cirrhosis; are at high risk for rupture if portal circulation pressure rises - bleeding varices are an emergency - the goal of treatment is to control bleeding, prevent complications, and prevent recurrence of the bleeding assessment: - hematemesis (vomiting blood) - melena - ascites - jaundice - hepatomegaly and splenomegaly - dilated abdominal veins - signs of shock ** rupture and hemorrhage of esophageal varices is the primary concern, because it is life-threatening ** interventions: 1. monitor vitals 2. elevate the HOB 3. monitor for orthostatic hypotension 4. monitor lung sounds for respiratory distress 5. administer O2 as prescribed 6. monitor LOC 7. maintain NPO status 8. administer IV fluids as prescribed to restore fluid volume and electrolyte imbalances; monitor I&O 9. monitor Hgb, Hct, and coagulation factors 10. administer blood transfusions or clotting factors as prescribed 11. assist in inserting a NG tube or balloon tamponade as prescribed; balloon tamponade is not used often because it is very uncomfortable for the client and its use is associated with complications 12. prepare to help with administering meds to induce vasoconstriction and reduce bleeding 13. instruct the client to avoid activities that will initiate vasovagal responses 14. prepare the client for endoscopic procedures or surgical procedures as prescribed endoscopic injection (sclerotherapy): - involves the injection of a sclerosing agent into and around bleeding varices - complications are chest pain, pleural effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus endoscopic variceal ligation: - involves ligation of the varices with an elastic rubber band - sloughing, followed by superficial ulceration occurs in the area of ligation within 3-7 days shunting procedures: - shunt blood away from the esophageal varices - portacaval shunting involves anastomosis of the portal vein to the inferior vena cava, diverting blood from the portal system to the systemic circulation - distal splenorenal shunt: the shunt involves anastomosis of the splenic vein to the left renal vein - the spleen conducts blood from the high-pressure varices to the low-pressure renal vein - mesocaval shunting: involves a side anastomosis of the superior mesenteric vein to the proximal end of the inferior vena cava - transjugular intrahepatic portosystemic shunt (TIPS): uses the normal vascular anatomy of the liver ti create a shunt with the use of a metallic stent. the shunt is between the portal and systemic venous system in the liver and is aimed at relieving portal hypertension.

Hemorrhoids

- dilated varicose veins of the anal canal - may be internal, external, or prolapsed - internal hemorrhoids lie above the anal sphincter and cannot be seen on inspection - prolapsed hemorrhoids can become thrombosed or inflamed - hemorrhoids are caused by portal HTN, straining, irritation, or increased venous or abdominal pressure assessment: - bright red bleeding with defecation - rectal pain - rectal itching interventions: 1. apply cold packs to the anal-rectal area followed by sitz baths as prescribed 2. apply witch hazel soaks and topical anesthetics as prescribed 3. encourage a high-fiber diet and fluids to promote bowel movements without straining 4. administer stool softeners as prescribed surgical interventions: 1. may include ultrasound, sclerotherapy, circular stapling, band ligation, or simple resection of the hemorrhoids post-op interventions: 1. assist the client to a prone or side-lying position to prevent bleeding 2. maintain ice packs over the dressing as prescribed until the packing is removed by the PHCP 3. monitor for urinary retention 4. administer stool softeners as prescribed 5. instruct the client to increase fluids and high-fiber foods 6. instruct the client to limit sitting to short periods of time 7. instruct the client in the use of sitz baths 3-4 times a day as prescribed

Pediatric musculoskeletal problems: Marfan's syndrome

- disorder of connective tissue that affects the skeletal system, cardiovascular system, eyes, and skin - it's caused by defects in the fibrillin-1 gene which serves as a building block for elastic tissue in the body, also the disorder can be inherited. - there is no cure assessment: - tall and thin body structure, slender fingers, long arms and legs, curvature of the spine - presence of visual problems and cardiac problems interventions: 1. monitor for visual problems and obtain visual exams on a regular schedule 2. monitor for curvature of the spine, especially during adolescence 3. cardiac meds may be prescribed to slow the HR to decrease stress on the aorta 4. instruct parents that the child should avoid participating in competitive athletics and contact sports to prevent injuring the heart 5. instruct parents to inform the dentist of the condition, antibiotics should be taken before dental procedures to prevent endocarditis 6. surgical replacement of the aortic root and valve may be necessary

varicose veins

- distended, protruding veins that appear darkened and torturous - vein walls weaken and dilate, and valves become incompetent assessment: - pain in the legs with dull aching after standing - a feeling of fullness in the legs - ankle edema - Trendelenburg's test: place the client in a supine position with the legs elevated. when the client sits up, if variscosities are present, veins fill from the proximal end instead of from the distal end. interventions: 1. emphasize the importance of anti-embolism stockings as prescribed 2. instruct the client to elevate the legs as much as possible 3. instruct the client to avoid constrictive clothing and pressure on the legs 4. prepare the client for sclerotherapy or vein stripping as prescribed sclerotherapy: - a solution is injected into the vein, followed by the application of a pressure dressing - incision and drainage of the trapped blood in the sclerosed vein is performed 14-21 days after the injection, followed by the application of a pressure dressing for 12-18 hours laser therapy: - a laser fiber is used to heat and close the main vessel contributing to the variscosity vein stripping: - varicose veins may be removed if they are larger than 4 mm in diameter or if they are in clusters; other treatments are usually tried before vein stripping

Diverticulosis and diverticulitis

- diverticulosis is an out-pouching or herniation of the intestinal mucosa - the disorder can occur in any part of the intestine but is most common in the sigmoid colon - diverticulitis is the inflammation of 1+ diverticula that occurs from penetration of fecal matter through the thin-walled diverticula; it can result in local abscess formation and perforation. - a perforated diverticulum can progress to intra-abdominal perforation with generalized peritonitis assessment: - LLQ abdominal pain that increases with coughing, straining, or lifting - fever - nausea and vomiting - flatulence - cramp-like pain - abdominal distention and tenderness - palpable, tender rectal mass may be present - blood in the stool interventions: 1. provide bed rest during the acute phase 2. maintain NPO or provide clear liquids during the acute phase as prescribed 3. introduce a fiber-containing diet gradually, when the inflammation has resolved 4. administer antibiotics, analgesics, and anticholinergics to reduce bowel spasms as prescribed 5. instruct the client to refrain from lifting, straining, coughing, or bending over to avoid increased intra-abdominal pressure 6. monitor for perforation, hemorrhage, fistulas, and abscesses 7. instruct the client to increase fluid intake to 2500-3000 mL a day unless contraindicated 8. instruct the client to eat soft high-fiber foods such as whole grains; the client should avoid high-fiber foods when inflammation occurs because they will irritate the mucosa further 9. instruct the client to avoid gas-forming foods or foods with indigestible roughage, seeds, nuts, or popcorn because these foods can get stuck in diverticula and cause inflammation 10. instruct the client to consume a small amount of bran daily and to take bulk-forming laxatives as prescribed to increase stool mass surgical interventions: 1. colon resection with primary anastomosis may be an option 2. temporary or permanent colostomy may be required for increased bowel inflammation

Adrenergic agonists

- dobutamine - dopamine - epinephrine - norepinephrine Dobutamine: - increases myocardial force and CO through stimulation of b-receptors - used in clients with HF and for clients undergoing cardiopulmonary bypass surgery dopamine: - increases BP and CO through positive inotropic action and increases renal blood flow through its action on a and b receptors - used to treat mild kidney failure caused by a low CO epinephrine: - used for cardiac stimulation in cardiac arrest - used for bronchodilation in asthma or allergic reactions - produces mydriasis (dilation of pupils) - produces local vasoconstriction when combined with local anesthetics and prolongs anesthetic action by decreasing blood flow to the site norepinephrine: - stimulates the heart in cardiac arrest - vasoconstricts and increases the BP in hypotension and shock adverse effects: - dysrhythmias - tachycardia - angina - restlessness - urgency or urinary incontinence interventions: 1. monitor vitals 2. monitor lung sounds 3. monitor urinary output 4. monitor ECG 5. administer the med through a large vein

Emollient laxatives

- docusate sodium - inhibit absorption of water so fecal mass remains large and soft - used to avoid straining

Hypophysectomy (surgical removal of the pituitary gland)

- done by a craniotomy or a endoscopic transnasal approach - craniotomy complications: IICP, bleeding, meningitis, and hypopituitarism - endoscopic transnasal complications: CSF leak, infection, diabetes insipidus, and hypopituitarism, but usually have less complications than craniotomy. an incision is made along the gym line and upper lip. post-op interventions: 1. monitor vitals, neuro status, and LOC 2. elevate the HOB 3. monitor for IICP 4. instruct the client to avoid sneezing, coughing, and blowing the nose 5. monitor for bleeding 6. monitor for and report signs of diabetes insipidus (monitor I&O, and report excessive urinary output) 7. if the entire pituitary was removed, clients will need lifelong replacement of ADH, cortisol, and thyroid hormone 8. monitor for and report signs of meningitis 9. administer antibiotics, analgesics, and antipyretics as prescribed 10. administer oral mouth rinses as prescribed. clients may be told to avoid using a toothbrush or brush teeth gently with an ultrasoft toothbrush for 10 days - 2 weeks after surgery 11. instruct the client on the administration of prescribed meds 12. monitor for and report postnasal drip or clear nasal drainage which may indicate a CSF leak. clear fluid should be checked for glucose.

Peripherally acting α-Adrenergic bockers

- doxazosin - prazosin - terazosin - decrease sympathetic vasoconstriction by reducing the effects of norepinephrine at peripheral nerve endings, resulting in vasodilation and decreased BP - used to maintain renal blood flow - used to treat HTN adverse effects: - orthostatic hypotension - reflex tachycardia - sodium and water retention - edema - weight gain - GI disturbances - drowsiness - nasal congestion interventions: 1. monitor vitals 2. monitor for fluid retention and edema 3. instruct the client to change positions slowly to prevent orthostatic hypotension 4. instruct the client in how to monitor the BP 5. instruct the client to monitor for edema 6. instruct the client to decrease salt intake 7. instruct the client to avoid OTC meds

Premature ventricular contractions (PVCs)

- early ventricular contractions result from increased irritability of the ventricles - PVCs frequently occur in repetitive patterns such as bigeminy, trigeminy, and quadrigeminy - the QRS complexes may be unifocal or multifocal (different shapes, with the impulse generating from different sites) interventions: 1. identify the cause and treat on the basis of the cause 2. evaluate O2 saturation and assess for hypoxemia, which can cause PVCs 3. evaluate electrolytes, particularly the K+ level because hypokalemia can cause PVCs 4. O2 and meds may be prescribed in the case of acute MI ** for the client experiencing PVCs, notify the PHCP or cardiologist if the client complains of chest pain or if the PVCs increase in frequency, are multifocal, occur on the T wave (R-on-T-phenomenon), or occur in runs of ventricular tachycardia**

newborn hyperbilirubinemia

- elevated serum bilirubin level (above 12) in a term newborn - therapy is aimed at preventing kernicterus, which results in permanent neurological damage resulting from the deposition of bilirubin in the brain cells assessment: - jaundice - elevated serum bilirubin levels - enlarged liver - poor muscle tone - lethargy - poor sucking reflex interventions: - monitor for the presence of jaundice, assess skin and sclera for jaundice - keep the newborn well hydrated to maintain blood volume - facilitate early, frequent feedings to speed up passage of meconium and encourage excretion of bilirubin - report to the PHCP any signs of jaundice in the first 24 hours of life and any abnormal signs and symptoms - prepare for phototherapy and monitor the newborn closely during the treatment - harming effects of phototherapy can occur, which are eye damage, dehydration, or sensory deprivation interventions: - follow specific instructions for phototherapy and biliblanket care - expose as much of the newborn's skin as possible - cover the genital area, and monitor the area for skin irritation or breakdown - cover the newborn's eyes with eye shields or patches, assure their eyelids are closed when they are applied - remove the shields or patches at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact and bonding with the parents - measure the lamp energy output with a photometer - monitor skin temp closely - increase fluids to compensate for water loss - expect loose green stools - monitor the newborn's skin color with the fluorescent light turned off, every 4-8 hours - monitor the skin for bronze baby syndrome, a grayish-brown discoloration of the skin, which is a complication of phototherapy - reposition the newborn every 2 hours - provide stimulation - if treatment is done at home, teach the parents about care and indications of the need to notify the PHCP - after treatment, continue monitoring for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued - turn off the phototherapy lights before drawing a blood specimen for serum bilirubin levels, and do not leave the specimen uncovered under fluorescent lights to prevent the breakdown of the bilirubin in the specimen

Proton pump inhibitors (PPIs)

- end in "prazole" - suppress gastric acid secretion - are used to treat active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions - contraindicated in hypersensitivity - common side effects are headache, diarrhea, abdominal pain, and nausea

The mechanisms of labor

- engagement: is the mechanism whereby the fetus nestles into the pelvis. it occurs when the presenting part reaches the level of the ischial spines - descent: is the process that the fetal head undergoes as it begins its journey through the pelvis. it is a continuous process from prior to engagement until birth and is assessed by the measurement of the station. - flexion: is a process of nodding of the fetal head forward towards the fetal chest - internal rotation: occurs at engagement into the pelvis - extension: enables the head to emerge when the fetus is in a cephalic position. it begins after the head crowns and is complete when the head passes under the symphysis pubis and occiput, and the anterior fontanel, brow, face, and chin pass over the sacrum and coccyx and are over the perineum. - restitution: is realignment of the fetal head with the body after the head emerges - external rotation: when the shoulders externally rotate after the head emerges and restitution occurs, so that the shoulders are in the anteroposterior diameter of the pelvis. - expulsion: is the birth of the entire body

Hyperosmolar hyperglycemic syndrome (HHS)

- extreme hyperglycemia occurs without ketosis or acidosis - usually occurs in people with type 2 DM assessment: - gradual onset - may be precipitated by infection, stressors, or poor fluid intake - manifested by altered CNS function with neurological symptoms - dehydration and electrolyte loss produces symptoms similar to DKA (polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, and coma) - lab values: glucose level > 800, serum ketones are negative, serum pH is not acidic, HCO3 is normal, and urine ketones are negative interventions: 1. treatment is similar to DKA 2. treatment includes fluid replacement, correction of electrolyte imbalances, and administration of insulin 3. fluid replacement in the older client must be done very carefully because of the potential for HF 4. insulin plays a less critical role in the treatment of HHS than it does for DKA since acidosis and ketones are negative, rehydration alone can decrease glucose levels in HHS.

Pediatric cardiovascular problems: mixed defects

- fully saturated systemic blood flow mixes with the desaturated blood flow, causing desaturation of the systemic blood flow - pulmonary congestion occurs and CO decreases - signs of HF are present, symptoms vary based on the degree of desaturation hypoplastic left heart syndrome: - underdevelopment of the left side of the heart occurs, resulting in a hypoplastic left ventricle and aortic atresia - mild cyanosis and signs of HF occur until the ductus arteriosus closes, then progressive deterioration with cyanosis and decreased CO are seen, leading to cardiovascular collapse - the defect is fatal in the first few months of life without intervention - surgical treatment: is needed, transplants in the newborn period are considered - in the pre-op period, the newborn requires mechanical ventilation and a continuous infusion of prostaglandin E1 to maintain ductal patency, ensuring adequate systemic blood flow Transposition of the great arteries or transposition of the great vessels: - the pulmonary artery leave the left ventricle and the aorta exits from the right ventricle - no communication exists between the systemic and pulmonary circulations - infants with minimal communication are severely cyanotic at birth - infants with large septal defects or a patent ductus arteriosus may be less severely cyanotic but may have symptoms of HF - cardiomegaly is evident a few weeks after birth - non-surgical management: - Prostaglandin E1 may be initiated to keep the ductus arteriosus open and to improve blood mixing temporarily - balloon atrial septostomy during cardiac catheterization may be performed to increase mixing from both sides of the heart and to maintain CO over a longer period of time - surgical management: - the arterial switch procedure re-establishes normal circulation with the left ventricle acting as the systemic pump and the creation of a new aorta total anomalous pulmonary venous connection: - the defect is a failure of the pulmonary veins to join the left atrium - the defect results in mixed blood being returned to the right atrium and shunted from the right to left through an ASD - the right side of the heart hypertrophies, whereas the left side of the heart may remain small - signs and symptoms of HF develop - cyanosis worsens with pulmonary vein obstruction, when obstruction occurs the infant's condition deteriorates rapidly - surgical management: - corrective repair is performed in early infancy - the pulmonary vein is anastomosed to the left atrium, the ASD is closed, and the anomalous pulmonary venous connection is ligated Truncus arteriosus: - is a failure of normal septation and division of the embryonic bulbar trunk into the pulmonary artery and aorta, resulting in a single vessel that overrides both ventricles - blood from both ventricles mixes into the common great artery, causing desaturation and hypoxemia - a murmur is present - the infant exhibits moderate to severe HF and variable cyanosis, poor growth, and activity intolerance - surgical management: - corrective surgical repair is performed in the first few months of life

Irritable bowel syndrome (IBS)

- functional disorder characterized by chronic or recurrent diarrhea, constipation, and abdominal pain or bloating - cause is unclear but may be influenced by environmental, immunological, genetic, hormonal, and stress factors interventions: 1. increase fiber 2. drink 8-10 cups of liquids per day 3. meds depend of symptoms but can include antidiarrheals or bulk-forming laxatives, lubiprostone or linaclotide for constipation-predominant IBS and alosetron for diahhrea-predominant IBS.

Amish beliefs related to end-of life care

- funerals are conducted in the home, are plain and simple - women are buried in their bridal dress at death - live on after death in heaven or hell - allow organ transplants except for the heart

newborn sepsis

- generalized infection from the presence of bacteria in the blood assessment: - pallor - tachypnea - tachycardia - poor feeding - abdominal distension - temperature instability interventions: - assess for periods of apnea or irregular respirations - if apnea is present, stimulate by gently rubbing the chest or foot - administer O2 as prescribed - monitor vitals, assess for fever - maintain warmth in a radiant warmer - provide isolation as needed - monitor I&O and obtain daily weight - monitor for diarrhea - assess feeding and sucking reflex, which may be poor - assess for jaundice - assess for irritability and lethargy - prepare for blood cultures and administer antibiotics as prescribed, and observe carefully for toxicity because a newborn's liver and kidneys are immature

newborn hypoglycemia

- glucose level less then 45 - normal glucose levels in a 1-day-old newborn is 45-60 and in a newborn older than 1 day is 50-90 assessment: - increased RR - twitching, nervousness, or tremors - unstable temp - lethargy, apnea, seizures, cyanosis interventions: - prevent low blood glucose level through early feedings - administer formula orally or glucose IV as prescribed - monitor for blood glucose levels as prescribed - monitor for feeding problems - monitor for periods of apnea - assess for shrill or intermittent cries - evaluate lethargy and poor muscle tone

Ovarian cancer

- grows rapidly, spreads fast, and is often bilateral - metastasis occurs by direct spread to the organs in the pelvis, by distal spread through the lymphatic system, or by peritoneal seeding - it is often asymptomatic in the early stages and most women are diagnosed in the later stages. it has a higher mortality rate than any other types of cancer in the female reproductive system, particularly among white women ages 55-65 and North American or European descent. - an exploratory laparotomy is performed to diagnose and stage the tumor - a transvaginal ultrasound may also be done for screening purposes but will not provide a definitive diagnosis assessment: - abdominal discomfort or swelling - GI disturbances - dysfunctional vaginal bleeding - abdominal mass - elevated tumor marker (A tumor marker is a biomarker found in blood, urine, or body tissues that can be elevated by the presence of one or more types of cancer) interventions: 1. external radiation may be used if the tumor has invaded other organs; intra-peritoneal radioisotopes may be instilled for a stage 1 disease 2. chemo is used post-op for most stages of ovarian cancer 3. intra-peritoneal chemo involves the instillation of chemo into the abdominal cavity 4. total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor debulking may be needed

Types of pelvis

- gynecoid: normal female pelvis, most favorable for successful labor and birth. - anthropoid: oval shaped, adequate outlet, narrow pubic arch - android: heart shaped or angulated, resembles male pelvis, not favorable for labor, cause slow descent and midpelvic arrest - platypelloid: flat with oval outlet, wide transverse diameter but short anteroposterior diameter making birth and vaginal labor difficult

Home care instructions for the client with hepatitis

- hand washing must be strict and frequent - do not share a bathroom unless the client is strict about personal hygiene - individual wash cloths, towels, utensils for eating, and toothbrushes and razors must be labeled and only used by the client - do not prepare food for other people - avoid alcohol and OTC meds (especially acetaminophen and sedatives) because they are hepatotoxic - increase activity gradually to prevent fatigue - consume small, frequent meals with high-carb low-fat foods - do not donate blood - you can have normal contact with people as long as strict hygiene is maintained - kissing/sexual activity should be discouraged until surface antigen results are negative - wear a medi-alert bracelet with the date of virus onset - inform health professionals of the onset of hepatitis - keep follow-up appointments with the PHCP

Risk conditions related to pregnancy: Hematoma

- hematoma is a collection of blood outside the vessels - assessment findings: abnormal, severe pain; pressure in perineal area, feels like she has to have a bowel movement; palpable, sensitive swelling in the perineal area, with discolored skin; inability to void; decreased Hg and Hct levels; and signs of shock, like pallor, tachycardia, and hypotension, if significant blood loss has occurred. - interventions: monitor vitals; monitor client for abnormal pain, especially when forceps delivery has been performed; apply ice to the hematoma site; administer analgesics as prescribed; monitor intake and output; encourage fluids and voiding, prepare for urinary catheterization if the client is unable to void; administer blood replacements as prescribed; monitor for signs of infection; administer antibiotics as prescribed because infection is common with hematoma formation; and prepare for incision and evacuation of the hematoma if necessary.

Hemoglobin and hematocrit

- hemoglobin serves as the vehicle for transporting O2 and CO2 - hematocrit is the RBC mass - normal levels for a male adult: Hg 14 - 18 Hct 42 - 52% - normal levels for a female adult: Hg 12 - 16 Hct 37 - 47% - fasting is not needed for this test - elevated Hg values may be caused by: COPD, high altitudes, polycythemia - elevated Hct values may be caused by: dehydration, high altitudes, polycythemia - below normal Hg values may be caused by: anemia or hemorrhage - below normal Hct values may be caused by: anemia, bone marrow failure, hemorrhage, leukemia, or overhydration

Fine crackles

- high-pitched crackling and popping noises heard during the end of inspiration and are not cleared by coughing. - may be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases.

Wheezes

- high-pitched, musical sound similar to a squeak. heard more commonly during expiration, but may also be heard during inspiration. occurs in small airways. - heard in narrow airway diseases such as asthma.

Pancreatic cancer

- highly malignant, grow rapidly, originate from the epithelium of the ductal system - is associated with increased age, history of diabetes, alcohol use, history of previous pancreatitis, smoking, ingestion of a high-fat diet, and exposure to environmental chemicals - usually no symptoms early on, prognosis is poor - endoscopic retrograde cholangiopancreatography for visualization of the pancreatic duct and biliary system and collection of secretions and tissue may be done assessment: - nausea and vomiting - jaundice - unexplained weight loss - clay-colored stools - glucose intolerance - abdominal pain interventions: 1. radiation and chemo 2. whipple procedure, which involves a pacreatic-duodenectomy with removal of the distal 1/3 of the stomach, and jejunum 4. post-op care measures and complications are similar to those for a client with pancreatitis and the client following gastric surgery; monitor blood glucose levels for transient hyper/hypoglycemia resulting from surgical manipulation of the pancreas

Dawn phenomenon

- hyperglycemia upon morning awakening that results in excessive early morning release of GH and cortisol - treatment requires an increase in the client's insulin dose or a change in their time of insulin administration

Hyperpituitarism (Acromegaly)

- hypersecretion of growth hormone by the anterior pituitary gland in an adult, caused primarily by pituitary tumors assessment: - large hands and feet - thickening and protrusion of the jaw - arthritic changes and joint pain - visual disturbances - diaphoresis - oily, rough skin - orangomegaly (abnormal enlargement of organs) - HTN, atherosclerosis, cardiomegaly, HF - dysphagia - deepening of the voice - thickening of the tongue, narrowing of the airway, sleep apnea - hyper-glycemia - colon polyps, increased colon cancer risk interventions: 1. provide meds to suppress GH or block its action 2. prepare the client for radiation of the pituitary gland if prescribed 3. prepare the client for hypophysectomy (surgical removal of the pituitary gland to treat cancerous or benign tumors) if planned 4. provide meds or non-pharm interventions for joint pain 5. provide emotional support to the client and family and encourage them to express feelings related to disturbed body image disturbance

Primary hypoaldosteronism (Conn's syndrome)

- hypersecretion of mineralocorticoids (aldosterone) from the adrenal cortex of the adrenal gland - most commonly is caused by an adenoma - excess secretion of aldosterone causes sodium and water retention and potassium excretion, leading to HTN and hyperkalemic alkalosis assessment: - symptoms related to hypokalemia, hypernatremia, and HTN - headache, fatigue, muscle weakness - cardiac dysrhythmias - paresthesias, tetany - visual changes - glucose intolerance - elevated serum aldosterone levels interventions: 1. monitor vitals 2,. monitor K+ and Na+ levels 3. monitor I&O and urine for specific gravity 4. monitor for hyperkalemia, especially for clients with impaired renal function or excessive K+ intake, because K+-retaining diuretics and aldosterone antagonists may be prescribed to promote fluid balance and control HTN 5. administer K+ supplements as prescribed to treat hypokalemia, clients taking K+-retaining diuretics and K+ supplements are at risk for hyperkalemia 6. prepare the client for an adrenalectomy 7. maintain sodium restriction post-op if prescribed 8. administer glucocorticoids pre-op as prescribed to prevent adrenal hypofunction and prepare for stress of surgery 9. monitor the client for adrenal insufficientcy post-op 10. instruct the client regarding the need for glucocorticoid therapy following adrenalectomy 11. instruct the client about the need to wear a medi-alert bracelet

Pediatric GI Problems: Hypertrophic pyloric stenosis

- hypertrophy of the muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. - it usually develops in the first few weeks of life, causing projectile vomiting, dehydration, metabolic alkalosis, and failure to thrive. assessment: - vomiting that progresses from mild regurgitation to forceful and projectile vomiting, it usually occurs after a feeding. - the vomit contains gastric contents such as milk or formula, may contain mucous, may be blood-tinged, and does not usually contain bile - hunger and irritability - peristaltic waves are visible from the left to right across the epigastrium during or immediately after a feeding - an olive-shaped mass in the epigastrium just right of the umbilicus - signs of dehydration and malnutrition - signs of electrolyte imbalances - metabolic alkalosis interventions: 1. monitor strict I&O 2. monitor vomiting episodes and stools 3. obtain daily weights 4. monitor for signs of dehydration and electrolyte imbalances 5. prepare the child and parents for pyloromyotomy if prescribed pyloromyotomy: - is an incision through the muscle fibers of the pylorus, may be performed laparoscopically pre-op interventions: 1. monitor hydration status by daily weights, I&O, and urine for specific gravity 2. correct fluid and electrolyte imbalances, administer fluids IV as prescribed 3. maintain NPO as prescribed 4. monitor the # and character of stools 5. maintain patency of the NG tube placed for stomach decompression post-op interventions: 1. monitor I&O 2. begin small, frequent feedings as prescribed 3. gradually increase the amount and interval between feedings until a full feeding schedule has been reinstated 4. feed the infant slowly, burp frequently, and handle the infant minimally after feedings 5. monitor for abdominal distention 6. monitor the surgical wound for signs of infection 7. instruct the parents about wound care and feedings

newborn of a diabetic mother

- hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, birth trauma, and congenital anomalies may be present assessment: - excessive size and weight as a result of excess fat and glycogen stores in tissues - edema or puffiness in the face or cheeks - signs of hypoglycemia, such as twitching, apnea, trouble breathing, lethargy, seizures, and cyanosis - hyperbilirubinemia - signs of respiratory distress such as tachypnea, cyanosis, retractions, grunting, and nasal flaring interventions: - monitor for signs of respiratory distress, birth trauma, and congenital anomalies - monitor bilirubin and glucose levels - monitor weight - feed the newborn soon after birth with breast milk or formula as prescribed - administer glucose IV to treat hypoglycemia if needed and as prescribed - monitor for edema - monitor for respiratory distress, tremors, or seizures

Hypopituitarism

- hyposecretion of 1 or more pituitary hormones - most commonly are the growth hormone (GH), luteinizing hormone, and follicle-stimulating hormone. assessment: - mild to moderate obesity (GH, TSH) - reduced CO (GH, ADH) - infertility, sexual dysfunction - fatigue, low bp - tumors of the pituitary may also cause headaches and visual defects interventions: 1. the client may need hormone replacement for the specific deficit hormones 2. provide emotional support to the client and family 3. encourage the client and family to express feelings related to body image disturbance or sexual dysfunction 4. client education is needed regarding the signs and symptoms of hypo-function and hyper-function related to insufficient or excess hormone replacement

diabetes insipidus

- hyposecretion of ADH by the posterior pituitary gland caused by stroke, trauma, or surgery, or it may have no cause - kidney tubules fail to resorb water - there is decreased ADH production, or ADH production is adequate, but kidneys do not respond appropriately to the ADH assessment: - excretion of large amounts of diluted urine - polydipsia - dehydration - inability to concentrate urine - low urine specific gravity (normal is 1.010-1.025) - fatigue - muscle pain and weakness - headache - postural hypotension that may progress to vascular collapse without rehydration - tachycardia interventions: 1. monitor vitals, neurological, and cardiovascular status 2. provide a safe environment 3. monitor electrolytes and for signs of dehydration 4. maintain intake of adequate fluids, IV hypotonic saline may be prescribed ti replace urinary losses 5. monitor I&O, weight, serum osmolality, and specific gravity of urine for excessive urinary output, weight loss, and low urinary specific gravity 6. instruct the client to avoid food or fluids that produce diuresis 7. vasopressin or desmopressin acetate may be prescribed, these are used with ADH deficiency if severe or chronic 8. instruct the client in the administration of meds as prescribed, desmopressin acetate may be administered by subcutaneous route, IV, intra-nasally, or orally; water for signs of water intoxication indicating over treatment 9. instruct the client to wear a medialert bracelet

Ventricular fibrillation

- impulses from many irritable foci in the ventricles fire in a totally disorganized manner - is a chronic rapid rhythm in which the ventricles quiver and there is no CO - VF is fatal if not resolved within 3-5 minutes - the client is unconscious with no pulse, BP, respirations, or heart sounds interventions: 1. initiate CPR until a defibrillator is available 2. the client is defibrillated immediately, check to make sure no one is touching the client or bed, when clear proceed with defibrillation 3. CPR is continued for 2 minutes, and the cardiac rhythm is reassessed to determine the need for further countershock 4. administer O2 as prescribed 5. administer antidysrhythmic therapy as prescribed

Thrombolytic medications

- include Alteplase and Tenecteplase - activate plasminogen which generates plasmin; the enzyme that dissolves clots. - they are used early in the course of a MI (within 4-6 hours after its onset), to restore blood flow, limit myocardial damage, preserve left ventricular function, and prevent death. - they are also used in arterial thrombosis, deep vein thrombosis, occluded shunts or catheters, and pulmonary emboli. contraindications: 1. active internal bleeding 2. history of hemorrhagic stroke 3. intracranial problems, including trauma 4. intracranial or intra-spinal surgery within the past 2 months 5. thoracic, pelvic, or abdominal surgery in the previous 10 days 6. history of hepatic or renal disease 7. uncontrolled HTN 8. recent, prolonged cardiopulmonary resuscitation 9. known allergy to the product or its preservatives adverse effects: 1. bleeding 2. dysrhythmias 3. allergic reactions interventions: 1. determine aPTT, PT, fibrinogen level, hematocrit, and platelet level 2. monitor vital signs 3. assess pulses 4. monitor for bleeding and check all excretions for occult blood 5. monitor for neurological changes such as slurred speech, lethargy, confusion, and hemiparesis 6. monitor for hypotension and tachycardia 7. avoid injections and venipunctures if possible 8. apply direct pressure over a puncture site for 20-30 minutes 9. handle the client gently and as little as possible when moving 10. instruct the client to use an electric razor for shaving and to brush teeth gently 11. withhold the med if bleeding develops, and notify the PHCP 12. aminocaproic acid is the antidote **bleeding is the primary concern for a client taking an anticoagulant, thrombolytic, or anti-platelet med**

parathyroid medications

- includes oral calcium supplements, vitamin D supplements, biophosphonates and calcium regulators, and meds to treat hypercalcemia - they regulate serum calcium levels - low levels of calcium stimulate parathyroid hormone release - hyperparathyroidism results in a high serum calcium level and bone demineralization, so meds are used to lower the calcium level - hypoparathyroidism causes low serum calcium level, which increases neuromuscular excitability, and treatment include calcium and vitamin D supplements. - calcium salts administered with digoxin increase the risk of digoxin toxicity - oral calcium salts reduce the absorption of tetracycline hydrochloride interventions: 1. monitor electrolyte and calcium levels 2. assess for signs and symptoms of hypocalcemia and hypercalcemia 3. assess for symptoms of tetany in the client with hypocalcemia 4. assess for renal calculi in the client with hypercalcemia 5. instruct the client on the signs and symptoms of hypercelcemia and hypocalcemia 6. instruct the client to check over-the-counter meds for calcium content 7. instruct the client receiving oral calcium supplements to maintain an adequate intake of vitamin D, because it enhances the absorption f calcium 8. instruct the client receiving calcium regulators such as alendronate sodium to swallow the tablet whole with water at least 30 minutes before breakfast and to not lie down for 30 minutes 9. instruct the client using nasal spray of calcitonin to alternate the nares 10. instruct the client using antihypercalcemic agents to avoid foods high in calcium including green leafy veggies, dairy, shellfish, and soy 11. instruct the client not to take other meds within 1 hour of taking a calcium supplement 12. instruct the client to increase fluid and fiber in the diet to prevent constipation associated with calcium supplements

Hepatitis A

- increased risk with crowded conditions and exposure to poor sanitation - transmission is by the fecal-oral route, person to person contact, parenteral, contaminated fruits or veggies or uncooked shellfish, contaminated water or milk, or poorly washed utensils. - incubation period is 2-6 weeks - infectious period is 2-3 weeks before and 1 week after the development of jaundice - diagnosed by the presence of HAV antibodies, increased levels of Immunoglobulin M and G which indicate infection and inflammation, ongoing inflammation of the liver, and previous infection is indicated by increased levels of Immunoglobulin G antibodies. - complication is fulminant (acute and fatal) hepatitis - prevention is by **strict hand washing**, stool and needle precautions, treatment of water supplies, serological screening of food handlers, hepatitis A vaccine (2 doses at 6 months apart), and administer immune globulin for individuals exposed who have never had the vaccine during the incubation period within 2 weeks of exposure. - immune globulin and hepatitis A vaccine are recommended for household members and sexual contacts of individuals with hepatitis A - pre-exposure prophylaxis with immune globulin is recommended for people traveling to countries with poor or uncertain sanitation conditions.

pneumonia

- infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles - the edema associated with inflammation stiffens the lungs, decreases lung compliance and vital capacity, and causes hypoxemia - pneumonia can be community-acquired or hospital-acquired - the chest x-ray film shows lobar or segmental consolidation, pulmonary infiltrates, or pleural effusions - a sputum culture identifies the organism - the WBC count and the RBC sedimentation rate are increased assessment: - chills - fever - pleuritic pain - tachypnea - rhonchi and wheezes - use of accessory muscles for breathing - mental status chages - sputum production interventions: 1. administer O2 as prescribed 2. monitor respiratory status 3. monitor for labored respirations, cyanosis, and cool and clammy skin 4. encourage coughing and deep breathing and use of the incentive spirometer 5. place the client in a semi-fowler's position to facilitate breathing and lung expansion 6. change the client's position often and ambulate as tolerated to mobilize secretions 7. provide chest physiotherapy 8. perform nasotracheal suctioning if the client is unable to clear secretions 9. monitor pulse oximetry 10. monitor and record color, consistency, and amount of sputum 11. provide a high-calorie, high-protein diet with small frequent meals 12. encourage fluids up to 3L/day to thin secretions unless contraindicated 13. provide a balance of rest and activity, increasing activity gradually 14. administer antibiotics as prescribed 15. administer antipyretics, bronchodilators, cough suppressants, mucolytic agents, and expectorants as prescribed 16. prevent the spread of infection by hand-washing and the proper disposal of secretions client education: 1. the importance of rest, proper nutrition, and adequate fluid intake 2. to avoid chilling and exposure to people with respiratory infections or viruses 3. regarding meds and the use of inhalants as prescribed 4. to notify the PHCP if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs ** teach clients that proper hand washing techniques, disposing of respiratory secretions properly, and receiving vaccinations assist in preventing the spread of the infection ** pneumococcal conjugate vaccine: - is used for the prevention of invasive pneumococcal disease in infants and children - pneumococcal polysaccharide vaccine is used for adults and high-risk kids under than age 2 - adverse effects are erythema, swelling, pain, and tenderness at the injection site, fever, irritability, drowsiness, and reduced appetite

Appendicitis

- inflammation of the appendix - rupture of the appendix may occur within hours, leading to peritonitis and sepsis assessment: - pain in the peri-umbilical area that descends to the RLQ - abdominal pain that is the most intense at McBurney's point - rebound tenderness and abdominal rigidity - low-grade fever - elevated WBC count - anorexia, nausea, vomiting - client in the side-lying position, with abdominal guarding and legs flexed - constipation or diarrhea appendectomy: - surgical removal of the appendix pre-op interventions: 1. maintain NPO 2. administer IV fluids to prevent dehydration 3. monitor for changes in pain level 4. monitor for signs of ruptured appendix and peritonitis (guarding of the abdomen, increased temp and chills, pallor, progressive abdominal distention and pain, restlessness, and tachycardia and tachypnea) 5. position the client in a right side-lying or low to semi-fowler's position to promote comfort 6. monitor bowel sounds 7. apply ice packs to the abdomen for 20-30 minutes every hour if prescribed 8. administer antibiotics as prescribed 9. avoid laxatives or enemas ** avoid application of heat to the abdomen for a client with appendicitis, because heat can cause rupture of the appendix leading to peritonitis, a life-threatening condition ** post-op interventions: 1. monitor temp and for signs of infection 2. assess incision for signs of infection like redness, swelling, or pain 3. maintain NPO status until bowel function has returned 4. advance the diet gradually as tolerated and as prescribed, when bowel sounds return 5. if the appendix did rupture expect a drain to be inserted, or the incision may be left open to heal from the inside out 6. expect that drainage from the drain may be profuse for the first 12 hours 7. position the client in a right side-lying or low to semi-fowler's position with the legs flexed to facilitate drainage 8. change the dressing as prescribed and record the type and amount of drainage 9. perform wound irrigations if prescribed 10. maintain NG tube suction and patency of the NG tube if present 11. administer antibiotics and analgesics as prescribed

Pediatric respiratory problems: Epiglottitis

- inflammation of the epiglottis caused by bacteria, kids with the Hib vaccine are at less risk - abrupt onset, most often in winter - emergency because it can progress to respiratory distress assessment: - high fever - sore, red, inflamed throat and pain on swallowing - absence of spontaneous cough - muffled voice, dysphagia, dyspnea, drooling - agitation - retractions as the child struggles to breathe - inspiratory stridor aggravated by the supine position - tachycardia - tachypnea progressing to more severe respiratory distress - tripod positioning: while supporting the body with the hands, the child leans forward, thrusts their chin forward, and opens their mouth in an attempt to widen the airway. - a fiberoptic nasal laryngectomy may be needed to assist in the dx interventions: 1. maintain a patent airway 2. assess respiratory status and breath sounds, noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor 3. do not take temp by the oral route 4. monitor the pulse ox 5. prepare the child for lateral neck films to confirm the dx 6. do not leave the child unattended 7. avoid placing the child in the supine position, because this position would affect the respiratory status further 8. maintain NPO 9. do not restrain or do anything to agitate the child 10. administer IV fluids as prescribed 11. administer IV antibiotics as prescribed, they are usually followed by PO antibiotics 12. administer analgesics and antipyretics (acetaminophen or ibuprofen) to reduce fever and throat pain as prescribed 13. administer corticosteroids to decrease inflammation and throat edema as prescribed 14. Heliox (mixture of O2 and helium) may be prescribed to reduce the work load of breathing, reduce airway turbulence, and helps relieve airway obstruction 15. provide cool mist O2 therapy as prescribed, high humidification cools the airway and decreases swelling 16. have resuscitation equipment available, and prepare for endotracheal intubation or tracheotomy for severe respiratory distress 17. ensure that the child is up to date with immunizations, including Hib conjugate vaccine

Pancreatitis

- inflammation of the pancreas that can be acute or chronic, with associated escape of pancreatic enzymes surrounding the tissue - acute pancreatitis occurs suddenly as 1 attack or can be recurrent, with resolutions - chronic pancreatitis is continual inflammation and destruction of the pancreas, with scar tissue replacing pancreatic tissue - precipitating factors include trauma, alcohol use, biliary tract disease, viral or bacterial disease, hyperlipidemia, hypercalcemia, cholelithiasis, hyperparathyroidism, ischemia vascular disease, and peptic ulcer disease acute pancreatitis: - assessment: - abdominal pain, with sudden onset at the midepigastric or LUQ with radiation to the back - pain aggravated by a fatty meal, alcohol, or lying in a recumbent position (lying down) - abdominal tenderness and guarding - nausea and vomiting - weight loss - absent or decreased bowel sounds - elevated WBCs and elevated glucose, bilirubin, alkaline phosphatase, and urinary amylase levels - elevated serum lipase and amylase levels - cullen's sign (discoloration of the abdomen and preiumbilical area) - turner's sign (bluish discoloration of the flanks) - interventions: 1. withhold food and fluid during the acute period and maintain hydration with IV fluids as prescribed 2. administer parenteral nutrition for severe nutritional depletion 3. administer supplemental preparations and vitamins and minerals to increase caloric intake as prescribed 4. an NG tube may be inserted if the client is vomiting or has biliary obstruction or paralytic ileus 5. administer opiates as prescribed for pain 6. administer H2 receptor antagonists or PPIs as prescribed to decrease hydrochloric acid production and prevent activation of pancreatic enzymes 7. instruct the client in the importance of follow-up visits 8. instruct the client to notify the PHCP if acute abdominal pain, jaundice, clay-colored stools, or dark-colored urine develops chronic pancreatitis: - assessment: - abdominal pain and tenderness - LUQ mass - steatorrhea and foul-smelling stools that may increase in volume as pancreatic insufficiency increases - weight loss - muscle wasting - jaundice - signs and symptoms of DM interventions: 1. instruct the client in the prescribed dietary measures (fat and protein intake may be limited) 2. instruct the client to avoid heavy meals 3. importance of avoiding alcohol 4. provide supplemental preparations and vitamins and minerals to increase caloric intake 5. administer pancreatic enzymes as prescribed to aid in the digestion and absorption of fat and protein 6. administer insulin or oral hypoglycemic meds as prescribed to control DM if present 7. instruct the client on the use of pancreatic enzyme meds 8. instruct the client on the treatment plan for glucose management 9. instruct the client to notify the PHCP if increased steatorrhea, abdominal distention or cramping, or skin breakdown develop 10. instruct the client on the importance of follow-up visits

Pediatric respiratory problems: pneumonia

- inflammation of the pulmonary parenchyma or alveoli or both, and may be caused by a virus, bacteria, or aspiration of a foreign substance - viral pneumonia occurs most common and is associated with a viral upper respiratory infection - prevention is with a pneumonia vaccine assessment: - for viral pneumonia - acute or insidious onset - range from mild fever, slight cough, and malaise to high fever, severe cough, and diaphoresis - non-productive or productive cough with whitish sputum - wheezes or fine crackles - for bacterial pneumonia - infant may show irritability, lethargy, poor feeding, abrupt fever, respiratory distress, and may have seizure if fever is very high - older child may have headache, chills, abdominal pain, and chest pain - hacking, non-productive cough - diminished breath sounds or scattered crackles - decreased breath sounds - as the infection resolves, the cough becomes productive and the cild expectorated purulent sputum, and coarse crackles and wheezing are noted interventions: - for viral pneumonia - treatment is symptomatic - administer O2 with cool humidified air - increase fluids - administer antipyretics for fevers - provide chest physiotherapy and postural drainage as prescribed - for bacterial pneumonia - blood cultures are taken and antibiotic therapy is initiated as soon as the dx is suspected, IV antibiotics are usually prescribed - administer O2 for respiratory distress and monitor pulse ox - place child in a cool mist tent as prescribed, cool humidification moistens the airways and assists in temp reduction - use a bulb syringe to suction mucus from the infant - administer chest physiotherapy and postural drainage every 4 hours - promote bed rest to conserve energy - encourage the child to lie on the affected side to splint the chest and reduce discomfort caused by pleural rubbing - encourage fluids - administer antipyretics for fever - monitor temp frequently because they have increased risk of febrile seizures - institute isolation precautions with pneumococcal or staphylococcal pneumonia - administer cough suppressants as prescribed before rest times and meals - continuous closed drainage may be needed if purulent fluid is present - fluid accumulation in the pleural cavity may be removed by thoracentesis, which also provides a means of obtaining fluid for culture and for instilling antibiotics directly into the pleural cavity

Gastritis

- inflammation of the stomach or gastric mucosa - acute gastritis is caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin and other NSAIDs, excessive alcohol intake, bile reflux, or radiation therapy. - chronic gastritis is caused by benign or malignant ulcers or by the bacteria H. pylori, and also may be caused by autoimmune diseases, dietary factors, meds, alcohol, smoking, or reflux. assessment: - acute gastritis: abdominal discomfort, anorexia, nausea, vomiting, headache, hiccuping, and reflux. - chronic gastritis: anorexia, nausea, vomiting, belching, heartburn after eating, sour taste in the mouth, and vitamin B12 deficiency interventions: 1. acute gastritis: food and fluids may be withheld until symptoms subside, afterward ice chips can be given followed by clear liquids and then solid foods as prescribed 2. monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and hypotension, and notify the PHCP if these occur. 3. instruct the client to avoid irritating foods, fluids, and other substances like highly seasoned or spicy foods, alcohol, caffeine, or nicotine 4. instruct the client in the use of prescribed meds such as antibiotics to treat H. pylori and antacids 5. provide the client with info about the importance of vitamin B12 injections if a deficiency is present

Pleurisy

- inflammation of the visceral and parietal membranes; may be caused by pulmonary infarction or pneumonia. - the visceral and parietal membranes rub together during respiration and cause pain. - pleurisy usually occurs on 1 side of the chest, usually in the lower lateral portions in the chest wall. assessment: - knife like pain aggravated on deep breathing and coughing - dyspnea - pleural friction rub heard on auscultation interventions: 1. identify and treat the cause 2. monitor lung sounds 3. administer analgesics as prescribed 4. apply hot or cold applications as prescribed 5. encourage coughing and deep breathing 6. instruct the client to lie on the affected side to splint the chest

Pediatric integumentary problems: eczema (dermatitis)

- inflammatory process of the epidermis - associated with family history, allergies, asthma, or allergic rhinitis - goals of management are to relieve the pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections - eczema in the infant: begins at 2-6 months of age and decreases with aging, spontaneous remission may occur at age 3 - eczema in childhood: occurs at age 2-3 - eczema in the adolescent: begins around age 12 and continues into the adult years or indefinitely - assessment: redness, scaliness, itching, minute papules (firm elevated lesions less than 1 cm in diameter), vesicles (similar to papules but filled with fluid), weeping oozing and crusting of lesions, lesions can occur on the scalp and face in infants, and creases of elbows, knees, wrists, ankles, and between buttocks and legs. - interventions: 1. baths and moisturizers are important, bath should be limited to 5-10 minutes, temp of water should be tepid. skin should be moisturized right after a bath. 2. topical meds should be applied within 3 minutes after a bath 3. anti-histamines and topical corticosteroids may be prescribed, corticosteroids are applied in a thin layer and rubbed into the area thoroughly 4. antibiotics may be prescribed for secondary infections 5. avoid exposure to skin irritants like irritating soaps, detergents, fabric softeners, diaper wipes, and powder 6. apply cool, wet compresses for short periods of time to soothe and alleviate itching, pat the skin dry 7. prevent of minimize scratching 8. eliminate conditions that increase itching like wet diapers, excessive bathing, ambient heat, woolen clothes, and rough fabrics or furry stuffed animals, and avoid exposure to latex 9. parents should wash clothing in a mild detergent and rinse throughly, putting the clothes through a second complete wash cycle without detergent to minimize residue remaining on the fabric 10. parents should initiate measures to prevent skin infections 11. parents should monitor lesions for signs of infection (honey-colored crusts with surrounding redness) and should seek medical intervention if noted.

Risk conditions related to pregnancy: HIV and AIDS

- interventions in the prenatal period: institute measures to prevent opportunistic infections, and avoid procedures that increase the risk of perinatal transmission, such as amniocentesis and fetal scalp sampling - interventions in the intrapartum period: avoid the use of internal scalp electrodes to monitor the fetus, avoid episiotomy to decrease the amount of maternal blood in the birth canal; avoid administering oxytocin because contractions induced by oxytocin can be strong and cause vaginal tears or necessitate an episiotomy; place heavy absorbent pads under the mom's hips to absorb amniotic fluid and blood; minimize the neonate's exposure to maternal blood and body fluids, and promptly remove the neonate from the mother's blood after delivery; suction fluids from the neonate promptly; and prepare to administer zidovudine as prescribed to the mother during labor and delivery - interventions during the postpartum period: monitor for signs of infection; place the mother in protective isolation if she is immunosuppressed; breast-feeding is restricted; instruct the mother to monitor for signs of infection and report them if they occur; and the newborn may room with the mother, however it may be placed in the NICU for the first 24 hours to complete lab work and receive the initial treatment.

Iron-deficiency anemia

- iron stores are depleted, resulting in a decreased iron supply for the manufacture of Hgb in RBCs. it commonly results from blood loss, increased metabolic demands, syndromes of GI malabsorption, and dietary inadequacy. assessment: - pallor - weakness and fatigue - low Hgb, Hct, and mean cellular volume levels - RBCs that are microcytic and hypochromic interventions: 1. increase oral intake of iron and instruct client in food choices that have a lot of iron 2. administer iron supplements as prescribed 3. IM injections of iron or IV administration are used for severe cases 4. teach the client how to administer the iron supplements: take between meals, take with a multivitamin or fruit juice because vitamin C increases its absorption, do not take with milk or antacids because they will decrease its absorption, instruct the client on the side effects of iron supplements (black stools, constipation, and foul aftertaste), and liquid iron preparations stain the teeth, they should be taken through a straw and the teeth should be brushed after.

pediatric hematological problems: Iron deficiency anemia

- iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs, RBCs are microlytic (small) and hypochromic (less color than normal) - liquid iron preparations may be prescribed, teach the parents and child that it should be taken through a straw and the teeth should be brushed after administration

newborn syphilis

- is a STI - congenital syphilis can cause premature birth, skin lesions, and abnormal skeletal development - causative organism is Treponema pallidum, a spirochete, which is able to cross the placenta throughout pregnancy and infect the fetus, usually after 18 weeks' gestation - risks include preterm birth, stillbirth, and low birth weight - congenital effects are irreversible and may include CNS damage and hearing loss assessment: - hepatosplenomegaly - joint swelling - palmar rash and lesions - anemia - jaundice - snuffles - ascites - pneumonitis - cerebrospinal fluid changes interventions: - monitor the newborn for signs of syphilis - prepare the newborn for serological testing if prescribed - administer antibiotic therapy as prescribed - use standard precautions and drainage and secretion (contact) precautions with suspected congenital syphilis - wear gloves when handling the newborn until antibiotic therapy has been administered for 24 hours - provide psychological support to the mother, and provide instructions regarding follow-up care to the newborn

Risk conditions related to pregnancy: chroioamnionitis

- is a bacterial infection of the amniotic cavity, it can result from premature or prolonged rupture of the membranes, vaginitis, amniocentesis, or intrauterine procedures. - assessment will show uterine tenderness and contractions, elevated temp, maternal or fetal tachycardia, foul odor to amniotic fluid, and leukocytosis. - interventions are to monitor maternal vitals and FHR; monitor for uterine tenderness, contractions, and fetal activity; monitor results of blood cultures; prepare for amniocentesis to obtain amniotic fluid for a gram stain and leukocyte count and other testing as prescribed; administer antibiotics as prescribed after cultures are obtained; administer oxytocic meds as prescribed to increase uterine tone; and prepare to obtain neonatal cultures after birth.

Digoxin

- is a cardiac glycoside. these inhibit the sodium-potassium pump, thus increasing intracellular calcium, which causes the heart muscle fibers to contract more efficiently. - they produce a positive inotropic action, which increases the force of myocardial contractions. - cardiac glycosides produce a negative chronotropic action, which slows the heart rate. - cardiac glycosides produce a negative dromotropic action that slows conduction velocity through the AV node - the increase in myocardial contractility increases cardiac, peripheral, and kidney function by increasing CO, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. As a result, fluid retention in the lungs and extremities is decreased. - it is a second-line drug for HF and cardiogenic shock, atrial tachycardia, atrial fibrillation, and atrial flutter; they are used less-frequently for rate control in atrial dysrhythmias (BBs and CCBs are used more often) - these meds are contraindicated in those with ventricular dysrhythmias and second or third-degree heart block. they should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia adverse effects: - anorexia, nausea, vomiting, diarrhea - bradycardia - visual disturbances: diplopia, blurred vision, yellow vision, photophobia - headache - fatigue, weakness - drowsiness **early signs of digoxin toxicity present as GI manifestations (anorexia, nausea, vomiting, diarrhea); then, HR abnormalities and visual disturbances appear** interventions:L 1. monitor for toxicity evidenced by anorexia, nausea, vomiting, visual disturbances (blurred or yellow vision), and dysrhythmias 2. monitor serum digoxin level, electrolyte levels, and renal function test results 3. the optimal therapeutic range for digoxin is 0.5-2.0 however a level on the low end may be preferred to avoid toxicity 4. an increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, or hypothyroidism 5. monitor the K+ level; if hypokalemia occurs, notify the PHCP 6. instruct the client to avoid OTC meds 7. monitor the client taking a K+-losing diuretic or corticosteroids closely for hypokalemia, because it can cause digoxin toxicity 8. note that older clients are more sensitive to digoxin toxicity 9. advise the client to eat foods high in K+ such as fresh and dried fruits, fruit juices, veggies, and potatoes 10. monitor the apical pulse for 1 full minute; if it is lower than 60 bpm, the med should be withheld and the PHCP should be notified 11. teach the client how to measure the pulse and t notify the PHCP if the pulse rate is lower than 60 or more than 100 bpm 12. teach the client the signs and symptoms of toxicity 13. antidote to digoxin is digoxin immune fab, and is used in extreme toxicity

Acne Vulgaris

- is a chronic skin disorder that usually begins in puberty and is more common in males, and lesions develop of the face, neck, chest, shoulders, and back. - it requires active treatment for control until it goes away interventions: 1. instruct the client on prescribed skin cleansing methods, with emphasis on not scrubbing the face and only using what's prescribed. 2. instruct the client in the administration of topical or oral meds as prescribed 3. instruct the client not to squeeze, prick, or pick at the lesions 4. instruct the client to use products that are labeled non-comedogenic and cosmetics that are water based 5. instruct the client on the importance of follow-up treatment

Psoriasis

- is a chronic, non-infectious skin inflammation occurring with remissions and exacerbations involving keratin synthesis that results in psoriatic patches; it may lead to an infection of the affected area - various forms exist, with psoriasis vulgaris being the most common - possible causes include stress, trauma, infection, hormonal changes, obesity, an autoimmune reaction, and climate changes; a genetic predisposition may also be the cause - the disorder can be exacerbated by the use of certain medications - Koebner phenomenon is the development of psoriatic lesions at a site of injury; prompt cleansing of the area may lessen or prevent this phenomenon - in some people with psoriasis, arthritis develops, which leads to joint changes similar to those seen in rheumatoid arthritis - the goal of therapy is to reduce cell proliferation and inflammation, and the type of therapy prescribed depends on the extent of the disease and the client's response to the treatment assessment: - pruritus - shedding silvery-white scales on a raised, reddened, round plaque that usually affects the scalp, knees, elbows, extensor surface of arms and legs, and sacral regions - yellow discoloration, pitting, and thickening of the nails or joints if they are affected - joint inflammation with psoriatic arthritis interventions: 1. provide emotional support to the client with affected body image alterations and decreased self-esteem 2. instruct the client on the use of prescribed therapies and to avoid over-the-counter meds 3. instruct the client not to scratch the affected area and keep the skin lubricated to minimize itching 4. monitor for and instruct the client to recognize and report signs and symptoms of secondary skin problems such as infection 5. instruct the client to wear light cotton clothing over affected areas 6. assist the client to identify ways to reduce stress if stress is a predisposing factor

Pediatric metabolic and endocrine problems: dehydration

- is a common fluid and electrolyte imbalance in infants and children - the organs that conserve water in infants and children are immature, placing them at risk for fluid volume deficit - causes include decreased fluid intake, diaphoresis, vomiting, diarrhea, diabetic ketoacidosis, and extensive burns or serious injuries assessment: - weight loss - tachycardia - tachypnea - orthostatic hypotension - irritable and thirsty - dry mucous membranes - decreased tears, sunken eyes - sunken anterior fontanel if severe - slowed capillary refill - oliguria or anuria interventions: - treat and eliminate the cause of the dehydration - monitor vitals - monitor weight - monitor I&O and urine for specific gravity - monitor LOC - monitor skin turgor and mucous membranes for dryness - for mild to moderate dehydration, provide oral rehydration therapy with pedialyte or a similar rehydration solution as prescribed, avoid carbonated beverages and fluids that contain high amounts of sugar - for severe dehydration, maintain NPO status to let the bowel rest and provide fluid and electrolyte replacement by the IV route as prescribed, if K+ is prescribed for IV administration, ensure the child has voided before administering and has adequate renal function - reintroduce a normal diet when rehydration is achieved - provide instructions to the parents about the types and amounts of fluid to encourage, signs for dehydration, and indications to notify the PHCP

Pediatric GI Problems: Hirschsprung's disease

- is a congenital anomaly that occurs as a result of an absence of ganglion cells in the rectum and other areas of the affected intestine. - mechanical obstruction results due to inadequate motility in a segment of the intestine - it may be a family congenital defect or may a result of another anomaly like Down's syndrome or genitourinary abnormalities. - a rectal biopsy specimen shows histological evidence of the absence of ganglionic cells - the most serious complication is enterocolitis; signs include fever, severe prostration, GI bleeding, and explosive diarrhea. - treatment is based on relieving chronic constipation with a stool softener and rectal irrigations, however many children require surgery. - treatment involves a 2-step procedure: - initially in the neonatal period, a temporary colostomy is made to relieve obstruction and allow the bowel to return to its normal size. - when the bowel returns to its normal size, a complete surgical repair is performed by a pull-through procedure to excise portions of the bowel, and the colostomy is closed. - assessment: - newborns: - failure to pass meconium stool - refusal to suck - abdominal distension - bile-stained vomit - children: - failure to gain weight and decreased growth - abdominal distension - vomiting - constipation alternating with diarrhea - ribbon-like and foul-smelling stools - interventions: - maintain a low-fiber, high-calorie high-protein diet - administer stool softeners as prescribed - administer daily rectal irrigations with normal saline to promote adequate elimination and prevent obstruction as prescribed - pre-op interventions: - assess bowel function - administer bowel prep as prescribed - maintain NPO status - monitor hydration and fluid and electrolyte status, provide fluids IV as prescribed for hydration - administer antibiotics or colonic irrigations with an antibiotic solution as prescribed to clear the bowel of bacteria - monitor strict I&O - obtain daily weight - measure abdominal girth daily - avoid taking the temp rectally - monitor for respiratory distress associated with abdominal distention - post-op interventions: - monitor vitals, avoid taking the temp rectally - measure abdominal girth daily and as needed - assess the surgical site for redness, swelling, and drainage - assess the stoma if present for bleeding or skin breakdown, it should be red and moist - assess the anal area for the presence of stool, redness, or discharge - maintain NPO status as prescribed and until bowel sounds return to normal or flatus is passed, usually 48-72 hours - maintain NG tube to allow intermittent suction until peristalsis returns - maintain IV fluids until the child tolerates appropriate oral intake, advancing the diet from clear liquids to regular as tolerated and prescribed - assess for dehydration and fluid overload - monitor strict I&O - obtain daily weight - assess for pain and provide comfort measures - provide the parents with instructions regarding colostomy and skin care - teach the parents about the appropriate diet and the need for adequate fluid intake

Pediatric integumentary problems: Impetigo

- is a contagious bacterial infection of the skin caused by hemolytic streptococci or staphylococci or both, it occurs most often during hot and humid months. - can occur due to poor hygiene, and can be a primary or secondary infection. - most common sites of infection are the face, around the mouth, hands, neck, and extremities. - the lesions begin as vesicles or pustules surrounded by edema and redness and progress to an exudative and crusting stage; after they crust the fluid becomes cloudy and they rupture, leaving honey-colored crusts covering ulcerated bases. - assessment: blisters and crusts, redness, pruritus, burning, and secondary lymph node involvement can be present. - interventions: 1. institute contact isolation; also use standard precautions and implement agency-specific isolation procedures for the hospitalized child; strict hygiene practices are important, because impetigo is highly contagious. 2. apply topical antibiotic ointments with a clean/sterile cotton swab without touching the tube opening, and instruct parents on the ointment and swab use; the infection is still communicable for 24-48 hours beyond the initiation of antibiotics 3. cover lesions with gauze bandages and tape to prevent spread of infection 4. assist the child with bathing daily with anti-bacterial soap 5. apply warm water compresses to the lesions 2-3 times a day, and rinse with mild soap and water to soften crusts for removal and to promote healing 6. oral antibiotics may be prescribed if there is no response to topical antibiotic treatment, it is very important to comply with the antibiotic regimen because secondary infections can result, and if the infectious agent is a streptococcal type it can infect the nephrons 7. apply moisturizers to prevent skin cracking and instruct parents on their use 8. instruct parents on how to prevent spread of infection, and to practice careful hand washing 9. inform parents the child needs to use separate towels, linens, eating utensils, and dishes 10. inform parents that all linen and clothing used by the child should be washed with detergent and hot water separately from those of other household members

Congenital clubfoot

- is a deformity of the ankle and foot that includes forefoot adduction, midfoot spination, hindfoot varus, and ankle equinus; the defect may be unilateral or umbilical - the goal of treatment is to achieve a painless planigrade (ability to walk on the sole of the foot with the heel on the ground) and stable foot. - long-term interval follow-up care is required until the child reaches skeletal maturity assessment: - deformities are described on the basis of the position of the ankle and foot - Talipes varus: inversion or bending inwards - Talipes valgus: Eversion or bending outwards - Talipus equinus: Plantar flexion in which the toes are lower than the heel - Talipes calcaneus: dorsiflexion in which the toes are higher than the heel interventions: 1. treatment begins as soon after birth as possible 2. manipulation and casting are performed weekly for 8-12 weeks because of the rapid growth of early infancy; a splint is then applied if casting and manipulation are successful 3. surgical intervention may be necessary if normal alignment is not achieved by about 6-12 weeks of age 4. monitor for pain, and monitor the neurovascular status of the toes * contact the PHCP immediately if signs of neurovascular impairment are noted in a child with a cast or a brace *

Ethambutol

- is a first line med to treat TB - bacteriostatic; interferes with cell metabolism and multiplication by inhibiting 1+ metabolites in susceptible organisms. it inhibits bacterial RNA synthesis and is active only during cell division. - slow-acting and must be used with other bactericidal agents. - contraindicated in clients with hypersensitivity or optic neuritis and in kids under 13 - caution with clients who have renal dysfunction, gout, ocular defects, diabetic retinopathy, cataracts, or ocular inflammatory conditions - caution in clients taking neurotoxic meds because the risk for neurotoxicity increases - adverse effects: hypersensitivity reactions, anorexia, nausea, vomiting, dizziness, malaise, mental confusion, joint pain, dermatitis, optic neuritis, peripheral neuritis, thrombocytopenia, increased uric acid levels, or anaphylactoid reactions. interventions: 1. assess the client for hypersensitivity 2. evaluate results of the CBC, uric acid, and renal and liver function studies 3. monitor for visual changes such as altered color perception and decreased visual acuity; if changes occur, withhold the medication and notify the PHCP 4. administer once every 24 hours and give with food to decrease GI upset 5. monitor uric acid concentration and assess for painful or swollen joints and for signs of gout 6. monitor I&O and for adequate renal function 7. assess mental status 8. monitor for dizziness and initiate safety precautions 9. assess for peripheral neuritis (numbness, tingling, or burning of the extremities); and if it occurs notify the PHCP client education: - that nausea, related to the med, can be prevented by taking the daily dose at bedtime or by taking the prescribed anti-nausea meds - to notify the PHCP immediately if any visual problems occur or if a rash, swelling, or pain in the joints; or numbness, tingling, or burning in the hands or feet occur

Pyrazinamide

- is a first line med to treat TB - exact mechanism of action is unknown - is used with at least 1 other anti-TB drug - contraindicated in clients with hypersensitivity - caution for clients with DM, renal impairment, or gout and in kids - may decrease the effects of allopurinol, colchicine, and probenecid - cross-sensitivity is possible with isoniazid, ethionamide, or nicotinic acid - adverse effects: increases liver function tests and uric acid levels, arthralgia, myalgia, photosensitivity, hepatotoxicity, and thrombocytopenia interventions: 1. assess for hypersensitivity 2. evaluate CBC, liver function test results, and uric acid levels 3. observe for hepatotoxic effects; if they occur, withhold the med and notify the PHCP 4. assess for painful or swollen joints 5. evaluate blood glucose level, because DM may be difficult to control while the client is on this med client education: - take the med with food to reduce GI distress - avoid sunlight or UV light until photosensitivity is determined

Rifampin

- is a first-line drug to treat TB - inhibits bacterial RNA synthesis, binds to DNA-dependent RNA polymerase and blocks RNA transcription. is used with at least 1 other anti-TB med. - contraindicated with clients who have a hypersensitivity, caution with clients with hepatic dysfunction or alcoholism, use of alcohol or hepatotoxic meds may increase the risk of hepatotoxicity, and decreases the effects of several meds, including oral anti-coagulants, oral hypoglycemics, chloramphenicol, digoxin, disopyramide phosphate, mexiletine, quinidine polygalacturonate, fluconazole, methadone hydrochloride, phenytoin, and verapamil hydrochloride adverse effects: - hypersensitivity reaction, including fever, chills, shivering, headache, muscle and bone pain, and dyspnea - heartburn, nausea, vomiting, and diarrhea - red-orange colored body secretions - vision changes - hepatotoxicity and hepatitis - increased uric acid levels - blood dyscrasias - colitis interventions: 1. assess for hypersensitivity 2. evaluate CBC, uric acid, and liver function test results 3. assess for signs of hepatitis, if they occur withhold the med and notify the PHCP 4. monitor for signs of colitis 5. assess for visual changes client education: - that urine, feces, sweat, and tears will be red-orange and that soft contact lenses can become permanently discolored - to notify the PHCP if jaundice occurs, develops weakness or fatigue, nausea, vomiting, sore throat, fever, or unusual bleeding occurs

Isoniazid

- is a first-line treatment for TB - bactericidal; inhibits the synthesis of mycolic acids and acts to kill actively growing organisms in the extracellular environment; inhibits the growth of dormant organisms in the macrophages and caseating granulomas. it is active only during cell division and is used with other meds. - contraindicated with clients with hypersensitivity or acute liver disease, use with caution in clients with chronic liver disease, alcoholism, or renal impairment, use with caution in patients taking nicotinic acid, use with cation in clients taking hepatotoxic meds because the client is at risk for hepatotoxicity increases - alcohol increases the risk of hepatotoxicity - may increase the risk of toxicity of carbamazepine and phenytoin - adverse effects: hypersensitivity reactions, peripheral neuritis, neurotoxicity, hepatotoxicity and hepatitis, increased liver function tests, pyridoxine deficiency, irritation at the injection site when given IM, nausea and vomiting, dry mouth, dizziness, hyperglycemia, and vision changes. interventions: 1. assess for hypersensitivity 2. assess for hepatic dysfunction 3. assess for sensitivity to nicotinic acid 4. monitor liver function test results 5. monitor for signs of hepatitis, such as anorexia, nausea, vomiting, weakness, fatigue, dark urine, or jaundice; if these symptoms occur, withhold the med and notify the PHCP 6. monitor for tingling, numbness, or burning of the extremities 7. assess mental status 8. monitor for visual changes, and notify the PHCP if they occur 9. assess for dizziness and initiate safety precautions 10. monitor CBC and blood glucose levels 11. administer isoniazid 1 hour before or 2 hours after a meal, because food may delay absorption 12. administer isoniazid at least 1 hour before antacids 13. administer pyridoxine as prescribed to reduce the risk of neurotoxicity ** many TB meds cause toxic effects such as hepatotoxicity, nephrotoxicity, neurotoxicity, optic neuritis, or orotoxicity. teach the client about the signs of toxicity and inform the client that the PHCP needs to be told if signs arise** client education: 1. avoid tyramine-containing foods because they may cause a reaction such as red and itching skin, a pounding heartbeat, lightheadedness, a hot and clammy feeling, or a headache; if this occurs, the client should notify the PHCP 2. to recognize the signs of neurotoxicity, hepatitis, and hepatotoxicity and to notify the PHCP if signs of these or vision changes occur.

Misoprostol

- is a gastric protectant - it is an anti-secretory med that enhances mucosal defenses, suppresses the secretion of gastric acid and maintains submucosal blood flow by promoting vasodilation. - used to prevent gastric ulcers caused by NSAIDs and aspirin - administered with meals - causes diarrhea and abdominal pain - contraindicated for use during pregnancy

Pediatric metabolic and endocrine problems: phenylketonuria

- is a genetic disorder that results in CNS damage from toxic levels of phenylalanine (an essential amino acid) in the blood - it is characterized by blood phenylalanine levels > 20, normal levels is 0-2 - all newborns are screened for it assessment: - digestive problems and vomiting - seizures - musty odor of the urine - mental retardation in older children: - eczema - hypertonia - hypopigmentation of the hair, skin, and irises - hyperactive behavior interventions: 1. the newborns should have begun feeding before specimen collection 2. if a test is positive a repeat is done 3. rescreen newborns by 14 days of age if the initial screening was done before 48 hours of age 4. if phenylketonuria is diagnosed prepare to initiate the following: - restrict phenylalanine intake, high-protein foods (meat and dairy products) and aspartame are avoided because they contain large amounts of phenylalanine - monitor physical, neurological, and intellectual development - stress the importance of follow-up treatment - encourage the parents to express their feelings about the diagnosis and discuss the risk of phenylketonuria in future children - educate the parents about the use of special preparation formulas and about the foods to avoid - consult with social care services to assist the parents with the financial burdens of purchasing special prepared formula

pediatric hematological problems: hemophilia

- is a group if bleeding disorders resulting from a deficiency of specific coagulation proteins - identifying the specific coagulation deficiency is important to provide definitive treatment with the specific replacement agent, aggressive replacement therapy is initiated to prevent chronic crippling effects from joint bleeding - carrier females pass the defect to males, females rarely get it - the primary treatment is with replacement of the missing clotting factor, additional meds like agents to relieve pain or corticosteroids may be prescribed depending on the source of bleeding - assessment: - abnormal bleeding in response to trauma or surgery - nosebleeds (epistaxis) - joint bleeding causing pain, tenderness, swelling, and limited range of motion - tendency to bruise easily - results of tests measuring platelet function are normal, results of tests that measure clotting factor function are abnormal - interventions: 1. monitor for bleeding and maintain bleeding precautions 2. prepare to administer factor VIII concentrates 3. DDAVP is a synthetic form of vasopressin that may be prescribed to treat mild hemophilia 4. monitor for joint pain, immobilize the affected extremity if it occurs 5. assess neurological status; children are at risk for intra-cranial hemorrhage 6. monitor the urine for hematuria 7. control joint bleeding by immobilization, elevation, application of ice, and application of pressure for 15 minutes for superficial bleeding 8. instruct the child and parents about the signs of internal bleeding 9. instruct parents how to control the bleeding 10. instruct parents regarding activities for the child, avoid contact sports, use protective devices when learning how to walk, and assist in developing an appropriate exercise plan 11. instruct the child to wear protective devices like helmets and knee and elbow pads wen participating in sports like bicycling and skating

pediatric hematological problems: von Willebrand's disease

- is a hereditary bleeding disorder characterized by a deficiency of or a defect in the protein called von Willebrand factor - it causes platelets to adhere to damaged endothelium, and the protein also serves as a carrier for factor VIII - it is characterized by an increased tendency to bleed from the mucous membranes assessment: - epistaxis - gum bleeding - bruising easily - and excessive menstrual bleeding interventions: 1. treatment and care are similar to that for hemophilia, including administering clotting factors 2. provide emotional support to the child and parents, especially if the child is experiencing a episode of bleeding 3. a child with a bleeding disorder needs to wear a medical alert bracelet

Cimetidine

- is a histamine 2-receptor antagonist that suppresses the secretion of gastric acid to alleviate symptoms of heart burn and assist in preventing complications of peptic ulcer disease. - can be given PO, IM, or IV - food reduces the rate of absorption; if taken orally with meals, absorption will be slowed. - IV administration can cause dysrhythmias and hypotension - antacids can decrease its absorption - it passes the blood-brain barrier and CNS side effects can occur, including mental confusion, agitation, psychosis, depression, anxiety, and disorientation. - dosage should be reduced in clients with renal impairment - it inhibits hepatic drug-metabolizing enzymes and can cause many other med levels to rise; if given with warfarin sodium, phenytoin, theophylline, or lidocaine the dosages of these meds should be reduced.

Ranitidine

- is a histamine 2-receptor antagonist that suppresses the secretion of gastric acid to alleviate symptoms of heart burn and assist in preventing complications of peptic ulcer disease. - can be given PO, IM, or IV - side effects are uncommon, and it does not penetrate the blood-brain barrier

Famotidine and Nizatidine

- is a histamine 2-receptor antagonist that suppresses the secretion of gastric acid to alleviate symptoms of heart burn and assist in preventing complications of peptic ulcer disease. - these meds do not need to be given with food

Pediatric renal and genitourinary problems: Nephrotic syndrome

- is a kidney disorder characterized by massive proteinuria hypoalbuminemia, and edema - the primary objectives of therapeutic management are to reduce the excretion of urinary protein, maintain protein-free urine, reduce edema, prevent infection, and minimize complications assessment: - child gains weight - periorbital and facial edema most prominent in the morning - lag, ankle, labial, or scrotal edema - urine output decreases, urine is dark and frothy - ascites (fluid in abdominal cavity) - BP normal or slightly decreased - lethargy, anorexia, and pallor - massive proteinuria - decreased serum protein and elevated serum lipid levels interventions: 1. monitor vitals I&O, and weight 2. monitor urine for specific gravity and protein 3. monitor for edema 4. diet is a regular diet without added salt may be prescribed if the child is in remission, sodium is restricted during periods of massive edema (fluids may also be restricted) 5. corticosteroid therapy is prescribed, monitor the child closely for infection 6. immunosuppressant therapy may be prescribed to reduce the relapse rate and induce long-term remission, or along with corticosteroids if the child is unresponsive to corticosteroid therapy alone 7. diuretics may be prescribed to reduce edema 8. plasma expanders like salt-poor human albumin may be used for a child who has severe edema 9. instruct parents about testing the urine for protein, med administration, side effects of meds, and general care of the child 10. instruct parents on the signs of infection and the need to avoid contact with other children who may be infectious

Diabetic ketoacidosis (DKA)

- is a life-threatening complication of type 1 DM that develops when severe insulin deficiency occurs - the main clinical manifestations include hyperglycemia, dehydration, ketosis, and acidosis assessment: - sudden onset - may be precipitated by infection, stressors, or inadequate insulin dose - manifested by ketosis (Kussmaul's respirations, fruity breath, nausea, and abdominal pain) and dehydration or electrolyte loss (polyuria, polydipsia, weight loss, dry skin, sunken eyes, soft eyeballs, lethargy, and coma) - lab findings: serum glucose > 300, serum ketones are + at a ratio of 1:2, acidic pH, serum HCO3 < 15, and urine ketones are +. interventions: 1. restore circulating blood volume and protect against cerebral, coronary, and renal hypoperfusion 2. treat dehydration with rapid infusions of IV 0.9% or 0.45% NS as prescribed; dextrose is added to IV fluids when the blood glucose reached 250-300. Too rapid administration of IV fluids; use of the incorrect types of IV fluids; and correcting the blood glucose level too fast leads to cerebral edema. 3. treat hyperglycemia with insulin IV 4. correct electrolyte imbalances 5. monitor K+ level closely, because when the client gets treatment for dehydration and acidosis, the K+ level will decrease and K+ replacement may be needed 6. cardiac monitoring should be in place for the client with DKA due to risks associated with abnormal K+ levels IV insulin administration: - use short-acting only - an IV bolus of short-acting 100 units of insulin may be prescribed before continuous insulin is started - the prescribed IV continuous insulin is prepared in 0.9% or 0.45% NS - always place the insulin on an IV infusion controller - insulin is infused continuously until sub-q administration resumes, to prevent a rebound glucose level - monitor vitals - monitor output and signs of fluid overload - monitor K+ and glucose levels and for signs of IICP - the K+ will fall rapidly within the first hour of treatment as the dehydration and acidosis are treated - K+ is administered IV in a diluted solution as prescribed, ensure adequate renal function before administering K+ client education: - take insulin as prescribed - determine the blood glucose level and test the urine for ketones every 3-4 hours - if the usual meal plan cannot be followed, substitute soft foods 6-8 times a day - if vomiting, diarrhea, or fever occurs, consume liquids every 30 minutes to prevent dehydration and provide calories - notify the PHCP if vomiting, diarrhea, or fever persists; if blood glucose levels are higher than 250-300 mg, if ketonuria is present for more than 24 hours, when unable to take food or fluids for a period of 4 hours, or when illness persists for more than 2 days.

Addisonian crisis

- is a life-threatening disorder caused by acute adrenal insufficiency. it is precipitated by stress, infection, trauma, surgery, or abrupt withdrawal of exogenous corticosteroid use - cause cause hyponatremia, hyperkalemia, hypoglycemia, and shock assessment: - severe headache - severe abdominal, leg, and lower back pain - generalized weakness - irritability and confusion - severe hypotension - shock interventions: 1. prepare to administer glucocorticoids IV as prescribed 2. administer IV fluids as prescribed to replace fluids and restore electrolyte balance 3. following resolution of the crisis, administer glucocorticoid and mineralocorticoid orally as prescribed 4. monitor vitals 5. monitor neurological status, noting irritability and confusion 6. monitor I&O 7. monitor lab values, especially sodium, potassium, and blood glucose levels 8. protect the client from infection 9. maintain bed rest and provide an adequate environment

Gastric cancer

- is a malignant growth of the mucosal cells in the inner lining of the stomach, with invasion to the muscle and beyond in advanced disease - no causative agent is known - risk factors are a diet of smoked highly salted or spiced or processed foods, smoking, alcohol, nitrate ingestion, or a history of gastric ulcers - complications are hemorrhage, obstruction, metastasis, and dumping syndrome - goal of treatment is to remove the tumor and provide a nutritional program assessment: - early stages: indigestion, abdominal discomfort, full feeling, and epigastric, back, or retrosternal pain - later stages: weakness and fatigue, anorexia and weight loss, nausea and vomiting, a sensation of pressure in the stomach, dysphagia and obstructive symptoms, iron deficiency anemia, ascites, and palpable epigastric mass interventions: 1. monitor vitals 2. monitor Hgb and Hct levels and administer blood transfusions as prescribed 3. monitor weight 4. assess nutritional status; encourage small, bland easily digestible meals with vitamins and mineral supplements 5. administer pain meds as prescribed 6. prepare the client for chemo or radiation as prescribed 7. prepare the client for surgical resection of the tumor as prescribed post-op interventions: 1. monitor vitals 2. place in fowler's position for comfort 3. administer analgesics and antiemetics as prescribed 4. monitor I&O, administer fluids and electrolyte replacement by IV as prescribed, and administer parenteral nutrition as indicated 5. maintain NPO status as prescribed for 1-3 days until peristalsis returns; assess bowel sounds 6. monitor nasogastric suction 7. do not irrigate or remove the NG tube; assist the PHCP with irrigation or removal 8. advance the diet from NPO to sips of clear water to 6 small bland meals a day as prescribed 9. monitor for complications such as hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency

skin cancer

- is a malignant lesion of the skin, which may or may not metastasize - over-exposure to the sun is a primary cause, other causes and conditions that place the individual at risk is chronic skin damage from repeated injury and irritation like tanning or use of tanning beds, genetics predisposition, ionizing radiation, light-skinned race, age older than 60, and an outdoor occupation \, or exposure to chemical carcinogens - diagnosis is confirmed by skin biopsy types: 1. basal cell: this cancer arises from the basal cells contained in the epidermis, metastasis is rare, but underlying tissue destruction can progress to organ tissue 2. Squamous cell: this cancer is a tumor of the epidermal keratinocytes and can infiltrate surrounding structures and metastasize to lymph nodes 3. melanoma: may occur at any place of the body, especially where birthmarks or new moles are apparent, it is highly metastatic to the brain, lungs, bone, and liver, with survival depending on early diagnosis and treatment assessment: - change in color, shape, or size of a preexisting lesion - pruritus - local soreness - the client needs to be informed about the risks associated with over-exposure to the sun and taught about the importance of performing monthly skin self-assessments interventions: 1. instruct the client about the risk factors and preventive methods 2. instruct the client to perform monthly skin assessments and to monitor for lesions that do not heal or change in character 3. advise the client to have moles or lesions that are subject to chronic irritation removed 4. advise the client to avoid contact with chemical irritants 5. instruct the client to wear layered clothing and use and reapply sunscreen when outdoors 6. instruct the client to avoid sun exposure between 10 am and 4 pm 7. management may include surgical or non-surgical interventions, and if medication is prescribed give instructions on its use 8. assist with surgical management, which may include cryosurgery, curettage, and electro-dessication or surgical excision of the lesion

Pediatric integumentary problems: Scabies

- is a parasitic skin disorder caused by Sarcoptes scabiei (itch mite) - infectious period is during the entire course of the infestation - assessment: pruritic papular rash, burrows into the skin and causes fine grayish-red lines that may be hard to see - interventions: 1. topical application of a scabicide to kill the mites 2. lindane shampoo is a product that should not be used by kids younger than too because of its risk for neuro-toxicity and seizures, all other products have contraindications for their use and should be followed 3. instruct parents on how to apply the scabicide; it is only applied from the neck down 4. when permethrin is prescribed, it is only applied to cool dry skin at least 30 minutes after bathing, the cream is massaged gently and thoroughly into all skin surfaces (not just areas that have the rash) from the head to the soles of the feet (avoid contact with the eyes), it is left on the skin for 8-14 hours, and then removed by bathing and a repeat treatment may be needed. 5. instruct the parents on the importance of frequent hand washing 6. instruct the parents that all bedding, clothing, and pillowcases used by the child need to be changed daily, washed in hot water with detergent, dried in a hot dryer, and ironed before reuse, and this process should continue for at least 1 week 7. instruct parents that non-washable toys and other items should be sealed for a least 4 days 8. anti-itch topical cream may be needed and antibiotics may be prescribed is a secondary infection develops

Risk conditions related to pregnancy: Abortion

- is a pregnancy that ends before 20 weeks of gestation, whether or not it was spontaneous or elective. - risk factors: advanced maternal age, those who have had a previous miscarriage or previous elective abortion, uterine abnormalities, prolonged time to achieve pregnancy, low serum progesterone, celiac disease, polycystic ovarian syndrome, thyroid dysfunction or Cushing's syndrome, systemic lupus erythematosus, infection, fever, trauma, low BMI, smoking, alcohol, cocaine use, certain meds, or high caffeine intake. - upon assessment you will see spontaneous vaginal bleeding, low uterine cramping or contractions, blood clots or tissue through the vagina, and hemorrhage and shock can result if bleeding is excessive. - interventions: maintain bed rest as prescribed, monitor vitals, monitor for cramping and bleeding, count perineal pads to evaluate blood loss, maintain IV fluids as prescribed and monitor for signs of hemorrhage or shock, prepare the client for dilation and cutterage as prescribed for an incomplete abortion, administer Rho immune globulin for Rh-negative women, and provide psychological support.

Streptomycin

- is a second-line med to treat TB - an aminoglycoside antibiotic used with at least 1 other anti-TB drug - contraindicated in clients with hypersensitivity, myasthenia gravis, parkinsonism, or 8th cranial nerve damage - used with caution in the older client, in neonates because of renal insufficiency and organ immaturity, and in young infants because it can cause CNS depression - the risk of toxicity increases when taken with other aminoglycosides or nephrotoxicity or ototoxicity-producing meds

Rifabutin

- is a second-line med to treat TB - inhibits bacterial protein synthesis and DNA to RNA - used for clients with HIV to treat TB - caution... it can affect blood levels of some meds, including oral contraceptives and some antivirals used to treat HIV infection. A non-hormonal method of birth control should be used instead of an oral contraceptive. - adverse effects: rash, GI disturbances, neutropenia, red to orange colored body secretions, Uveitis (eye inflammation), myositis (muscle inflammation), arthralgia (joint pain), hepatitis, chest pain with dyspnea, and flu-like syndrome. interventions: 1. observe for hepatotoxic effects; if they occur, withhold the med and notify the PHCP. (hepatotoxic effects include Rash, stomach pain, nausea and vomiting, fatigue, dark-colored urine, light-colored bowel movements, jaundice, and loss of appetite). 2. assess for pain or swollen joints 3. assess for ocular pain or blurred vision client education: - take the med without regard to food

Aminosalicylic acid

- is a second-line med to treat TB - inhibits folic acid metabolism in bacteria - is used when resistance to other TB meds is expected - contraindicated with hypersensitivity to aminosalicylates, salicylates, or compounds containing the para-aminophenol group - aminobenzoates block the absorption of aminosalicylate sodium - adverse effects: hypersensitivity, bitter taste in the mouth, GI tract irritation, exfoliative dermatitis, blood dyscrasia, crystalluria, and changes in thyroid function interventions: 1. assess for hypersensitivity 2. offer water to rinse the mouth and chewing gum or hard candy to alleviate the bitter taste in the mouth 3. encourage fluids to prevent crystalluria 4. monitor I&O client education: 1. discard the med and get a new supply if a purplish-brown discoloration occurs 2. take the med with food 3. urine may turn red on contact with bleach if bleach was used to clean the toilet 4. do not take aspirin or OTC meds without the DR's approval 5. report signs of blood dyscrasia such as sore throat or mouth, malaise, fatigue, bruising, or bleeding

Rifapentine

- is a second-line med to treat TB - is only used for pulmonary TB - cautions... can affect blood levels of some meds, such as oral contraceptives and warfarin, and some meds used to treat HIV. - adverse effects: red to orange colored body secretions, hepatotoxicity interventions: 1. obtain baseline liver function studies and assess throughout therapy 2. observe for hepatotoxic effects; if they occur, withhold the med and notify the PHCP client education: 1. the med can be taken without regard to food 2. avoid sunlight or UV light until photosensitivity is determined 3. red to orange colored body secretions may occur

Ethionamide

- is a second-line med to treat TB - mechanism of action is unknown - is used when resistance to other TB meds is expected - contraindicated in clients with hypersentitivity - used in clients with DM or renal dysfunction - adverse effects: nausea, vomiting, anorexia, metallic taste in mouth, orthostatic hypotension, jaundice, mental changes, peripheral neuritis (weakness, tingling, pain), and rash interventions: 1. assess liver and renal function labs 2. monitor glucose levels in the client with DM 3. administer pyridoxine as prescribed to reduce the risk of neurotoxicity client education: - take the med with food to reduce GI upset - change positions slowly - report signs of a rash, which can progress to exfoliative dermatitis if the med is not discontinued

Capreomycin sulfate

- is a second-line med to treat TB - mechanism of action is unknown - used when significance to other meds is expected - administered IM - the risk of nephrotoxicity, ototoxicity, and neuromuscular blockade is increased with the use of aminoglycosides (end in mycin) or loop diuretics (end in semide) - used with caution in clients with renal insufficiency, acoustic nerve impairment, hepatic disorder, myasthenia gravis, or parkinsonism - do not give to clients receiving streptomycin - adverse effects: nephrotoxicity, ototoxicity, and neuromuscular blockade interventions: 1. perform baseline audiometric testing 2. assess renal, hepatic, and electrolyte levels before administration 3. monitor I&O 4. reconstituted med may be stored for 48 hours at room temp 5. administer IM, deep into a large muscle mass 6. rotate injection sites 7. observe injection site for redness, excessive bleeding, or inflammation client education: 1. do not perform tasks that require mental alertness 2. report any hearing loss, balance disturbances, respiratory difficulty, weakness, or signs of hypersensitivity reactions

Pediatric GI Problems: Intussusception

- is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that's affected. assessment: - colicky abdominal pain that causes the child to scream and draw the knees to the abdomen, similar to the fetal position - vomiting of gastric contents - bile-stained fecal emesis - small jelly-like stools with blood and mucous - irregular bowel sounds - tender distended abdomen, possible with a palpable sausage-shaped mass in the URQ interventions: - monitor for signs of perforation and shock as evidenced by fever, increased HR, changes in LOC or BP, and respiratory distress, and report immediately - antibiotics, IV fluids, and decompression with a NG tube may be prescribed - monitor for the passage of normal stool which indicates that intussusception has reduced itself - prepare for hydrostatic reduction as prescribed, if no signs of perforation or shock occur - hydrostatic reduction = a catheter is inserted into the rectum of the child, and under fluoroscopic guidance, air or water is instilled into the large bowel in an attempt to resolve the prolapse - post-hydrostatic reduction: monitor for the return of normal bowel sounds, for the passage of barium, and the characteristics of stool; administer clear fluids, and advance the diet gradually as prescribed - if surgery is required, post-op care is similar to any other abdominal surgery

Endometrial (uterine) cancer

- is a slow-growing tumor arising from the endometrial mucosa of the uterus, associated with menopausal years - metastasis occurs through the lymphatic system to the ovaries and the pelvis, by the blood to the lungs, liver, and bone, or intra-abdominally to the peritoneal cavity. - risk factors: use of estrogen replacement therapy (ERT), nulliparity, polycystic ovary disease, increased age, late menopause, family history of uterine cancer or hereditary nonpolyposis colorectal cancer, obesity, HTN, or diabetes. assessment: - abnormal bleeding, especially in post-menopausal women - vaginal discharge - low back, pelvic, or abdominal pain - enlarged uterus in advanced stages interventions: 1. external or internal radiation is used alone or in combination with surgery, depending on the stage of cancer 2. chemo is used to treat advanced or recurrent disease 3. progesterone therapy with medication may be described for estrogen-dependent tumors 4. anti-estrogen meds may also be prescribed 5. surgical interventions: total abdominal hysterectomy and bilateral salpingo-oophorectomy

Candida albicans

- is a superficial fungal infection of the skin and mucous membranes - also known as a yeast infection (oral candidiasis), or thrush when it occurs in the mouth - risk factors are immunosuppression, long-term antibiotic therapy, diabetes mellitus, and obesity - commonly occurs in the skin folds, perineum, vagina, axilla, and under the breasts assessment: - infection of the skin: the skin is red and irritated and may itch and sting - infection of the mouth: the mucous membranes of the mouth may be red and have whitish patches interventions: 1. teach the client to keep skin fold areas clean and dry 2. for the hospitalized client, inspect skin fold areas frequently, turn and reposition often, and keep the skin and bed linens clean and dry 3. provide frequent mouth care as prescribed and avoid irritating products 4. provide food and fluids that are tepid in temp, and non-irritating to mucous membranes 5. anti-fungal meds may be prescribed

Pediatric oncological problems: neuroblastoma

- is a tumor that originates from the embryonic neural crest cells that normally give rise to adrenal medulla and the sympathetic ganglia - most tumors develop in the adrenal gland or the retroperitoneal sympathetic chain, other sites include the head, neck, chest, or pelvis - most children present with it before age 10 - most presenting signs are caused by the tumor compressing adjacent normal tissues and organs - diagnostic evaluation is aimed at locating the primary site of the tumor, analyzing the break down products excreted in the urine, namely vanillylmandelic acid, homovanillic acid, dopamine, and norepinephrine, permits detection of suspected tumor before and after medical intervention - the prognosis is poor due to the frequency of invasiveness of the tumor, and because in most cases a diagnosis is not made until after metastasis has occurred, the younger the child is at diagnosis the better the outcome. therapeutic management: - surgery is performed to remove as much of the tumor as possible and to get biopsy specimens, in the early stages complete removal of the tumor is the treatment of choice - surgery usually is limited to biopsy in the later stages due to extensive metastasis - radiation is commonly used with later-stage disease and provides palliative care for metastatic lesions in bones, lungs, liver, and brain - chemo is used for extensive local or disseminated disease assessment: - firm, non-tender, irregular mass in the abdomen that crosses the midline - urinary frequency or retention from compression of the kidney, bladder, or ureter - lymphadenopathy, especially in the cervical and supraclavicular areas - bone pain if skeletal involvement - supraorbital ecchymosis, preiorbital edema, and exophthalmos as a result of invasion of retrobulbar fort tissue - pallor, weakness, irritability, anorexia, and weight loss - signs of respiratory impairment with a thoracic lesion - signs of neurological impairment with an inracranial lesion - paralysis from compression of the spine pre-op interventions: - monitor for signs and symptoms related to the location of the tumor - provide emotional support to the child and parents post-op interventions: - monitor for post-op complications related to the location or organ of the surgery - monitor for complications related to chemo or radiation if prescribed - provide support to the parents and encourage them to express their feelings, many parents feel guilt for not having recognized the child's symptoms earlier - refer parents to appropriate community services

Pheochromocytoma

- is a tumor usually found in the adrenal medulla, or the chest, bladder, abdomen, and brain. is usually benign but can be malignant. - excessive amounts of epinephrine and norepinephrine are secreted - diagnostic tests is a 24-hr usine test to detect VMA - primary treated by surgical removal of the adrenal gland - treatment of symptoms is when surgical removal is not possible - complications are hypertensive crisis, hypertensive retinopathy and neuropathy, cardiac enlargement, dysrhythmias, HF, MI, increased platelet aggregation, and stroke - death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm assessment: - HTN - severe headaches - palpitations - flushing or profuse diaphoresis - pain in chest or abdomen with nausea and vomiting - heat intolerance - weight loss - tremors - hyperglycemia interventions: 1. monitor vitals 2. monitor for HTN crisis, monitor for complications that can occur with HTN crisis, such as stroke, cardiac dysrhythmias, and MI 3. instruct the client not to smoke, drink caffeine, of change positions suddenly 4. prepare to give adrenergic-blocking agents to control HTN 5. monitor serum glucose level 6. promote rest and a non-stressful environment 7. provide a diet high in calories, vitamins, and minerals 8. prepare the client for adrenalectomy 9. avoid stimuli that can precipitate a HTN crisis, such as increased abdominal pressure or vigorous abdominal palpitation

Pediatric oncological problems: Hodgkin's disease

- is a type of lymphoma: a malignancy of the lymph nodes that originates in a single lymph node and metastasizes to other sites such as the spleen, liver, bone marrow, lungs, and mediastinum - is characterized by the presence of Reed-Sternberg cells noted in a lymph biopsy specimen - peak incidence is mid-adolescence - possible causes are viral infections, and previous exposure to alkylating chemical agents - prognosis is excellent - primary treatment are radiation and chemo used in combination or alone, depending on the clinical stage of the disease assessment: - painless enlargement of lymph nodes - the sentinel node located near the left clavicle may be the first enlarged - nonproductive cough as a result of mediastinal lymphadenopathy - abdominal pain as a result of enlarged retroperitoneal nodes - advanced lymph node and extra-lymphatic involvement may cause systemic symptoms like fever, anorexia, nausea, weight loss, night sweats, and pruritus. - positive biopsy specimen of a lymph node and bone marrow - computed tomography scan of the liver, spleen, and bone marrow may be done to detect metastasis interventions: - for early stages without mediastinal node involvement, the treatment is extensive external radiation of the involved lymph node regions - radiation and chemo are used with later stages - monitor for med-induced pancytopenia and an abnormal depression of all cellular components of blood, which increases the risk for infection, bleeding, and anemia - monitor for signs of bleeding and infection - protect the child from infection - monitor for adverse effects related to chemo or radiation, the most common of extensive irradiation is malaise which can be difficult for adolescents or older children to tolerate physically and psychologically - monitor for nausea and vomiting, and administer antiemetics as prescribed

oxytocin

- is a uterine stimulant used to increase contractions to induce labor, mag sulfate should be easily accessible. - also controls postpartum bleeding adverse effects: - allergies, dysrhythmias, changes in BP, uterine rupture, and water intoxication - can cause uterine hypertonicity resulting in fetal or maternal adverse effects - high doses can cause hypotension, with rebound HTN - postpartum hemorrhage can occur and should be monitored for, because the uterus may become atonic when the medication wears off. - should not be used in a client who cannot deliver vaginally or in a client with hypertonic uterine contractions, and in a client with active genital herpes. interventions: - monitor maternal vitals every 15 minutes - monitor frequency, duration, and force of contractions and resting uterine tone every 15 minutes - monitor FHR every 15 minutes, notify the OB if any changes occur - if nonreassuring FHR or uterine hyperstimulation occur, stop infusion, turn client on her side, increase IV rate of the prescribed additive fluid, and administer O2 - monitor for signs of water intoxication - have emergency equipment readily accessible - document the dose and time of medication and the client's response - keep the client and family informed of the client's progress

retinopathy of prematurity

- is a vascular disorder involving gradual replacement of the retina by fibrous tissue and blood vessels - primarily caused by prematurity and the use of supplemental O2 for over 30 days assessment: - leukocoria (white tissue on the retro-lental space), vitreous hemorrhage, strabismus, and cataracts interventions: - laser photocoagulation surgery

Hepatitis E

- is a water-borne virus - is prevalent in areas where sewage disposal in inadequate or where communal bathing in contaminated rivers is practiced - risk of infection is in crowds or exposure to poor sanitation - it presents as a mild disease except in women who are in the third trimester of pregnancy, who have a high mortality rate. - travelers and eaters/drinkers of contaminated foods are at increased risk - transmission is by the fecal-oral route, person to person contact, parenteral, contaminated fruits or veggies or uncooked shellfish, contaminated water or milk, or poorly washed utensils. - incubation period is 2-9 weeks - detection of IgM and IgG antibodies are used to detect hep E - complications are high mortality rate in pregnant women and fetal demise - prevention is by strict hand washing, and treatment of water supplies and sanitation measures

Pericarditis

- is acute or chronic inflammation of the pericardium - chronic pericarditis is a chronic thickening or the pericardium and constricts the heart causing compression. - the pericardial sac becomes inflamed - the pericarditis can result in loss of pericardial elasticity or an accumulation of fluid within the sac - HF and cardiac tamponade may result assessment: - pain in the anterior chest that radiates to the left side of the neck, shoulder, and neck - pain is grating and is aggravated by breathing (particularly in inspiration), coughing, and swallowing. - pain is worse when in the supine position and may be relieved by leaning forward - pericardial friction rub (scratchy, high-pitched sound) is heard on auscultation and is produced by the rubbing of the inflamed pericardial layers - fever and chills - fatigue and malaise - elevated WBC count - ECG changes with acute pericarditis, ST-segment elevation with the onset of inflammation, atrial fibrillation is also common. - signs of right heart failure in clients with chronic pericarditis interventions: 1. assess the nature of the pain 2. place the client in a high-fowler's position, or upright and leaning forward 3. administer O2 4. administer analgesics, NSAIDs, or corticosteroids for pain as prescribed 5. auscultate for a pericardial friction rub 6. check blood culture results to identify a causative organism 7. administer antibiotics for a bacterial infection as prescribed 8. administer diuretics and digoxin as prescribed to the client with chronic constrictive pericarditis, surgical incision of the pericardium or pericardiectomy may be necessary 9. monitor for signs of cardiac tamponade 10. notify the PHCP if signs of cardiac tamponade occur

Hypertensive crisis

- is an acute and life-threatening condition requiring immediate reduction in BP - emergency treatment is required, because target organ damage (brain, heart, kidneys, or retina of the eye) can occur quickly - death can be caused by stroke, kidney failure, or cardiac disease assessment: - an extremely high BP, systolic over 180 and/or diastolic over 120 - headache - drowsiness and confusion - blurred vision - changes in mental status - tachycardia and tachypnea - dyspnea - cyanosis - seizures interventions: 1. maintain a patent airway 2. administer anti-hypertensive meds IV as prescribed 3. monitor vitals, assessing BP every 5 minutes 4. monitor neurological status 5. maintain bed rest, with the HOB elevated at 45 degrees 6. assess for hypotension during the administration of anti-hypertensives; place the client in a supine position if hypotension occurs 7. have emergency medications and resuscitation equipment available 8. monitor IV therapy, assessing for fluid overload 9. use a foley catheter as prescribed 10. monitor intake and urinary output, if oliguria or anuria occurs notify the PHCP

Legionnaire's disease

- is an acute bacterial infection caused by Legionella pneumophila - sources of the organism include contaminated cooling tower water and warm stagnant water supplies, including water vaporizers, water sonicators, whirlpool spas, and showers - person-to-person contact does not occur, the risk for infection is increased by the presence of other conditions assessment: - influenza-like symptoms with a high fever, chills, muscle aches, and a headache that may progress to a dry cough, pleurisy, and sometimes diarrhea interventions: 1. treatment is supportive and antibiotics may be prescribed

Pediatric neurological and cognitive problems: Reye's syndrome

- is an acute disease in which the functioning of the brain is affected by some agent or condition, is characterized by cerebral edema and fatty changes in the liver, and the diagnosis is made by lab studies and liver biopsy - may follow a viral illness - do not administer aspirin , acetaminophen or ibuprofen are the meds of choice - early diagnosis and aggressive treatment are needed, the goal of treatment is to maintain effective cerebral perfusion and control IICP assessment: - history of viral illness 4-7 days before the onset of symptoms - fever - nausea, vomiting - signs of altered liver function like lethargy - increased blood ammonia levels interventions: 1. provide rest and decrease stimuli 2. assess neurological status 3. monitor for altered LOC and signs of IICP 4. monitor for signs of altered hepatic function and results of liver function studies 5. monitor I&O 6. monitor for signs of bleeding and impaired coagulation, like prolonged bleeding time

Cardiomyopathy

- is an acute or chronic disorder of the heart muscle - treatment is palliative, not curative, and the client needs to deal with numerous lifestyle changes and a shortened life span 1. dilated cardiomyopathy: - fibrosis of myocardium and endocardium, dilated chambers, and mural wall thrombi are prevalent - s/s: fatigue, weakness, left-sided HF, dysrhythmias or heart block, systemic or pulmonary emboli, S3 and S4 gallops, and moderate to severe cardiomegaly - tx: symptomatic treatment of HF, vasodilators, control of dysrhythmias, and heart transplant surgery 2. non-obstructed cardiomyopathy: - hypertrophy of the walls, hypertrophied septum, and relatively small chamber size. - s/s: dyspnea, angina, fatigue, syncope, palpitations, mild cardiomegaly, S4 gallop, ventricular dysrhythmias, sudden death is common, and HF. - tx: symptomatic treatment, beta blockers, conversion of atrial fibrillation, surgery: ventriculomyotomy or muscle resection with mitral valve replacement, and digoxin, nitrates, and other vasodilators contraindicated with the obstructed form 3. obstructed cardiomyopathy: - same pathophysiology as for non-obstructed except for obstruction of left ventricular outflow tract associated with the hypertrophied septum and mitral valve incompetence. - s/s: same as for non-obstructed except with mitral regurgitation murmur, atrial fibrillation - tx: same as for non-obstructed 4. restrictive cardiomyopathy: - mimics constrictive pericarditis, fibrosed walls cannot expand or contract, and chambers are narrowed and emboli are common - s/s: dyspnea and fatigue, right-sided HF, mild to moderate cardiomegaly, S3 and S4 gallops, heart block, and emboli - tx: supportive treatment of symptoms, treatment of HTN, conversion from dysrhythmias, exercise restrictions, and emergency treatment of acute pulmonary edema

pediatric hematological problems: Thalassemia Major

- is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin - both parents must be carriers to pass it to the child - the incidence is highest in those of mediterranian descent such as italians, greeks, syrians, and their offspring - treatment is supportive, the goal is to maintain normal hemoglobin levels by administering blood transfusions - bone marrow transplants may be offered by an alternative therapy - a splenectomy may be performed in a child with severe splenomegaly who requires repeated transfusions. it will assist in relieving abdominal pressure and increase the life span of supplemental RBCs assessment: - frontal bossing (protruding forehead) - maxillary prominence - wide-set eyes with a flattened nose - greenish yellow skin tone - hepatosplenomegaly - severe anemia - microlytic, hypochromic RBCs interventions: 1. administer blood transfusions and monitor for transfusion reactions 2. monitor for iron overload; treated with chelation therapy with deferasirox or deferoxamine to prevent organ damage from the elevated levels of iron caused by multiple transfusion therapy 3. if the child has had a splenectomy, instruct parents to report any signs of infection because of increased risk for sepsis 4. ensure parents understand the importance of the child getting pneumococcal and meningococcal vaccines in addition to the annual flu vaccine and the regularly scheduled vaccines 5. provide genetic counseling to parents

Risk conditions related to pregnancy: placenta previa

- is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. - total (complete): the internal cervical os is covered entirely by the placenta when the cervix is dilated fully - partial: the lower border of the placenta is within 3 cm of the internal cervical os but does not fully cover it - marginal (low-lying): the placenta is implanted in the lower uterus, but its lower border is more than 3 cm from the internal cervical os. - management depends on the classification of the placenta previa and gestational age of the fetus. - assessment findings include sudden onset of painless, bright red vaginal bleeding occurs in the last half of pregnancy; uterus is soft, relaxed, and nontender; and the fundal height may be more than expected for gestational age. - interventions include monitor maternal vitals, FHR, and fetal activity; prepare for an ultrasound to confirm the diagnosis; vaginal exams or any other actions that would stimulate uterine activity are avoided; maintain bed rest in a side-lying position as prescribed; monitor amount of bleeding and treat any signs of shock; administer IV fluids, blood products, or tocolytic medications as prescribed, and Rh0 immune globulin may be prescribed; if bleeding is heavy, a C-section may be performed. ** vaginal exams are contraindicated if the client is suspected of having placenta previa ***

Pediatric neurological and cognitive problems: meningitis

- is an infection of the CNS caused by bacteria or viruses that may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinuses or ears, or systemic infections - a diagnosis of bacterial meningitis is made by testing CSF by a lumbar puncture, increased WBCs, elevated proteins, and decreased glucose levels - viral meningitis is associated with viruses like mumps, paramyxovirus, herpesvirus, and enterovirus assessment: - signs and symptoms vary, depending on the type, age of the child, and duration of the preceding illness - fever chills headache - vomiting, diarrhea - poor feeding or anorexia - nuchal rigidity - poor or high, shrill cry - altered LOC, such as lethargy or irritability - bulging anterior fontanel in an infant - positive Kernig's sign (inability to extend the leg when the thigh is flexed anteriorly at the hip) and Brudzinski's sign (neck flexion causes adduction and flexion movements of the lower extremities) in kids and adolescents - muscle or joint pain - petechial or purpuric rashes - ear that chronically drains interventions: 1. provide respiratory isolation precautions for at least 24 hours after antibiotics are started 2. administer antibiotics and antipyretics as prescribed 3. perform neurological assessments and monitor for seizures, assess for the complication of inappropriate anti-diuretic hormone secretion, causing fluid retention and hypo-natremia 4. assess for changes in LOC and irritability 5. monitor for purpuric or petechial rash and for signs of thromboemboli 6. assess nutritional status, monitor I&O 7. monitor for hearing loss 8. determine close contacts of the child with meningitis because they need prophylactic treatment 9. pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis

Pediatric integumentary problems: Pediculosis capitis (lice)

- is an infestation of the hair and scalp with lice - intubation period for eggs is 7-10 days - are transmitted by direct and indirect contact, such as sharing brushes, towels, bedding, etc - assessment: child scratches scalp excessively, pruritus caused by the insect, nits (white eggs) are observable on the hair shaft, and adult lice are difficult to see. - interventions: 1. use a lice removal product as prescribed and follow directions, most of these products cannot be used in kids younger than 6 months old, daily removal of eggs with extra fine comb should be done, instruct parents that siblings may also need treatment, grooming items should not be shared, the child's clothes should be washed in hot water separately from other items, bedding and clothing needs to be changed daily and washed, non-essential bedding and clothing can be stored in a tightly sealed container for 2 weeks and then washed, furniture and carpets need to be vacuumed, teach the child not to share grooming items or clothing, and lice on the eyelashes or eyebrows need to be removed manually.

Endocarditis

- is an inflammation of the inner lining of the heart and valves - occurs primarily in clients who are IVDA, have had valve replacements or repair of the valves with prosthetic materials, or have other structural cardiac defects - ports of entry for the infecting organism include the oral cavity, infections, and surgery or invasive procedures including IV line placement assessment: - fever - anorexia, weight loss - fatigue - cardiac murmurs - HF - embolic complications from vegetation fragments traveling through the arterial circulation - petechiae - splinter hemorrhages in the nail beds - Osler's nodes (reddish, tender lesions) on the pads of the fingers, hands, and toes - janeway lesions (non-tender hemorrhagic lesions) on the fingers, toes, nose, or earlobes - splenomegaly - clubbing of the fingers interventions: 1. provide adequate rest balanced with activity to prevent thrombus formation 2. monitor for signs of HF 3. monitor for splenic emboli, as evidenced by sudden abdominal pain radiating to the left shoulder and the presence of rebound abdominal tenderness on palpation 4. monitor for renal emboli, as evidenced by flank pain radiating to the groin, hematuria, and pyuria 5. monitor for confusion, aphasia, or dysphasia, which may indicate CNS emboli 6. monitor for pulmonary emboli as evidenced by pleuritic chest pain, dyspnea, and cough 7. assess skin, mucus membranes, and conjunctiva for petechiae 8. assess nail beds for splinter hemorrhages 9. assess for olser's nodes on the pads of the fingers, hands, and toes 10. assess for janeway lesions on the fingers, toes, nose, or earlobes 11. assess for clubbing of the fingers 12. evaluate blood culture results 13. administer antibiotics IV as prescribed 14. plan and arrange for discharge and provide required resources for the continues maintenance of IV antibiotics home care for the client with infective endocarditis: - teach the client to maintain aseptic technique during setup and administration of IV antibiotics - instruct the client to administer IV antibiotics at scheduled times to maintain the blood level - instruct the client to monitor IV catheter sites for signs of infection and report this immediately to the PHCP or cardiologist - instruct the client to record the temp daily for up to 6 weeks and to report fever - encourage oral hygiene at least twice a day with a soft toothbrush and rinse well with water after brushing - the client should avoid the use of oral irrigation devices and flossing to avoid bacteremia - teach the client to cleanse any skin lacerations thoroughly and apply an antibiotic ointment as prescribed - the client should inform all PHCPs of history of endocarditis and ask about the use of prophylactic antibiotics prior to invasive respiratory procedures and dentistry - teach the client to observe for signs and symptoms of embolic conditions and HF

Pediatric cardiovascular problems: rheumatic fever

- is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin, blood vessels, and CNS. - the most serious complication is rheumatic heart disease, which affects the cardiac valves, particularly the mitral valve - it manifests 2-6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract - jones criteria are used to determine the diagnosis: - major criteria: carditis, arthralgia, chorea, erythema marginatum, and subcutaneous nodules - minor criteria: fever, arthralgia, elevated erythrocyte sedimentation rate or +C-reactive protein level, and prolonged PR interval on ECG assessment: - low-grade fever that spikes in the afternoon - elevated anti-streptolysin O titer - elevated erythrocyte sedimentation rate - elevated C-reactive protein level - Aschoff bodies (lesions) found in the heart, blood vessels, brain, and serous surfaces of the joints and pleura - assessment of a child with rheumatic fever includes asking if they have had a recent sore throat, because it manifests 2-6 weeks after an untreated or partially treated bacterial infection of the upper respiratory tract interventions: 1. assess vitals 2. control joint pain and inflammation with massage and alternating hot and cot applications as prescribed 3. provide bed rest during acute febrile stage 4. limit physical exercise in a child with carditis 5. administer antibiotics as prescribed 6. administer salicylates and anti-inflammatory agents as prescribed, these meds should not be administered before the diagnosis is confirmed because they may mask polyarthritis 7. initiate seizure precautions if the child has chorea 8. instruct the parents about the importance of follow-up and the need for antibiotic prophylaxis for dental work, infection, and invasive procedures 9. advise the child to inform the parents if anyone in school develops a streptococcal throat infection

Crohn's disease

- is an inflammatory disease that can occur anywhere in the GI tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses - characterized by remissions and exacerbations assessment: - fever - cramp-like colicky pain after meals - diarrhea with mucus and pus - abdominal distention - anorexia, nausea, vomiting - weight loss - anemia - dehydration - electrolyte imbalances - malnutrition interventions: - care is similar to that for the client with ulcerative colitis; however, surgery may be necessary but is avoided for as long as possible because recurrence of the disease process in the same region is likely to occur

Pediatric eye, ear, and throat problems: Otitis media

- is an inflammatory disorder caused by an infection of the middle ear as a result of a blocked eustachian tube, which prevents normal drainage and can be acute or chronic - it is a common complication of a respiratory virus - infants and kids have eustachian tubes that are shorter, wider, and straighter, making them more prone to infection prevention: - feeding infants in an upright position - maintain routine immunizations - encourage breast-feeing for the first 6 motnhs of life - avoid exposure to tobacco smoke and allergens assessment: - fever - acute onset of ear pain - crying, irritability, lethargy - loss of appetite - rolling head from side to side - pulling on or rubbing the ear - purulent ear drainage - red, opaque, bulging, immobile tympanic membrane on otoscopic exam - signs of hearing loss interventions: - encourage fluids - instruct the child to avoid chewing - provide local heat or cold as prescribed to decrease discomfort, and have the child lie with the affected ear down - instruct the parents how to clean the drainage from the external ear canal with sterile swabs or gauze - instruct parents in the administration of antipyretics or analgesics like acetaminophen or ibuprofen - instruct the parents in the administration of antibiotics - screening for hearing loss may be needed - otitis externia: - inflammation of the external auditory canal, which can occur with or without infection, also called "swimmer's ear" - assessment: rapid onset of symptoms within 48 hours, symptoms include otalgia (earache), pruritus, fullness, drainage, and impaired hearing - a low-grade fever may be present - tenderness on manipulation of the site is noted - may have regional lymphadenopathy - treatment is with topical antibiotics and may include neomycin with or without polymyxin B or a fluoroquinolone preparation myringotomy: - a surgical incision into the tympanic membrane to provide drainage of the purulent middle ear fluid, may be done using a laser - tympanoplasty tubes, which are small, cylinder-shaped tubes may be inserted into the middle ear to allow continued drainage and to equalize pressure and allow ventilation of the middle ear post-op interventions: - instruct the parents and child to keep ear dry - wear earplugs while bathing - parents can give an analgesic like acetaminophen or ibuprofen to relieve discomfort after insertion or tympanoplasty tubes - parents should be taught that the child should not blow their nose for 7-10 days after surgery - instruct the parents that if the tubes fall out, it is not an emergency but the PHCP should be notified, and they look like tiny, white, spool-shaped tubes

Pediatric cardiovascular problems: cardiac catheterization

- is an invasive cardiac procedure to determine cardiac defects - provides info about O2 sat of blood in great vessels and heart chambers - may be done for diagnostic, interventional, or electrophysiological reasons - may be performed outpatient - risks include hemorrhage from the entry site, clot formation and subsequent blockage distally, and transient dysrhythmias - general anesthesia is usually unnecessary pre-op interventions: - determine accurate height and weight, this info is used to select correct catheter size - obtain presence of allergy to iodine - assess for symptoms of infection, including a diaper rash - assess and mark bilateral pulses - assess baseline O2 sat - familiarize the parents and child with hospital procedures and equipment - educate the child and parents about the procedure - allow the child and parents to verbalize feelings and concerns regarding the procedure and the disorder post-op interventions: - monitor the cardiac monitor and o2 sat for 4 hours after the procedure - assess the pulses below the catheter site for presence, equality, and symmetry - assess the temp and color of the affected extremity and report coolness, which may indicate arterial obstruction - monitor vitals every 15 minutes for 1 hour, then every 30 minutes for 2 hours, and every hour for the last 4 hours - assess the pressure dressing for intactness and signs of hemorrhage - check the bed sheets under the extremity for blood, which indicates bleeding from the entry site - if bleeding is present provide continuous pressure at the cardiac catheter entry site and report it immediately - immobilize the affected extremity in a flat position for at least 4-6 hours for the venous entry site and 6-8 hours for the arterial entry site as prescribed - hydrate the child by the oral or IV route or both routes as prescribed - administer acetaminophen or ibuprofen for pain or discomfort as prescribed - prepare the parents and child, for surgery if appropriate discharge teaching for the parents and child: - remove the dressing the day after the procedure and cover it with a bandage for 2-3 days as prescribed - keep the site clean and dry - avoid tub baths for 2-3 days - observe for redness, edema, drainage, bleeding, and fever, and report any of these signs immediately - avoid strenuous activity - the child may return to school - provide a diet, as tolerated - administer acetaminophen or ibuprofen for pain, discomfort, or fever - keep a follow-up appointment with the pediatrician

Buerger's disease (thromboangiitis obliterans)

- is an occlusive disease of the median and small arteries and veins - the distal upper and lower limbs are affected most commonly assessment: - intermittent claudication - ischemic pain that is more severe at night - aching pain more severe at night - cool, numb, or tingling sensation - diminished pulses in the distal extremities - extremities that are cool and red in the dependent position - development of ulcers in the extremities interventions are the same for raynaud's disease

Morphine sulfate

- is an opioid analgesic - used to ease acute pain resulting from myocardial infarction or cancer, for dyspnea resulting from pulmonary edema, and as a pre-op medication - the major concern is respiratory depression - postural hypotension, urine retention, constipation, and pulmonary constriction may also occur, monitor client for adverse effects. - may cause nausea and vomiting by increasing vestibular sensitivity - contraindicated in severe respiratory disorders, head injuries, severe renal disease, or seizure activity, and in the presence of IICP - monitor bowel sounds for decreased peristalsis, constipation may occur - monitor pupils for changes, pinpoint pupils may indicate an overdose

Pediatric renal and genitourinary problems: UTI

- is bacterial invasion of the urinary tract from flora from the skin or GI tract - uncircumcised male infants are more likely to develop it than circumcised male infants - hygiene and wiping from front to back is important to prevent UTIs in kids - children may experience asymptomatic bacteruria, so if there is a suspicion of infection in the urinary tract, they should be screened and treated accordingly

Herpes Zoster (shingles)

- is caused by a reactivation of the varicella zoster virus, it can occur in any immunocompromised state in a client with a history of chickenpox - herpes zoster eruptions occur in a segmental distribution on the skin area along the infected cranial and spinal nerves it lied dormant in. they show up after several days of discomfort in the area. - the diagnosis is determined by visual examination and by a Tzanck smear to verify herpes infection and viral culture to identify the organism - post-herpetic neuralgia (severe pain) can remain after the lesions resolve - herpes zoster is contagious to people who have never had chickenpox and who have not been vaccinated against the disease - herpes simplex is another type of virus that may be type 1 (a cold sore on mouth or on genitals) or type 2 (genitals). assessment: - unilaterally clustered skin vesicles along peripheral sensory nerves of the trunk, thorax, or face - fever, malaise - burning and pain - paresthesia - pruritus interventions: 1. isolate the client, maintain standard and contact precautions when vesicles are present 2. assess for signs and symptoms of infection, such as skin or eye infections, and skin necrosis can also occur 3. assess neurovascular status and 7th cranial nerve function; Bell's palsy is a complication 4. use an air mattress and bed cradle on the hospitalized client's bed, keep the environment cool because warmth and touch aggravate the pain 5. prevent the client from scratching and rubbing the affected area 6. instruct the client to wear lightweight, loose, cotton clothing and to avoid wool and synthetic clothing 7. teach the client about prescribed therapies; astringent compresses may be prescribed to relieve irritation and pain and to promote crust formation and healing 8. teach the client about measures to keep the skin clean and to prevent infection 9. teach the client about topical treatment and antiviral meds, antiviral therapies begun within 3 days of the rash reduce pain and lessen the likelihood of post-herpetic neuralgia 10. the vaccination for shingles is recommended for adults age 50+ to reduce the risk of occurrence and the associated long-term pain

pediatric hematological problems: sickle cell anemia

- is caused when the normal Hemoglobin A is replaced by the abnormal Hemoglobin S - is caused by inheritance of a gene for a structurally abnormal part of the Hg chain - more common in African Americans - for screening purposes the sickle turbidity test called Sickledex is used because it can be performed on blood from a fingerstick and yields results in 3 minutes, however if the result is positive hemoglobin electrophoresis is needed to see if the child has the trait or actually has the disease. - hemoglobin S is sensitive to O2 content changes of the RBC - insufficient O2 causes the cells to assume a sickle shape, the cells become rigid and clump together, and obstruct capillary blood flow - conditions that precipitate sickling include fever, dehydration, emotional or physical stress and any condition that increases the need for O2 - sickle cell crises are acute exacerbations of the disease and vary in severity and frequency, and include vaso-occlusive crisis, splenic sequestration, hyper-hemolytic crisis, and aplastic crisis - the sickling response is reversible under conditions of adequate O2 and hydration, after repeated sickling, the cell becomes permanently sickled. - an interprofessional approach to care is needed, care focuses on prevention of exposure to infection and maintaining normal hydration, and treatment of the crisis with hydration, O2, pain management, and bed rest. - vaso-occlusive crisis: caused by the stasis of blood with clumping of cells in the micro-circulation, ischemia, and infarction. manifestations are painful swelling of hands, feet, and joints, fever, and abdominal pain. - splenic sequestration: caused by pooling and clumping of blood in the spleen (hyper-splenism). manifested by profound anemia, hypovolemia, and shock - hyperhemolytic crisis: is an accelerated rate of RBC destruction, is manifested by jaundice, anemia, and reticulocytosis - aplastic crisis: caused by diminished production and increased destruction of RBCs and is triggered by viral infection or depletion of folic acid. manifestations are profound anemia and pallor interventions: 1. maintain adequate hydration and blood flow through oral and IV fluids, and provide electrolyte replacement as needed. pain will not subside without adequate hydration. 2. administer O2 and blood transfusions as prescribed to increase tissue perfusion. exchange transfusions may be prescribed which reduce the # of sickling cells and the risk of complications 3. administer analgesics around the clock 4. the child should assume a comfortable position, keeping their extremities extended to promote venous return; elevate the HOB no more than 30 degrees; avoid putting strain on painful joints; and do not raise the knees 5. encourage consumption of a high-calorie, high-protein diet with folic acid supplements 6. administer antibiotics as prescribed to prevent infection 7. monitor for signs of complications lie increased anemia, decreased perfusion, and shock (mental status changes, pallor, or vital sign changes) 8. instruct the child and parents about the early signs of crisis and how to prevent it 9. ensure the child receives pneumococcal and meningococcal vaccines and an annual flu vaccine due to susceptibility of infections 10. a splenectomy may be needed for clients who experience recurrent splenic sequestration 11. inform parents of the hereditary aspects of the disorder 12. administration of meperidine for pain is avoided because of risk of normeperidine-induced seizures

Pediatric GI Problems: Celiac disease

- is characterized by an intolerance to gluten, which is the main component of wheat, barley, rye, and oats. - results in the amino acid glutamine which is toxic to intestinal mucosal cells - occurs most often between ages 1-5 - there's usually an interval of 3-6 months between the introduction of gluten and the onset of symptoms - strict dietary avoidance of gluten prevents the risk of developing malignant lymphoma and other GI malignancies assessment: - acute or insidious diarrhea - steatorrhea - anorexia - abdominal pain and distention - muscle wasting, particularly in the buttocks and extremities - vomiting - anorexia - irritability celiac crisis: - precipitated by fasting, infection, or ingestion of gluten - causes profuse watery diarrhea and vomiting - can lead to rapid dehydration, electrolyte imbalance, and severe acidosis interventions: - maintain a gluten free diet, using corn, rice, and millet as grain sources - instruct the parents and child about lifelong elimination of gluten sources - administer mineral and vitamin supplements including iron, folic acid, and fat-soluble vitamins A, D, E, and K - teach the child and parents about a gluten-free diet and about reading food labels carefully - instruct the parents in measures to prevent celiac crisis - inform the parents about celiac sprue association

Frostbite

- is damage to tissues and blood vessels as a result of prolonged exposure to cold - fingers, toes, face, nose, and ears are often affected assessment: - first-degree: involves white plaque surrounded by a ring of hyperemia and edema - second-degree: large, clear fluid-filled blisters with partial-thickness skin necrosis - third-degree: involves the formation of small hemorrhagic blisters, usually followed by eschar formation involving the hypodermis requiring debridement - fourth-degree: no blisters or edema are noted; full-thickness necrosis with visible tissue loss extending into muscle and bone, which may result in gangrene. Amputation may be required. interventions: 1. reward the affected part rapidly and continuously with a warm water bath or towels at 104 - 107.6 degrees to thaw the frozen part 2. handle the affected areas gently and immobilize 3. avoid using dry heat, and never rub or massage the part, which may result in further tissue damage 4. the rewarming process may be painful, analgesics may be necessary 5. avoid compression of the injured tissues and apply only loose and non-adherent sterile dressings 6. monitor for signs of compartment syndrome 7. tetanus prophylaxis is necessary, and topical and systemic antibiotics may be prescribed 8. debridement of necrotic tissue may be needed, amputation may be necessary if gangrene develops

Dystocia

- is difficult labor that is prolonged or more painful - occurs due to problems caused by uterine contractions, the fetus, or the bones and tissues of the maternal pelvis - the fetus may be excessively large, malpositioned, or in abnormal presentation - contractions may be hypotonic or hypertonic - hypotonic contractions are short, irregular, and weak; amniotomy and oxytocin infusion may be treatment measures - hypertonic contractions are painful, occur frequently (6+ within 10 minutes), and are uncoordinated, treatment depends on the cause and includes pain relief measures and rest - can result in maternal dehydration, infection, fetal injury, or death - assessment: - excessive abdominal pain - abnormal pattern of contractions - fetal distress - maternal or fetal tachycardia - lack of progress in labor - interventions: - assess FHR, monitor for fetal distress - monitor uterine contractions - monitor maternal temp and HR - assist with pelvic exams, measurements, ultrasound, and other procedures - administer prophylactic antibiotics if prescribed to prevent infection - administer IV fluids are prescribed - monitor I&O - maintain hydration - instruct the client in breathing and relaxation techniques - perform fetal monitoring per protocol if oxytocin is prescribed for hypotonic uterine contractions - monitor color of amniotic fluid - provide rest and comfort as with a normal delivery, such as back rubs ad position changes - assess the client's fatigue and pain, and administer sedatives and pain meds as prescribed - assess for prolapse of the cord after membranes rupture

Pediatric GI Problems: imperforate anus

- is incomplete development or absence of the anus in its normal position in the perineum types: - a membrane is noted over the anal opening, with a normal anus just above the membrane - there is a complete absence of the anus (anal agenesis) with a rectal pouch ending some distance above - rectum ends blindly or has a fistula connection to the perineum, urethra, bladder, or vagina assessment: - failure to pass meconium stool - absence or stenosis of the anal rectal canal - presence of an anal membrane - external fistula to the perineum pre-op interventions: - determine the presence of an anal opening - monitor for the presence of stool in the urine and vagina (indicates a fistula) and report immediately - administer IV fluids as prescribed - prepare the child and parents for the surgical procedures, including the potential for colostomy post-op interventions: - monitor skin for signs of infection - the preferred position is the side-lying prone position with the hips elevated or in a supine position with the legs suspended at a 90-degree angle to the trunk to reduce edema and pressure on the surgical site - keep the anal surgical incision clean and dry and monitor for redness, swelling, and drainage - maintain NPO status and NG tube if in place - maintain IV fluids until GI motility returns - provide care for colostomy, if present, as prescribed - a new colostomy stoma may be red and edematous, but the edema should decrease with time - instruct the parents to perform anal dilation if prescribed to achieve and maintain bowel patency - instruct the parents to only use anal dilators supplied by the PHCP and a water-soluble lubricant and to insert the dilator no more than 1-2 cm into the anus to prevent damage to the mucosa

Rupture of the uterus

- is incomplete or complete separation of the uterine tissue as a result of a tear in the wall of the uterus from the stress of labor - complete: direct communication between the perineal cavities - incomplete: rupture into the peritoneum covering the uterus, but not into the peritoneal cavity - manifestations vary with degree of rupture - risk factors are labor after a previous C-section, over-distended uterus after C-section, or abdominal trauma - assessment: - abdominal pain or tenderness - chest pain - contractions may stop or fail to progress - rigid abdomen - absent FHR - signs of maternal shock - fetus palpated outside the uterus - interventions: - monitor and treat signs of shock - prepare the client for a C-section - provide emotional support

Pediatric GI Problems: Appendicitis

- is inflammation of the appendix - when the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis, sepsis, septic shock, and potentially death - treatment is surgical removal of the appendix before perforation occurs assessment: - pain in the periumbilical area that descends to the RLQ - abdominal pain that's most intense at McBurney's point (RLQ) - referred pain indicating the presence of peritoneal irritation - rebound tenderness and abdominal rigidity - elevated WBCs - side-lying position with abdominal guarding to relieve pain - difficulty walking and pain in the right hip - low-grade fever - anorexia, nausea, and vomiting after onset of pain - diarrhea peritonitis: - results from perforated appendix - assessment: - increased fever - progressive abdominal distention - tachycardia and tachypnea - pallor - chills - restlessness and irritability - indicated buy a sudden relief of pain and then a subsequent increase in pain accompanied by right guarding of the abdomen appendectomy: - surgical removal of the appendix pre-op interventions: - maintain NPO status - administer IV fluids and electrolytes as prescribed to prevent dehydration and correct electrolyte imbalances - monitor for changes in pain level - monitor for signs of a ruptured appendix and peritonitis - avoid administering pain meds so changes in pain level aren't masked - administer antibiotics as prescribed - monitor bowel sounds - position in a right-side lying or low to semi-fowlers position to promote comfort - apply ice packs to the abdomen for 20-30 mins every hour if prescribed - avoid the application of heat to the abdomen - avoid laxatives or enemas post-op interventions: - monitor vitals - maintain NPO status until bowel function has returned, advancing the diet gradually as tolerated and as prescribed when bowel sounds return - assess the incision site for signs of infection - monitor drainage from the drain, which may be inserted if perforation occurred - position the client in a side-lying or low to semi-fowler's position with the legs slightly flexed to facilitate drainage - change the dressing as prescribed, and record the type and amount of drainage - perform wound irrigations if prescribed - maintain NG tube suction and patency of the tube if present - administer antibiotics and analgesics as prescribed

Cholecystitis

- is inflammation of the gallbladder, can be acute or chronic - acute inflammation is associated with gallstones, called cholelithiasis - chronic results when insufficient bile emptying and gallbladder muscle wall disease cause a fibrotic and contracted gallbladder - a calculous cholecystitis occurs in the absence of gallstones and is caused by bacterial invasion assessment: - nausea and vomiting - indigestion - belching - flatulence - epigastric pain that radiates to the right shoulder or scapula - pain localized in the RUQ and triggered by a high-fat or high-volume meal - guarding, rigidity, rebound tenderness - mass palpated in the RUQ - Murphy's sign (cannot take a deep breath when the examiners fingers are passed below the hepatic margin because of pain) - fever - tachycardia - signs of dehydration - biliary obstruction (choledolithiasis): jaundice, dark and foamy urine, steatorrhea and clay-colored feces, and pruritus interventions: 1. maintain NPO during nausea and vomiting episodes 2. maintain NG decompression as prescribed for severe vomiting 3. administer antiemetics for nausea and vomiting 4. administer analgesics to relieve pain and reduce spasm 5. administer antispasmodics (anticholinergics) to relax smooth muscle 6. instruct the client with chronic cholecystitis to eat small, low-fat meals 7. instruct the client to avoid gas-forming foods 8. prepare the client for non-surgical and surgical procedures as prescribed surgical interventions: 1. cholecystectomy: removal of the gallbladder 2. choledocholithotomy: incision into the common bile duct to remove the gallstone post-op interventions: 1. monitor for respiratory complications caused by pain at the incision site 2. encourage coughing and deep breathing and early ambulation 3. instruct the client about splinting the abdomen to prevent discomfort during coughing 4. administer antiemetics for nausea and vomiting 5. administer analgesics for pain relief 6. maintain NPO and NG tube suction as prescribed 7. advance the diet from clear liquids to solids as tolerated and as prescribed 8. maintain and monitor drainage from the T-tube, if present

Pediatric respiratory problems: laryngotrachebronchitis (Croup)

- is inflammation of the larynx, trachea, and bronchi, caused by viruses like the flu, pneumonia, or RSV - is the most common type of croup, may be viral or bacterial and occurs most in kids younger than 5 - has a gradual onset that may be preceded by an upper respiratory infection assessment: - there are 3 stages - stage 1: low-grade fever, hoarseness, croup cough, inspiratory stridor, fear, and irritability and restlessness - stage 2: continuous respiratory stridor, retractions, use of accessory muscles, crackles and wheezing, and labored respirations - stage 3: continued restlessness, anxiety, pallor, diaphoresis, tachypnea, and signs of anorexia and hypercapnia - stage 4: intermittent cyanosis progressing to consistent cyanosis, and anemic episodes which progress to cessation of breathing interventions: 1. maintain a patent airway 2. assess respiratory status and monitor pulse ox; and monitor for nasal flaring, retractions, and inspiratory stridor 3. monitor for adequate respiratory exchange (cyanosis and pallor) 4. elevate the head of the bed and provide rest 5. provide humidified O2 as prescribed for a hospitalized child using a cool air or mist tent 6. instruct the parents to use a cool air vaporizer at home, or breathe in cool air 7. provide and encourage fluid intake, IV fluids may be prescribed to maintain hydration if the child is unable to orally intake fluids 8. administer analgesics to reduce fever 9. teach parents to avoid giving cough syrups or cold medicines, because they may dry and thicken secretions 10. administer corticosteroids to reduce inflammation 11. administer antibiotics if a bacterial infection is present 12. Heliox (mixture of helium and O2) may be prescribed 13. have resuscitation equipment available 14. provide appropriate reassurance and education to the parents or caregivers

Pediatric respiratory problems: Bronchitis

- is inflammation of the trachea and bronchi - usually occurs from a respiratory infection - isolation precautions should be implemented for a child with an upper respiratory infection until the causative agent is known - it is usually mild and the causative agent is usually viral assessment: - fever - dry, hacking, and non-productive cough that is worse at night and becomes productive in 2-3 days interventions: 1. treat symptoms as necessary 2. monitor for respiratory distress 3. provide cool, humidified air to the child 4. encourage increased fluid intake, the child may drink beverages as long as their respiratory status is stable 5. administer antipyretics for a fever 6. administer a cough suppressant to promote rest

internal fetal monitoring

- is invasive - requires rupture of the membranes and the mother to be 2-3 cm dilated - an electrode is attached to the presenting part of the fetus

Precipitous labor and delivery

- is labor lasting longer than 3 hours - interventions: - ensure that a precipitous delivery tray is available - stay with the client at all times - provide emotional support and keep the client calm - encourage the client to pant between contractions - prepare for rupturing membranes when the head crowns if they are not already ruptured - do not try to prevent the fetus from being delivered - if delivery is needed before arrival of the PHCP, do the following: 1. apply gentle pressure to the fetal head upward toward the vagina to prevent damage to the fetal head and vaginal lacerations; support the perineal area. 2. support the infant's body during delivery 3. deliver the infant between contractions, checking for the cord around the neck 4. use restitution to deliver the posterior shoulder 5. use gentle downward pressure to move the anterior shoulder under the pubic symphysis 6. bulb suction the infant's mouth first, and then suction each naris 7. dry and then cover the infant to keep the body warm 8. allow the placenta to separate naturally 9. place the infant on the mother's abdomen or breast to induce uterine contractions

Fundal height

- is measured to evaluate the gestational age of the fetus - during the 2nd and 3rd trimesters (weeks 18-30), fundal height in cm approximately equals the fetal age in weeks + or - 2 cm. - at 16 weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus - at 20 - 22 weeks, the fundus is approximately at the location of the umbilicus - at 36 weeks the fundus is at the xiphoid process

Risk conditions related to pregnancy: incompetent cervix

- is related to structural or functional defects of the cervix. - treatment involves surgical placement of a cervical cerclage. - assessment findings include vaginal bleeding and fetal membranes visible through the cervix. - interventions are to provide bed rest, hydration, and tocolysis (suppression of premature labor) to inhibit uterine contractions; prepare for cervical cerclage (at 10 - 14 weeks of gestation as prescribed) in which a band of fascia or non-absorbable ribbon is placed around the cervix beneath the mucosa to constrict the internal os; after cervical cerclage tell the client to refrain from intercourse, standing too long and heavy lifting; the cervical cerclage is removed after 37 weeks of gestation or left in place and a C-section is performed, if removed it needs to be repeated with each successive pregnancy; after placement of the cervical cerclage monitor for contractions, rupture of the membranes, and signs of infection; and instruct the client to report to the PHCP any post-procedure vaginal bleeding or increased uterine contractions.

Thyroidectomy

- is removal of the thyroid gland - performed when persistent hyperthyroidism exists - subtotal thyroidectomy is removal of a portion of the thyroid gland and is preferred method pre-op interventions: 1. obtain vitals and weight 2. assess electrolytes 3. assess for hyperglycemia 4. instruct client to perform coughing and deep-breathing and to support the neck in the post-op period when coughing and moving 5. administer anti-thyroid meds, iodides, propranolol, and glucocorticoids as prescribed to prevent thyroid storm post-op interventions: 1. monitor for respiratory distress 2. have a trache set, O2, and suction at the bedside 3. limit talking, assess level of hoarseness 4. avoid neck flexion and stress on the suture line 5. monitor for laryngeal nerve damage as evidenced by airway obstruction, dysphonia, high-pitched voice, stridor, dysphagia, and restlessness 6. monitor for signs of hypocalcemia and tetany, which can be caused by trauma to the parathyroid gland 7. prepare to give calcium gluconate as prescribed for tetany 8. monitor for thyroid storm 9. maintain the client in the semi-fowler's position, monitor the surgical site for edema and bleeding and check the dressing in the front and back of the neck, and monitor for inflammation which can block the airway.

Amniotomy

- is the artificial rupture of the amniotic membranes by the provider using an amnihook or other sharp object to stimulate labor - is performed if the fetus is at a 0 or a +1 or +2 station - increases the risk of prolapsed cord and infection - monitor FHR before and after amniotomy - record time of amniotomy, FHR, and characteristics of the fluid - meconium-stained amniotic fluid may be associated with fetal distress - bloody amniotic fluid may indicate abruptio placentae or fetal trauma - an unpleasant odor to amniotic fluid is associated with infection - polyhydramnios is associated with maternal diabetes and certain congenital disorders - oligohydraminos is associated with intrauterine growth restriction and congenital disorders - expect more variable decelerations after rupture of the membranes as a result of possible cord compression during contractions - limit client activity if prescribed

Pediatric GI Problems: GERD

- is the backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter - most infants with GERD have a mild problem that improved in a year and requires medical therapy only - it occurs when gastric contents reflux into the esophagus or oropharynx and produce symptoms assessment: - passive regurgitation or emesis - poor weight gain - irritability - hematemesis - heartburn in older kids - anemia from blood loss interventions: 1. assess amount and characteristics of emesis 2. assess the relationship of vomiting to the times of feedings and infant activity 3. monitor breath sounds before and after feedings 4. assess for signs of aspiration after the feeding like drooling, coughing, or dyspnea 5. place suction equipment at the bedside 6. monitor I&O 7. monitor for signs and symptoms of dehydration 8. maintain IV fluids as prescribed positioning: - the infant is placed in the supine position during sleep unless there is a very high risk of aspiration - in kids older than 1 year position with the head of bed elevated diet: - provide small frequent feedings with predigested formula to decrease the amount or regurgitation - nutrition by a NG tube may be prescribed if severe regurgitation and poor growth are present - formula may be thickened by adding cereal - breast feeding can continue, and the mother may provide more frequent feedings or thicken the milk with cereal - burp the infant frequently when feeding and handle the infant minimally after feedings, monitor for coughing during feedings and other signs of aspiration - for toddlers feed solid foods first, then liquids - instruct the parents to avoid feeding fatty foods, chocolate, tomato, carbonated liquids, fruit juices, citrus, and spicy foods - instruct the parents that the child should avoid vigorous play after feeding just before bedtime medications: - anti-acids for symptoms relief - proton pump inhibitors and histamine receptor antagonists to decrease gastric acid secretion

Pediatric GI Problems: Diarrhea

- is the cause of dehydration in young kids - causes are infections of the GI tract, antibiotic therapy, rotavirus, and parasitic infections. - causes of chronic diarrhea are malabsorption disorders, inflammatory bowel disease, immunodeficiencies, food intolerances, and other nonspecific factors. - rotavirus is a cause of serious gastroenteritis and is a hospital acquired infection that is most severe in kids 3-24 months old assessment: - character of stools - presence of pain and abdominal cramping - signs of dehydration and fluid and electrolyte imbalances - signs of metabolic acidosis interventions: 1. monitor character, amount, and frequency of diarrhea 2. provide enteric isolation as required, instruct the parents in effective handwashing 3. maintain skin integrity 4. monitor strict I&O 5. monitor electrolyte levels 6. monitor for signs and symptoms of dehydration 7. monitor for mild to moderate dehydration, provide oral rehydration therapy with Pedialyte or a similar rehydration solution as prescribed, avoid carbonated beverages because they are gas-producing, and avoid fluids with high amounts of sugar 8. for severe dehydration, maintain NPO to give the bowel a rest and provide fluid and electrolyte replacement by IV, if K+ is prescribed for IV administration, ensure the child has voided before administering and has adequate renal function 9. reintroduce a normal diet when rehydration is achieved

Pleural effusion

- is the collection of fluid in the pleural space - any condition that interferes with secretion or drainage of this fluid will lead to pleural effusion assessment: - pleuritic pain that is sharp and increases with inspiration - progressive dyspnea with increased movement of the chest wall on the affected side - dry, non-productive cough caused by bronchial irritation or mediastinal shift - tachycardia - fever - decreased breath sounds over the affected area - chest x-ray film that shows pleural effusion and a mediastinal shift away from the fluid if the effusion is more than 250 mL interventions: 1. identify and treat the underlying cause 2. monitor breath sounds 3. place the client in a Fowler's position 4. encourage coughing and deep breathing 5. prepare the client for thoracentesis 6. if pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed Pleurectomy: - consists of surgically stripping the parietal pleura away from the visceral pleura - this produces an intense inflammatory response that promotes adhesion formation between the 2 layers during healing Pleurodesis: - involves the installation of a sclerosing substance into the pleural space by a thoracotomy tube - the substance creates an inflammatory response that scleroses (hardens) tissue together.

Risk conditions related to pregnancy: fetal death in utero

- is the death of a fetus after the 20th week of gestation and before birth. - the client can develop DIC if the dead fetus remains in the uterus for 3+ weeks - Assessment: absence of fetal movement, absence of fetal heart tones, maternal weight loss, lack of fetal growth or decrease in fundal height, no evidence of fetal cardiac activity, and other characteristics that suggest death noted on the fetal ultrasound. - interventions: prepare for the birth of the fetus, support the client's decisions about labor birth and the postpartum period, provide support and ask what will be helpful, provide assistance, accept behaviors like sadness, anger, and hostility from the parents, refer to the parents to a support group, and be aware of the religious, cultural, and spiritual beliefs of the parents and ensure their beliefs are respected and implemented as appropriate.

Amniotic fluid embolism

- is the escape of amniotic fluid into the maternal circulation - it deposits into the pulmonary arterioles and is usually fatal to the mother - assessment: - abrupt onset of respiratory distress and chest pain - cyanosis - fetal bradycardia and distress if delivery has not occurred at the time of embolism - interventions: - institute emergency measures to maintain life - administer 8-10 L/min of O2 by face mask or resuscitation bag delivering 100% O2 - prepare for intubation and mechanical ventilation - position the client on her side - administer IV fluids, blood products, and meds as prescribed to correct coagulation failure - monitor fetal status - prepare for emergency delivery when the client is stabilized - provide emotional support to the client, partner, and family

Heart failure

- is the inability of the heart to maintain adequate CO to meet the metabolic needs of the body because of impaired pumping ability - diminished CO results in inadequate peripheral tissue perfusion. - the client may develop acute pulmonary edema - can be acute or chronic assessment: - right-sided heart failure: dependent edema, jugular venous distention, abdominal distention, hepatomegaly, splenomegaly, anorexia and nausea, weight gain, nocturnal diuresis, swelling of the fingers and hands, and increased or decreased BP. - left-sided heart failure: signs of pulmonary congestion, dyspnea, tachypnea, crackles in the lungs, dry hacking cough, paroxysmal nocturnal dyspnea, and increased or decreased BP. **signs of left sided HF are evident in the pulmonary system, signs of right sided HF are evident in the systemic circulation** priority nursing actions for pulmonary edema (in the acute episode of HF): 1. place the client in high-fowler's position 2. administer O2 3. assess the client quickly, including assessing lung sounds 4. ensure than an IV access device is in place 5. prepare for the administration of a diuretic and morphine sulfate. 6. insert a foley catheter as prescribed. 7. prepare for ventilation and intubation support, if required 8. document the event, actions taken, and the client's response interventions following the acute episode: 1. assist the client to identify precipitating risk factors of HF and methods of eliminating those risks 2. encourage the client to verbalize feelings about the lifestyle changes required as a result of the HF 3. instruct the client in the prescribed medication regimen, which may include digoxin, a diuretic, ACE inhibitors, low-dose beta-blockers, and vasodilators 4. advise the client to notify the PHCP if side effects occur from the med 5. advise the client to avoid OTC medications 6. instruct the client to contact the PHCP if they're unable to take the meds due to illness 7. instruct the client to avoid large amounts of caffeine 8. instruct the client about the prescribed low-sodium, low-fat, and low-cholesterol diet 9. provide the client with a list of K+-rich foods because diuretics can cause hypokalemia (except for K+-retaining diuretics) 10. instruct the client regarding fluid restriction, if prescribed, advising the client to spread the fluid out during the day and to suck on hard candy to reduce thirst 11. instruct the client to balance periods of activity and rest 12. advise the client to balance periods of activity and rest 13. instruct the client to monitor daily weight 14. instruct the client to report signs of fluid retention such as edema or weight gain

Pediatric GI Problems: Lactose intolerance

- is the inability to tolerate lactose as a result of an absence of or a deficiency of lactose, an enzyme found in the secretions of the small intestine that is required for the digestion of lactose assessment: - symptoms occur after the ingestion of dairy - abdominal distention - cramps, abdominal pain, colic - diarrhea and excessive flatus interventions: 1. eliminate daily or take an enzyme supplement 2. provide information to the parents about enzyme tablets that pre-digest the lactose 3. substitute soy-based products for cow's milk or human milk 4. allow milk consumption as tolerated 5. instruct the child and family that the child should drink milk with other foods instead of by itself 6. encourage consumption of hard cheese, cottage cheese, and yogurt which contains the inactive lactase enzyme 7. encourage ingestion of small amounts of dairy products daily to help the colonic bacteria adapt to ingested lactose 8. instruct the parents about foods that have lactose 9. instruct the parents on the importance of vitamin D and calcium supplements

External version

- is the manipulation of the fetus from an unfavorable position to a favorable one for birth - is indicated for an abnormal presentation that exists after the 34th week - monitor vitals - if the mother is Rh negative, ensure that Rh0(D) immune globulin was given at 28 weeks of gestation - prepare for a non-stress test to evaluate fetal well-being - IV fluids and tocolytic therapy may be given to relax the uterus and permit easier manipulation of the fetus - ultrasound is used during the procedure to evaluate fetal position and placental placement and guide the direction of the fetus - the abdominal wall is manipulated to direct the fetus into a cephalic presentation if possible - monitor BP and identify vane cava compression - monitor for unusual pain - after the procedure, perform a non-stress test to evaluate fetal well-being, monitor for uterine activity, ruptured membranes, and decreased fetal activity, and with Rh-negative client perform a Kleihauer-Betke test as prescribed to detect the presence and amount of fetal blood in the maternal circulation and to identify clients who need additional Rh0(D) immune globulin

Pediatric oncological problems: osteosarcoma (Osteogenic Sarcoma)

- is the most common bone cancer in kids - cancer is usually found in the metaphysis of long bones, especially in the lower extremities, with most occurring in the femur - the peak age of incidence is 10-25 years old - symptoms in the earliest stage are almost always attributed to extremity injury or normal growing pains - treatment may include surgical resection (limb salvage procedure) to save a limb or remove affected tissue, or amputation - chemo is used to treat cancer and may be administered before and after surgery assessment: - localized pain on the affected site that may be attributed to trauma or the vague complaint of "growing pains", pain is relieved by a flexed position - palpable mass - limping if weight-bearing leg is affected - progressive limited ROM and the child's reduction in ability of physical activity - child may be unable to hold heavy objects because of their weight or pain - pathological fractures can occur at the tumor site interventions: - prepare the child and family for prescribed treatment modalities, which may include surgical resection of the limb by limb salvage to remove affected tissue, amputation, and chemo - communicate honestly with the child and family and provide support - prepare for a prosthetic fitting as needed - assist the child with dealing with self-image issues as needed - instruct the child and parents about the potential development of phantom limb pain that may occur after amputation, characterized by tingling, itching, and a painful sensation in the area where the leg was amputated

Pediatric oncological problems: nephroblastoma (Wilms' tumor)

- is the most common intra-abdominal and kidney tumor of childhood, it may manifest unilaterally or locally or bilaterally, sometimes with metastasis to other organs - the peak incidence is of 3 years of age - occurrence is associated with a genetic inheritance and with several congenital anomalies - therapeutic management includes a combines treatment of surgery (partial or total nephrectomy) and chemo with or without radiation, depending on the clinical stage and the histological pattern of the tumor assessment: 1. swelling or mass in the abdomen, is usually non-tender, confined to one side, and deep within the flank 2. urinary retention or hematuria 3. anemia caused by hemorrhage within the tumor 4. pallor, anorexia, and lethargy resulting from anemia 5. HTN caused by secretion of excess amounts of renin by the tumor 6. weight loss and fever 7. symptoms of lung involvement, like dyspnea, SOB, and pain in the chest if metastasis has occurred pre-op interventions: - monitor vitals - avoid palpation of the abdomen, place a sign at the bedside that says not to palpate the abdomen - measure abdominal girth 1x a day - be cautious when bathing, moving, or handling the child to keep the tumor intact; rupture of the tumor can cause the cancer cells to spread throughout the abdomen, lymph system, and blood stream post-op interventions: - monitor temp and bp closely - monitor for signs of hemorrhage and infection - monitor strict intake and output closely - monitor for abdominal distention, monitor bowel sounds and other signs of GI activity due to the risk of intestinal obstruction

Risk conditions related to pregnancy: abruptio placentae

- is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus has delivered. - assessment findings include dark red vaginal bleeding, there may be an absence of visible blood if the bleeding is high in the uterus or is minimal; uterine pain and/or tenderness; uterine rigidity; severe abdominal pain; signs of fetal distress; and signs of maternal shock if bleeding is excessive. - interventions are to monitor maternal vitals and FHR; assess for excessive vaginal bleeding, abdominal pain, and an increase in fundal height; maintain bed rest, administer O2, IV fluids, and blood products as prescribed; place the client in trendelenburg's position if indicated to decrease the pressure of the fetus on the placenta, or place in the lateral position with the head of the bed flat if hypovolemic shock occurs; monitor and report any uterine activity; prepare for delivery of the fetus as quickly as possible, with vaginal delivery preferable if the fetus is healthy and stable and the presenting part is in the pelvis, emergency C-section may be performed if the fetus is alive but shows signs of distress; and monitor for signs of disseminated intravascular coagulation in the postpartum period. ** know the difference between placenta previa and abruptio placentae. In placenta previa, there is painless, bright red vaginal bleeding, and the uterus is soft, relaxed, and non-tender. In abruptio placentae there is dark red vaginal bleeding, uterine pain or tenderness or both and uterine rigidity **

Pediatric respiratory problems: SIDS

- is the unexpected death of an apparently healthy infant younger than 1 year old - cause is unknown - death usually occurs when they sleep - is most frequent when infant is 2-3 months old - incidence is higher in boys, native americans, african americans, hispanics, and lower socioeconomic groups - lowest in breast-fed infants and infants sleeping with a pacifier - high risk in infants in prone position, sleeping on soft bedding, overheating, stress, co-sleeping, mother who smokes or abused drugs in the pregnancy, and exposure to tobacco smoke after birth. prevention and interventions: - place them in supine for sleep - teach mother risk factors - alter head position during sleep, avoid excessive time in infant seats and bouncers, place infant prone while awake and monitor them

Risk conditions related to pregnancy: tuberculosis

- is transmitted by airborne route - multi-drug resistant strains can result from improper compliance, non-compliance with treatment programs, or development of mutations. - trans-placental transmission is rare, transmission can occur during birth through aspiration of infected amniotic fluid, the newborn can become infected from contact with infected individuals. - active disease during pregnancy has been associated with an increase in HTN disorders of pregnancy. - diagnosis is by a chest radiograph which is only done after 20 weeks of gestation, and a lead shield for the abdomen is needed. - assessment findings of the mother are possible symptomatic, fever and chills, night sweats, weight loss, fatigue, cough with green/yellow sputum, dyspnea, or pleural pain. - assessment findings of the newborn are fever, lethargy, poor feeding, failure to throve, respiratory distress, hepatosplenomegaly, meningitis, and the disease may spread to all major organs. - interventions for the mother are to administer isoniazid, pyrazinamide, and rifampin daily for 9 months as prescribed, and ethambutol is added if med resistance is likely. pyridoxine should be administered with isoniazid to the pregnant client to prevent fetal neurotoxicity caused by isoniazid, and promote breast feeding only if the client is not infected. - interventions for the newborn are to prevent disease and treat early infection, skin testing is performed on the newborn at birth, and the newborn may be placed on isoniazid therapy, and the skin test is repeated in 3 - 4 months, and the med is stopped once the test is negative. if the skin test is positive, the newborn should receive isoniazid for at least 6 months as prescribed, and if the mother's sputum is free of organisms the newborn does not need to be isolated from her.

Bishop score

- is used to determine maternal readiness for labor and evaluated cervical status and fetal position - is indicated before the induction of labor - 5 factors are assigned a score of 0-3 and the total score is calculated: 1. dilation of cervix: 0 cm is score of 0; 1-2 cm is score of 1; 3-4 cm is score of 2; and 5 cm or greater is score of 3 2. effacement of cervix: 0-30% is score of 0; 40-50% is score of 1; 60-70% is score of 2; and 80% or greater is score of 3 3. consistency of cervix: firm is score of 0, medium is score of 1; and soft is score of 2 4. position of cervix: posterior is 0; mid-position is 1; and anterior is 2 5. station of presenting part: -3 station is 0; -2 station is 1; -1 station is 2; and +1 or +2 is 3 - a score of 8 or greater indicates that the chance of a successful vaginal delivery is good and the cervix is favorable for induction.

Raynaud's disease

- is vasospasm of the arterioles and arteries of the upper and lower extremities - causes constriction of the vessels - attacks occur with exposure to cold or stress - affects primarily the fingers, toes, ears, and cheeks assessment: - blanching of the extremity, followed by cyanosis from vasoconstriction - reddened tissue when the vasospasm is relieved - numbness, tingling, swelling, and a cold temp of the affected body part interventions: 1. monitor pulses 2. administer vasodilators as prescribed 3. instruct the client about med therapy 4. assist the client to identify and avoid precipitating factors such as cold and stress 5. instruct the client to avoid smoking 6. instruct the client to wear warm clothing in cold weather 7. advise the client to avoid injuries to fingers and hands

phytonadione

- is vitamin K - is not synthesized until intestinal bacteria are present in the newborn (5-8 days) - used to prevent hemorrhagic disorders - can cause hyperbilirubinemia interventions: - protect the med from light - give during the early newborn period - give IM in the lateral aspect of the mid third of the vastus lateralis muscle of the thigh - monitor for bruising at injection site and bleeding from the cord - monitor for jaundice and bilirubin levels

Sinus bradycardia

- less than 60 bpm - treatment may be needed if the client is symptomatic (signs of decreased CO) - a low HR can be normal for athletes interventions: 1. attempt to determine the cause, withhold med suspected of causing bradycardia and notify the PHCP 2. administer O2 as prescribed for the symptomatic client 3. administer atropine sulfate as prescribed to increase the HR 4. be prepared to apply a non-invasine (transcutaneous) pacemaker if the atropine sulfate does not increase the HR sufficiently 5. avoid additional doses of atropine sulfate because this will induce tachycardia 6. monitor for hypotension and administer fluids IV as prescribed 7. depending on the cause of the bradycardia, the client may need a permanent pacemaker

Lipids

- lipids consist of cholesterol, triglycerides, and phospholipids - a lipid assessment includes total cholesterol, LDL, HDL, and triglycerides - normal cholesterol levels: less than 200 - normal HDLs: above 60 - normal LDLs: less than 100 - normal triglycerides: 40-160 in males, 35-135 in females - increased cholesterol, LDL levels, and triglycerides place the client at risk of coronary artery disease. - HDLs help protect against the risk of coronary artery disease - instruct the client to abstain from food and fluid except for water for 12-14 hours before the test and from alcohol for 24 hours before the test. also the client should not have a meal high in cholesterol the night before the test - elevated cholesterol and LDL levels may be caused by: biliary obstruction, cirrhosis hyperlipidemia, hypothyroidism, idiopathic hypercholesterolemia, renal disease, uncontrolled diabetes, or oral contraceptive use - elevated triglyceride levels may be caused by: diabetes, hyperlipidemia, hypothyroidism, or liver disease - below normal cholesterol and LDL values may be caused by: excessive liver disease, hypothyroidism, malnutrition, or use of corticosteroids - below normal levels of triglycerides may be caused by: hyperthyroidism, malabsorption syndrome, or malnutrition

Coarse crackles

- low-pitched bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration and are not cleared by coughing. - May be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases like in fine and medium crackles but the condition is worse and may be heard in terminally ill clients with diminished gag reflex. also heard in pulmonary edema and pulmonary fibrosis.

Vitamin B12-deficiency anemia

- macrocytic anemia that results from an inadequate intake of vitamin B12 or a lack of its absorption. - pernicious anemia is caused by a lack of intrinsic factor that is needed to digest vitamin B12 assessment: - severe pallor - fatigue - weight loss - smooth, beefy red tongue - slight jaundice - paresthesias of the hands and feet - disturbances with gait and balance interventions: 1. increase intake of foods high in vitamin B12; like citrus fruits, dried beans, green leafy veggies, liver, nuts, organ meats, and brewer's yeast if the anemia is a result of dietary insufficiency. 2. administer vitamin B12 injections as prescribed, weekly at first and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of the intrinsic factor or disease or surgery of the ileum.

Intestinal tumors

- malignant lesions that develop in the cells lining the bowel wall or develop as polyps in the colon or rectum - complications include bowel perforation with peritonitis, hemorrhage, abscess and fistula formation, and complete intestinal obstruction. - risk factors are age above 50, previous colorectal polyps or history of colorectal cancer, history of chronic inflammatory bowel disease, and history of ovarian or breast, endometrial, and stomach cancers assessment: - blood in stool - anorexia, vomiting, weight loss - anemia - abnormal stools - guarding or abdominal distention, abdominal mass is a late sign - cachexia is a late sign (weakness and wasting of the body) - masses noted on the barium enema, colonoscopy, CT scan, and sigmoidoscopy interventions: 1. monitor for signs of complications which include bowel perforation with peritonitis, abscess or fistula formation, hemorrhage, and complete intestinal obstruction 2. monitor for signs of bowel perforation, which include low BP, rapid and weak pulse, distended abdomen, and elevated temp 3. monitor for signs of intestinal obstruction, which include vomiting, pain, constipation, and abdominal distention; provide comfort measures 4. note that an early sign of intestinal obstruction is increased peristaltic activity, which produces an increase in bowel sounds; hypoactive bowel sounds may be heard as it progresses 5. prepare for radiation pre-op to facilitate surgical resection, and post-op to reduce the risk of recurrence or to reduce pain, hemorrhage, bowel obstruction, or metastasis - surgical interventions include bowel resection, local lymph node resection, and creation of a colostomy or ileostomy

Lung cancer

- malignant tumor of the bronchi and peripheral lung tissue - lungs are a common target for metastasis to other tissues - bronchogenic cancer spreads through direct extension and lymphatic dissemination - is classified according to histological cell type - diagnosis is made by chest X-ray, CT and PET scan, or MRI, and by bronchoscopy and sputum studies which demonstrate a positive cytological study for cancer cells - causes include cigarette smoking, or exposure to environmental and occupational pollutants assessment: - wheezing - cough, dyspnea - hoarseness - hemoptysis, blood-tinged or purulent sputum - chest pain - anorexia and weight loss - weakness - diminished or absent breath sounds, respiratory changes interventions: 1. monitor vitals 2. monitor breathing patterns and respiratory changes , monitor for hemoptysis 3. assess for tracheal deviation 4. administer analgesics and prescribed pain management 5. place in fowler's position to help breathe easier 6. administer O2 and humidification as prescribed 7. monitor pulse ox 8. provide respiratory treatments as prescribed 9. administer bronchodilators and corticosteroids as prescribed to reduce inflammation, edema, and bronchospasm 10. provide a high-calorie, high-protein, high-vitamin diet 11. provide activity as tolerated, rest periods, and active and passive ROM exercises 12. non-surgical interventions: radiation and chemo 13. surgical interventions: laser therapy, thoracentesis and pleurodesis, thoractomy (opening into the thoracic cavity) with pneumonectomy (removal of 1 lung), thoractomy with lobectomy (surgical removal of 1 lobe of the lung), thoractomy with segmental resection (surgical removal of a lobe segment) post-op interventions: 1. monitor vitals 2. assess cardiac and respiratory status, auscultate lung sounds 3. maintain the chest tube drainage system which drains air and blood that accumulates in the pleural space, monitor for excess bleeding 4. administer O2 as prescribed 5. check the surgeon's prescriptions regarding client positioning, avoid complete lateral turning 6. monitor pulse Ox 7. provide activity as tolerated 8. encourage active ROM exercises of the operative shoulder as prescribed

Pediatric eye, ear, and throat problems: Epistaxis (nosebleed)

- may result from trauma, foreign bodies, nose picking, or mucosal inflammation - recurrent epistaxis and severe bleeding may indicate an underlying disease - apply pressure

Medium crackles

- medium-pitched, moist sound heard about halfway through inspiration and are not cleared by coughing. - May be heard in pneumonia, heart failure, asthma, and restrictive pulmonary diseases like in fine crackles but the condition is worse.

tocolytics

- meds that produce uterine relaxation and suppress uterine activity - used to halt uterine contractions and prevent preterm birth - includes magnesium sulfate, terbutaline, and nifedipine - maternal contraindications = severe preeclampsia and eclampsia, active vaginal bleeding, intrauterine infection, cardiac disease, placental abruption, and poorly controlled diabetes - fetal contraindications = estimated gestational age over 37 weeks, cervical dilation over 4 cm, fetal demise, lethal fetal anomaly, chorioamnionitis, acute fetal distress, and chronic intrauterine growth restriction. interventions for the client receiving tocolytic therapy: - position the client on her side to enhance placental perfusion and reduce pressure on the cervix - monitor maternal vitals, fetal status, and labor status frequently - monitor for signs of adverse effects to the meds - monitor daily weight and I&O status, provide fluids as prescribed - offer comfort measures and provide psychosocial support

Treatment for inflammatory bowel disease

- meds used to treat inflammatory bowel disease: 1. antimicroboals: - ciprofloxacin - metronidazole - rifaximin - clarithromycin 2. 5-aminosalicylates: - balsalazide - mesalamine - olsalazine - sulfasalazine 3. corticosteroids: - budesonide - prednisone - hydrocortisone 4. immunosuppressants: - azathioprine - cyclosporine - mercaptopurine - tacrolimus 5. immunomodulators - adalimumab - certolizumab - infliximab - natalizumab - inflammatory bowel disease comes in 2 forms: Crohn's disease and ulcerative colitis - antimicrobials may be prescribed to prevent or treat secondary infection - 5-animosalicylates: decrease GI inflammation, adverse effects include nausea, rash, arthralgia (joint pain), and hematological disorders - corticosteroids: act as an anti-inflammatory to decrease GI inflammation - immunomodulators: monoclonal antibodies modulate the immune response to induce and maintain remission

Leopold's maneuvers

- methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds - if the head is in the fundus a hard, round, movable object is felt. the buttocks feel soft and have an irregular shape and are more difficult to move. - the fetus's back should be felt on 1 side of the abdomen - irregular knobs and lumps may be on the hands, feet, elbows, and knees are felt on the opposite side of the abdomen.

Leukotriene modifiers

- montelukast - zafirlukast - zileuton - used in the prophylaxis and treatment of chronic bronchial asthma (not for acute asthma episodes) - inhibit bronchoconstriction caused by specific antigens and reduce airway edema and smooth muscle constriction - contraindicated in clients with hypersensitivity and in breast-feeding mothers - should be used with caution in clients with impaired hepatic function - coadministration of inhaled glucocorticoids increases the risk of upper respiratory infection - adverse effects: headache, nausea, vomiting, dyspepsia, diarrhea, generalized pain, myalgia, fever, dizziness interventions: 1. assess frequency of exacerbations 2. assess changes in lung function 3. assess liver function and lab values 4. monitor for cyanosis client education: 1. take the med 1 hour before or 2 hours after meals 2. increase fluid intake 3. do not discontinue the med and take it as prescribed, even during symptom-free periods

testicular cancer

- most often occurs between the ages 15 and 40 - cause is unknown, but a history of undescended testicle and genetic predisposition have been associated with increased risk - metastasis occurs to the lung, liver, bone, and adrenal glands by the blood and to the retroperitoneal lymph nodes by the lymphatic channels - early detection is by performing monthly testicular self-exams right after the shower when the scrotal skin is moist and relaxed. first, gently lift each testicle, each one should feel like an egg (firm but not hard) and smooth with no lumps. then place middle fingers on the underside of each testicle and the thumbs on top and gently roll the testicle between the thumb and finger to feel for any lumps, swelling, or mass. if you notice any changes notify the PHCP. assessment: - painless testicular swelling - dragging or pulling sensation of the scrotum - palpable lymphadenopathy, abdominal masses, and gynecomastia may indicate metastasis - late signs are back or bone pain and respiratory symptoms interventions: 1. administer chemo as prescribed 2. prepare the client for radiation therapy as prescribed 3. prepare the client for unilateral orchiectomy if prescribed for diagnosis and primary surgical management or radial orchiectomy (surgical removal of the affected testes, spermatic cord, and regional lymph nodes) 4. prepare the client for retroperitoneal lymph node dissection if prescribed to stage the disease and reduce tumor volume so that chemotherapy and radiation therapy are more effective 5. discuss reproduction, sexuality, and fertility information and options with the client 6. identify reproductive options with the client such as sperm storage, donor insemination, and adoption post-op interventions: 1. monitor for signs of bleeding and wound infection, antibiotics may be given to prevent wound infection 2. monitor I&O 3. provide and explain pain management measures, apply an icepack with an intervening layer of cloth to reduce swelling in the first 48 hours 4. notify the PHCP if chills, fever, increasing pain or tenderness, or drainage from the incision occur 5. after the orchiectomy, instruct the client to avoid heavy lifting and strenuous activity for whatever length of time the PHCP says 6. instruct the client to perform a monthly testicular self-exam on the remaining testicle 7. inform the client that sutures will be removed in 7-10 days post-surgery

Hepatitis B

- non-seasonal, and affects all ages - increased risk with IVDA, clients undergoing long-term hemodialysis, and health care workers. - transmission is by blood or body fluid contact, infected blood products, infected saliva or semen, contaminated needles, sexual contact, parenteral, perinatal period, and blood or body fluid contact at birth. - the incubation period is 6-24 weeks - the infection is established by the hepatitis B antigen-antibody systems in the blood, the presence of hepatitis B surface antigen is the marker establishing the diagnosis, the client is considered infectious if these antigens are present in the blood, if the hepatitis B surface antigen is still present after 6 months the client is considered to have chronic hepatitis B, the presence of antibodies to hepatitis B surface antigen indicates recovery and immunity to hepatitis B, and hepatitis B early antigen is detected in the blood about 1 week after the appearance of the hepatitis B surface antigen and its presence determines the infective stage of the disease. - complications are fulminant hepatitis, chronic liver disease, cirrhosis, and primary hepatocellular carcinoma - prevented by strict hand washing, screening blood donors, testing all pregnant women, and needle precautions - avoid sexual contact and contact with body fluids in people who test positive for the Hepatitis B surface antigen - hepatitis B vaccine comes in adult and pediatric forms, there is also an adult vaccine that protects against hepatitis A and B - hepatitis B immune globulin is for people exposed to hepatitis B through sexual contact or through the percutaneous or transmucosal routes who have never had hepatitis B or the vaccine.

WBC count

- normal level: 5,000 - 10,000 - elevated values may be due to: inflammatory and infectious processes, leukemia - below normal values occur in: aplastic anemia, autoimmune diseases, overwhelming infection, and side effects of chemotherapy and radiation - monitor the client receiving chemotherapy closely because of their risk for neutropenia, neutropenia places them at increased risk for infection. - normal differential levels: Neutrophils: 40% to 60% or 2,000 - 6,000 Lymphocytes: 20% to 40% or 1,000 - 4,000 Monocytes: 2% to 8% or 100 - 800 Eosinophils: 1% to 4% or 50 - 400 Basophils: 0.5% to 1% or 25 - 100

Somogyi phenomenon

- normal or elevated glucose levels present at bedtime, then hypoglycemia occurs around 2-3 am which causes an increase in the production of counter-regulatory hormones - by around 7 am, in response to the counter-regulatory hormones, the blood glucose rebounds significantly to the hyperglycemic range - treatment includes a decrease in the client's insulin dose or a increase in their bedtime snack, or both - clients experiencing this may complain of early morning headaches, night sweats, or nightmares caused by the early morning hypoglycemia

Platelet count

- normal platelet levels: 150,000 - 400,000 - elevated values may be caused by: acute infection, chronic leukemia, chronic pancreatitis, cirrhosis, collagen disorders, polycythemia, postsplenectomy, high altitudea, and chronic cold weather - below normal values may be caused by: acute leukemia, chemotherapy, disseminated intravascular coagulation, hemorrhage, infection, systemic lupus erythematosus, or thrombocytopenic purpura - monitor the venipuncture site for bleeding in clients who have thrombocytopenia - bleeding precautions should be initiated in clients whose platelet levels fall sufficiently below the normal levels - monitor platelet levels closely in clients receiving chemotherapy due to risk of thrombocytopenia - any client who is going to have an invasive procedure should have coagulation studies and platelet counts done before hand.

Pediatric cardiovascular problems: defects with decreased pulmonary blood flow

- obstructed pulmonary blood flow and an anatomical defect (ASD or VSD) between the right and left sides of the heart are present - pressure on the right side of the heart increases, exceeding the pressure on the left side, which allows desaturated blood to shunt right to left, causing desaturation in the left side of the heart and in the systemic circulation - typically hypoxemia and cyanosis appear tetralogy of fallot: - includes 4 defects: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy - if pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left. if systemic resistance is higher than pulmonary resistance, the shunt is from left to right - infants: - an infant may be acutely cyanotic at birth, or may have mild cyanosis that progresses over the first year of like as pulmonic stenosis worsens - a murmur is present - acute episodes of cyanosis and hypoxemia called blue spells occur when the infant's O2 requirements exceed the blood supply, such as during periods of crying, feeding, or defecating - priority nursing actions for infants with hypercyanotic spells: 1. place the infant in the knee-chest position 2. administer 100% O2 3. administer morphine 4. administer IV fluids 5. document occurrence, actions taken, and the infant's response children: - with increasing cyanosis, squatting, clubbing of fingers, and poor growth may occur - squatting is a compensatory mechanism to facilitate increased return of blood flow to the heart for oxygenation - clubbing is an abnormal enlargement of the distal fingers - surgical management: palliative shunt - the shunt increases pulmonary blood flow and increases O2 saturation in infants who cannot undergo a pulmonary repair - the shunt provides blood flow to the pulmonary arteries from the left or right subclavian artery - surgical management: complete repair - complete repair usually is performed in the first year of life - the repair requires a median sternotomy and cardiopulmonary bypass Tricuspid atresia: - is failure of the tricuspid valve to develop - no communication exists between the right artia and right ventricle - blood flows through an ASD or a patent foramen ovale to the left side of the heart and through a VSD to the right ventricle and out through the lungs - the defect often is associated with pulmonic stenosis and transposition of the great arteries - the defect results in complete mixing of unoxygenated and oxygenated blood in the left side of the heart, resulting in systemic desaturation, pulmonary obstruction, and decreased pulmonary blood flow. -cyanosis, tachycardia, and dyspnea ae often seen in the newborn - older children exhibit signs of chronic hypoxemia and clubbing - management: - if the ASD is small, the defect may be closed during cardiac catheterization, otherwise, surgery is needed

Preterm labor

- occurs after the 20th week but before the 37th week of gestation. - risk factors: a history of medical conditions, present and past OB problems, infection, and social and environmental factors like substance abuse. - additional risk factors are a multifetal pregnancy which contributes to over-distention of the uterus, anemia which decreases O2 supply to the uterus, and age younger than 18 years or a first pregnancy and age older than 40. - assessment: - uterine contractions - abdominal cramping - low back pain - pelvic pressures or heaviness - change in character or amount of usual discharge - may be thicker or thinner, bloody, brown, or colorless, or odorless - rupture of amniotic membranes - presence of fetal fibronectin in cervical canal - shortening of cervical length - interventions: - focus on stopping the labor: identify and treat infection, restrict activity, and ensure hydration - maintain bed rest and lateral position - monitor fetal status - administer fluids - administer medications as prescribed and monitor for side effects of tocolytics - use 17 alpha-hydroxyprogesterone caproate known as 17P injection to decrease the risk of preterm delivery.

Hepatitis C

- occurs any time of the year, in any age group, is common among IVDA and the most common cause is post-transfusion hepatitis - risks are similar to those for hepatitis B, because both are transmitted parenterally (acquiring an infectious agent into one's body through something other than the gastrointestinal (or enteral) route) - increased risk in people who are IVDA, clients who get frequent transfusion, and healthcare personnel. - transmission is the same as hepatitis B, and is primarily through blood - incubation period is 5-10 weeks - the anti-hepatitis C virus is the antibody to hepatitis C virus and is measured to detect chronic states of hepatitis C - complications include chronic liver disease, cirrhosis, and primary hepatocellular carcinoma - prevented by strict hand washing, needle precautions, and screening blood donors.

ventricular tachycardia

- occurs due to a repetitive firing of an irritable ventricular ectopic focus at a rate of 140-250 beats per minute - may be 3 beats or more, or may be a sustained rhythm - VT can lead to cardiac arrest - for stable clients with sustained VT (with pulse and no signs of decreased CO) administer O2 as prescribed and antidysrhythmics as prescribed - for unstable clients with VT (with pulse and signs of decreased CO) administer O2 and antidysrhythmics as prescribed, prepare for synchronized cardioversion if the client is unstable, the PHCP may attempt cough cardiopulmonary resuscitation (CPR) by asking the client to cough hard every 1-3 seconds - pulseless clients with VT: defibrillation and CPR

pulmonary embolism

- occurs when a thrombus forms (most commonly in a deep vein), detaches, travels to the right side of the heart, and then lodges in a branch of the pulmonary artery. - clients prone to a PE are those at risk for deep vein thrombosis, including those with prolonged immobilization, surgery, obesity, pregnancy, HF, advanced age, or a history of thromboembolism - fat emboli can occur as a complication following fracture of a long bone and can cause pulmonary emboli - treatment is aimed at prevention through risk factor recognition and elimination assessment: - apprehension and restlessness - blood-tinged sputum - chest pain - cough - crackles and wheezes on auscultation - cyanosis - distended neck veins - dyspnea accompanied by anginal and pleuritic pain, exacerbated by inspiration - feeling of impending doom - hypotension - petechiae over the chest and axilla - shallow respirations - tachypnea and tachycardia priority nursing actions for a suspected PE: 1. notify the rapid response team and PHCP 2. reassure the client and elevate the HOB 3. prepare to administer the O2 4. obtain vitals and check lung sounds 5. prepare to obtain ABGs 6. prepare for the administration of heparin therapy or other therapies 7. document the event, interventions taken, and the client's response to treatment

Acute respiratory failure

- occurs when insufficient O2 is transported to the blood or inadequate CO2 is removed from the lungs and the client's compensatory mechanisms fail - causes are a mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles - in O2 failure, or hypoxemic respiratory failure, O2 may reach the alveoli but cannot be absorbed or used properly, resulting in a PaO2 lower than 60, and SaO2 less than 90% on RA, or a PaCO2 greater than 50 which occurs with acidosis. - respiratory failure can be hypoxemic, hypercapnic, or both. inadequate gas exchange is the mechanism behind the failure. arterial O2, CO2, or both are not kept at normal levels resulting in failure. - many clients experience both hypoxemic and hypercapnic respiratory failure and retained CO2 in the alveoli displace O2, contributing to the hypoxemia - manifestations of respiratory failure are related to the extent and rapidity of change in PaO2 and PaCO2 assessment: - dyspnea - restlessness - confusion - tachycardia - HTN - dysrhythmias - decreased LOC - alterations in respirations and breath sounds - headache interventions: 1. identify and treat the cause of the respiratory failure 2. administer O2 to maintain the PaO2 level higher than 60-70 3. place the client in the Fowler's position 4. encourage deep breathing 5. administer bronchodilators as prescribed 6. prepare the client for mechanical ventilation if supplemental O2 cannot maintain acceptable O2 and CO2 levels

Valvular heart disease

- occurs when the heart valves cannot open fully (stenosis) or cannot close completely (insufficiency or regurgitation) - valvular heart disease prevents efficient blood flow through the heart types: 1. mitral stenosis: valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left atrium to the left ventricle 2. mitral insufficiency, regurgitation: valve is incompetent, preventing complete valve closure during systole 3. mitral valve prolapse: valve leaflets protrude into the left atrium during systole 4. aortic stenosis: valvular tissue thickens and narrows the valve opening, preventing blood from flowing from the left ventricle into the aorta. Symptoms include dyspnea on exertion, angina, syncope on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, and harsh systolic crescendo-decrescendo murmur. interventions are to prepare the client for valve replacement as indicated. 5. aortic insufficiency: valve is incompetent, preventing complete valve closure during diastole. symptoms include dyspnea, angina, tachycardia, fatigue, orthopnea, paroxysmal nocturnal dyspnea, and blowing decrescendo diastolic murmur. prepare the client for valve replacement as indicated. 6. tricuspid stenosis: Tricuspid stenosis is a narrowing of the tricuspid valve opening. Tricuspid stenosis restricts blood flow between the upper (atrium) and lower (ventricle) part of the right side of the heart. symptoms include easily fatigue, effort intolerance, fluttering sensations in the neck, cyanosis, signs of right HF (ascites, hepatomegaly, peripheral edema, jugular vein distention with clear lung fields), symptoms of decreased CO, and a rumbling diastolic murmur. interventions are to prepare the client for valve replacement as indicated. 7. Tricuspid insufficiency: is a type of valvular heart disease in which the tricuspid valve of the heart, located between the right atrium and right ventricle, does not close completely when the right ventricle contracts (systole). Symptoms are asymptomatic in mild situations, signs of right HF (ascites, hepatomegaly, and peripheral edema), pleural effusion, and systolic murmur heard at the left sternal border 4th intercostal space. prepare the client for valve replacement as indicated. 8. pulmonary stenosis and pulmonary insufficiency: may be asymptomatic in mild conditions, dyspnea, fatigue, syncope, signs of right sided HF (ascites, hepatomegaly, peripheral edema), and a systolic thrill heard at the left sternal border. prepare the client for a pulmonary valve commissurotomy (The valve leaflets are cut to loosen the valve slightly, allowing blood to pass easily) for a pulmonary stenosis, and for a pulmonary valve replacement as indicated for pulmonary insufficiency

Pediatric neurological and cognitive problems: Head injury

- open head injury is when there's a fracture of the skull or penetration of the skull by an object - closed head injury is when there is blunt trauma, is more serious than open head injury because it causes a change in ICP, this can also be caused by shaken baby syndrome - manifestations depend on the type of injury and the amount of IICP assessment: - IICP - the child's LOC provides the earliest indication of an improvement or deterioration of their neurological condition - early signs: - slight changes in vitals - slight changes in LOC - infant - irritability, high-pitched cry, bulging fontanel, increased head circumference, dilated scalp veins, Macewen's sign (cracked-pot sound on percussion of the forehead), and setting sun sign (sclera is visible above the iris) - child - headache, vomiting, visual disturbances, seizures - late signs: - significant decrease in LOC - bradycardia - decreased motor and sensory responses - alteration in pupil size and reactivity - decorticate (flexed) positioning (adduction of the arms and shoulders, arms are flexed on the chest with the wrists flexed and hands fisted, the lower extremities are flexed and adducted, seen with severe dysfunction of the cerebral cortex) - decerebrate (extended) positioning (rigid extension and pronation of the arms and the legs, indicates a dysfunction of the midbrain) - Cheyne-stokes respirations - coma interventions: 1. immobilize the neck and spine after a head injury if a cervical or other spinal injury is suspected. when a spinal cord injury is ruled out, elevated the HOB 15-30 degrees to facilitate venous drainage, if not contraindicated. 2. ,monitor the airway, administer O2 as prescribed 3. assess injuries 4. position the client so the head stays midline to avoid jugular vein compression, which can increase ICP 5. monitor vitals, neurological function, and LOC closely 6. notify the PHCP if signs of IICP occur 7. reduce stimuli, attempt to minimize an infant's crying 8. withhold sedating meds during the acute phase of the injury so that changes in LOC can be assessed 9. initiate seizure precautions 10. monitor for decreased responsiveness to pain 11. maintain NPO status or provide clear liquids if prescribed until it is determined the client will not vomit 12. monitor prescribed IV fluids carefully to avoid IICP/edema and minimize over-hydration 13. monitor for alterations in fluids and electrolytes 14. assess wounds and dressings for the presence of drainage, and monitor for nose or ear drainage which can indicate leaking of CSF 15. administer tepid sponge baths or place the child on a hypothermia blanket if hyperthermia occurs 16. avoid suctioning the nares because of the possibility of the catheter entering the brain through a fracture, which places the child at high risk of secondary infection 17. give acetaminophen as prescribed to relieve headache, anti-convulsants for seizures, and antibiotics if a laceration is present, and prepare to administer prophylactic tetanus toxoid 18. a corticosteroid or osmotic diuretic may be prescribed to reduce cerebral edema 19. monitor for signs of brainstem involvement 20. monitor for signs of epidural hematoma, asymmetrical pupils may indicate a neurosurgical emergency that requires evacuation of the hematoma

Clinical manifestations of metabolic alkalosis

- pH greater than 7.45, HCO3 greater than 28 - assessment findings: Neurological: - lethargy, irritability, confusion, headache Cardiovascular: - low bp, tachycardia, dysrhythmias GI: - anorexia, nausea, vomiting Neuromuscular: - tetany, tremors, tingling of the extremities, muscle cramps, hypertonic muscles, seizures Respiratory: - rate and depth of respirations decrease

Clinical manifestations of respiratory alkalosis

- pH is greater than 7.45, PaCO2 less than 35 - assessment findings: Neurological: - dizziness, lightheadedness, confusion, headache Cardiovascular: - low bp, tachycardia, dysrhythmias GI: - nausea, vomiting, diarrhea, epigastric pain Neuromuscular: - tetany, numbness, tingling of extremities, hyperreflexia, seizures Respiratory: rate and depth of respirations decrease, hyperventilation occurs when lungs are unable to compensate

Clinical manifestations of metabolic acidosis

- pH is less than 7.35, HCO3 is less than 21 - assessment findings: Neurological: - lethargy, confusion, dizziness, headache, coma Cardiovascular: - decreased bp, dysrhythmias, cold clammy skin GI: - nausea, vomiting, diarrhea, abdominal pain Neuromuscular: - muscle weakness Respiratory: - deep, rapid respirations, called Kussmaul's respirations

Clinical manifestations of respiratory acidosis

- pH is less than 7.35, Paco2 is greater than 45 - Assessment findings: Neurological: - lethargy, confusion, dizziness, headache, coma Cardiovascular: - decreased bp - dysrhythmias - warm, flushed skin Neuromuscular: - seizures Respiratory: - increased rate and depth of respirations - hypoventilation and hypoxia occur when lungs are unable to compensate

Normal arterial blood gases

- pH: 7.35 - 7.45 - PaCO2: 35-45 - HCO3: 21 - 28 - PaO2: 80 - 100

Risk conditions related to pregnancy: obesity

- places the client as risk for gestational diabetes, gestational HTN, preeclampsia, venous thromboembolism, and increased need for C-section. - delivery complications can result from difficulty obtaining IV access, epidural access, intubation, and decreased O2 consumption with associated increased cardiac output, stressing the heart. - negative effects on the newborn include stillbirth, premature birth, congenital anomalies, future obesity, heart disease, and difficulty with breast feeding. - obese women have lower prolactin response to sucking in the first week postpartum contributing to high rates of breast feeding failure. - potential post-delivery complications and their interventions: - thromboembolism formation is a concern, use stockings, sequential compression devices (SCDs), and pharmacological venous thromboembolism prophylaxis may be needed post-delivery. - postpartum hemorrhage is more common, as well as difficulty locating the fundus. - endometritis is common - early ambulation is encouraged to prevent venous thromboembolism formation. - and frequent monitoring and cleaning of surgical incisions is needed to prevent infection or dehiscence due to excess abdominal fat.

Risk conditions related to pregnancy: UTIs

- pregnancy is a predisposing factor for UTIs - other predisposing conditions are history of UTIs, urinary tract anomalies, low socioeconomic status, sexual activity, young age, sickle cell trait, poor hygiene, anemia, diabetes, obesity, and catheterization. - screening is done at the first prenatal visit or at 12-16 weeks of gestation. re-screening is done if mom is high-risk. - assessment: frequency and urgency, burning while peeing, voiding in small amounts, inability to void, incomplete emptying of the bladder, lower abdominal or back discomfort, bladder spasms, cloudy, dark, or foul-smelling urine, hematuria, malaise, fever, chills, and WBC count over 11,000 on urinalysis. - interventions: get a culture for culture and sensitivity, increase fluids up to 3,000 mL/day, administer prescribed meds, sitz baths or heat to the abdomen may provide comfort, use sterile technique if inserting catheter, provide perineal care for client with catheter, discourage caffeine, client education is avoid alcohol, take meds as prescribed, take antibiotics entire course as prescribed, repeat urine culture following treatment, and prevent recurrence of cystitis.

Sarcoidosis

- presence of epithelial cell tubercles in the lung - the cause is unknown, but a high titer of Epstein-Barr virus may be noted - viral incidence is highest in African Americans and young adults assessment: - night sweats - fever - weight loss - cough and dyspnea - skin nodules - polyarthritis - Kveim test: sarcoid node antigen is injected intradermally and causes a local nodular lesion in about 1 month interventions: 1. administer corticosteroids to control symptoms 2. monitor temp 3. increase fluids 4. provide frequent periods of rest 5. encourage small, frequent, nutritious meals

Heparin sodium

- prevents thrombin from converting fibrinogen to fibrin - prevents thromboembolism - the therapeutic dose does not dissolve clots but prevents new thrombus formation blood levels: - the normal activated partial thromboplastin time (aPTT) is 30-40 seconds - when on heparin, the therapeutic range for the aPTT is 1.5-2.5 the normal value (45-100) - aPTT should be measured every 4-6 hours during initial continuous therapy or until the client has been therapeutic for a specified time frame, and then daily per agency protocol - if the aPTT is too long, per agency protocol, the dosage should be lowered - if the aPTT is to short, per agency protocol, the dosage should be increased interventions: 1. monitor the aPTT 2. monitor platelet count 3. observe for bleeding gums, bruises, nose-bleeds, hematuria, hematemesis, occult blood in the stool, and petechiae 4. instruct the client regarding measures to prevent bleeding 5. the antidote to heparin is protamine sulfate 6. when administering heparin sub-cutaneously, inject in the abdomen with a 5/8 inch 25-28 gauge needle at a 90 degree angle and do not aspirate or rub the injection site 7. continuous IV infusions must be run on an infusion pump to ensure a precise rate of delivery

Adrenal cortex insufficiency (Addison's disease)

- primary adrenal insufficiency (Addison's disease) refers to hypo-secretion of adrenal cortex hormones, and autoimmune destruction is a common cause. it requires life long replacement of adrenal cortex hormones (glucocorticoids and mineralocorticoids) if significant hypo-secretion occurs; the condition is fatal if left untreated. - secondary adrenal insufficiency is caused by hypo-secretion of ACTH from the anterior pituitary gland, mineralocorticoid release is spared. - loss of glucocorticoids leads to decreased vascular tone, decreased vascular response to epinephrine and norepinephrine, and decreased gluconeogenesis - loss of mineralocorticoid aldosterone leads to dehydration, hypotension, hyponatremia,and hyperkalemia. assessment: - lethargy, fatigue, muscle weakness - GI disturbances - weight loss - menstrual changes in women, impotence in men - hypoglycemia, hyponatremia - hyperkalemia, hypercalcemia - hypotension - hyperpigmentation of the skin (bronzed) with primary disease interventions: 1. monitor vitals, weight loss, and I&O 2. monitor WBCs, blood glucose, and K+ Na+, and Ca2+ levels 3. administer glucocorticoid and / or mineralocorticoid meds as prescribed 4. observe for addisonian crisis caused by stress, infection, trauma., or surgery client education: - need for life-long glucocorticoid replacement and possible mineralocorticoid replacement - corticosteroid replacement will need to be increased during times of stress - avoid individuals with infections - avoid strenuous exercise and stressful situations - avoid OTC meds - diet should be high in protein and carbs; clients taking glucocorticoids should be prescribed calcium and vitamin D supplements to maintain normal levels and ti protect against corticosteroid-induced osteoporosis; some clients taking mineralocorticoids may be prescribed a diet high in sodium - wear a medialert bracelet - report signs and symptoms of complications, such as under-replacement and over-replacement of corticosteroid hormones

diabetic nephropathy

- progressive decrease in kidney function assessment: - microalbuminuria (small amounts of albumin in the urine) - thirst - fatigue - anemia - weight loss - signs of malnutrition - frequent UTIs - signs of neurogenic bladder interventions: 1. early prevention methods include controlling HTN and blood glucose levels 2. assess vitals 3. monitor I&O 4. monitor BUN, creatinine, and uric albumin levels 5. restrict dietary protein, sodium, and K+ intake as prescribed 6. avoid nephrotoxic meds 7. prepare the client for dialysis if planned 8. prepare the client for kidney transplant if planned 9. prepare the client for pancreas transplant if planned

Warfarin sodium

- prolongs clotting time, is monitored by the lab test prothrombin time (PT) and the international normalized ratio (INR). - it is used for long-term anti-coagulation and is used mainly to prevent thromboembolic conditions such as thrombophlebitis, pulmonary embolism, and embolism formation caused by a fib, thrombosis, MI, and heart valve damage. blood levels: - the normal PT is 11-12.5 seconds - warfarin prolongs the PT, and the therapeutic range is 1.5-2 times the control value (16.5-25) - the normal INR is 0.81-1.2 - INR on warfarin should be 2-3, the INR for high dose warfarin therapy should be 3-4.5. - if the PT is longer than 30 seconds and the INR is greater than 3, initiate bleeding precautions - if the INR is below the recommended range, the dose should be increased - clients may sometimes be prescribed "bridge therapy" where heparin is used as the same time as warfarin until the INR reaches the recommended range. Then, the heparin is discontinued. interventions: 1. monitor the PT and INR 2. observe for bleeding gums, bruises, nose-bleeds, hematuria, hematemesis, occult blood in the stool, and petechiae 3. instruct the client regarding diet and measures to prevent bleeding 4. the antidote for warfarin is phytonadione (vitamin K)

Histoplasmosis

- pulmonary fungal infection caused by spores of Histoplasma capsulatum - transmission occurs by inhalation of spores, which commonly are found in contaminated soil - spores are usually found in bird droppings assessment: - similar to pneumonia - positive skin test for histoplasmosis - + agglutination test - splenomegaly, hepatomegaly interventions: 1. administer O2 as prescribed 2. monitor breath sounds 3. administer antiemetics, antihistamines, antipyretics, and corticosteroids as prescribed 4. administer fungicidal meds as prescribed 5. encourage coughing and deep breathing 6. place the client in the semi-fowler's position 7. monitor vitals 8. monitor for nephrotoxicity from fungicidal meds 9. instruct the client to wear a mask and spray on the floor with water before sweeping barn and chicken coops

Atrial fibrillation

- rapid impulses from atria at 350-600 per minute - the atria quiver, which lead to the formation of thrombi - usually no definitive P wave is observed, only fibrillatory waves before each QRS complex interventions: 1. administer O2 2. administer anticoagulants as prescribed because of the risk of emboli 3. administer cardiac meds as prescribed to control the ventricular rhythm and assist in the maintenance of CO 4. prepare the client for cardioversion as prescribed 5. instruct the client in the use of meds as prescribed to control the dysrhythmia

What to document when using a safety device

- reason for the safety device - method of use for the safety device - date and time of application of the safety device - duration of use of the safety device and the client's response - release from safety device with periodic exercise and circulatory, neurovascular, and skin assessment - assessment of continued need for safety device - evaluation of the client's response

Pediatric renal and genitourinary problems: Glomerulonephritis

- refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus, most of which is caused by an immunological reaction. - the disorder results in proliferative and inflammatory changes within the glomerular structure - destruction, inflammation, and sclerosis of the glomeruli and kidneys occur - inflammation of the glomeruli results from an antigen-antibody reaction produced by infection elsewhere in the body - loss of kidney function develops - causes include immunological diseases, autoimmune diseases, antecedent group A B-streptococcal infection of the pharynx or skin, and history of pharyngitis or tonsillitis 2-3 weeks before symptoms - types: acute occurs 2-3 weeks after a streptococcal infection. chronic may occur after the acute phase or slowly over time - complications include kidney failure, hypertensive encephalopathy, pulmonary edema, HF, or seizures. assessment: - periorbital and facial edema that is more prominent in the morning - anorexia - decreased urinary output - cloudy, smokey, brown-colored urine - pallor, irritability, lethargy - in an older child headaches, abdominal or flank pain, and dysuria - HTN - proteinuria that produces a persistent and excessive foam in the urine - azotemia - increased BUN and creatinine levels - increased anti-streptolysin O titer interventions: 1. assess airway patency, vitals, and weight 2. assess for dyspnea, bounding rapid pulse, dysrhythmias, and HTN 3. assess for distended hand and nack veins 4. assess for generalized edema and check amount of urinary output 5. notify the PHCP and carry out prescriptions, including water and sodium restriction and administration of diuretics

Premature rupture of the membranes

- refers to the rupture of the membranes prior to the onset of labor - the gestational age usually determines the plan and intervention - when the rupture of the membranes is before term and birth, infection is a risk - assessment: - presence of fluid pooling in vaginal vault; nitrazine test is positive - amount, color, consistency, and odor of fluid needs to be assessed - vitals are monitored; an elevated temp may indicate an infection - fetal monitoring is needed; fetal tachycardia may indicate maternal infection - interventions: - assist with tests to assess gestational age - avoid vaginal exams because of the risk of infection - monitor maternal and fetal status for signs of compromise or infection - administer antibiotics as prescribed

Parathyroidectomy

- removal of 1 or more of the parathyroid glands - parathyroid tissue is transplanted into the forearm or near the sternocleidomastoid muscle, allowing the secretion of PTH to continue pre-op interventions: 1. monitor electrolytes, calcium, phosphate, and magnesium levels 2. ensure calcium levels are decreased to near normal levels 3. inform the client that talking may be painful for the first day or two after surgery post-op interventions: 1. monitor for respiratory distress 2. place a trache set, O2, and suction equipment at the bedside 3. monitor vitals 4. position the client in semi-fowler's position 5. assess neck dressing for bleeding 6. monitor for hypocalcemic crisis, shown by tingling and twitching in the extremities and face 7. assess for + Trousseau's sign or Chvosek's sign which indicates tetany 8. monitor for laryngeal nerve damage 9. instruct the client in the administration of calcium and vitamin D supplements as prescribed

transient tachypnea of the newborn

- respiratory condition that results from incomplete reabsorption of fetal lung fluid in full term newborns, usually disappears within 24 to 48 hours assessment: - tachypnea - expiratory grunting - retractions - nasal flaring - fluid breath sounds head on auscultation - cyanosis interventions: - supportive care - O2 administration

Newborn vital signs

- resting HR: 110-160 - 90-110 if sleeping - up to 180 if crying - auscultate the fourth intercostal space for 1 full minute - RR 30-60, assess for 1 full minute - axillary temp: 97.7-100.2 - bp is usually not done unless a cardiac issue is suspected, should be 80-90 / 40-50

Myxedema coma

- result of persistently low thyroid production; can be precipitated by an acute illness, rapid withdrawal of thyroid meds, anesthesia and surgery, hypothermia, or the use of sedatives and opioid analgesics assessment: - hypotension - bradycardia - hypothermia - hyponatremia - hypoglycemia - generalized edema - respiratory failure - coma interventions: 1. maintain a patent airway 2. institute aspiration precautions 3. administer NS or hypertonic saline IV fluids as prescribed 4. administer levothyroxine sodium IV as prescribed 5. administer glucose IV as prescribed 6. administer corticosteroids as prescribed 7. assess the client's temp hourly 8. monitor BP often 9. keep the client warm 10. monitor for changes in mental status 11. monitor for electrolyte and glucose levels

Risk conditions related to pregnancy: pyelonephritis

- results from bacterial infections that extend upward from the bladder through the blood vessels and lymphatics. - frequently follows untreated urinary tract infections and is associated with increased incidence of anemia, low birth weight, gestational HTN, pre-mature labor and delivery, and premature rupture of the membranes. - assessment findings include fever and chills, tachycardia and tachypnea, nausea, flank pain on the affected side, costovertebral angle tenderness, headache, dysuria, frequency and urgancy, cloudy/bloody/foul-smelling urine, and increased WBCs in the urine. - interventions are to monitor vitals; encourage fluid intake up to 3,000 mL/day to reduce fever and prevent dehydration; monitor I&O and ensure output is a minimum of 1500 mL in 24 hours; monitor weight; encourage adequate rest; instruct the client about a high calorie low-protein diet; provide warm, moist compresses to the flank area to help relieve pain; encourage the client to take warm baths for pain relief; administer analgesics, antipyretics, urinary antiseptics, and antiemetics as prescribed; monitor for signs of kidney disease; and encourage a follow-up urine culture.

Hyperthyroidism

- results from hyper-secretion of thyroid hormones - characterized by an increased rate of metabolism - a common cause is Grave's disease (toxic diffuse goiter) - clinical manifestations are called thyrotoxicosis - TSH levels are usually low assessment: - personality changes like irritability, agitation, and mood swings - nervousness, hand tremors - weakness, muscle aches, paresthesias - heat intolerance - weight loss - smooth, soft skin and hair - palpitations, cardiac dysrhythmias - diarrhea - protruding eyeballs (exopthalmos) - diaphoresis - HTN - enlarged thyroid gland (goiter) interventions: 1. provide adequate rest 2. administer sedatives as prescribed 3. provide a cool and quiet environment 4. obtain daily weights 5. provide a high-calorie diet 6. avoid administration of stimulants 7. administer anti-thyroid meds, like methimazole or propylthiouracil, that block thyroid synthesis as prescribed 8. administer iodine preparations as prescribed which inhibit the release of thyroid hormone 9. administer propranolol for tachycardia as prescribed 10. prepare the client for radioactive iodine therapy as prescribed, to destroy thyroid cells 11. prepare the client for subtotal thyroidectomy if prescribed 12. elevate the HOB if a client has exophthalmos, and instruct on a low-salt diet, administer artificial tears, encourage the use of dark glasses, and tape the eyelids closed at night if necessary. 13. allow the client to express concerns about body image changes

Hypothyroidism

- results from hypo-secretion of thyroid hormones and characterized by a decreased rate of metabolism - T4 is low, TSH is elevated - primary hypothyroidism: the source of dysfunction is the thyroid gland; the thyroid cannot produce enough hormones. - secondary hypothyroidism: the thyroid is not being stimulated by the pituitary to release hormones assessment: - lethargy and fatigue - weakness, muscle aches, paresthesias - intolerance to cold - weight gain - dry skin and hair and loss of body hair - bradycardia - constipation - generalized puffiness and edema around the face and eyes (myxedema) - forgetfulness and loss of memory - menstrual disturbances - goiter may or may not be present - cardiac enlargement, tendency to develop HF interventions: 1. monitor vitals, including heart rhythm 2. administer thyroid replacement; levothyroxine sodium is most commonly prescribed 3. instruct the client about thyroid replacement therapy and the clinical manifestations of hypo and hyper thyroidism related to under or over replacement of the hormone 4. instruct the client in a low-calorie, low-cholesterol, low-saturated fat diet; discuss a daily exercise program like walking 5. assess the client for constipation; provide roughage and fluids to prevent constipation 6. provide a warm environment 7. avoid sedatives and opioid analgesics because increased sensitivity to these meds; may precipitate myxedema coma 8. monitor for OD of thyroid meds characterized by tachycardia, chest pain, restlessness, nervousness, and insomnia 9. instruct the client to report episodes of chest pain or other signs of OD immediately

Pediatric GI Problems: irritable bowel syndrome

- results from increased motility, which can lead to spasm and pain - the diagnosis is based on the elimination of pathological conditions - the syndrome is a self-limiting, intermittent problem with no definitive treatment. - stress and emotional factors may contribute to its occurrence assessment: - diffuse abdominal pain unrelated to meals or activity - alternating constipation and diarrhea with the presence of undigested food and mucus in the stool interventions: - reassure the parents and child that the problem is self-limiting and intermittent and will resolve - anticholinergics may be prescribed; anti-depressants may be needed in severe cases - encourage the maintenance of a healthy, well-balanced, moderate-fiber, and low-fat diet. - encourage health promotion activities such as exercise and school activities - inform the parents of psychosocial resources if required

venous insufficiency

- results from prolonged venous HTN, which stretches the veins and damages the valves - the resultant edema and venous stasis cause venous stasis ulcers, swelling, and cellulitis - treatment focuses on decreasing edema and promoting venous return from the affected extremity - treatment for venous stasis ulcers focuses on healing the ulcer and preventing stasis and ulcer recurrence assessment: - stasis dermatitis or brown discoloration along the ankles, extending up the calves - edema - ulcer formation: edges are uneven, ulcer bed is pink, and granulation is present; usually located on the lateral malleolus ** for venous insufficiency, leg elevation is usually prescribed to assist with the return of blood to the heart ** interventions: 1. instruct the client to wear elastic or compression stockings during the day and evening if prescribed (instruct the client to put on elastic stocking upon awakening, and before getting out of bed); it may be necessary to wear the stockings for the remainder of the client's life 2. instruct the client to avoid prolonged sitting or standing, constrictive clothing, or crossing the legs when seated 3. instruct the client to elevate the legs above the level of the heart for 10-20 minutes every few hours each day 4. instruct the client in the use on an intermittent sequential pneumatic compression system, if prescribed (use twice daily for 1 hour in the am and pm) 5. advise the client with an open ulcer that the compression system is applied over a dressing wound care: 1. provide care to the wound as prescribed 2. assess the client's ability to care for the wound, and initiate home care resources as needed 3. if an Unna boot (dressing constructed on gauze moistened with zinc oxide) is prescribed, the PHCP will change it weekly 4. the wound is cleansed with normal saline before application of the Unna boot; providone-iodine and hydrogen peroxide are not used, because they destroy granulation tissue 5. the Unna boot is covered with an elastic wrap that hardens to promote venous return and prevent stasis 6. monitor for signs of arterial occlusion from an Unna boot that may be too tight 7. keep tape off the client's skin 8. occlusive dressings like polyethylene film or a hydrocolloid dressing may be used to cover the ulcer medications: 1. apply topical agents to the wound as prescribed to debride the ulcer, eliminate necrotic tissue, and promote healing 2. when applying topical debriding agents, apply an oil-based agent such as petroleum jelly on surrounding skin to protect healthy tissue 3. administer antibiotics as prescribed if infection or cellulitis occurs

Islamic beliefs related to end-of life care

- second degree male relatives should be contact people and determine whether or not the client or family is given information - client may choose to face Mecca (West or SW of the U.S.) - the head should be elevated above the body - do not discuss about death - stopping medical treatment is against the will of their god - grief is expressed through slapping or hitting the body, only a muslim of the same sex may handle the body after death, or non-muslims who wear gloves and touch the body as little as possible - permit organ transplant for the purpose of saving one's life

Respiratory distress syndrome in newborn

- serious lung disorder caused by immaturity and inability to produce surfactant, resulting in hypoxemia and acidosis assessment: - signs of respiratory distress: tachypnea, nasal flaring, expiratory grunting, retractions, see-saw respirations, decreased breath sounds, and apnea - pallor and cyanosis - hypothermia - poor muscle tone interventions: - monitor color, RR, and degree of effort breathing - maintain airway and cardiopulmonary function and support respirations as prescribed - monitor ABGs and O2 levels as prescribed; ensure O2 that's delivered is at the lowest possible concentration needed to maintain adequate oxygenation - any premature newborn who needed O2 should get an eye exam before discharge to assess for retinal damage - position the newborn on the side or back, with the head slightly extended - administer respiratory therapy (percussion and vibration) as prescribed, use padded small plastic cup or small O2 mask for percussion, use padded electric toothbrush for vibration - provide nutrition - support bonding - prepare parents for period of O2 dependency if necessary - encourage the mother to pump the breasts for future breast feeding if she desires - encourage parental participation in the newborn's care - prepare to administer surfactant replacement therapy

Hypokalemia

- serum K+ level lower than 3.5 Assessment findings: Cardiovascular: - thready, weak, irregular pulse - weak peripheral pulses - orthostatic hypotension - dysrhythmias Respiratory: - shallow, ineffective respirations - diminished breath sounds Neuromuscular: - anxiety, lethargy, confusion, coma - skeletal muscle weakness, leg cramps - loss of tactile discrimination - paresthesias - deep tendon hyporeflexia GI: - decreased motility, hypoactive bowel sounds, absent bowel sounds - nausea, vomiting, constipation, abdominal distention - paralytic ileus ECG changes: - ST depression - shallow, flat, or inverted T wave - prominent U wave Causes: Burns, Cushing's syndrome, deficient dietary intake of potassium, severe diarrhea, diuretic therapy, GI fistula, insulin administration, pyloric obstruction, vomiting, or starvation

newborn of mother with HIV

- should be monitored closely throughout the pregnancy - serial ultrasound screenings should be done throughout pregnancy to identify IUGR - weekly non-stress test after 32 weeks of gestation and biophysical profiles may be necessary during pregnancy - newborns born to HIV-positive mothers may test positive because the mother's antibodies may persist in the newborn for 18 months after birth - the use of anti-viral meds, the reduction of newborn exposure to maternal blood and body fluids, and early identification of HIV in pregnancy can reduce the transmission to the newborn - all newborns born to HIV-positive mothers acquire maternal antibodies to the HIV infection, but not all get the infection - the newborn may be asymptomatic for the first several months-years of life transmission: - across placental barrier - during labor and birth - breast milk assessment: - possibly no signs at birth - signs of immunodeficiency - hepatomegaly - splenomegaly - lymphadenopathy - impairment of growth and development interventions: - clean the newborn's skin carefully before any invasive procedure - circumcisions are not done on kids with HIV+ mothers until the newborn's status is determined - newborn can room with mother if hospital policies allow - all HIV-exposed newborns should be treated with meds to prevent infection - antiretroviral meds can be administered as prescribed for the first 6 weeks of life or longer - newborns at risk for HIV should be seen by the PHCP at 1 week, 2 weeks, 1 month, and 2 months of age immunizations: - live vaccines such as MMR should not be done until status is determined

Antineoplastic medications

- side effects from chemotherapy are usually from the effects of antineoplastic meds on normal cells. - examples of meds: Methotrexate, Pemetrexed, Pralatrexate, Trimetrexate, Azathioprine, Cladribine, Fludarabine, Mercaptopurine, Thioguanine, Azacitidine, Capecitabine, Cytarabine, Decitabine, Floxuridine, Fluorouracil, Gemcitabine, and Trifluridine/Tipracil. side effects: - mucositis (is the painful inflammation and ulceration of the mucous membranes lining the digestive tract) - alopecia (hair loss) - anorexia, nausea, vomiting - diarrhea - anemia - low wbc count - thrombocytopenia - infertility, sexual alterations - neuropathy interventions: 1. monitor CBC, WBCs, platelets, uric acid, and electrolytes 2. initiate bleeding precautions if thrombocytopenia occurs 3. when platelets are less than 50,000, minor trauma can lead to episodes of prolonged bleeding. when they are less than 20,000 spontaneous and uncontrollable bleeding can occur. Withhold the med if the platelet count drops, initiate bleeding precautions, and notify the PHCP. 4. monitor for petechiae, ecchymoses, bleeding of the gums, and nosebleeds 5. avoid IM injections and venipunctures to prevent bleeding 6. withhold the med and initiate neutropenic precautions if the neutrophil count decreases by below 18%, and notify the PHCP 7. monitor for signs of a sore throat, unusual bleeding, and symptoms of an infection 8. inform the client that loss of appetite may also be the result of taste changes or a bitter taste from the meds 9. monitor for nausea and vomiting and provide a high-calorie diet with protein supplements 10. administer antiemetics several hours before chemo and for 12 to 48 hours after as prescribed, because antineoplastic meds stimulate the vomiting center in the brain 11. encourage hydration, IV fluids are given before and during therapy 12. promote a fluid intake of at least 2000 mL per day to maintain adequate renal function 13. antineoplastic meds may also cause the rapid destruction of cells, resulting in the release of uric acid. Allopurinol may be prescribed to lower the serum uric acid level. - there are also interventions for maintaining a safe and effective care environment, preserving psychosocial integrity, health promotion and maintenance, and monitoring for an anaphylactic reaction.

Pediatric oncological problems: Brain tumors

- signs and symptoms depend on its size, location, and age of the child, most common diagnostic test is MRI - therapeutic management includes surgery, radiation, and chemo, the treatment of choice is removal of the tumor without residual neurological damage assessment: - headache that is worse on awakening and improves during the day - vomiting that is unrelated to eating - ataxia (degenerative disease of nervous system) - seizures - behavioral changes - clumsiness, awkward gait, difficulty walking - diplopia (double vision) - facial weakness - monitor for signs and symptoms of IICP in a child with a brain tumor and after a craniotomy, notify the PHCP if signs occur pre-op interventions: - perform a neurologic assessment every 4 hours - institute seizure precautions and safety measures - assess weight and nutritional status - shave the child's head as prescribed - prepare the child as much as possible, tell the child they will wake up with a large head dressing post-op interventions - assess neurologic and motor functions and LOC - monitor temp closely, it may be elevated with hypothalamus or brainstem involvement during surgery, maintain a cooling blanket at the bedside - monitor for signs of respiratory infection - monitor for signs of meningitis (opisthotonos, Kernig's and Brudzinski's signs) - monitor for signs of IICP - monitor for hemorrhage, checking the back of the head dressing for posterior pooling of blood, mark drainage edges with a marker, reinforce dressing as needed, and do not change dressing without a prescription - assess pupillary response, sluggish, dilated, or unequal pupils are reported immediately because they indicate IICP and potential brainstem herniation - monitor for colorless drainage on the dressing and from the ears or nose, which indicates cerebrospinal fluid and should be reported immediately, assess for the presence of glucose in the drainage (dipstick) - assess the surgeon's prescription for positioning, including the degree of neck flexion - monitor IV fluids closely - promote measures that prevent vomiting which increases ICP and the risk for incisional rupture - provide a quiet environment - administer analgesics as prescribed - provide emotional support to the child and parents, and promote optimal growth and development

Antidysrhythmic medications

- suppress dysrhythmias by inhibiting normal pathways of electrical conduction through the heart - class I antidysrhythmics include sodium-channel blockers, class II are BBs, class III are potassium-channel blockers, and class IV are CCBs sodium-channel blockers: - disopyramide - procainamide - quinidine sulfate - lidocaine - mexiletine hydrochloride - phenytoin - flecainide acetate - propafenone hydrochloride adverse effects: - hypotension - HF - worsened or new dysrhythmias - nausea, vomiting, or diarrhea BBs: - acebutolol - esmolol - propranolol - metoprolol - nadolol - atenolol adverse effects: - dizziness - fatigue - hypotension - bradycardia - HF - dysrhythmias - heart block - bronchospasms - GI distress potassium-channel blockers: - amiodarone - dofetilide - ibutilide - sotalol adverse effects: - hypotension - bradycardia - nausea, vomiting - amiodarone hydrochloride may cause pulmonary fibrosis, photosensitivity, bluish skin, discoloration, corneal deposits, peripheral neuropathy, tremor, poor coordination, abdominal gait, and hypothyroidism - the ECG should be monitored for clients receiving amiodarone or dofetilide, because they may prolong the QT interval, potentially leading to torsades de pointes CCBs: - verapamil - diltiazem adverse effects: - dizziness - hypotension - bradycardia - edema - constipation other antidysrhythmias: - adenosine - digoxin interventions for antidysrhythmics: 1. monitor HR, RR, and BP 2. monitor the ECG 3. provide continuous cardiac monitoring 4. maintain serum therapeutic med levels 5. before administering lidocaine, always check the vial label to prevent administering a form that contains epinephrine or preservatives, because these solutions are used for local anesthesia only 6. do not administer antidysrhythmics with food, because food may affect absorption 7. mexiletine may be administered with food or antacids to reduce GI distress 8. always administer IV antidysrhythmics by an infusion pump 9. monitor for signs of fluid retention such as weight gain, peripheral edema, or SOB 10. advise the client to limit fluid and salt intake to minimize fluid retention 11. monitor respiratory, thyroid, and neurological functions 12. instruct the client to change positions slowly to minimize orthostatic hypotension 13. instruct the client taking amiodarone to use sunscreen and protective clothing to prevent photosensitivity reactions 14. encourage the client to increase fiber intake to prevent constipation

Opioid analgesics

- suppress pain impulses, but can also suppress respiration and coughing - assess for allergy to med - clients with a history of impaired renal or liver function may only be able to tolerate low doses - IV route = produces effects faster, lasts shorter - can cause physical dependence - administer 30-60 minutes before painful activities - withhold medication and notify dr if respirations are less than 12 per minute or if bradycardia develops - assess bp for hypotension before administering to decrease risk of adverse effects - auscultate the lungs for normal breath sounds - encourage turning, deep breathing, and incentive spirometry to decrease risk of pneumonia and atelectasis - monitor the clients LOC - initiate safety precautions - monitor IandO, assess for urinary retention, constipation is a common side effect - take PO doses with milk or a snack to reduce gastric irritation - instruct client to avoid activities that require alertness like driving - assess effectiveness of medication 30 minutes after administering - have an opioid antagonist like naloxone, O2, and resuscitation equipment available

Adrenalectomy

- surgical removal of the adrenal gland pre-op interventions: 1. monitor electrolytes 2. assess for dysrhythmias 3. monitor for hyperglycemia 4. protect the client from infections 5. administer glucocorticoids as prescribed post-op interventions: 1. monitor vitals 2. monitor I&O; if output is below 30 mL/hr tell the PHCP because this can result in kidney injury and indicate impending shock 3. monitor weight daily 4. monitor electrolyte and serum glucose levels 5. monitor for signs of hemorrhage and shock, especially during the first 24-48 hours 6. monitor for manifestations of adrenal insufficiency 7. assess the dressing for drainage 8. monitor for paralytic ileus 9. administer IV fluids as prescribed to maintain blood volume 10. administer glucocorticoids and mineralocorticoids as prescribed 11. administer pain meds as prescribed 12. provide pulmonary interventions as prescribed to prevent atelectasis 13. instruct the client the importance of hormone replacement therapy after surgery 14. instruct the client on the symptoms of under-replacement and over-replacement of hormones 15. instruct the client to wear a medi-alert bracelet

Pediatric neurological and cognitive problems: Submersion injury

- survival of at least 24 hours after submersion in a fluid - hypoxia/asphyxiation is the primary problem because it results in extensive cell damage, cerebral cells sustain irreversible damage after 4-6 minutes of submersion - additional problems are aspiration and hypothermia - the outcome is predicted on the basis of the length of submersion, neurological responsiveness, reactive pupils, and a normal cardiac rhythm - a child who was submerged for longer than 10 minutes and does not respond to cardiopulmonary life support measures within 25 minutes has a extremely poor prognosis interventions: 1. provide ventilatory and circulatory support 2. monitor respiratory status 3. monitor for aspiration pneumonia 4. monitor neurological status closely 5. teach parents to provide adequate supervision of infants and small kids around water to prevent accidents

Uremic syndrome

- systemic clinical and laboratory manifestations of severe and/or end-stage kidney disease due to the accumulation of nitrogenous waste products in the blood caused by the kidney's inability to filter the wastes assessment: - oliguria - presence of protein, RBCs, and casts in the urine - elevated urea, uric acid, K+, and Mg+ levels in the urine - hypotension or HTN - alterations in LOC - electrolyte imbalances - stomatitis - nausea or vomiting - diarrhea or constipation interventions: 1. monitor vitals for HTN, tachycardia, or an irregular HR 2. monitor serum electrolyte levels 3. monitor I&O for oliguria 4. provide a limited but high-quality protein diet as prescribed 5. provide a limited Na+, nitrogen, K+, and phosphate diet as prescribed 6. assist the client to cope with body image disturbances caused by uremic syndrome

Prothrombin time (PT) and international normalized ratio (INR)

- the PT measures the amount of time it takes in seconds for a clot to form - is used to assess the effects of warfarin therapy, or to screen for dysfunction of the extrinsic clotting system due to liver disease, vitamin K deficiency, or disseminated intravascular coagulation - normal PT is 11 - 12.5 seconds - a PT value within -2 or +2 seconds of the control value is considered normal - orally administered anticoagulation therapy usually maintains the PT at 1.5 - 2 times the laboratory control value - the INR is used to measure the effects of some anticoagulants - the normal value for the INR is 0.81 - 1.20 seconds - if a PT is prescribed, draw the specimen before beginning the anticoagulation therapy, and note the time of the collection - provide direct pressure to the venipuncture site for 3 - 5 minutes - concurrent therapy of warfarin and heparin can lengthen the PT for up to 5 hours after administering the dose - diets high in green leafy veggies can increase the absorption of vitamin K, which shortens the PT - for both the PT and INR, elevated values can occur in clients with a deficiency in clotting factors, liver disease, vitamin K deficiency, or warfarin therapy - if the PT value is longer than 25 seconds and the INR value is longer than 3.0 seconds in a client receiving IV warfarin therapy, initiate bleeding precautions

Activated partial thromboplastin time (aPTT)

- the aPTT evaluates how well the intrinsic clotting system is functioning - it is used to monitor the effectiveness of heparin therapy and to screen for coagulation disorders - normal reference range: 30 to 40 seconds - if the client is on intermittent heparin therapy, draw the blood sample 1 hour before the next dose - do not draw samples from the arm in which heparin in infusing - provide direct pressure to the venipuncture site for 3-5 minutes - transport specimen to the lab immediately - the aPTT should be within 1.5 - 2.5 times normal when the client is receiving heparin therapy - elevated levels may occur with a deficiency in clotting factors, hemophilia, heparin therapy, or liver disease - initiate bleeding precautions in any client receiving heparin therapy, at risk for thrombocytopenia, or whose aPTT value is prolonged (above 100).

Gastroesophageal reflux disease (GERD)

- the backflow of gastric and duodenal contents into the esophagus - the reflux is caused by an incompetent lower esophageal sphincter (LES), pyloric stenosis, or a mobility disorder assessment: - heartburn, epigastric pain - dyspepsia (indigestion) - nausea, regurgitation - pain and difficulty with swallowing - hypersalivation interventions: 1. instruct the client to avoid factors that decrease LES pressure or cause esophageal irrigation, such as peppermint, chocolate, coffee, fried or fatty foods, carbonated drinks, alcoholic beverages, and cigarette smoking 2. instruct the eat a low-fat high-fiber diet and to avoid eating and drinking 2 hours before bed, to avoid wearing tight clothes, and elevate the head of the bed 6-8 inches. 3. avoid the use of anticholinergics, which delay stomach emptying, also NSAIDs and other meds that have acetylsalicylic acid need to be avoided 4. instruct the client regarding prescribed meds such as antacids, H2 receptor antagonists, or proton pump inhibitors 5. instruct the client regarding the administration of prokinetic meds if prescribed which accelerate gastric emptying 6. surgery may be needed in extreme cases when meds are unsuccessful, this involves a fundoplication (wrapping a portion of the gastric fundus around the sphincter area of the esophagus); and surgery may be performed laparoscopically

Erythroblastosis fetalis

- the destruction of RBCs that results from antigen-antibody reaction - characterized by hemolytic anemia or hyperbilirubinemia - exchange of fetal and maternal blood occurs when the placenta separates at birth, antibodies are harmless to the mother but attach to the RBCs of the fetus and cause hemolysis - sensitization is rare with the first pregnancy assessment: - anemia - jaundice that develops within the first 24 hours after birth - edema interventions: - administer Rho immune globulin to the mother during the first 72 hours after birth if the Rh-negative mother delivers an Rh-positive fetus but remains unsensitized - assist with exchange transfusion after birth or intrauterine transfusion as prescribed - the newborn's blood is replaced with Rh-negative blood to stop the destruction of the newborn's RBCs, the Rh-negative blood is replaced with the newborn's own blood gradually - provide support to the parents

Pediatric GI Problems: Vomiting

- the major concerns when a child is vomiting are the risk for dehydration, the loss of fluid and electrolytes, and the development of metabolic alkalosis. - additional concerns are aspiration and the development of atelectasis or pneumonia. - causes of vomiting are acute infectious illnesses, IICP, toxic ingestions, food intolerance, mechanical obstruction of the GI tract, metabolic disorders, and psychogenic disorders. assessment: - character of vomitus - signs of aspiration - presence of pain and abdominal cramping - signs of dehydration and fluid and electrolyte imbalances - signs of metabolic alkalosis interventions: 1. maintain a patent airway 2. position the child on the side to prevent aspiration 3. monitor the character, amount, and frequency of the vomiting 4. assess the force of the vomiting, projectile vomiting may indicate pyloric stenosis or IICP 5. monitor strict I&O 6. monitor for signs and symptoms of dehydration, like a sunken fontanel, non-elastic skin turgor, dry mucous membranes, decreased tear production, vital sign changes, and oliguria 7. monitor electrolyte levels 8. provide oral rehydration therapy as tolerated; begin feeding slowly with a small amount of fluid at frequent intervals 9. administer antiemetics as prescribed 10. assess for abdominal pain and diarrhea 11. advise the parents to inform the PHCP of signs of dehydration, blood in the vomit, forceful vomiting, or abdominal pain

Risk conditions related to pregnancy: Diabetes mellitus

- the newborn of a diabetic mother may be large in size, and is at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, hypocalcemia, and congenital anomalies. - pregnant women should be screened for gestational diabetes between 24 and 28 weeks of gestation with a 1 hour glucose tolerance test. - if that test comes back abnormal, a 3 hour oral glucose challenge test is used to confirm gestational diabetes. - risk factors for gestational diabetes are older than 35 years old, obesity, non-white race, previous unexplained perinatal loss, previous child born with congenital anomalies, polycystic ovarian syndrome, multiple gestation, 1st degree relative with diabetes or gestational diabetes, previous delivery of a fetus weighing more than 9 lbs, maternal birth weight less than 6 lb or more than 9 lb, previous pregnancy with gestational diabetes, glycosuria, essential or pregnancy-related HTN, and use of glucocorticoids. - assessment may show excessive thirst, hunger, weight loss, frequent urination, blurred vision, recurrent UTIs and vaginal yeast infections, glycosuria and ketonuria, signs of gestational HTN and preeclampsia, polyhydraminos, and large for gestational age fetus. - interventions are to employ diet, medications, exercise, and blood glucose as follows: less than 95 after fasting, 130-140 1 hour post-meal, and less than 120 2 hours post-meal; encourage moderate physical activity; facilitate referral to diabetic educator and nutritionalist; observe for signs of hyperglycemia, hypoglycemia, ketonuria, and glycosuria; monitor weight; maintain calories as prescribed with adequate oral medications or insulin therapy so glucose moves into the cells; assess for signs of maternal complications such as preeclampsia; monitor for signs of infection; instruct client to report burn, itching, pain, vaginal discharge, or any other sign of infection to the PHCP; assess fetal status and monitor for signs of fetal compromise; schedule visits every 2 weeks until 36 weeks and then every week from 36 weeks until labor - interventions during labor: monitor fetal status continuously for signs of distress and if noted prepare the client for immediate c-section, and carefully regulate insulin and provide glucose IV as prescribed because labor depletes glycogen - interventions during the postpartum period: observe the mother closely for a hypoglycemia reaction because a decline in insulin requirements normally occurs, re-regulate insulin needs as prescribed after the 1st day postpartum according to blood glucose, assess dietary needs based on blood glucose and insulin requirements, and monitor for signs of infection or postpartum hemorrhage.

Prostate cancer

- the risk increases in men with each decade after the age of 50 - metastasis to the bone, lungs, liver, and kidneys is a concern - cause is not known, risk increases with STIs, increased age, heavy metal exposure, and smoking - it is more common among african americans assessment: - no symptoms in early stages - hard pea-sized nodules palpated on rectal exam - hematuria - late symptoms include weight loss, urinary obstruction, and bone pain radiating from the lumbosacral area down the leg - the prostate-specific antigen level is elevated in various non-cancerous conditions, and should not be used as a screening test without a rectal exam. It is often used to measure response to therapy. - diagnosis is made by biopsy of the prostate gland non-surgical interventions: 1. prepare the client for hormone manipulation therapy or active surveillance with prostate specific antigen (PSA) and digital rectal exam 2. luteinizing hormone may be prescribed to slow the rate of growth of the tumor 3. med adverse effects include decreased libido, hot flashes, breast tenderness, osteoporosis, loss of muscle mass, and weight gain. 4. pain med, radiation, corticosteroids, and biophosphonates may be prescribed for palliation of advanced prostate cancer 5. prepare the client for external beam radiation or brachytherapy, which may be prescribed alone or with surgery, to reduce the lesion and decreases metastasis 6. prepare the client for the administration of chemo in cases of hormone resistant tumors surgical interventions: 1. prepare the client for orchiectomy to limit the production of testosterone 2. prepare the client for prostatectomy 3. cryosurgical ablation is a minimally invasive procedure that be an alternative to radical prostatectomy; liquid nitrogen freezes the gland, and the dead cells are absorbed by the body 4. Transurethral resection of the prostate (TURP) may be performed for palliative care; the procedure involves inserting a scope into the urethra to remove excess prostate tissue 5. following TURP, monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by excessive absorption of bladder irrigation during surgery. signs include altered mental status, bradycardia, increased BP, and confusion

Risk conditions related to pregnancy: hepatitis B

- the risks of prematurity, low birth weight, and neonatal death increase if the mom has a Hep B infection - interventions: limit the # of vaginal exams, remove maternal blood from the neonate immediately after birth, suction fluid from the neonate immediately after birth, bathe the neonate before any invasive procedures, clean and dry the eyes of the neonate before giving eye meds, prevent the newborn from getting the infection by giving it a vaccine soon after birth once it is bathed, discourage the mom from kissing the neonate until it's gotten the vaccine, inform the mom the neonate will receive the first Hep B vaccine right after birth then the 2nd at 1 month and and then the 3rd at 6 months old, and tell the mother breast feeding is not contraindicated if the neonate has received the vaccine.

Obtaining informed consent

- the surgeon is responsible for explaining the surgical procedure and answering questions. - the nurse is responsible for obtaining the client's signature on the consent form for surgery, which indicates they agree and understand the procedure - the nurse may witness the client's signing of the consent form - the nurse needs to document the witnessing and signing of the consent form after the client acknowledges they understand - minors may need a parent or guardian to sign the consent form - clients who are not alert or oriented may need power of attorney or a legal guardian to sign the consent form - obtaining telephone consent from a legal guardian or power of attorney is acceptable, but there needs to be a second nurse to witness.

Peripheral vasodilators

- these include the a-adrenergic blockers clonidine, guanfacine, and methyldopa - the CCBs diltiazem, nifedipine, nimodipine, and verapamil - and the hemorrheologic agent Pentoxifylline which acts by helping blood flow more easily through narrowed arteries. - peripheral vasodilators act by decreasing peripheral resistance by exerting a direct action on either the arteries or the arteries and veins. - they increase blood flow to the extremities and are used in peripheral vascular disorders of venous and arterial vessels. - they are most effective for disorders resulting from vasospasm (Raynaud's disease) - they may decrease some symptoms of cerebral vascular insufficiency adverse effects: - lightheadedness, dizziness - orthostatic hypotension - tachycardia - palpitations - flushing - GI distress interventions: 1. monitor vitals, especially the BP and the HR 2. monitor for orthostatic hypotension and tachycardia 3. monitor for signs of inadequate blood flow to the extremities, such as pallor, feeling cold, and pain 4. instruct the client that it may take up to 3 months for a desired therapeutic response 5. advise the client not to smoke, because smoking increases vasospasm 6. instruct the client to avoid aspirin unless approved by the PHCP 7. instruct the client to take the medication with meals if GI disturbances occur 8. instruct the client to avoid alcohol, because it may cause a hypotensive reaction 9. encourage the client to change positions slowly to avoid orthostatic hypotension

Venous thrombosis

- thrombus can be associated with an inflammatory process - when a thrombus develops, inflammation occurs, thickening of the vein wall and leading to embolization. types: 1. thrombophlebitis: thrombus associated with vein inflammation 2. phlebothrombosis: thrombus without vein inflammation 3. phlebitis: vein inflammation associated with invasive procedures, such as IV lines 4. deep vein thrombophlebitis: more serious than a superficial thrombophlebitis because of the risk for pulmonary embolism risk factors for thrombus formation: - venous stasis from varicose veins, HF, immobility - hypercoagulability disorders - injury to the venous wall from IV injections, administration of vessel irritants - following surgery, particularly orthopedic and abdominal surgery - pregnancy - ulcerative colitis - use of oral contraceptives - certain malignancies - fractures or other injuries of the pelvis or lower extremities

Levothyroxine sodium, liothyronine sodium, liotrix, and thyroid dessicated

- thyroid hormones used to replaced thyroid hormone deficit in hypothyroidism or myxedema coma. - they enhance the action of oral anticoagulants, sympathomimetics, and antidepressants and decrease the action of insulin, oral hypoglycemics, and digitalis preparations; their action is decreased by phenytoin and carbamazepine - they should be given at least 4 hours apart from multivitamins, aluminum hydroxide, and magnesium hydroxide, simethicone, calcium carbonate, phosphate binders, bile acid sequestrants, iron, and sucralfate, because these meds decrease the absorption of thyroid replacements.

True labor vs. false labor

- true labor: contractions occur regularly, become stronger, last longer, and occur closer together. cervical dilation and effacement are progressive. and the fetus usually becomes engaged in the pelvis and begins to descend - false labor: does not produce dilation, effacement, or descent. contractions are irregular without progression. and activities such as walking often relieves false labor.

Forceps delivery

- two double-crossed spoon like blades are used to assist in the delivery of the fetal head - reassure the mother and explain the need for forceps - monitor the mother and fetus during delivery - check the neonate and mother after delivery for any possible injury - assist with repair of lacerations

Pediatric GI Problems: umbilical and inguinal hernia and hydrocele

- umbilical hernia: is a protrusion of the bowel through an abnormal opening in the abdominal wall - in kids, hernias most commonly occur at the umbilicus and also through the inguinal canal - hydrocele: is the presence of abdominal fluid in the scrotal sac assessment: - umbilical hernia: soft swelling or protrusion around the umbilicus that is usually reducible with a finger - inguinal hernia: refers to a painless inguinal swelling that is reducible. swelling may disappear during periods of rest and is most noticeable when the infant cries or coughs - incarcerated hernia: occurs when the descended portion of the bowel becomes tightly caught in the hernial sac, compromising blood supply. this represents a medical emergency requiring surgical repair. assessment findings include irritability, tenderness at the site, anorexia, abdominal distention, and difficulty defecating. the protrusion cannot be reduced, and complete intestinal obstruction and gangrene may occur - non-communicating hydrocele: occurs when residual peritoneal fluid is trapped in the scrotum with no communication to the peritoneal cavity. the hydrocele usually disappears by age 1 as the fluid is re-absorbed. - communicating hydrocele: is associated with a hernia that remains open from the scrotum to the abdominal cavity. assessment includes a bulge in the inguinal area or the scrotum that increases with crying or straining and decreases when the infant is at rest. Parents may also report the bulge is smaller in the morning and increases in size throughout the fay. - hernia post-op interventions: - monitor vitals - assess for wound infection - monitor for redness or drainage - monitor I&O and hydration status - advance the diet as tolerated - administer analgesics as prescribed - hydrocele post-op interventions: - provide ice bags and a scrotal support to relieve pain and swelling - instruct the parents that tub baths need to be avoided until the incision heals - instruct the parents that strenuous physical activity needs to be avoided - advise parents that the scrotum may not immediately return to normal size

Contact precautions

- used for C Diff, respiratory infections, influenza, wound and skin infections, and eye infections. - indirect contact transmission may occur when a contaminated object is encountered. - client has a private room or can be with client who has same organism in their body - use gloves and a gown whenever entering the client's room

Droplet precautions

- used for adenovirus, diphtheria, epiglottitis, influenza, meningitis, mumps, pneumonia, parvovirus B19, pertussis, rubella, scarlet fever, sepsis, and streptococcus pharyngitis. - client has a private room or may be paired with a client whose body has same organism - wear a surgical mask when within 3 feet of the client, place a mask on the client when the client needs to leave the room.

Fasting blood glucose

- used to diagnose diabetes and hypoglycemia - instruct the client to fast for 8-12 hours before the test - instruct the client with diabetes to withhold their morning dose of insulin until after the blood is drawn - normal rangefor fasting glucose: 70 - 99 - elevated levels may be caused by: acute stress, cerebral lesions, Cushing's syndrome, diabetes, hyperthyroidism, or pancreatic insufficiency - below normal levels may be caused by: Addison's disease, hepatic disease, hypothyroidism, insulin overdose, pancreatic tumor, pituitary hypofunction, or postdumping syndrome.

Omalizumab

- used to treat allergy-induced asthma and administered subcutaneously every 2-4 weeks - the dose is titrated on the basis of the serum IgE level and body weight - contraindicated in those with hypersensitivity to the med - adverse effects: injection site reactions, viral infections, upper respiratory infections, sinusitis, headache, pharyngitis, anaphylaxis, malignancies interventions: 1. assess respiratory rate, rhythm, and depth and auscultate lung sounds 2. assess for allergies and/or allergic reaction symptoms such as rash or urticaria 3. have meds for the treatment of severe hypersensitivity reactions available during initial administration in case anaphylaxis occurs client education: 1. that respiratory improvement will not be immediate 2. not to stop taking or decrease the dose of currently-prescribed asthma meds unless instructed 3. to avoid receiving live virus vaccines for the duration of the treatment

Lactulose

- used to treat hepatic encephalopathy and chronic constipation - it promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon and lowering the ammonia level (the normal ammonia level is 10-80 mcg/dL) - it improves protein tolerance in clients with advanced hepatic cirrhosis - is administered orally in the form of a syrup or rectally

Airborne precautions

- used with measles, chickenpox (varicella), disseminated varicella zoster, and TB. - the client's room is maintained under negative pressure, and the door stays closed except for when you enter and exit. - a UV germicide irradiation filter is used in the room - healthcare workers wear a respiratory mask (N-95 or higher), a surgical mask is placed on the client when they need to leave the room, and they only leave the room when necessary.

Pediatric immune problems and infectious diseases: Influenza

- various strains of influenza can occur - its a viral infection that affects the respiratory system and is highly contagious - children, pregnant women, people with pre-existing health conditions, and those with a compromised immune system are at high risk for developing complications - it's caused by contact with an infected person or by touching an infected object prevention: - flu vaccine - wash hands frequently and teach hand-washing techniques - avoid kids who are ill - keep the child home from school or away from others until the child has been fever-free and at least 24 hours assessment: - sudden high fever - headache, body ache, fatigue, chills, cough, congestion, sore throat, loss of appetite, vomiting, and diarrhea interventions: - anti-viral meds if prescribed, fluids, rest, pain relievers, and family and child teaching about prevention measures

Pediatric renal and genitourinary problems: enuresis

- when a child is unable to control bladder function, the child doesn't have control over this condition interventions: 1. perform urinalysis and urine culture as prescribed to rule out infection or an existing disorder 2. assist the family with identifying a treatment plan that best fits the needs of the child 3. limit fluid intake at night, and encourage the child to void just before going to bed 4. involve the child in caring for the wet sheets and changing the bed to assist the child to take ownership of the problem 5. provide reward systems as appropriate for the child 6. incorporate behavioral conditioning techniques 7. desmopressin may reduce urine production at night, anticholinergics may reduce bladder contractions and increase bladder capacity 8. encourage follow-up to determine the effectiveness of the treatment

Pediatric cardiovascular problems: obstructive defects

- when blood exiting a part of the heart meets an area of anatomical narrowing (called stenosis) causing obstruction of blood flow - the location of stenosis is usually near the valve of the obstructive defect - infants and kids exhibit signs of HF - children with mild obstruction may be asymptomatic Aortic stenosis: - is a narrowing or stricture of the aortic valve, causing resistance to blood flow from the left ventricle to the aorta, resulting in decreased CO, left ventricular hypertrophy, and pulmonary vascular congestion. - valvular stenosis is the most common type and is usually caused by malformed cusps - a murmur is present - infants with severe defects show signs of decreased CO - children show signs of activity intolerance, chest pain, and dizziness when standing for long periods - management: - dilation of the narrowed valve may be done during cardiac catheterization - surgical aortic valvotomy (palliative) may be done; a valve replacement may be required at a second procedure Coarctation of the aorta: - is localized narrowing near the insertion of the ductus arteriosus - BP is higher in the upper extremities than in the lower ones, bounding pulses in the arms, weak or absent femoral pulses, and cool lower extremities may be present - signs of HF may occur in infants - signs and symptoms of decreased CO may be present - children may experience headaches, dizziness, fainting, and epistaxis resulting from HTN - management of the defect may be done by balloon angioplasty in kids, restenosis can occur - surgical management: - mechanical ventilation and meds to improve CO are often needed before surgery - resection of the coarcted portion with end-to-end anastomosis of the aorta and enlargement of the constricted section, using a graft, may be required - because the defect is outside the heart, cardiopulmonary bypass is not required, and a thoracotomy incision is used Pulmonary stenosis: - is narrowing at the entrance of the pulmonary artery - resistance to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow; the right ventricle may be hypoplastic - pulmonary atresia is the extreme form of pulmonary stenosis in that there is total fusion of the commissures and no blood flow to the lungs - murmur is present - infants or kids may be asymptomatic - newborns with severe narrowing are cyanotic - if pulmonary stenosis is severe, HF occurs - signs and symptoms of decreased CO may occur - management: dilation of the narrowed valve may be done during cardiac catheterization - surgical management: in infants a transventricular (closed) valvotomy procedure is done, in children a pulmonary valvotomy with cardiopulmonary bypass is done

Pediatric cardiovascular problems: defects with increased pulmonary blood flow

- when communication of the heart along the septum or an abnormal connection between the great arteries allows the blood to flow from the high-pressure left side to the low-pressure right side of the heart - the infant typically shows signs and symptoms of HF Atrial septal defect (ASD): - is an abnormal opening between the atria that causes an increased flow of oxygenated blood into the right side of the heart - right atrial and ventricular enlargement occurs - infants may be asymptomatic or may develop HF - signs and symptoms of decreased CO may be present, which are decreased peripheral pulses, activity intolerance, feeding difficulties, hypotension, irritability, restlessness, lethargy, oliguria, pale and cool extremities, and tachycardia - there are different types: ASD 1, ASD 2, and ASD 3 - management: - the defect may be closed during a cardiac catheterization - open repair with cardiopulmonary bypass may be performed and usually is done before school age Atrioventricular canal defect: - results from incomplete fusion of the endocardial cushions - is the most common cardiac defect in Down's syndrome - a murmur is present - the infant usually has mild to moderate HF, with cyanosis increasing with crying - signs and symptoms of decreased CO may be present - management can include pulmonary artery banding for infants with severe symptoms (palliative) or complete repair by cardiopulmonary bypass Patent ductus arteriosus: - is failure of the fetal ductus arteriosus (shunt connecting the aorta and pulmonary artery) to close within the first weeks of life - a characteristic machinery-like murmur is present - an infant may be asymptomatic or may show signs of HF - a widened pulse pressure and bounding pulses are present - signs and symptoms of decreased CO may be present - management: - Indomethacin, a prostaglandin inhibitor, may be given to close a patent ductus in premature infants and some newborns - the defect may be closed during cardiac catheterization, or the defect may require surgical management Ventricular septal defect (VSD): - is an abnormal opening between the right and left ventricles - many close spontaneously during the first year of life in kids with small or moderate defects - a characteristic murmur is present - signs and symptoms of HF are commonly present - signs and symptoms of decreased CO may be present - management: - closure during cardiac catheterization may be possible - open repair may be done with cardiopulmonary bypass

Pediatric renal and genitourinary problems: cryptorchidism

- when one or both testes fail to descend through the inguinal canal into the scrotal sac - testes are not palpable or easily guided into the scrotum upon assessment interventions: 1. monitor during the first 6 months of life to determine if spontaneous descent occurs 2. surgical correction is commonly done at 6 months of age 3. monitor for bleeding and infection post-op 4. instruct parents on post-op home care measures, including preventing infection, pain control, and activity restrictions 5. provide an opportunity for parental counseling if the parents are concerned about the future fertility of the child

Anemia

- when the body lacks RBCs or Hgb. the most common causes are acute blood loss, decreased or faulty RBC production, or the destruction of RBCs. - there are several types of anemia; the main types are related to acute and chronic blood loss, anemia of chronic diseases, anemias caused by nutritional deficiencies, and hereditary anemias. - treatment focuses on treating the cause of the condition and varies based o the type of anemia. - acute blood loss anemia is characterized by normal RBCs. clients at risk are those who are post-op, with active bleeding problems, or immunocompromised clients with a reduction in blood components. Hgb, Hct, and RBCs can be low. assessment: - fatigue - weakness - pallor or slight jaundice if RBC destruction occurs - SOB - dysrhythmias - chest pain - tachycardia - cool extremities interventions: 1. administer blood products and hematopoietic meds as prescribed, which are used to treat anemia related to acute and chronic conditions. 2. encourage a diet rich in the deficient nutrient if the anemia is caused by malnutrition, such as iron, folate, or vitamin B12 supplementation. 3. control and address the source of bleeding if anemia is caused by acute blood loss and assess client for sources of frank and occult bleeding. contact the PHCP and prepare for replacement therapy if acute blood loss occurs.

Prolapsed umbilical cord

- when the umbilical cord is displaced between the presenting part and the amnion or is protruding through the cervix, causing compression of the cord and compromising fetal circulation - assessment: - the client feels that something is coming through the vagina - umbilical cord is visible or palpable - FHR is irregular and slow - FHR monitor shows variable decelerations or bradycardia after rupture of membranes - if fetal hypoxia is severe, violent fetal activity may occur and then cease - interventions: - the nurse stays with the client and asks another nurse to call the PHCP immediately - the goal is to relieve cord pressure immediately so the fetus can recieve adequate O2 - the nurse never attempts to push the cord into the uterus - if the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline - this situation is an emergency, and delivery must occur, usually by a C-section - elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand to relieve cord pressure - place the client into extreme Trendelenburg's or modified Sim's position, or a knee-chest position - administer O2 8-10 L/min by face mask to the client - monitor FHR and assess the fetus for hypoxia - prepare to start IV fluids or increase the rate of administration of an appropriate solution - prepare for immediate birth - document the event, actions taken, and the client's response

Uterine inversion

- when the uterus completely or partially turns inside out - can occur during delivery or after delivery of the placenta - risk factors are fundal implantation of the placenta, manual extraction of he placenta, short umbilical cord, uterine atony, leiomyomas, and abnormally adherent placental tissue - assessment: - a depression in the fundal area of the uterus is noted - the interior of the uterus may be seen through the cervix or protruding through the vagina - the client has severe pain - hemorrhage is evident - the client shows signs of shock - interventions: - monitor for hemorrhage and signs of shock, and treat shock - prepare the client for a return of the uterus to the correct position by the vagina, if unsuccessful, laparotomy with replacement to the correct position is done

Risk conditions related to pregnancy: STIs

1. Chlamydia: - is associated with an increased risk for premature birth, stillbirth, neonatal conjunctivitis, and newborn chlamydial pneumonia. - can cause salpingitis (inflammation of the fallopian tubes), pelvic abscesses, ectopic pregnancy, chronic pelvic pain, and infertility. - assessment findings: usually is asymptomatic but may have dysuria or dyspareunia, bleeding between periods or after intercourse, cervical discharge, or pelvic pain. - interventions: screen the client to determine if she is high risk, this is indicated for all pregnant clients if the client is in a high-risk group or if infants from previous pregnancies have developed neonatal conjunctivitis or pneumonia; instruct the client in the importance of re-screening, because re-infection can occur as the client nears term; ensure that her sexual partner is treated for the infection; treatment for both gonorrhea and chlamydia should be done which includes antibiotics; and complications in pregnancy may include septic spontaneous abortion or miscarriage, preterm delivery, premature rupture of the membranes, chorioamnionitis, disseminated gonococcal infection, opthalmia neonatorum, and postpartum metritis. 2. Syphilis: - caused by treponema pallidum - transmission is by physical contact with syphiltic lesions, which usually are found on the mouth, skin, and genitals - the infection may cause abortion or premature labor and is passed to the fetus after the 4th month of pregnancy as congenital syphilis. - assessment findings: - the primary stage: is the most infectious stage, appearance of ulcerative, painless lesions produced by spirochetes at point of entry into the body. - secondary stage: highly infectious stage, appearance of lesions about 6 weeks - 6 months after primary stage, located anywhere on the skin and mucous membranes, and generalized lymphadenopathy. - tertiary stage: entrance of spirochetes into internal organs, causing permanent damage, symptoms occur 10 - 30 years after untreated primary lesion, invasion of CNS causes meningitis, ataxia, general paresis, and progressive mental deterioration, and harmful affects on the aortic valve and aorta. - interventions: a serum test for syphilis is done on the first prenatal visit, prepare to re-test at 36 weeks of gestation because the disease may be acquired after the initial visit, if the test result is positive treat with an antibiotic, sonographic evaluation is necessary to assess for signs of placental syphilis, instruct the client that treatment of her partner is needed if infection is present, and intercourse should be avoided until treated, complications include transmission to fetus (100% in primary and secondary stages), congenital anomalies, deafness, neurological impairment, and death occurs in 50% of cases, and those with syphilis should also be tested for HIV. 3. Gonorrhea: - causes inflammation in the mucous membranes of the genital and urinary tracts, transmission is by sexual intercourse, and the infection may be transmitted to the newborn's eyes during delivery causing blindness (opthalmia neonatorum). - assessment findings are usually asymptomatic, vaginal discharge, and lower abdominal pain - interventions include testing during the initial prenatal exam and repeated during the 3rd trimester in high-risk clients, instruct the client that treatment of her partner is needed if infection is present, and complications are similar to those of chlamydia. 4. HPV: - infection affects the cervix, urethra, anus, penis, and scrotum. - is transmitted through sexual contact - assessment findings include large wart-like growths on the genitals, cervical changes may be noted because HPV is associated with cervical malignancies. - interventions include removal of lesions after birth, encourage annual pap smear test, sexual contact should be avoided until lesions heal, and C-sections is indicated only if genital warts are obstructing the pelvic outlet or if vaginal delivery would result in excessive bleeding. 5. trichomoniasis: - is transmitted by sexual contact, a normal saline wet smear of vaginal secretions indicates the presence of the protozoa, infection is associated with premature rupture of the membranes and postpartum endometriosis. - assessment findings include yellow - green frothy vaginal discharge, and inflammation of the vulva and/or vagina may occur. - interventions include metronidazole may be prescribed and the sexual partner may need to be treated. 6. Bacterial vaginosis: - is transmitted by sexual contact, and associated with premature labor and birth. - assessment findings include a "fishy" odor to vaginal secretions and increased odor after intercourse, and a microscopic exam of vaginal secretions identifies the infection. - interventions are metronidazole may be prescribed and treatment of the sexual partner. 7. Vaginal candidiasis: - candida albicans is the most causative organism, predisposing factors include the use of antibiotics, diabetes, and obesity, and it is diagnosed by identifying the spores. - assessment findings are vulvar and vaginal pruritus, and white lumpy cottage cheese like vaginal discharge. - interventions are an antifungal preparation may be prescribed, oral fluconazole should be avoided during pregnancy due to the risk of miscarriage, for extensive irritation and swelling sitz baths may help, and the sexual partner may need to be treated.

The 4 stages of labor

1. The first stage of labor - is made up of the latent, active, and transition stages - latent phase: dilation is 1-4 cm - uterine contractions occur every 15-30 minutes, are 15-30 seconds long, and are mild intensity - encourage mother and partner to participate in care, assist with comfort measures, changes in position, and ambulation, keep mother and partner informed of progress, offer fluids and ice chips, and encourage voiding every 1-2 hours. - active phase: dilation is 4-7 cm - contractions occur every 3-5 minutes, and 30-60 seconds long, and are moderate intensity - encourage maintenance of effective breathing patterns, provide a quiet environment, keep mother and partner informed of progress, promote comfort with back rubs, sacral pressure, pillow support, and position changes, offer fluids and ice chips, and encourage voiding every 1-2 hours - transition phase: dilation is 8-10 cm - contractions are every 2-3 minutes, are 45-90 seconds long, and are strong intensity - encourage rest between contractions, wake mother at the beginning of a contraction so she can begin breathing pattern, keep mother and partner informed of progress, provide privacy, offer fluid and ice chips, and encourage voiding every 1-2 hours 2. The second stage of labor - cervical dilation is complete (10 cm) - progress of labor is measured by a descent of the fetal head through the birth canal - uterine contractions occur every 2-3 minutes, last 60-75 seconds, and are strong intensity - increase in bloody show occurs - mother feels urge to push (Ferguson reflex) - assist mother in pushing efforts - interventions in this stage: perform assessments every 5 minutes, monitor maternal vitals, monitor FHR before, during, and after a contraction, determine the frequency, duration, and intensity of uterine contractions, provide mother with encouragement and praise and provide for rest between contractions, keep mother and partner informed of progress, maintain privacy, provide ice chips, assist mother to a position that promotes comfort and facilitates pushing efforts such as lithotomy, semisitting, kneeling, side-lying, or squatting, monitor for signs of approaching birth such as perineal bulging or visualization of the fetal head, and prepare for birth. 3. the third stage of labor - contractions occur until the placenta is expelled - placental separation and expulsion occur - expulsion of the placenta occurs 5-30 minutes after the birth of the infant - interventions in this stage are to assess maternal vitals, assess uterine status, provide parents with explanation regarding expulsion of the placenta, uterine fundus remains firm and is located 2 finger-breadths below the umbilicus after expulsion of the placenta, examine the placenta for cotyledons and membranes to verify that it is intact, assess mother for shivering and provide warmth, and promote paternal-neonatal attachment 4. The fourth stage of labor - is 1-4 hours after birth - BP returns to pre-labor level, pulse is slightly lower than during labor, and fundus remains contracted in the midline 1-2 finger-breaths below the umbilicus - monitor lochia discharge, it may be moderate in amount and red in color in this stage - interventions in this stage are to perform maternal assessments every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly for 2 hours; provide warm blankets; apply ice packs to the perineum; massage the uterus if needed, and teach the mother to massage the uterus; and provide breast-feeding support as needed.

postpartum client teaching

1. demonstrate newborn care skills 2. provide the opportunity for the client to bathe the newborn 3. instruct in feeding technique 4. instruct the client to avoid heavy lifting for at least 3 weeks 5. instruct the client to plan for at least 1 rest period per day 6. instruct the client that contraception should begin after birth with the initiation of intercourse. with rubella immunization, avoid conception for 1-3 months based on the PHCP's recommendation. 7. instruct the client in the importance of follow-up which should be scheduled in 4-6 weeks 8. instruct the client to report any signs of chills, fever, increased lochia, or depressed feelings to the PHCP

positive inotropic and cardiotonic meds

1. dobutamine: used for short-term management of HF; increases myocardial contractility, improving cardiac performance 2. dopamine: used as a short-term rescue measure for clients with severe, acute HF. Increases myocardial contractility, improving cardiac performance. dilates renal blood vessels and increases renal blood flow and urine output. 3. milrinone lactate: used for short-term management of HF, may be given before a heart transplant. - these meds stimulate myocardial contractility and produce a positive inotropic effect. - they are used for short-term management of advanced HF; the increase in myocardial contractility improves cardiac, peripheral, and kidney function by increasing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. as a result, fluid retention in the lungs and extremities is decreased. adverse effects: 1. dysrhythmias 2. hypotension 3. thrombocytopenia 4. hepatotoxicity manifested by elevated liver enzyme levels 5. hypersensitivity manifested by wheezing, SOB, pruritus, urticaria, clammy skin, and flushing interventions: 1. positive inotropic and cardiotonic meds are used for IV administration. for continuous IV infusion, administer with an infusion pump. Stop the infusion if the client's BP drops of dysrhythmias occur. 2. monitor the apical pulse and BP 3. monitor for hypersensitivity 4. assess lung sounds for wheezing and crackles 5. monitor for edema 6. monitor for relief of HF as noted by reduction in edema and lessening of dyspnea, orthopnea, and fatigue 7. monitor electrolyte and liver enzymes, platelets, and renal function studies; the meds may decrease K+ and increase liver enzyme levels; continuous ECG monitoring is done during administration.

FHR patterns

1. fetal bradycardia and tachycardia - fetal bradycardia is less than 110 bpm - fetal tachycardia is greater than 160 bpm - if either of these occur, change the position of the mother, administer O2, and assess the mother's vitals. Notify the PHCP as soon as possible. 2. variability - fluctuations in baseline FHR - absent or non-detected variability is considered non-reassuring - decreased variability can result from fetal hypoxemia, acidosis, or certain medications - a temporary decrease in variability can occur when the fetus is in a sleep state (sleep states do not last longer than 30 minutes) 3. Accelerations - brief, temporary increases in FHR of at least 15 bpm more than baseline and lasting at least 15 seconds - usually are a reassuring sign, reflecting a responsive, non-acidotic fetus - usually occur with fetal movement - may be non-periodic (have no relation to contractions) or periodic (with contractions) - may occur with uterine contractions, vaginal exams, mild cord compressions, or when the fetus is in a breech presentation. 4. early decelerations - are decreases in FHR below baseline; the rate at the lowest point of the deceleration usually remains greater than 100 bpm - occur during contractions as the fetal head is pressed against the mother's pelvis or soft tissues, and return to baseline FHR by the end of the contraction - tracing shows a uniform shape and mirror image of uterine contractions - are not associated with fetal compromise and require no intervention 5. late decelerations - are non-reassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency - the patterns look similar to early decelerations, but begin after the contraction begins and return to baseline after the contraction ends - the degree of decline in FHR from the baseline is not related to the amount of uteroplacental insufficiency 6. variable decelerations - are caused by conditions that restrict flow through the umbilical cord - do not have the uniform appearance of early and late decelerations - they are significant when FHR declines to less than 70 bpm for 60+ seconds before returning to baseline - interventions are to discontinue oxytocin, change mother's position, administer O2, assess the mother's vitals, notify PHCP, and assist with amnioinfusion if prescribed

Healing by intention

1. first intention: wound edges are approximated and held in place with sutures until healing occurs; would is easily closed and dead space is eliminated 2. Second intention: this type of healing occurs with injuries or wounds that have tissue loss and require gradual filling in of the dead space with connective tissue 3. third intention: this type f healing involves delayed primary closure and occurs with wounds that are intentionally left open for several days for irrigation or removal of debris and exudates; once debris has been removed and inflammation resolves, the wound is closed by first intention.

Physiological maternal changes in the postpartum period

1. involution: - is the rapid decrease in size of the uterus as it returns to the pre-pregnant state - clients who breast feed may have a more rapid involution - assessment: the weight of the uterus decreases from 2 lb to 2 oz in 6 weeks. the endometrium regenerates. the fundus steadily descends into the pelvis. fundal height decreases about 1 cm per day. by 10 days postpartum, the uterus cannot be palpated. a flaccid fundus indicates uterine atony, and it should be massaged until firm, a tender fundus indicates an infection. afterpains decrease in frequency after the first few days. 2. lochia: - is discharge from the uterus that contains blood from vessels of the placental site and debris from the decidua - assessment: rubra is bright red discharge that occurs from birth to day 3. serosa is brownish pink diacharge that occurs from days 4-10. alba is white discharge that occurs from days 11-14. discharge should smell like normal menstrual flow, it decreases daily in amount, and may increase with ambulation. 3. ovarian function and menstruation: - ovarian function depends on how rapidly the pituitary function is restored. - menstrual flow resumes in 1-2 months in non-breastfeeding mothers - it resumes in 3-6 months in breastfeeding mothers - breast feeding mothers may experience amenorrhea during the entire period of lactation if they are exclusively breastfeeding. 4. breasts: - secrete colostrum for the first 48-72 hours after birth - decreased estrogen and progesterone levels after birth stimulates prolactin levels which promote breast milk production. - breasts fill with milk on the third day after birth - engorgement occurs on day 4 - breast feeding relieves engorgement - breast care for non-breastfeeding mothers: avoid nipple stimulation, apply a breast binder, wear a snug-fitting bra, apply ice packs, or take a mild analgesic for engorgement, and engorgement usually resolves in 24-36 hours after it begins. 5. GI tract: - clients are usually hungry after birth - constipation may occur, bowel movement should occur by the 2nd or 3rd postpartum day - hemorrhoids are common

Anesthesia during labor

1. local anesthesia: is used for blocking pain during an episiotomy, is administered just before the birth of an infant, and has no effect on the fetus 2. lumbar epidural block: injection site is in epidural space at L3 to L4, is administered after labor is established or as partial anesthesia just before a scheduled C-section, it relieves pain from contractions and numbs the vagina and perineum - the block may cause hypotension, bladder distention, and a prolonged second stage - assess maternal bp and bladder frequently - maintain the mother in a side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava - administer IV fluids as prescribed - increase fluids as prescribed if hypotension occurs - observe for any adverse effects from opioid epidurals such as nausea, vomiting, pruritus, or respiratory depression 3. intrathecal opioid analgesics: the med is injected in the subarachnoid space and has a rapid onset of action, it may be used in combination with a lumbar epidural block 4. subarachnoid (spinal) block: injection site is in the spinal subarachnoid space L3-L5, the block is administered just before birth - the anesthetic relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities - the anesthetic may cause maternal hypotension or postpartum headache - the mother must lie flat for 8 - 12 hours after a spinal injection - administer IV fluids as prescribed 5. general anesthesia: may be used for some surgical interventions, the mother is not awake ** provides maternal danger of respiratory depression, vomiting, and aspiration

Antiemetics

1. serotonin antagonists: - dolasteron - granisetron - ondansetron 2. glucocorticoids: - dexamethasone - methylprednisolone 3. substance P/Neurokinin-1 antagonists: - aprepitant - fosaprepitant - rolapitant 4. Benzodiazepine: - lorazepam 5. dopamine antagonists: - chlorpromazine - perphenazine - prochlorperazine - promethazine - haloperidol - droperidol - metoclopramide - trimethobenzamide 6. cannabinoids: - dronabinol - nabilone 7. anticholinergics: - scopolamine transdermal 8. antihistamines - cyclizine - dimenhydrinate - diphenhydramide - hydroxyzine - meclizine hydrochloride - are used to control vomiting and motion sickness - the choice of the antiemetic is determined by the cause of the nausea and vomiting - monitor vitals, I&O, and for signs of dehydration and fluid and electrolyte imbalances - limit odors in the client's room when the client is nauseated and vomiting - limit oral intake to clear fluids when the client is nauseous and vomiting ** antiemetics can cause drowsiness, so the priority intervention is to protect the client from injury **

Newborn reflexes

1. sucking and rooting: - touch the newborn's cheek with nipple - the baby turns their head towards the nipple, opens mouth, takes hold of nipple, and sucks - usually disappears after 3-4 months but may persist for 1 year 2. swallowing reflex: - occurs spontaneously after getting fluids - able to swallow in coordination with sucking without gagging, coughing, or vomiting 3. tonic neck or fencing: - gently turn the head to one side while sleeping - their arm and leg on that side should extend outward, the arm and leg on the opposite side should flex - disappears in 3-4 months 4. Palmar-plantar grasp: - place a finger on the palm of their hand and on the base of their toes - their finger's should curl around the finger and toes curl downward - palmar response lessens in 3-4 months, plantar in 8 months 5. moro reflex: - hold baby in a semi-sitting position and allow the head and trunk to fall back to a 30-degree angle - the newborn should extend and flex their body sharply and abduct their arms and legs, with their thumb and fingers in a C shape - present at birth until 6 months of age, a persistent response lasting longer than 6 months may indicate a neurological abnormality 6. Startle reflex: - make a loud noise and their arms adduct while their elbows flex, their hands clench, disappears within 4 months 7. pull-to-sit response: - pull them up by their wrists while they are lying down, the head lags until they are upright, and then it is level with their chest and shoulders momentarily before falling forward, the head then lifts for a few minutes - the response depends on their muscle tone 8. Babinski's sign: plantar reflex: - use a finger to stroke the heel of the foot moving up to the toes, their toes hyper-extend while their big toe dorsiflexes - disappears after 1 year - absence of this reflex indicates a need for a neurological exam 9. stepping or walking: - hold the newborn up, place their foot on a table, they will make a walking motion - is present for 3-4 months 10. crawling: - place the newborn on their stomach, they will make a crawling motion - disappears after 6 weeks old

Erik Erikson's stages of psychosocial development

1. trust vs mistrust: infancy (birth to 18 months) - task: attachment to the primary caregiver - successful: trust in people, faith and hope about the environment and future - unsuccessful: difficulty relating to people, suspicion, trust-fear conflict, fear of the future 2. autonomy vs. shame and doubt: early childhood (18 months to 3 years) - task: gaining some basic control over self and environment - successful: sense of self-control and adequacy, willpower - unsuccessful: independence-fear conflict, severe feelings of self-doubt, lack of self-control 3. initiative vs. guilt: 3-6 years - task: becoming purposeful and directive - successful: ability to initiate own activities, sense of purpose - unsuccessful: aggression-fear conflict, sense of inadequacy or guilt 4. industry vs. inferiority: 6-12 years - task: developing social, physical, and learning skills - successful: competence, ability to learn and work - unsuccessful: sense of inferiority, difficulty learning and working 5. identity vs. role confusion: 12-20 years - task: developing a sense of identity - successful: sense of personal identity - unsuccessful: unsure about own identity, have a weak sense of self, experience role confusion, and are confused about the future 6. intimacy vs. isolation: 20-35 years - task: establishing intimate bonds of love and friendship - successful: ability to love deeply and commit oneself - unsuccessful: emotional isolation, egocentricity 7. generativity vs. stagnation: 35-65 - task: fulfilling life goals that involve family, career, and society - successful: ability to give and care for others - unsuccessful: self-absorption, inability to grow as a person 8. integrity vs. despair 65 - death - task: looking back over one's life and accepting its meaning - successful: sense of integrity and fulfillment - unsuccessful: dissatisfaction with life

Fluid volume deficit assessment findings

Cardiovascular: - thready, increased pulse rate - decreased blood pressure and orthostatic hypotension - flat neck and hand veins - diminished peripheral pulses - decreased central venous pressure - dysrhythmias Respiratory: - increased rate and depth of respirations - dyspnea Neuromuscular: - decreased central nervous system activity, from lethargy to coma - fever - skeletal muscle weakness Renal: - decreased urine output Integumentary: - dry skin - poor turgor, tenting - dry mouth Gastrointestinal: - decreased motility and diminished bowel sounds - constipation - thirst - decreased body weight Lab findings: - increased serum osmolality - increased hematocrit - increased BUN - increased Na+ - increased urine specific gravity

Cranial nerve 9

Glossopharyngeal - controls swallowing, sensation in pharyngeal soft palate and tonsillar mucosa, taste perception, and salivation - test taste perception, ask the client to say "ahh" and watch for symmetrical movement of pharynx, and initiate gag reflex.

Renal function studies

Serum creatinine: - is a specific indicator of renal function - increased levels indicate a slowing of the GFR - instruct the client to avoid excessive exercise for 8 hours and excessive red meat intake for 24 hours before the test - normal level for males: 0.6 - 1.2 - normal level for females: 0.5 - 1.1 - elevated levels occur in severe renal disease - below normal levels occur in diseases with decreased muscle mass such as muscular dystrophy and myasthenia gravis Blood Urea Nitrogen (BUN) - urea is normally filtered in the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in the urine. - normal level: 10-20 - elevated levels indicate a slowing of the GFR - elevated levels may be due to burns, dehydration, GI bleeding, increase in protein breakdown due to fever or stress, renal disease, shock, or UTI - below normal levels may be due to: fluid overload, malnutrition, severe liver damage, or syndrome of inappropriate antidiuretic hormone

Pediatric neurological and cognitive problems: Autism spectrum disorders

assessment: - abnormal or lack of comfort seeking behaviors - lack of social play - impairment in peer relationships - lack of awareness of the existence of feelings or others - abnormal or lack of speech - abnormal non-verbal communication - lack of imaginative play - persistent preoccupation or attachment to objects - self-injurious behaviors - must maintain a normal routine - produces repetitive body movements interventions: 1. determine the child's routines, habits, and preferences and maintain consistency 2. determine the specific ways the child communicated 3. avoid placing demands on the child 4. implement safety precautions as needed 5. initiate referrals to special needs programs 6. provide support to parents

deep vein thrombophlebitis

assessment: - calf or groin tenderness or pain with or without swelling - positive homan's sign may be noted (calf pain at dorsiflexion of the foot), but this is not a reliable measure because it may be a false positive sign - warm skin that is tender to touch interventions: 1. provide bed rest as prescribed 2. elevate the affected extremity above the level of the heart as prescribed 3. avoid using the knee gatch or a pillow under the knees 4. do not massage the extremity 5. provide thigh-high or knee-high antiembolism stockings as prescribed to reduce venous stasis and assist in the venous return of blood to the heart; teach how to apply and remove stockings 6. administer intermittent or continuous warm, moist compresses as prescribed 7. palpate the site gently, monitoring for warmth and edema 8. measure and record the circumferences of the thighs and calves 9. monitor for SOB and chest pain, which can indicate pulmonary emboli 10. administer thrombolytic therapy (tissue plasminogen activator) as prescribed, which must be initiated within 5 days after the onset of symptoms 11. administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots 12. monitor activated partial thromboplastin time during heparin therapy 13. administer warfarin as prescribed following heparin therapy when the symptoms of deep vein thrombophlebitis has resolved 14. monitor prothrombin time and INR during warfarin therapy 15. monitor for the adverse effects associated with anticoagulant therapy client education for clients with deep vein thrombophlebitis: 1. instruct the clients concerning the hazards if anticoagulation therapy 2. recognize the s/s of bleeding 3. avoid prolonged sitting or standing, constrictive clothing, or crossing the legs when seated 4. elevate the legs for 10-20 minutes every few hours each day 5. plan a progressive walking program 6. inspect the legs for edema, and measure the circumference of the legs 7. wear anti-embolism stockings as prescribed 8. avoid smoking 9. avoid any meds unless prescribed by the PHCP or cardiologist 10. instruct the client concerning the importance of follow-up PHCP visits and lab studies 11. wear a medic-alert bracelet

Pediatric neurological and cognitive problems: Intellectual disability

assessment: - deficits in cognitive skills and level of adaptive functioning - delays in fine and gross motor skills - speech delays - decreased spontaneous activity - non-responsiveness - irritability - poor eye contact during feeding interventions: 1. medical strategies are focused on correcting structural deformities and treating associated behaviors 2. implement community and educational devices 3. promote care skills 4. assist with communication and socialization skills 5. facilitate appropriate play time 6. initiate safety precautions as necessary 7. assist the family in decisions regarding care 8. provide info regarding support services and community agencies

Pediatric neurological and cognitive problems: ADHD

assessment: - fidgets with hands or feet, squirms in seat - easily distracted - difficulty following instructions - poor attention span - shifts from 1 uncompleted activity to another - talks a lot - interrupts others - engages in dangerous activities without considering consequences interventions: 1. provide information to parents about the disorder and treatment plan, encourage support groups 2. treatment includes behavioral therapy, meds, maintaining a consistent environment, and appropriate classroom placement 3. behavioral therapy focuses on preventing undesirable behavior 4. maintain a consistent home and classroom and provide safety measures 5. promote self-esteem 6. stimulant meds may be prescribed, possible side effects are appetite suppression and weight loss, nervousness, tics, insomnia, and increased BP 7. instruct the child and parents about med administration and the need for regular follow up

Pediatric developmental dysplasia of the hip

assessment: - infant - shortening of the limb on the affected side - restricted abduction of the hip on the affected side when the infant is placed supine with knees and hips flexed (limited ROM in the affected hip) - unequal gluteal folds when the infant is prone and legs are extended against the examining table - positive Ortolani's sign: when the examiner abducts the thigh and applies gentle pressure forward over the greater trochanter, a clicking sensation indicates a dislocated femoral head moving into the acetabulum - positive Barlow's test: the examiner adducts the hips and applies gentle pressure down and back with the thumbs, in hip dysplasia the examiner can feel the femoral head move out of the acetabulum - older infant and child: - affected leg is shorter than the other - the head of the femur can be felt to move up and down in the buttock when the extended thigh is pushed first towards the child's head and then pulled distally - positive Trendelengurg's sign: the child stands on one foot and then the other foot, holding onto a support and bearing weight on the affected hip, the pelvis tilts downwards on the normal side instead of upwards, as it would normally with stability - greater trochanter is prominent - marked lordosis or waddling gait is noted in bilateral dislocations interventions: 1. birth - 6 months old: splinting of the hips with a Pavlik harness to maintain flexion and abduction and external rotation (worn continuously until hip is stable in about 3-6 months) - age 6-18 months: gradual reduction by traction followed by closed reduction or open reduction if necessary under general anesthesia, child is placed in a hip spica cast for 2-4 months until the hip is stable, and then a flexion-abduction brace is applied for 3 months - older child: operative reduction and reconstruction is usually required - parents are instructed regarding proper foot care of a Pavlik harness, spica cast, or abduction brace

addicted newborn

assessment: - irritability - tremors - hyperactivity and hypertonicity - respiratory distress - vomiting - high-pitched cry - sneezing - fever - diarrhea - excessive sweating - poor feeding - extreme sucking of fists - seizures interventions: - monitor respiratory and cardiac status frequently - monitor temp and vitals - hold newborn firmly and close to the body during feeding and when giving care - initiate seizure precautions - provide small, frequent feedings and allow a longer period for feeding - monitor I&O - administer IV hydration if prescribed - protect the newborn's skin from injury that can be caused by the hyperactive rubbing from jitters - swaddle the newborn - place the newborn in a quiet room and provide stimulation - allow the mother to express feelings such as anxiety and guilt - refer the mother for treatment of a substance abuse problem

postpartum interventions

assessment: - monitor vitals - assess pain level - assess height, consistency, and location of the fundus - monitor color, amount, and odor of lochia - assess breasts for engorgement - monitor perineum for swelling or discoloration - monitor for perineal lacerations or episiotomy for healing - assess incisions and dressings for a client who has a C-section - monitor bowel sounds - monitor I&O - encourage frequent voiding - encourage ambulation - assess extremities for thrombophlebitis - administer Rh0 immune globulin within 72 hours after birth to the Rh-negative mother who have birth to a Rh-positive baby - evaluate rubella immunity, if not immune administer vaccine - assess bonding with the newborn - assess emotional status

phlebitis

assessment: - red, warm area radiating up the vein and extremity - pain - swelling interventions: 1. apply warm, moist soaks as prescribed to dilate the vein and promote circulation (assess temp of soak before applying) 2. assess for signs of complications such as tissue necrosis, infection, or pulmonary embolus

meconium aspiration syndrome

assessment: - respiratory distress present at birth: tachypnea, cyanosis, retractions, nasal flaring, grunting, crackles, and rhonchi - nails, skin, and umbilical cord may be stained a yellow-green color interventions: - if the newborn is delivered in an active, crying state with no evidence of respiratory distress, no intervention is necessary - if the newborn is delivered and exhibits inactivity and lack of cry, endotracheal suctioning is performed. if the newborn also exhibits lack of respiratory effort and a low HR, additional interventions will be needed. - newborns with severe meconium aspiration syndrome may benefit from extracorporeal membrane oxygenation; this therapy uses a modified heart-lung machine and provides oxygen to the circulation, allowing the lungs to rest and decreasing pulmonary HTN and hypoxemia.

Pediatric renal and genitourinary problems: Hemolytic-uremic syndrome

assessment: - triad of anemia, thrombocytopenia, and kidney failure - proteinuria, hematuria, and presence of urinary casts - BUN and serum creatinine levels are elevated, Hgb and Hct decreased interventions: 1. hemodialysis or peritoneal dialysis may be prescribed if the child is anuric 2. strict monitoring of fluid balance is needed, fluid restrictions may be prescribed if the child is anuric 3. institute measures to prevent infection 4. provide adequate nutrition 5. other treatments include measures to treat manifestations and the administration of blood products to treat severe anemia

infant skills at 10-11 months

can change from prone to sitting, walks while holding onto furniture, stands up securely, entertains self for periods of time

Serous drainage

clear or straw colored, occurs as a normal part of the healing process

amniotic fluid

consists of 800 - 1200 mL by the end of pregnancy, surrounds, cushions, and protects the fetus, allows for fetal movement, maintains body temp of fetus, contains fetal urine and is a measure of fetal kidney function, the fetus modifies the amniotic fluid by urination, swallowing, and movement of fluid through the respiratory tract.

infant skills at 6-7 months

creeps, sits with support, imitates, exhibits fear of strangers, holds arms out, frequent mood swings, waves bye

fetal heart rate (FHR)

depends on gestational age; is 160 - 170 bpm in the 1st trimester, then lowers to 110 - 160 bpm in 2nd and 3rd trimesters, FHR is about twice the maternal HR.

Expectorants and mucolytic agents

expectorant: - Guaifenesin Mucolytic: - Acetylcysteine - expectorants loosen bronchial secretions so that they can be eliminated with coughing; they are used for a dry unproductive cough and to stimulate bronchial secretions - mucolytic agents thin mucus secretions to help make the cough more productive - mucolytic agents with dextromethorphan should not be used by clients with COPD because they suppress the cough - Acetylcysteine can increase airway resistance and should not be used in clients with asthma. This med can also be used to prevent liver damage in acetaminophen overdose, as well as to protect the kidneys in the event that diagnostic testing requiring contrast dye is done - adverse effects: GI irritation, rash, and oropharyngeal irritation interventions: 1. Acetylcysteine, administered by nebulization, should not be mixed with another medication. 2. if acetylcysteine is administered with a bronchodilator, the bronchodilator should be administered 5 minutes before the acetylcysteine 3. monitor for side effects of acetylcysteine such as nausea and vomiting, stomatitis, and runny nose client education: 1. take the med with a full glass of water to loosen mucus 2. maintain adequate fluid intake 3. cough and deep breathe

umbilical cord

has 2 arteries and 1 vein, the arteries carry deoxygenated blood and waste from the fetus, the vein carries oxygenated blood and provides oxygen and nutrients to the fetus

Interventions to assist the client in achieving erik erikson's stages of development

infancy: - hold often - offer comfort during painful procedures - meet their needs for food and hygiene - encourage parents to play an active role while the infant is hospitalized early childhood: - allow self-feeding - encourage removing and putting on their own clothes - allow for choice late childhood: - offer medical equipment for play - respect their choices and expression of feelings school age: - encourage continuing schoolwork while hospitalized - encourage the child to bring favorite toys to the hospital adolescence: - take health history and perform exams without parent present - allow them a choice in their plan of care early adulthood: - include support from client's partner or significant other - assist with rehab and contacting support services as needed before return to work middle adulthood: - assist in choosing creative ways to foster social development - encourage volunteer activities late adulthood: - listen attentively to reminiscent stories about their life accomplishments - assist with making changes to living arrangements

Nutrition throughout growth and development

infant: - breastfeed first 6 months then breastfeed with additional foods from 6-12 months - introduce new foods one at a time 4-7 days apart to assess for allergies - do not give cow milk before 1 year Pregnancy: - increase dietary protein by 60 g - increase calcium and iron and folic acid Breastfeeding: - increased intake of protein, vitamins A, B, C, calcium, and adequate fluid intake - consume extra 500 calories a day - avoid alcohol, caffeine, drugs Older adult: - adequate calcium and vitamin D to prevent osteoporosis

physiological changes in the older client

integumentary system: - loss of pigment in hair and skin - wrinkles - thinning and easy bruising and tearing of the skin - decreased skin turgor, elasticity, and fat - increased thickness and decreased growth of nails - decreased perspiration - dry, itchy, scaly skin - overgrowth and thickening of certain areas of the skin neurological system: - slowed reflexes - slight tremors and difficulty with fine motor movement - loss of balance - increased awakening after sleep onset - increased susceptibility to hypo/hyperthermia - short-term memory decline possible, long-term is usually maintained Musculoskeletal system: - decreased mass and strength of muscles - decreased mobility, ROM, flexibility, coordination, and stability - change of gait with shorter step and wider base - decrease in height - increased brittleness of the bones - deterioration of joint capsule components ** the older client is at risk for falls due to the changes that occur in the neurological and musculoskeletal systems ** Cardiovascular system: - diminished energy and endurance with lowered tolerance to exercise - decreased compliance of the heart muscle due to remodeling of the heart after an MI or long standing HTN; the valves become thicker and more rigid due to calcification - decreased CO and efficiency of blood return - decreased compensatory response so less able to respond to increased demands on the heart - decreased resting HR which may be due to meds - peripheral pulses can be weak due to decreased CO - increased BP but susceptible to postural hypotension respiratory system: - decreased stretch and compliance of the chest - decreased strength and function of respiratory muscles - decreased size and number of alveoli - RR usually unchanged - decreased ability to cough and expectorate sputum Hematological system: - hg and hct levels usually are at lower end - average - prone to decreased blood clotting - decreased protein available for protein-bound meds Immune system: - lymphocyte counts commonly low with altered immunoglobulin production - decreased resistance to infection and disease GI system: - decreased caloric needs due to lowered basal metabolic rate - decreased appetite, thirst, and oral intake - decreased lean body weight - slowed gastric motility - increased constipation - increased susceptibility to dehydration - tooth loss - difficulty chewing/swallowing food Endocrine system: - decreased sensation of hormones - decreased metabolic rate - decreased glucose tolerance with resistance to insulin in peripheral tissues Renal/urinary system: - decreased kidney size, function, and ability to concentrate urine - decreased GFR - decreased capacity of the bladder - increased residual urine and increased incidence of infection and possibly incontinence - impaired med excretion Reproductive system: - decreased testosterone production and size of testes - changes in the prostate gland leading to urinary problems like retention, hesitancy, or stress incontinence leading to UTIs - decreased production of hormones with cessation of menses - decreased vaginal muscle tone and lubrication - impotence or sexual dysfunction Special senses: - decreased visual acuity - decreased accommodation in eyes, requiring increased adjustment time to changes in light - decreased peripheral vision and increased sensitivity to glare - presbyopia and cataract formation - possible loss of hearing ability, low-pitched tones are heard more easily - inability to discern taste of foods - decreased sense of smell - changes in touch sensation - decrease in pain awareness

Hemodialysis interventions and complications

interventions: 1. monitor vitals before, during, and after dialysis; the client's temp may be elevated because of the slight warming of the blood, but indicate the PHCP about excessive temp elevations because this could indicate sepsis, requiring blood cultures 2. monitor lab values, especially the BUN, creatinine, and CBCs before during and after dialysis 3. assess the client for fluid overload before dialysis and fluid volume deficit after dialysis 4. weigh the client before and after dialysis to determine fluid loss; note that the client will not urinate or only urinate small amounts 5. assess the patency of the blood access device before during and after dialysis 6. monitor for bleeding; heparin is added to the dialysis bath to prevent clots from forming in the dialyzer or the blood tubing 7. monitor for hypovolemia during dialysis, which can occur from blood loss or excess fluid and electrolyte removal 8. provide adequate nutrition; the client may not eat before or during dialysis 9. identify the client's reactions to the treatment and support coping mechanisms; encourage independence and involvement in care **withhold antihypertensives and other meds that can affect the BP or result in hypotension until after hemodialysis treatment. also withhold meds that could be removed by dialysis such as water soluble vitamins, certain antibiotics, and digoxin.**

Nasal decongestants

non-glucocorticoids: - oxymetazoline - phenylephrine hydrochloride - pseudoephedrine hydrochloride glucocorticoids: - beclomethasone - budesonide - ciclesonide - flunisolide - flutocasone propionate - fluticasone furoate - mometasone - triamcinolone - include adrenergic, anticholinergic, and corticosteroid meds - shrink the nasal mucosal membranes and reduce fluid secretion - used for allergic rhinitis, hay fever, and acute coryza (profuse nasal discharge) - contraindicated or used with extreme caution in clients with HTN, cardiac disease, hyperthyroidism, or DM - adverse effects: nervousness, restlessness, insomnia, HTN, and hyperglycemia interventions: 1. monitor for cardiac dysrhythmias 2. monitor blood glucose levels client education: ** nasal decongestants can cause tolerance and rebound nasal congestion (vasodilation) caused by irritation of nasal mucosa. Therefore, the client needs to be informed that these meds should not be used for longer than 48 hours ** 1. avoid consuming caffeine in large amounts because it can increase restlessness and palpitations 2. the importance of limiting the use of nasal sprays and drops to prevent rebound nasal congestion; consider weaning off one nare at a time to prevent this.

Cranial nerve 1

olfactory nerve - controls sense of smell - test by having the client smell scents

Antitussives

opioids: - codeine phosphate, codeine sulfate - hydrocodone non-opioids: - benzonatate - dextromethorphan - diphenhydramine hydrochloride - act on the cough control center in the medulla to suppress the cough reflex; used for a cough that is non-productive and non-irritating - adverse effects: dizziness, drowsiness, sedation, GI irritation, nausea, dry mouth, constipation, and respiratory depression interventions: 1. encourage the client to take adequate fluids with the medication 2. encourage the client to sleep with the head of the bed elevated 3. note that med dependency can occur 4. avoid administration to the client with a head injury or a post-op cranial surgery client 5. avoid administration to the client using opioids, sedative-hypnotics, barbiturates, or certain anti-depressants because CNS depression can occur client education: 1. if the cough lasts longer than 1 week and a fever or rash occurs, notify the PHCP 2. avoid hazardous activities 3. avoid the use of alcohol

Cranial nerve 2

optic nerve - controls vision - test by snellen chart

Freud's psychosexual stages of development

oral stage: birth to 1 year - infant is concerned with self-gratification, operates on the id or pleasure principle. sense of trust and security when infant's needs are met. - ego begins as the infant begins to see self independent from the caregiver, this marks the beginning of their sense of self. anal stage: 1-3 years - toilet training occurs and child gains pleasure over learning to control their body, allows them a sense of accomplishment and achievement. - conflict during this stage is their demands from society and parents and the sensations of pleasure associated with the anus. - the child begins to gain a sense of control over instincts and learns to delay immediate gratification to gain a future goal. phallic stage: 3-6 years - the child experiences pleasurable and conflicting feelings associated with the genital - pleasure of masturbation and fantasy life of children set the stage for the Oedipus complex - their unconscious sexual attraction to and wish to possess the opposite sex parent, their hostility and de4sire to remove the parent of the same sex, and the guilt about these wishes constitute the challenges the child faces. - the conflict is resolved when the child begins to identify with the parent of the same sex. - the emergence of the superego is the solution to and the result of these intense impulses latency stage: 6-12 - their sexual impulses are channeled into a more socially acceptable level of activity - growth of ego functions and the ability to care about and relate to others outside the home is the task of this stage of development genital stage: 12+ years - emergences at adolescence with the onset of puberty - gratification is gained by own body - develop satisfying sexual and emotional relationships with members of the opposite sex. - they plan life goals and gains a strong self of self and personal identity

Anti-platelet medications

oral: - acetylsalicylic acid - anagrelide - cilostazol - clopidogrel - dipyridamole - ticlopidine - ticagrelor parenteral: - abciximab - eptifibatide - tirofiban - anti-platelet meds inhibit the aggregation of platelets in the clotting process, prolonging the bleeding time. - they can be used with anti-coagulants - they can be used in the prophylaxis of long-term complications following a MI, coronary revascularization, stents,. and stroke - they are contraindicated in those with bleeding disorders and known sensitivity adverse effects: - bruising - hematuria - GI bleeding - tarry stools interventions: 1. a blood test may be prescribed to determine the client's sensitivity to the med before starting administration 2. monitor vitals 3. instruct the client to take meds with food if GI upset occurs 4. monitor bleeding time 5. instruct the client to monitor for side and adverse effects and in the measures to prevent bleeding

chorion

outer member enclosing the amniotic cavity, becomes vascularized and forms the fetal part of the placenta

Pediatric cardiovascular problems: cardiac surgery

post-op interventions: 1. monitor vitals frequently, and notify the surgeon if fever occurs 2. monitor for signs of sepsis including fever, chills, diaphoresis, lethargy, and altered LOC 3. maintain strict aseptic technique 4. monitor lines, tubes, and catheters that are in place and monitor for s/s of infection 5. assess for signs of discomfort like irritability, restlessness, and changes in HR, RR, and BP 6. administer pain meds as prescribed 7. administer antibiotics and antipyretics as prescribed 8. promote rest and sleep 9. facilitate parent-child contact as soon as possible home care after surgery: - omit play outside for several weeks - avoid activities where the child could fall and be injured for 2-4 weeks - avoid large crowds for 2 weeks - follow a no-added salt diet if prescribed - do not add any new foods to the infant's diet - do not place creams, lotions, or powders on the incision site until it's completely healed - the child may return to school usually the 3rd week of discharge, starting with half-days - the child should not participate in physical education for 2 months - discipline the child normally - the 2-week follow-up is important - avoid immunizations, invasive procedures, and dental visits for 2 months, they can and should be normally resumed after 2 months - the child should have a dental visit every 6 months after age 3 years and inform the dentist of the cardiac problem so antibiotics can be prescribed if needed - call the pediatrician if coughing, tachypnea, cyanosis, vomiting, diarrhea, anorexia, pain, or fever occur, or any redness, swelling, or drainage occur at the incision site

Stages of fetal development

preembryonic period: first 2 weeks after conception embryonic period: day 15 - week 8 after conception fetal period: week 8 - birth week 1: blastocyst is free floating weeks 2 - 3: - embryo is 1.5 - 2 mm long - lung buds appear - blood circulation begins - heart is tubular and begins to beat - neural plate becomes brain and spinal cord week 5: - embryo is 0.4 - 0.5 cm long - embryo is 0.4 g - double heart chambers are visible - heart is beating - limb buds form week 8: - embryo is 3 cm long - embryo is 2 g - eyelids begin to fuse - circulatory system through umbilical cord is well established - every organ system is present week 12: - fetus is 6 - 9 cm long - fetus is 19 g - face is well formed - limbs are long and slender - kidneys begin to form urine - spontaneous movements occur - heartbeat is detected by doppler transducer between 10 - 12 weeks week 16: - fetus is 11.5 - 13.5 cm long - fetus is 100 g - active movements are present - fetal skin is transparent - lanugo hair begins to develop - skeletal ossification occurs - sex of fetus is usually recognizable by ultrasound week 20: - fetus is 16 - 18.5 cm long - fetus is 300 g - lanugo covers entire body - has nails - muscles are developed - enamel and dentin are depositing - heartbeat is detected by regular fetoscope week 24: - fetus is 23 cm long - weighs 600 g - hair on head is formed - skin is reddish and wrinkled - reflex hand grasps are present - vernix caseosa covers entire body - fetus can hear week 28: - is 27 cm long - weighs 1100 g - limbs are well flexed - brain is developing rapidly - eyelids open and close - lungs are developed enough to provide gas exchange - neonate can breathe if born week 32: - 31 cm long - weighs 1800 - 2100 g - bones are fully developed - subcutaneous fat has developed week 36: - 35 cm long - weighs 2200 - 2600g - skin is pink and body is rounded - skin is less wrinkled - lanugo is disappearing week 40: - 40 cm long - weighs more than 3200 g - skin is pinkish and smooth - lanugo may be present on upper arms and shoulders - vernix caseosa decreases - nails extend beyond fingertips - plantar creases run down the heel - testes are in the scrotum - labia majora are well developed

Pediatric integumentary problems: Burn injuries

priority nursing actions: 1. stop the nursing process 2. assess for a patent airway 3. begin resuscitation if needed using compressions, airway, breathing (CAB) 4. remove burned clothes and jewelry 5. cover the wounds with a clean cloth at the site of injury 6. keep the child warm 7. transport the child to the ED - kids who are burned are more at risk for fluid and heat loss, dehydration, and metabolic acidosis than adults because they have less BSA and thinner skin - the higher proportion of body fluid to body area in kids increases their risk of cardiovascular problems - burns involving more than 10% of their BSA require fluid resuscitation - infants and kids are at increased risk for protein and calorie deficiency because they have less muscle mass and body fat - scarring is more severe in kids; and disturbed body image is an issue for them - an immature immune system presents an increased risk of infection for infants and young kids - a delay in growth may occur after a burn extent of burn injury: - rule of 9s used is specific to age of child - to determine fluid resuscitation needed, vitals urine output adequacy of capillary filling and sensory capabilities are all assessed - fluid replacement is needed during the first 24 hours - crystalloid solutions are often prescribed in the initial phase of therapy, colloid solutions such as albumin, plasma-lyte (combined electrolyte solution), or fresh frozen plasma are useful in maintaining plasma volume

placenta

provides exchange of nutrients and wastes between fetus and mother, begins to form at implantation, is formed by week 12, produces hormones to maintain pregnancy, transfers immunoglobulin during the 3rd trimester to provide the fetus with passive immunity, by week 10 - 12 genetic testing can be done by chorionic villus sampling (CVS).

sanguineous drainage

red drainage from trauma to a blood vessel, may occur with wound cleansing or other trauma to the wound bed, it is abnormal in wounds

Chest injuries

rib fracture: - results from direct blunt chest trauma and causes a potential for intra-throracic injury, such as pneumothorax, hemothorax, or pulmonary contusion. - pain with movement, deep breathing, and coughing results in impaired ventilation and coughing results in impaired ventilation and inadequate clearance of secretions assessment: - pain and tenderness at the injury site that increases with inspiration - shallow respirations - client splints chest - fractures noted on the chest x-ray interventions: 1. note that the ribs usually reunite spontaneously 2. open reduction and internal rotation of the ribs may be done 3. place the client in a fowler's position 4. administer pain meds as prescribed to maintain adequate ventilatory status 5. monitor for increased respiratory distress 6. instruct the client to self-splint with the hands, arms, or a pillow 7. prepare the client for an intercostal nerve block as prescribed if the pain is severe flail chest: - occurs from blunt chest trauma associated with accidents, which may result in hemothorax and rib fractures - the loose segment of the chest wall becomes paradoxical to the expansion and contraction of the rest of the chest wall assessment: - paradoxical respirations (inward movement of a segment of the thorax during inspiration with outward movement during expiration) - severe pain in the chest - dyspnea - cyanosis - tachycardia - hypotension - tachypnea, shallow respirations - diminished breath sounds interventions: 1. maintain the client in fowler's position 2. administer O2 as prescribed 3. monitor for increased respiratory distress 4. encourage coughing and deep breathing 5. administer pain meds as prescribed 6. maintain bed rest and limit activity to reduce O2 demands 7. open reduction and internal fixation of the ribs may be done 8. prepare for intubation with mechanical ventilation, with positive-end-expiratory-pressure (PEEP) for severe flail chest associated with respiratory failure and shock pulmonary contusion: - characterized by interstitial hemorrhage associated with intra-alveolar hemorrhage, resulting in decreased pulmonary compliance - the main complication is acute respiratory distress syndrome (ARDS) assessment: - dyspnea - restlessness - increased bronchial secretions - hypoxemia - hemoptysis - decreased breath sounds - crackles and wheezes interventions: 1. maintain a patent airway and adequate ventilation 2. place the client in fowler's position 3. administer O2 as prescribed 4. monitor for increased respiratory distress 5. maintain bed rest and limit activity to reduce O2 demands 6. prepare for mechanical ventilation with PEEP if required

infant skills at 8-9 months

sits steadily unsupported, crawls, may stand while holding on, begins to stand without help

infant skills at 2-3 months

smiles, turns head side to side, follows objects, and holds head in midline

Bariatric surgery

surgical reduction of gastric capacity or absorptive ability that may be performed on a client with morbid obesity to produce long-term weight loss - surgery may be performed by laparoscopy, the decision is based on the client's weight, body build, history of abdominal surgery, and current medical disorders - obese clients are at increased post-op risk for pulmonary and thromboembolic complications and death - surgery can prevent the complications of obesity, such as DM, HTN, and other cardiovascular disorders, or sleep apnea - the client needs to agree to modify his or her lifestyle, lose weight, keep the weight off, and obtain support from available community resources such as the american obesity association, american society of bariatric surgery, or overeaters anonymous. post-op interventions: 1. care is similar to that for the client undergoing laparoscopic or abdominal surgery 2. as prescribed, if the client can tolerate water, clear liquids are introduced slowly in 1 ounce (30 mL) cups for each serving once bowel sounds have returned and the client passes flatus 3. as prescribed, clear fluids are followed by pureed foods, juices, thin soups, and milk 24-48 hours after clear fluids are tolerated, then the diet is progressed to nutrient-dense regular food client teaching about diet: - avoid alcohol, high-protein foods, and foods high in sugar and fat - eat slowly and chew food well - progress food types and amounts as prescribed - take nutritional supplements as prescribed, which may include calcium, iron, multivitamins, and vitamin B12 - monitor and report signs of complications, such as dehydration and gastric leak (persistent abdominal pain, nausea, and vomiting)

Normal vitals signs for newborn

temp: 96.8-99 HR: 120-160 RR: 30-60 BP: 80-90 / 40-50

Quickening

the first perception of fetal movement that occurs between the 16th and 20th week of gestation.

Parity

the number of births past 20 weeks of gestation, whether or not the fetus was born alive or not.

Judaism beliefs related to end-of life care

- a client placed on life support should remain on it until death - a dying person should not be left alone - autospy and cremation are not allowed - some oppose prolonging life after irreversible brain damage

Sinus tachycardia

- 100-180 bpm interventions: 1. determine the cause 2. decrease the HR to normal by treating the underlying cause

Preterm newborn

- 20-37 weeks of gestation assessment: - RR irregular with periods of apnea - body temp below normal - poor suck and swallow reflexes - diminished bowel sounds - urinary output is decreased or increased - thin extremities - minimal creases on palms and soles - extends extremities, does not maintain flexion - lanugo is present in wooly patches - thin skin with visible vessels and minimal fat - skin may appear jaundiced - testes are undescended in boys - labia majora are narrow in girls interventions: - monitor vitals every 2-4 hours - maintain airway and cardiopulmonary functions - administer O2 and humidification as prescribed - monitor I&O and electrolytes - monitor daily weight - maintain the newborn in a warming device - avoid exposure to infections

Pediatric immune problems and infectious diseases: HIV

- AIDS is caused by the human immunodeficiency virus HIV and is characterized by generalized dysfunction of the immune system - HIV infects CD4+ T cells, a gradual decrease in these cells occurs, and this results in a progressive immunodeficiency. - HIV is transmitted through blood, semen, vaginal secretions, and breast milk. assessment: - common conditions in children with AIDS: - candidal esophagitis - cryptosporidosis - cytomegalovirus disease - herpes simplex disease - lymphoid intestinal pneumonitis - mycobacterium avium-intracellulare infection - pneumocystisis jiroveci pneumonia - pulmonary candidiasis - recurrent bacterial infections - wasting syndrome - common conditions in children with HIV: - chronic cough - chronic or recurrent diarrhea - developmental delay or regression of developmental milestones - failure to thrive - hepatosplenomegaly - lymphadenopathy - malaise and fatigue - night sweats - oral candidiasis - parotitis - weight loss Care of the child with HIV or AIDS: - primary goals are to decelerate the replication of the virus, prevent opportunistic infections, provide nutritional support, treat symptoms, and treat opportunistic infections - provide prophylaxis as prescribed against opportunistic infections, particularly during the first year of life. - after 1 year of age, the need for prophylaxis is determined on the basis of the presence and severity of immunosuppression or a history of pneumonia - continuing prophylaxis is based on the child's HIV status, history of opportunistic infections, and CD4+ counts anti-retroviral meds: - is used to suppress viral replication and slow the decline of the CD4+ cell counts, preserve immune function, reduce the incidence and severity of opportunistic infections, and delay disease progression - the meds affect different stages of the HIV life cycle to prevent reproduction of new viral particles - combination therapy may be prescribed and includes the use of more than 1 antiretroviral med immunization: - if a child has symptomatic HIV infection or severe immunosuppression, the guidelines are to only administer the inactivated influenza vaccine that's given IM and yearly. measles vaccine should not be given, immunoglobulin may be prescribed after measles exposure. only the inactivated polio vaccine that is given IM should be used. the rotavirus vaccine should not be given. varicella-zoster virus vaccine should not be given, the immunoglobulin may be prescribed after a chickenpox exposure. tetanus immunoglobulin may be prescribed for tetanus-prone wounds caregiver instructions: - wash hands often - assess for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity, and oral lesions. notify the Dr if any of these occur - assess for opportunistic infections - administer anti-retroviral meds as prescribed - the child needs to be restricted from having contact with people with infections or other contagious illnesses - keep immunizations up to date - provide a high-calorie and high-protein diet - do not share eating utensils - wash all eating utensils in the dishwasher - cover any of the child's uneaten food and formula and refrigerate, discard after 24 hours - do not allow the child to eat fresh fruits/veggies or raw meat or fish - wear gloves while caring for the child, especially when in contact with bodily fluids and changing diapers - change their diapers often, avoid food areas - fold their disposable soiled diapers inward, close with tabs, and dispose in a tightly-covered plastic-lined container - dispose of trash daily - clean up any bodily fluid spills with a bleach solution education for an adolescent with HIV: - educate about high-risk behaviors and importance of avoiding them - identify the methods of transmission of HIV - emphasize on the importance of abstinence from sexual contact, like intercourse - emphasize the importance of using safe condoms if intercourse is planned - identify the resources available for support and other issues

Acute Kidney Injury (AKI)

- AKI is the rapid loss of kidney function from renal cell damage - occurs abruptly and can be reversible - AKI leads o cell hypoperfusion, cell death, and decompensation of renal function - the prognosis depends on the cause and the condition of the client - near-normal or normal kidney function may resume gradually causes: - pre-renal: outside the kidney; caused by intra-vascular volume depletion such as with blood loss associated with trauma or surgery, dehydration, decreased CO, decreased peripheral vascular resistance, decreased renal blood flow, and pre-renal infection or obstruction. - intra-renal: within the parenchyma of the kidney; caused by tubular necrosis, prolonged pre-renal ischemia, intra-renal infection or obstruction, and nephrotoxicity. - post-renal: between the kidney and urethral meatus; such as bladder neck obstruction, bladder cancer, calculi, and post-renal infection. phases of AKI: 1. onset: begins with precipitating event 2. oliguric phase: elevated BUN and serum creatinine levels, decreased or normal urine specific gravity, decreased GFR and creatinine clearance, hyperkalemia, normal or decreased sodium level, hypervolemia, hypocalcemia, and hyperphosphatemia 3. diuretic phase: gradual decline in BUN and serum creatinine levels (but still elevated), continued low creatinine clearance with improving GFR, hypokalemia, hyponatremia, and hypovolemia 4. recovery phase (convalescent): increased GFR, stabilization or continual decline in BUN and serum creatinine levels toward normal, and then complete recovery (may take 1-2 years). oliguric phase: - for some clients, oliguria does not occur and the urine output is still normal; otherwise, the duration of oliguria is 8-15 days; the longer the duration, the less chance there is of recovery. - sudden decrease in urine output, it is less than 400 mL/day - sighs of excess fluid volume = HTN, edema, pleural and pericardial effusions, dysrhythmias, HF, and pulmonary edema. - signs of uremia = anorexia, nausea, vomiting, and pruritus - signs of metabolic acidosis = Kussmaul's respirations - neurological changes = tingling of extremities, drowsiness progressing to disorientation, and then coma - signs of pericarditis = friction rub, chest pain with inspiration, and low-grade fever - with early recognition or potential for AKI, the client may be treated with fluid challenges (IV boluses of 500-1000 mL over 1 hour) - restrict fluid intake; if HTN occurs, daily fluid allowances may be 400-1000 mL plus the measured urinary output - administer meds, such as diuretics, as prescribed to increase renal blood flow and diuresis of retained fluid and electrolytes Diuretic phase: - urine output rises slowly, followed by diuresis (4-5 L/day) - excessive urine output indicates that damaged nephrons are recovering their ability to excrete wastes - dehydration, hypovolemia, hypotension, and tachycardia can occur - LOC improves - administer IV fluids as prescribed which may contain electrolytes to replace losses recovery (convalescent) phase: - recovery is a slow process; complete recovery may take 1-2 years - urine volume returns to normal - memory improves - strength increases - the older adult is less likely to regain full kidney function than a younger adult - AKI can progress to chronic kidney disease (CKD) **the signs and symptoms of AKI are primarily caused by the retention of nitrogenous wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes** interventions: 1. monitor vitals, especially for signs of HTN, tachycardia, tachypnea, and an irregular HR 2. monitor urine and I&O hourly and urine color and characteristics 3. monitor daily weight noting than an increase of 0.5 lb/day indicates fluid retention 4. monitor for changes in BUN, serum creatinine, and serum electrolyte levels 5. monitor for acidosis; may need to be treated with sodium bicarb 6. monitor urinalysis for protein level, hematuria, casts, and specific gravity 7. monitor for altered LOC which is caused by uremia 8. monitor for signs of infection because the client may not exhibit an elevated temp or an increased WBC count 9. monitor the lungs for wheezes and rhonchi, and monitor for edema, which indicates fluid overload 10. administer the prescribed diet, which is usually a low to moderate protein (to decrease the workload of the kidneys) and high carb diet; ill clients may require nutritional support with supplements, enteral feedings, or parenteral nutrition 11. restrict K+ and Na+ intake as prescribed based on the electrolyte level 12. administer meds as prescribed; be alert to the mechanism for metabolism and excretion of all prescribed meds 13. be alert to nephrotoxic meds, which may be prescribed 14. be alert to the PHCP's adjustment of med dosages for kidney injury 15. prepare the client for dialysis if prescribed; continuous renal replacement therapy may be used in AKI to treat fluid volume overload or rapidly developing azotemia (elevated levels of urea and other nitrogen compounds in the blood) and metabolic acidosis 16. provide emotional support by allowing opportunities for the client to express concerns and fears by encouraging family interactions 17. promote consistency in caregivers

Probable signs of pregnancy

- Hegar's sign: compressibility and softening of the lower uterine segment that occurs at about week 6 - Goodell's sign: softening of the cervix that occurs at the beginning of the 2nd month - Chadwick's sign: violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at week 6 - Ballottment: rebounding of the fetus against the examiner's fingers on palpation - Braxton hick's contractions - positive pregnancy test

Substances to avoid with anti-coagulants

- allopurinol - cimetidine - corticosteroids - green, leafy veggies and other foods high in vitamin K - NSAIDs - oral hypoglycemic agents - phenytoin - salicylates - sulfonamides - ginko and ginseng (herbs)

Influenza

- also called the flu, is a highly contagious acute viral respiratory infection. it may be caused by several viruses. - yearly vaccination is recommended to prevent the disease, especially for those older than 50, those with chronic illness or who are immunocompromised, those living in institutions, and health care personnel providing direct care to clients. - the vaccine is contraindicated in the individual with egg allergies. - additional prevention measures include avoiding those who have developed influenza, frequent and proper hand washing, and cleaning and disinfecting surfaces that have become contaminated with secretions. Avian influenza A: - affects birds and not usually humans, however human cases have been reported in some places. a vaccine has been developed in case a pandemic virus was to emerge. reported symptoms are similar to those for other flus, and other prevention measures are thorough cooking of poultry products, avoiding contact with wild animals, frequent and proper hand washing techniques, and cleaning and disinfecting surfaces that have become contaminated with secretions. Swine (H1N1) influenza: - a strain of flu that consists of genetic materials from swine, avian, and human influenza viruses. - signs and symptoms are those that are present with the seasonal flu, in addition vomiting and diarrhea commonly occur. - prevention and treatment are the same for the seasonal flu. assessment: - acute onset of fever and muscle aches - headache - fatigue, weakness, anorexia - sore throat, cough, rhinorrhea interventions: 1. encourage rest 2. encourage fluids to prevent pulmonary complications (unless contraindicated) 3. monitor lung sounds 4. provide supportive therapy such as antipyretics or antitussives as indicated 5. administer antiviral meds as prescribed for the current strain of influenza influenza vaccine: - is recommended yearly, usually september - april - the nasal spray vaccine (live) is approved only for healthy people aged 2-49, and is not approved for pregnant women. - the flu shots (inactivated vaccine) are approved for kids as young as 6 months old and are safe for pregnant women. - everyone should get the flu vaccine. high priority are pregnant women, household contacts or caregivers of people under 6 months, people 6 months to 24 years old, healthcare workers, and adults aged 25-64 with chronic medical conditions like asthma or a weakened immune system which increases their risk of flu complications. - contraindications of the inactivated vaccine are hypersensitivity, active infection, Gullain-Barre syndrome, active febrile illness, and children under 6 months old. - contraindications of the live vaccine are kids under 2 or adults over 50, pregnant women, children or adolescents on long-term aspirin therapy, and those with severe nasal congestion or long-term conditions like DM, anemia or blood disorders, or heart, kidney, or lung disease - adverse effects of the inactivated vaccine: localized pain and swelling at the injection site, general body aches and pain, malaise, and fever. - adverse effects of the live vaccine: runny nose or nasal congestion, cough, headache, or sore throat. interventions: 1. the IM route is recommended for he inactivated vaccine, adults and older kids should be vaccinated in the deltoid muscle. 2. monitor for adverse effects of the vaccine 3. monitor for hypersensitivity reactions in clients getting the vaccine for the first time client education: 1. about the importance of an annual vaccination 2. that the inactivated vaccine contains non-infectious killed viruses and cannot cause influenza 3. that any respiratory disease unrelated to influenza can occur after getting vaccinated 4. that if the live vaccine is received, the virus can be shed in secretions up to 2 days after vaccination 5. that development of antibodies in adults takes 2 weeks antiviral meds for influenza: - use during outbreaks of influenza depends on the current strain of influenza - diagnosis of influenza should include rapid diagnostic tests, because infections from other pathogens may cause symptoms similar to the influenza infection - may also be administered as prophylaxis against infection but should not replace vaccination - contraindicated in hypersensitive clients adverse effects: - Amantadine: drowsiness, anxiety, psychosis, depression, hallucinations, tremors, confusion, insomnia, orthostatic hypotension, HF, blurred vision, constipation, dry mouth, urinary frequency and retention, leukopenia, photosensitivity, and dermatitis - Oseltamivir: insomnia, diarrhea, abdominal pain, and cough - Rimantadine: depression, hallucinations, tremors, seizures, insomnia, poor concentration, asthenia, gait abnormalities, anxiety, confusion, pallor, palpitations, hypotension, edema, tinnitus, eye pain, constipation, dry mouth, anorexia, abdominal pain, diarrhea, dyspepsia, and rash - Zanamivir: ear, nose, and throat infections, diarrhea, nasal symptoms, cough, sinusitis, and bronchitis - Peramivir: diarrhea, constipation, insomnia, and high blood pressure interventions: 1. administer within 2 days of onset of symptoms 2. monitor for side and adverse effects of specific meds client education: - that the med may not prevent the transmission of influenza to others - about the need to adjust activities if dizziness or fatigue occur - about management of side effects of various meds - to take the med exactly as prescribed and for the duration of the prescription

Pediatric GI Problems: Hepatitis

- an acute or chronic inflammation of the liver that may be caused by a virus, a med reaction, or another disease process - hepatitis A: - highest incidence is among preschool-school-aged kids - many infected kids are asymptomatic, but mild nausea, vomiting, and diarrhea may occur - infected children who are asymptomatic can still spread it - Hepatitis B: - most infections are acquired perinatally - newborns are at risk if the mother is infected or was a carrier during pregnancy - high-risk groups are those with hemophilia or other disorders requiring multiple blood transfusions, those involved with IV drug use, institutionalized kids, preschool children in infectious areas, and children who participate in sex. - infection can cause a carrier state and lead to eventual cirrhosis or hepatocellular carcinoma in adulthood - hepatitis D occurs in kids already infected with hepatitis B - assessment: - in the prodromal or anicteric phase: - lasts 5-7 days - absence of jaundice - anorexia, malaise, lethargy, easily fatigued - fever - nausea and vomiting - epigastric or RUQ pain - arthralgia (joint pain) and rashes - hepatomegaly - in the icteric phase: - jaundice - dark urine and pale stools - pruritus prevention: - immuloglobulin provides passive immunity and may be effective for pre-exposure prophylaxis to prevent the infection - hepatitis B immunoglobulin provides passive immunity and may be effective in preventing infection after a 1-time exposure, should be given immediately after the exposure; and should also be given to newborns whose mothers are positive for the hepatitis B surface antigen - proper hand washing and standard precautions, as well as enteric precautions can prevent the spread of viral hepatitis. interventions: 1. strict hand washing is required 2. hospitalization is required in the event of impaired blood clotting or severe and sudden hepatitis 3. standard precautions and enteric precautions and followed during hospitalization 4. provide enteric precautions for at least 1 week after the onset of jaundice for the patient with hepatitis A 5. the hospitalized child is usually not isolated in a separate room unless they are fecally incontinent and items are likely to be contaminated with feces 6. children are discouraged from sharing toys 7. instruct the child and parents in effective hand washing techniques 8. instruct the parents to disinfect diaper-changing surfaces thoroughly with a solution made up of 1/4 cup bleach in 1 gallon of water 9. maintain comfort and provide adequate rest 10. provide a low-fat well balanced diet 11. inform the parents that because hepatitis A is not infectious 1 week after the onset of jaundice, the child may return to school at that time if they feel well enough 12. inform the parents that jaundice may appear worse before it resolves 13. caution the parents about administering any meds to the child; explain the role of the liver in detoxification and excretion of meds 14. instruct the parents about the signs of the child's condition worsening, such as changes in neurological status, bleeding, and fluid retention

Pediatric musculoskeletal problems: Juvenile idiopathic arthritis

- an autoimmune inflammatiry disease affecting the joints and other tissues, such as articular cartilage, occurs most often in girls - treatment is supportive (there is no cure) and directed towards preserving joint function, controlling inflammation, minimizing deformity, and reducing the impact that the disease may have on development of the child - treatment includes meds, physical and occupational therapies, and child and family education - a pediatric rheumatology team can manage the complex needs of the child and family most effectively. the team may consist of a pediatric rheumatologist, physical and occupational therapist, and nurse specialist. - surgical intervention may be implemented if the child has a problem with joint contractures and unequal growth of extremities assessment: - stiffness, swelling, and limited motion occur in affected joints - affected joints are warm to touch, tender, and painful - joint stiffness is present on arising in the morning and after inactivity - Uveitis (inflammation of sutures in the uveal tract) can occur and cause blindness - there are no definitive tests used to diagnose juvenile idiopathic arthritis - some lab tests like elevated erythrocyte sedimentation rate or determination of the presence of leukocytosis may support evidence of the disease - radiographs may show soft tissue swelling and joint space widening from synovial fluid in the joint interventions: 1. facilitate social and emotional development 2. instruct parents and child in the administration of meds, meds may be given alone or in combination and are prescribed depending on the progression of the disease - corticosteroid injections: prescribed when only a few joints are affected, usually do not have significant side effects - oral corticosteroids: may be prescribed for only a short time and at the lowest dose possible. long-term use is associated with side effects such as weight gain, poor growth, osteoporosis, cataracts, avascular necrosis, HTN, and risk of infection - disease modifying anti-rheumatic drugs (DMARDS): used as a 2nd-line treatment when many joints are involved or the child doesn't respond to corticosteroid injections. Biologics may also be prescribed, and include anti-tumor necrosis factor agents. All of these medications cause side effects that need to be discussed with the child and / or parents. 3. assist the child with ROM exercises and instruct on prescribed exercises 4. encourage normal performance of ADLs 5. instruct parents and the child in the use of hot or cold packs, splinting, and positioning the affected joint in a neutral position during painful episodes. begin simple isometric exercises as soon as the child is able. 6. encourage and support prescribed physical and occupational therapy 7. instruct in the importance of preventive eye care and reporting visual disturbances 8. assess the child's and family's perceptions regarding the chronic illness, plan to discuss the nature of a chronic illness and the associated life alterations that result from the chronic progression of the disorder

large for gestational age

- at or above the 90th percentile on the intrauterine growth curve assessment: - birth trauma or injury - respiratory distress - hypoglycemia interventions: - monitor vitals and for respiratory distress - monitor for hypoglycemia - initiate early feedings - monitor for infection and initiate measures to prevent sepsis

angina

- chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and O2 supply - angina is caused by an imbalance between O2 supply and demand - causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary artery spasm, or conditions increasing myocardial O2 consumption ** the goal of treatment for angina is to provide relief from the acute attack, correct the imbalance between myocardial O2 supply and demand, and prevent the progression of the disease and further attacks to reduce the risk of MI** patterns of angina: 1. stable angina: - occurs with activities that involve exertion or emotional stress; relieved with rest or nitroglycerin. - usually has a stable pattern of onset, duration, severity, and relieving factors 2. unstable angina: - associated with worsening cardiac ischemia, occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time. - lasts longer than 15 minutes - pain may not be relieved by nitroglycerin 3. variant angina: - also called Prinzmetal's angina - results from coronary artery spasm - may occur at rest - attacks may be associated with ST segment elevation 4. intractable angina: - is a chronic, incapacitating angina that is unresponsive to interventions assessment: - pain that may develop slowly or quickly, may be mild or moderate, substernal, crushing, or squeezing pain may occur, pain may radiate to the shoulders, arm, jaw, neck, or back, pain intensity is unaffected by breathing, pain usually lasts less than 5 minutes, however it may last as long as 15-20 minutes, and it is relieved by nitroglycerin or rest - dyspnea - pallor - sweating - palpitations and tachycardia - dizziness and syncope - HTN - digestive disturbances diagnostic studies: 1. ECG: ST segment depression or T wave inversion during an episode of pain 2. stress testing: chest pain or changes in the ECG or vital signs during testing may indicate ischemia 3. Troponin and cardiac enzyme levels are normal during angina 4. cardiac catheterization: provides a definitive diagnosis by providing information about the patency of the coronary arteries interventions: 1. immediate management: - assess pain, institute pain relief measures - administer O2 by nasal cannula as prescribed - assess vitals and provide continuous cardiac monitoring and nitroglycerin as prescribed to dilate the coronary arteries, reduce the O2 requirements of the myocardium, and relieve chest pain - ensure that bed rest is maintained, place the client in semi-fowler's position, and stay with the client - obtain a 12-lead ECG - establish IV access 2. following the acute episode: - assist the client to identify events that precipitate angina - instruct the client to stop activity and rest if the chest pain occurs, sit down and take nitroglycerin as prescribed; the client is usually instructed to call 911 if the nitroglycerin doesn't relieve the pain, and many PHCPs recommend that the client also chew on aspirin 3. meds: - anti-platelet therapy may be prescribed to inhibit platelet aggregation and reduce the risk of developing an acute MI

Codeine sulfate

- is an opioid analgesic - may also be used in low doses as a cough suppressant - may cause constipation - common drugs in this class are hydrocodone and oxycodone

African americans beliefs related to end-of life care

- discuss issues with their spouse or older family members - family is highly valued and is central to terminally ill members - open displays of emotion are common and accepted - may prefer to die at home

native americans beliefs related to end-of life care

- family meetings may be held to make decisions about end-of-life care and the types of treatments that should be pursued - some groups may avoid contact with the dying; may prefer to die in the hospital

Tuberculosis (TB)

- highly communicable disease caused by Mycobacterium tuberculosis - it primarily affects the respiratory system, especially in the upper lobes, where the O2 content is highest, but it can also affect other areas of the body, such as the brain, intestines, peritoneum, kidney, joints, and liver. - an exudative response causes a non-specific pneumonitis and the development of granulomas in the lung tissue - TB has a insidious onset, and many clients are not aware of the symptoms until the disease is well advanced. - improper or non-compliant use of treatment programs may cause the development of mutations in the tubercle bacilli, resulting in a multi-drug resistant strain of TB. - the goal of treatment is to prevent transmission, control symptoms, and prevent progression of the disease risk factors: - child younger than 5 years of age - drinking unpasteurized milk if the cow is infected with TB - homeless individuals or those from a lower socioeconomic class, minority group, or refugee group - individuals in constant, frequent contact with an untreated or undiagnosed individual - individuals living i crowded areas such as LTC facilities, prisons, and mental health facilities - older clients - individuals with malnutrition, infection, immune dysfunction, or HIV; or immunosuppressed as a result of medication therapy - individuals who abuse alcohol or are IVDA transmission: - is airborne or droplet - when infected people are detected, they are assessed with a TB skin test and chest X-rays to determine infection with TB - after the infected person has received TB meds for 2-3 weeks, the risk of transmission is reduced greatly disease progression: - droplets enter the lungs and the bacteria forms a tubercle lesion - the defense systems of the body encapsulate the tubercle, leaving a scar - if encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes, and cause an inflammatory response - primary lesions form; the primary lesions may become dormant but can be reactivated and become a secondary infection when re-exposed to the bacterium - in an active phase, TB can cause necrosis and cavitation of lesions (cavities), leading to rupture, the spread of necrotic tissue, and damage to various parts of the body client history: - ask about prior exposure of TB, their country of origin and travel to foreign countries in which the incidence of TB is high, recent history of the flu, pneumonia, febrile illness, cough, or foul-smelling sputum production, previous tests for TB and their results, recent bacillus Calmette-Guerin (BCG) vaccine which is given to people who are coming from or traveling to foreign countries to increase their resistance to TB ** an individual who has received a BCG vaccine will have a + TB skin test result and should be evaluated for TB with a chest X-ray ** clinical manifestations: 1. may be asymptomatic during primary infection 2. fatigue 3. lethargy 4. weight loss 5. anorexia 6. low-grade fever 7. chills 8. night sweats 9. persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood 10. chest tightness and a dull, aching chest pain may accompany the cough - chest assessment: in advanced disease dullness with percussion over involved parenchymal areas, bronchial breath sounds, rhonchi, and crackles indicate advanced disease. Partial obstruction of a bronchus caused by endobronchial disease or compression by lymph nodes may produce localized wheezing and dyspnea. - a blood test by an enzyme-linked immunosorbent assay assists in diagnosing the infection. - sputum cultures: are obtained to confirm the infection and then after meds are started are used to determine the effectiveness of therapy. most clients have negative cultures after 3 months of treatment. - Tuberculin skin test (TST): a positive reaction does not mean that active disease is present but indicates pervious exposure to TB or the presence of an inactive disease. once the test result is +, it will be positive in all future tests. - skin test interpretation depends on the measurement of the induration in millimeters and the person's risk of being infected with TB and their progression of the disease if infected. - once their skin test is +, a chest X-ray is needed to rule out active TB or to detect old healed lesions. the hospitalized client: - the client with active TB is placed under airborne isolation precautions in a negative-pressure room; to maintain negative-pressure, the door of the room must be tightly closed. - the room should have 6 exchanges of fresh air per hour and should be ventilated to the outside environment, if possible - the nurse wears a particulate respirator when caring for the client and a gown when the possibility of clothing contamination exists. - thorough hand washing is required before and after caring for the client. - if the client needs to leave the room for a test or procedure the client is required to wear a surgical mask. - respiratory isolation is discontinued when the client is no longer considered infectious - after the infected individual has received TB medications for 2-3 weeks, the risk of transmission is reduced greatly. client education: - provide the client and family with info about TB and allay concerns about the contagious aspect of the infection - instruct the client to follow the med regimen exactly as prescribed and to always have a supply of the med on hand - advise the client that the med regimen is continued up to 12 months depending on the situation - advise the client of the adverse effects of the med and ways of minimizing them to ensure compliance - reassure the client that after 2-3 weeks of med regimen, it is unlikely the client will infect anyone - advise the client to resume activities gradually - instruct the client about the need for adequate nutrition and a well-balanced diet (foods rich in iron, protein, vitamin C) to promote healing and prevent recurrence of the infection - inform the client and family that respiratory isolation is not needed because family members have already been exposed - instruct the client to cover the mouth and nose when coughing or sneezing and to place tissues in plastic bags - instruct the client and family about hand washing - inform the client that a sputum culture is needed every 2-4 weeks once med therapy is started - inform the client that when the results of 3 sputum cultures is negative, the client is no longer considered infectious and usually can return to former employment - advise the client to avoid excessive exposure to silicone or dust because these substances can cause further lung damage - instruct the client regarding the importance of compliance with treatment, follow-up care, and sputum cultures as prescribed

newborn hypothyroidism

- is a decrease in the production of thyroid hormone assessment: - protruding or thick tongue - dull look, swollen face - decreased muscle tone - lab tests reveal low thyroid production interventions: - focus on thyroid replacement

Coronary artery disease

- is a narrowing or obstruction of 1 or more coronary arteries as a result of atherosclerosis, which is an accumulation of lipid-containing plaque in the arteries - the disease causes decreases perfusion of myocardial tissue and inadequate myocardial O2 supply, leading to HTN, angina, dysrhythmias, MI, HF, and death - collateral circulation, more than 1 artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older people - the development of collateral circulation takes time and develops when chronic ischemia occurs 1to meet metabolic demands; therefore, an occlusion of a coronary artery in a younger person is more likely to be lethal than one in an older person - symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia - coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75% - the goal of treatment is to alter the atherosclerotic progression assessment: - possibly asymptomatic periods with normal findings - chest pain - palpitations - dyspnea - syncope - cough or hemoptysis - excessive fatigue diagnostic studies: - ECG: shows ST segment depression, T wave inversion, or both; the ST segment returns to normal when blood flow returns - with infarction, cell injury results in ST segment elevation, followed by T wave inversion and an abnormal Q wave - cardiac catheterization: shows the presence of atherosclerotic lesions - blood lipid levels: may be elevated, cholesterol-lowering meds may be prescribed to reduce the development of atherosclerotic plaques interventions: 1. assist the client to identify risk factors that can be modified and to set goals to promote lifestyle changes to reduce the impact of risk factors 2. assist the client to identify barriers to adherence with the therapeutic regimen and to identify methods to overcome barriers 3. instruct the client regarding a low-calorie, low-sodium, low-cholesterol, and low-fat diet, with an increase in dietary fiber - stress that dietary changes should be incorporated for the rest of the client's life; instruct the client regarding prescribed medications - provide community resources to the client regarding exercise, smoking cessation, and stress reduction as appropriate surgical procedures: - PTCA to compress the plaque against the walls of the artery and dilate the vessel - laser angioplasty to vaporize the plaque - atherectomy to remove the plaque from the artery - vascular stent to prevent the artery from closing ad to prevent re-stenosis - coronary artery bypass grafting past the occluded artery to improve blood flow to the myocardial tissue at risk for ischemia and infarction medications: - nitrates to dilate the coronary articles and decrease preload and afterload - calcium channel blockers to dilate coronary arteries and reduce vasospasm - cholesterol-lowering meds to reduce the development of atherosclerotic plague - beta blockers to reduce the BP in individuals who are hyperactive

Aortic aneurysms

- is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of the aorta. - the goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture. - types of aortic aneurysms: 1. Fusiform: diffuse dilation that involves the entire circumference of the arterial segment 2. Saccular: distant localized outpouching of the artery wall 3. Dissecting: when the blood separates the layers of the artery wall, forming a cavity between them 4. False (pseudoaneurysm): occurs when the clot and connective tissue are outside the arterial wall as a result of vessel injury or trauma to all 3 layers of the arterial wall assessment depends on location: - thoracic aneurysm: - pain extending to the neck, shoulder, lower back, or abdomen; syncope; dyspnea; increased pulse; cyanosis; hoarseness, difficulty swallowing because of pressure from the aneurysm - abdominal aneurysm: - prominent, pulsating mass in the abdomen, at or above the umbilicus; systolic bruit over the aorta; tenderness on deep palpation; and abdominal or lower back pain - rupturing aneurysm: - severe abdominal or lower back pain, lumbar pain radiating to the flank and groin, hypotension, increased pulse rate, signs of shock, and hematoma at flank area diagnostic tests: - are done to confirm the presence, size, and location of the aneurysm - tests include abdominal ultrasound, CT scan, and arteriography interventions: 1. monitor vitals 2. obtain information regarding back or abdominal pain 3. question the client regarding the sensation of pulsation in the abdomen 4. check peripheral circulation, including pulses, temp, and color 5. observe for signs of rupture 6. note any tenderness over the abdomen 7. monitor for abdominal distention non-surgical interventions: 1. modify risk factors 2. instruct the client regarding the procedure for monitoring BP 3. instruct the client on the importance of regular PHCP visits to follow the size of the aneurysm 4. instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilical area, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs, to notify the PHCP ** instruct the client with an aortic aneurysm to report immediately to the PHCP the occurrence of chest or back pain, SOB, difficulty swallowing, or hoarseness** pharmacological interventions: 1. administer anti-hypertensives to maintain the BP within normal limits and prevent the strain on the aneurysm 2. instruct the client about the purpose of the meds 3. instruct the client about the side effects and schedule of the meds abdominal aortic aneurysm resection: - is surgical resection or excision of the aneurysm, the excised section is replaced with a graft that is sewn end to end. - pre-op interventions: 1. assess all peripheral pulses as a baseline for post-op comparison 2. instruct the client in coughing and deep breathing - post-op interventions: 1. monitor vitals 2. monitor peripheral pulses distal to the graft site 3. monitor for signs of graft occlusion, including changes in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention. 4. limit elevation of the HOB to 45 degrees to prevent flexion of the graft 5. monitor for hypovolemia and kidney failure resulting from significant blood loss during surgery 6. monitor urine output hourly and notify the PHCP if it is lower than 30 ml/hour 7. monitor serum creatinine and BUN daily 8. monitor respiratory status and auscultate breath sounds 9. encourage turning, coughing and deep breathing, and splinting the incision 10. ambulate as prescribed 11. prepare the client for discharge by providing instructions regarding pain management, wound care, and activity restrictions 12. instruct the client not to lift heavy objects for 12 weeks 13. avoid activities requiring pushing, pulling, or straining 14. instruct the client not to drive until approved by the PHCP 15. endovascular aneurysm grafting involves insertion of a graft using a vascular catheter; it does not require an abdominal incision. thoracic aneurysm repair: - a thoractomy or median sternotomy approach is used to enter the thoracic cavity - the aneurysm is exposed and excised, and a graft or prothesis is sewn onto the aorta - total cardiopulmonary bypass is necessary to excision of aneurysms in the ascending aorta - partial cardiopulmonary bypass is used for clients with an aneurysm in the descending aorta - post-op interventions: 1. monitor vitals and neurological and renal status 2. monitor for signs of hemorrhage, like a drop in BP and increased HR and RR, and report them to the PHCP immediately 3. monitor chest tubes for an increase in the chest drainage, which may indicate bleeding or separation of the graft site 4. assess sensation and motion of all extremities and notify the PHCP if deficits are noted, which can occur because of a lack of blood supply to the spinal cord during surgery 5. monitor respiratory status and auscultate breath sounds 6. encourage turning, coughing and deep breathing while splinting the incision 7. prepare the client fir discharge by providing instructions about pain management, wound care, and activity restrictions 8. instruct the client not to lift objects heavier than 15 to 20 pounds for 6-12 weeks 9. advise the client to avoid activities requiring pushing, pulling, or straining 10. instruct the client not to drive until approved by the PHCP

Pressure injury

- is an impairment of skin integrity - a tissue compression restricts blood flow to the skin, which can result in tissue ischemia, inflammation, and necrosis; once a pressure injury forms, it is difficult to heal. - prevention of skin breakdown in any part of the client's body is a major role for the nurse - risk factors are skin pressure, skin shearing and friction, immobility, malnutrition, incontinence, and decreased sensory perception. assessment and staging: 1. stage 1: skin is intact, area is red and does not blanch with external pressure, area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue 2. stage 2: skin is not intact, partial-thickness skin loss of the dermis occurs, presents as a shallow open ulceration with a red-pink wound bed or as an intact open-ruptured serum-filled blister 3. stage 3: full-thickness skin loss extends into the dermis and subcutaneous tissues, and slough may be present. Subcutaneous tissue may be visible, and undermining and tunneling may or may not be present. 4. stage 4: full-thickness skin loss is present with exposed bone, tendon, or muscle. slough or eschar may be present, and undermining or tunneling may be present interventions: ** avoid direct massage to a reddened skin area, because massage can damage the capillary beds and cause tissue necrosis ** 1. identify clients at risk for developing a pressure injury 2. institute measures to prevent pressure injury, like appropriate positioning, using pressure relief devices, ensuring adequate nutrition, and developing a plan for skin cleansing and care 3. perform frequent skin assessments and monitor for an alteration in skin integrity 4. keep the client's skin dry and the sheets wrinkle-free; if the client is incontinent, then check them frequently and change pads or any items placed under them immediately after they're soiled 5. use creams and lotions to lubricate the skin and a barrier protection ointment for the incontinent client 6. turn and reposition the immobile client every 2 hours or more frequently if needed, provide active and passive ROM exercises at least every 8 hours 7. if a pressure injury is present, record the location and size of the wound (length, width, and depth in cm), monitor and record the type and amount of exudates and a culture may be prescribed, and assess for undermining and tunneling. depending on agency policy, it may be required to have picture documentation on file of a pressure injury or other disruption in skin integrity that may include a client identifier, measuring device, and a label indicating wound laterality and location. if a wound or other skin problem is noted, it may be necessary to request a referral to a wound care and / or a nutrition specialist. 8. serosanguinous exudate may be noted; purulent exudates indicate colonization of the wound with bacteria. 9. use agency protocols for skin assessment and management of a wound 10. treatment may include wound dressings and debridement, and skin grafting may be necessary. 11. other treatments may include electrical stimulation to the wound area which increases blood vessel growth and stimulates granulation; vacuum-assisted wound closure which removes infectious material from the wound and promotes granulation; hyperbaric O2 therapy because administration of O2 under high pressure raises tissue O2 concentration; and the use of topical growth factors which stimulate cell growth.

Pediatric cardiovascular problems: heart failure

- is an inability of the heart to pump a sufficient amount of blood to meet the metabolic and O2 needs of the body - in infants and young ids, inadequate caloric output most often is caused by congenital heart defects that produce an excessive volume or pressure load on the myocardium. - a combination of left-sided and right-sided HF is usually present - the goals of treatment are to improve cardiac function, remove accumulated fluid and sodium, decrease caloric demands, improve tissue O2 and decrease O2 consumption, and depending on the cause surgery may be required. assessment: - early signs are tachycardia, especially during rest and slight exertion - tachypnea - profuse scalp diaphoresis, especially in infants - fatigue and irritability - sudden weight gain - respiratory distress - signs of left-sided HF: crackles and wheezes, cough, dyspnea, grunting in infants, head bobbing in infants, nasal flaring, orthopnea, periods of cyanosis, retractions, and tachypnea - signs of right-sided HF: ascites, hepatosplenomegaly, jugular vein distention, oliguria, peripheral edema (especially dependent edema and periorbital edema), and weight gain interventions: 1. monitor for early signs of HF 2. monitor for respiratory distress 3. monitor apical pulse and for dysrhythmias 4. monitor for hyperthermia and for other signs of infection 5. monitor strict I&O, weigh diapers for most accurate output 6. monitor daily weight and assess for fluid retention, a weight gain of 1 pound in one day is caused by accumulation of fluid 7. monitor for edema, auscultate lung sounds, and report abnormal findings to the provider 8. elevate the head of the bed in semi-fowler's position 9. maintain a neutral thermal environment to prevent cold stress in infants 10. provide rest and decreased environmental stimuli 11. administer cool humidified O2 as prescribed, using an O2 hod fr young infants and a nasal cannula or face mask for older infants and children 12. organize nursing activities to allow for un-interrupted sleep 13. maintain adequate nutritional status 14. feed when hungry and soon after awakening, conserving energy and O2 supply 15. provide small, frequent feedings 16. administer meds as prescribed which may include digoxin, diuretics, and afterload reducers such as ACE-inhibitors 17. administer digoxin as prescribed: assess apical hr before administration, withhold digoxin if the apical rate is less than 90-110beats per minute in infants and young children and less than 70 beats per minute in older children, and check the prescribed dose carefully to ensure it is safe and age-appropriate 18. monitor digoxin levels and for signs of digoxin toxicity, such as anorexia, poor feeding, nausea, vomiting, bradycardia, and dysrhythmias 19. the optimal therapeutic digoxin level range is 0.8-2, toxicity is usually seen at levels >2. 20. administer ACE inhibitors as prescribed: monitor for hypotension, renal dysfunction, and cough when they are administered, assess BP, serum protein, albumin, BUN, creatinine, WBCs, urine output, urine specific gravity, and urinary protein level 21. administer diuretics such as furosemide as prescribed: monitor for signs and symptoms of hypokalemia (K+ level <3.5), including muscle weakness and cramping, confusion, irritability, restlessness, and inverted T waves or prominent U waves on an ECG. if signs and symptoms are present and the child is also being given digoxin, monitor closely for digoxin toxicity, because hypokalemia potentiates digoxin toxicity 22. administer K+ supplements and provide dietary sources of K+ as prescribed. supplemental K+ should be given only if indicated by serum K+ levels and if the patient has adequate renal function. encourage foods that the child will eat that are high in K+ like bananas, baked potato skins, and peanut butter. 23. monitor serum electrolyte levels, especially the K+ level 24. limit fluid intake in the acute stage 25. monitor for dehydration 26. monitor Na+ levels as prescribed, normal levels are 135-145. many infant formulas have higher sodium that breast milk. 27. instruct the parent about administration of digoxin: - administer as prescribed - use an accurate measuring device as provided by the pharmacist - administer 1 hour before or 2 hours after feedings - use a calendar to mark off the dose administered - do not mix meds with food or fluids - if a dose is missed and more than 4 hours have gone by, withhold the dose and give the next dose as scheduled. if less than 4 hours have gone by, administer the missed dose - if the child vomits, do not administer a second dose - if more than 2 consecutive doses have been missed, called the pediatrician - if the child has teeth, give water after the med and brush teeth - monitor for signs of toxicity - notify the Dr. if the child becomes ill - keep the med locked away - call the poison control center if accidental toxicity occurs 28. instruct the parents in CPR.

Breast cancer

- is classified as invasive when it penetrates the tissues surrounding the mammary duct and grows in an irregular pattern - metastasis occurs by the lymph nodes - common sites of metastasis are bone and lungs and may also go to the brain and liver. - diagnosis is made by breast biopsy through a needle aspiration or by surgical removal of the tumor with microscopic examination for malignant cells - risk factors: age, family history of breast cancer, early menarche and late menopause, previous breast cancer or uterine or ovarian cancer, nulliparity or late first birth, obesity, or high-dose radiation exposure to the chest. assessment: - mass felt during self-examination of the breast - presence of the lesion on a mammogram - a fixed, irregular, non-encapsulated mass that is typically painless in the early stages - asymmetry - bloody or clear nipple discharge - nipple retraction or elevation - skin dimpling, retraction, or ulceration - skin edema or orange-tint - axillary lymphadeopathy - lymphedema of the affected arm - symptoms of bone or lung metastasis in late stage - early detection is with performing regular breast self-exams. perform them 7-10 days after period. - non-surgical interventions: 1. chemo 2. radiation 3. hormonal manipulation using meds in post-menopausal women or other meds for estrogen receptor-positive tumors 4. monoclonal antibodies (trastuzumab) for human epidermal growth factor receptor 2 + breast cancer - surgical interventions are lumpectomy, simple mastectomy, or modified radial mastectomy - post-op interventions: 1. monitor vitals 2. position the client in semi-fowlers, turn from the back to the unaffected side, with the arm elevated above the level of the heart to promote drainage and prevent edema 3. encourage coughing and deep breathing 4. if a jackson-pratt drain is used, maintain suction and record the amount of drainage and drainage characteristics; teach the client about home management of the drain 5. assess the operative site for infection, swelling, or the presence of fluid collection under the skin flaps or in the arm 6. monitor the incision site for restriction of the dressing, impaired sensation, or color changes of the skin 7. if breast reconstruction was performed, the client will return from surgery usually with a surgical brassiere and a prosthesis in place 8. use a pressure sleeve as prescribed if edema is severe 9. maintain fluid and electrolyte balance, administer diuretics and provide a low-salt diet as prescribed for severe lymphedema 10. consult with the PHCP and physical therapist regarding an appropriate exercise program, and assist the client with the prescribed exercise program 11. instruct the client about home care measures following a mastectomy: - avoid overuse of the arm during the first few months - to prevent lymphedema, keep the affected arm elevated - provide incision care with an emollient as prescribed to soften and prevent wound contracture - encourage support groups - encourage the client to perform breast self-exams on the remaining breast and surgical site once healed - protect the affected hand and arm - avoid strong sunlight on the affected arm - do not let the affected arm hand dependent - do not carry anything heavy on the affected arm - avoid trauma, cuts, bruises, or burns to the affected side - avoid wearing constricting clothing or jewelry on the affected side - wear gloves when gardening - use thick over mitts when cooking - use a thimble when sewing - apply hand cream several times a day - use a cream cuticle remover - call the PHCP if signs of inflammation occur in the affected arm - wear a medic-alert bracelet stating which arm is at risk for lymphedema

Glycosylated hemoglobin (HgbA1C)

- is the blood glucose bound to Hg - reflects how well blood glucose levels have been for the past 3-4 months - fasting is not required for the test - normal: less than 6% - elevated levels may be due to: nondiabetic hyperglycemia, poorly controlled diabetes - below normal veles may be caused by: chronic blood loss, chronic kidney disease, pregnancy, or sickle cell anemia

Rhonchi

- low-pitched, coarse, loud, slow snoring or moaning tone. actually sounds like snoring. heard mostly during expiration, coughing may clear it. - heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis.

bulk-forming laxatives

- methylcellulose - polycarbophil - psyllium - absorb water into the feces and increase bulk to produce large and soft stools - contraindicated in bowel obstruction - dependency can occur with long-term use - adverse effects include GI disturbances, dehydration, and electrolyte imbalances

Cervical cancer

- metastasis usually is confined to the pelvis, but distant metastasis occurs through lymphatic spread. - risk factors include HPV infection, cigarette smoking, reproductive behavior including having sex before 17 years old, multiple sex partners, or male partners who have multiple sex partners - screening is with regular gynecological exams and Pap test, with treatment of precancerous abnormalities, decreases the incidence and mortality of cervical cancer. assessment: - painless vaginal postmenstrual and postcoital bleeding - foul-smelling or serosanguineous vaginal discharge - pelvic, lower back, leg, or groin pain - anorexia and weight loss - leakage of urine and feces from the vagina - dysuria - hematuria - cytological changes on Pap test interventions: 1. non-surgical = chemotherapy, cryosurgery, external radiation, internal radiation implants, or laser therapy 2. surgical = conization, hysterectomy, or pelvic exenteration laser therapy: - is used when all boundaries of the lesion are visible during colposcopic examination - energy from the beam is absorbed by fluid in the tissues, causing them to vaporize - minimal bleeding is associated with the procedure - slight vaginal discharge is expected following the procedure, and healing occurs in 6-12 weeks cryosurgery: - involved freezing of the tissues, using a probe, with subsequent necrosis and sloughing - no anesthesia is needed although cramping may occur during the procedure - a heavy watery discharge will occur for several weeks following the procedure - instruct the client to avoid intercourse and the use of tampons while the discharge is present conization: - a cone-shaped area of the cervix is removed - it allows the women to retain reproductive capability - long-term follow-up care is needed because new lesions can develop - the risks of the procedure include hemorrhage, uterine perforation, incompetent cervix, cervical stenosis, and preterm labor in future pregnancies hysterectomy: - is performed for micro-invasive cancer if children are not desired - a vaginal approach is most commonly used - a radial hysterectomy and bilateral lymph node dissection may be performed for cancer that has spread beyond the cervix but not to the pelvic wall - post-op interventions: 1. monitor vitals 2. assist with coughing and deep-breathing exercises 3. assist with ROM exercises and provide early ambulation 4. apply anti-embolism stockings or sequential compression devices as prescribed 5. monitor I&O, urinary catheter drainage, and hydration status 6. monitor bowel sounds 7. assess the incision site for signs of infection 8. administer pain meds as prescribed 9. instruct the client to limit stair climbing for 1 month as prescribed and to avoid sitting in tub baths or for long periods of time 10. avoid strenuous activity or heavy lifting 11. consume foods that promote tissue healing 12. avoid intercourse for 3-6 weeks as prescribed 13. instruct the client in signs associated with complications pelvic exenteration: - is the removal of all pelvic contents including the bowel, vagina, and bladder, is a surgical procedure performed for recurrent cancer is there is no evidence of metastasis outside the pelvis and no lymph node involvement - when the bladder is removed, an ileal conduit is created and located on the right side of the abdomen to divert urine - a colostomy may need to be created on the left side of the abdomen for the passage of feces - post-op interventions: 1. monitor for signs of altered respiratory status 2. monitor incision site for infection 3. monitor I&O and for signs of dehydration 4. monitor for hemorrhage, shock, and for signs of deep vein thrombosis 5. apply anti-embolism stockings or sequential compression devices as prescribed 6. administer prophylactic heparin as prescribed 7. administer perineal irrigations and sitz baths as prescribed 8. instruct the client to avoid strenuous activity for 6 months 9. instruct the client that the perineal opening, if present, may drain for several months 10. instruct the client in the care of the ileal conduit and colostomy, if created 11. provide sexual counseling, because vaginal intercourse is not possible after anterior and total pelvic exenteration

Pediatric oncological problems: leukemia

- proliferating immature WBCs depress the bone marrow, causing anemia from decreased RBCs, infection from neutropenia, and bleeding from thrombocytopenia (decreased platelets) - risk factors include genetic, viral, immunological, and environmental factors and exposure to radiation, chemicals, and meds. - acute lymphocytic leukemia (ALL) is most common in children - is more common in males - treatment involves chemo, possibly radiation, and possibly hematopoietic stem cell transplantation assessment: - fever, pallor, fatigue, anorexia, hemorrhage, bone and joint pain, and pathological fractures are caused by the infiltration of bone marrow by malignant cells. - signs of infection due to neutropenia - hepatosplenomegaly and lymphadenopathy - the child may have normal, elevated, or low WBCs - decreased Hg and Hct levels - decreased platelets - positive bone marrow biopsy specimen identifies immature WBCs - signs of IICP results from CNS involvement - signs of cranial or spinal nerve involvement - manifestations indicate the invasion of leukemic cells into the kidneys, testes, prostate, ovaries, GI tract, or lungs - most common sites for infection are the skin, respiratory tract, and GI tract - platelet transfusions are usually reserved for acute bleeding episodes that do not respond to local treatment and may occur during chemo - packed RBCs may be used for children with severe blood loss - assist the parents and children in selecting a well-balanced diet - provide small meals that require little chewing and are not irritating to the oral mucosa - assist the child in self-care and mobility activities - allow adequate rest periods during care - do not perform nursing activities unless they are essential - monitor for severe bone marrow suppression, blood cell counts are very low - monitor for infection and bleeding - protect the child from life-threatening infections - monitor for nausea, vomiting, and alteration in bowel function - administer stool softeners as prescribed to avoid straining if constipation occurs - provide gentle rectal hygiene if needed - administer antiemetics before chemo as prescribed - monitor for signs of dehydration, hemorrhagic cystitis, and peripheral neuropathy - assess oral mucous membranes for mucositis, administer frequent mouth rinses per agency policy to promote healing or prevent infection - instruct the parents and child in the signs and symptoms to watch after chemo and when to notify the PHCP - inform them hair loss may occur from chemo and will regrow in 3-6 months - instruct them about the care for a central venous access device as indicated - listen to the child and family and encourage them to verbalize their feelings and express their concerns - introduce the family to other families of children with cancer if appropriate - consult social services and chaplains as needed - monitor a child receiving chemo closely for signs of infection

Hinduism beliefs related to end-of life care

- rituals include tying a thread around the neck or wrist of the dying person, sprinkling them with sparkling water, and placing a basil leaf of their tongue - after death, the sacred threats are not removed and the body is not washed - some prefer cremation and desire to cast their ashes into the holy river

Pacemakers

- temporary or permanent device that provides electrical stimulation and maintains the HR when the client's intrinsic pacemaker fails to provide an adequate rate 1. a synchronous (demand) pacemaker senses the client's rhythm and paces only if the client's intrinsic rate falls below the set pacemaker rate for stimulating deplarization 2. an asynchronous (fixed rate) pacemaker: paces at a preset rate regardless of the client's intrinsic rhythm and is used when the client is asystolic or very bradycardic 3. overdrive pacing: suppresses the underlying rhythm in tachydysrhythmias so that the sinus node will regain control of the heart spikes: - when a pacing stimulus is delivered to the heart, a spike (straight vertical line) is seen on the monitor or ECG strip - spikes precede the chamber being paced; a spike preceding a P wave indicates that the atrium is paced, and a spike preceding the QRS complex indicates the ventricle is being paced - an atrial spike followed by a P wave indicates atrial depolarization, and a ventricular spike followed by a QRS complex represents ventricular depolarization, this is called a capture temporary pacemakers: 1. noninvasive transcutaneous pacing: - is used as a temporary emergency measure in the very bradycardic or asystolic client until invasive pacemaking can be initiated - large electrode pads are placed on the client's chest and back and are connected to an external pulse generator - wash the skin with soap and water before applying electrodes - it's not necessary to shave the hair or apply alcohol to the skin - place the posterior electrode between the spine and left scapula behind the heart, avoiding placement over bone - place the anterior electrode between V2 and V5 positions over the heart; do not place the anterior electrode over female breast tissue, displace the breast tissue and place the pad under the breast - do not take the pulse or BP on the left side, the results will not be accurate because of the muscle twitching and electrical current - ensure the electrodes are in good contact with the skin - set the pacing rate as prescribed, establish stimulation threshold to ensure capture - if loss of capture occurs, assess the skin contact of the electrodes and increase the current until capture is regained - evaluate the client for discomfort from cutaneous and muscle stimulation, and administer analgesics as needed 2. invasine transvenous pacing: - pacing lead wire is placed through antecubital, femoral, jugular, or subclavian vein into the right atrium or ventricle to it's in direct contact with the endocardium - monitor the pacemaker insertion site - restrict client movement to prevent lead wire displacement 3. invasine epicardial pacing: - applied by using a transthoracic approach; the lead wires are threaded loosely on the epicardial surface of the heart after cardiac surgery 4. reducing the risk of microshock: - use only inspected and approved equipment - insulate the exposed part of wires with plastic or rubber materials (fingers of rubber gloves) when wires are not attached to the pulse generator, cover with non-conductive tape - ground all electrical equipment, using a 3-pronged plug - wear gloves when handling exposed wires - keep dressings dry ** vitals are monitored and cardiac monitoring is done continuously for the client with a temporary pacemaker** 5. permanent pacemakers: - pulse generator is internal and surgically implanted in a sub Q pocket below the clavicle - the leads are passed transvenously by the cephalic or subclavian vein to the endocardium on the right side of the heart; postoperatively, limitation of arm movement on the operative side is required to prevent lead wire dislodgement - permanent pacemakers may be single-chambered, in which the lead wire is placed in the chamber to be paced, or dual-chambered in which the lead wires are placed in both the right atrium and the right ventricle - biventricular pacing of the ventricles allows for synchronized depolarization and is used for moderate to severe HF to improve CO - a permanent pacemaker is programmed when inserted and can be reprogrammed if needed by non-invasive transmission by an external programmer to the implanted generator - pacemakers can be powered by a lithium battery with an average life span of 10 years, nuclear powered with a life span of 20 years or more, or designed to be recharged externally - pacemaker function can be checked in the PHCP's office or clinic by a pacemaker interrogator or programmer or from home, using a special phone transmitter device - the client may be provided with a device placed over the pacemaker battery generator with an attachment to the phone, the heart rate then can be transmitted to the clinic client teaching for pacemakers: - instruct the client about the pacemaker, including the programmed rate - instruct the client in the signs of battery failure and when to notify the PHCP or cardiologist - instruct the client to report any fever, redness, swelling, or drainage from the insertion site - report signs of dizziness, weakness or fatigue, swelling of the ankles or legs, chest pain, or SOB - keep a pacemaker identification card in the wallet and wear a medic-alert bracelet - instruct the client on how to check their pulse, to take their pulse daily, and to maintain a diary of pulse rates - wear loose-fitting clothing over the pulse generator site - avoid contact sports - inform all PHCps that a pacemaker has been inserted - instruct the client to inform airport security that they have a pacemaker, because it may set off the security detector - instruct the client that most electrical appliances can be used without any interference with the functioning of the pacemaker; however, advise the client not to operate electrical appliances directly over the pacemaker site - avoid transmitter towers and anti-theft devices in stores - instruct the client that if any unusual feelings occur when near any electrical devices, to move 5-10 feet away and check the pulse - instruct the client about the methods of monitoring the function of the deice - emphasize the importance of follow-up with the PHCP - use cellphones on the opposite side of the pacemaker

Steps to prevent injury to the healthcare worker when moving a client

- use available safety equipment - keep weight close to your body - bend at the knees - tighten abs and tuck in the pelvis - maintain the trunk erect and knees bent so that multiple muscle groups work together in a coordinated manner

Bladder cancer

- undergoes malignant changes and may infiltrate the bladder wall - predisposing factors include cigarette smoking, exposure to industrial chemicals, and exposure to radiation - the bone, liver and lungs are common sites for metastasis - as the tumor grows it can extend into the rectum, vagina, and other pelvis soft tissues and retroperitoneal structures assessment: - painless hematuria is most common sign - frequency, urgency, dysuria - clot-induced obstruction - bladder wash specimens and biopsy confirm diagnosis - radiation: indicated for advanced disease that cannot be eradicated by surgery, to relieve pain, to decrease bowel obstruction and control potential hemorrhage and leg edema - intracavity radiation protects adjacent tissue - external beam radiation used with chemo increases survival - complications of radiation include abacterial cystitis, proctitis, fistula formation, Ileitis or colitis, and bladder ulceration and hemorrhage. - surgical interventions include 1. transurethral resection (TUR) of bladder tumor: is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. During TUR surgery, a cystoscope is passed into the bladder through the urethra. A tool called a resectoscope is used to remove the cancer for biopsy and to burn away any remaining cancer cells. 2. Partial cystectomy: is surgery to remove part of the bladder. in the post-op period, the capacity of the bladder is only 60 mL, then increases gradually to 200-400 mL. maintenance of a continuous output of urine following surgery is needed to prevent bladder distention and stress on the suture line. A urethral catheter and a suprapubic catheter may be left in place for 2 weeks until it's healed. 3. cystectomy and urinary diversion: Cystectomy is a surgery to remove the urinary bladder. The surgeon also needs to create a urinary diversion; a new way to store urine and have it leave your body. 4. Ileal conduit: is a system of urinary drainage which a surgeon creates using the small intestine after removing the bladder. To do this, the surgeon takes a short segment of the small intestine and places it at an opening he has made on the surface of the abdomen to create a mouth, or stoma. complications include obstruction, pyelonephritis, leakage at the anastomosis site, stenosis, hydronephrosis, calculi, skin irritation and ulceration, and stromal defects. 5. Kock pouch: is a continent pouch formed by the terminal ileum after colectomy. post-op, the client has a urinary catheter in place to drain urine continuously until the pouch has healed. it is irrigated gently with normal saline to prevent obstruction and after removal of the urinary catheter, the client is instructed in how to self-catheterize and to drain the reservoir at 4-6 hour intervals. 6. Indiana pouch: is a surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed. 7. creation of a neobladder: your surgeon takes out your existing bladder and forms an internal pouch from part of your intestine. The pouch, called a neobladder, stores your urine. the client empties the neobladder by relaxing the external sphincter and creating abdominal pressure, or by using intermittent self-catheterization 8. percutaneous nephrostomy or pyelostomy: Pyelostomy is a rarely performed procedure in which an externalized catheter drains the renal pelvis. A percutaneous nephrostomy is the placement of a small, flexible rubber tube (catheter) through your skin into your kidney to drain your urine. It is inserted through your back or flank. nursing interventions are stabilizing the tube to prevent dislodgment and monitoring output 9. ureterostomy: is the creation of a stoma (a new, artificial outlet) for a ureter or kidney. The procedure is performed to divert the flow of urine away from the bladder when the bladder is not functioning or has been removed. potential problems are infection, skin irritation, and obstruction to urinary flow as a result of strictures at the opening 10. veiscostomy: the bladder is sutured to the abdomen, and the stoma is created in the bladder wall. the bladder empties through the stoma.

Medication inhalation devices

1. metered dose inhaler: uses a chemical propellant to push the med out of the inhaler 2. dry-powder inhaler: delivers med without using chemical propellants, but it requires strong and fast inhalation 3. nebulizer: delivers fine liquid mists of med through a tube or a mask that fits over the nose and mouth, or without a mouthpiece, using air or oxygen under pressure 4. if 2 different inhaled meds are prescribed and 1 of the meds contains a glucocorticoid (corticosteroid), administer the bronchodilator first and then the corticosteroid second. ** if 2 different inhaled meds are prescribed, instruct the client to wait 5 mins after administration of the first med before inhaling the second. if a second dose of the same med is needed, tell the client to wait 1-2 minutes before taking the second dose**

Common post-operative complications and their interventions

1. Pneumonia and atelectasis - assess lung sounds - reposition the client every 1-2 hours - encourage the client to deep breathe, cough, and use the incentive spirometer as prescribed - provide chest physiotherapy and postural drainage as prescribed - encourage fluid intake and early ambulation - use suction to clear secretions if the client is unable to cough 2. hypoxemia - monitor for signs of hypoxemia - notify the surgeon - monitor pulse oximetry and lung sounds - administer O2 as prescribed - encourage deep breathing, coughing, and use of the spirometer - turn and reposition the client frequently and encourage ambulation 3. Pulmonary embolism - notify surgeon immediately because it is life threatening and requires emergency action - monitor vitals - administer O2, medications, and treatments as prescribed 4. hemorrhage - provide pressure to bleeding site - notify the surgeon - administer O2 as prescribed - administer IV fluids and blood as prescribed - prepare the client for a surgical procedure as necessary 5. shock - elevate the legs - notify the surgeon - determine and treat the cause of shock - administer O2 as prescribed - monitor LOC - monitor vitals for increased HR or decreased BP - monitor I&O - assess color, temp, turgor, and moisture of the skin and mucous membranes - administer IV fluids, blood, and colloid solutions as prescribed 6. thrombophlebitis - monitor legs for swelling, inflammation, pain, tenderness, venous distention, and cyanosis; notify the surgeon if any of these are present - elevate the extremities 30 degrees without putting pressure on the popliteal area - encourage the use of antiembolism stockings as prescribed, remove the stockings twice a day to wash and inspect the legs - use a sequential compression device as prescribed - perform passive ROM exercises q 2 hours if the patient is confined to bed rest - encourage early ambulation as prescribed - do not allow the client to dangle the legs - instruct the client not to sit in 1 position for an extended period of time - administer anticoagulants such as heparin sodium or enoxaparin as prescribed 7. Urinary retention - monitor for voiding - assess for a distended bladder by palpation and bladder scanning if indicated - encourage ambulation as prescribed - encourage fluid intake unless contraindicated - assist the client to void by helping them stand - provide privacy - pour warm water over the perineum or allow the client to hear running water to promote voiding - contact the surgeon and catheterize the client as prescribed after all noninvasive techniques have been attempted 8. Constipation - assess bowel sounds - encourage fluid intake up to 3000 mL/day - encourage early ambulation - encourage consumption of fiber foods - provide privacy and adequate time - administer stool softeners and laxatives as prescribed 9. paralytic ileus - monitor I&O - maintain NPO status until bowel sounds return - maintain patency of NG tube if in place and assess patency and drainage - encourage ambulation - administer IV fluids or parenteral nutrition as prescribed - administer meds as prescribed to increase GI motility and secretions

Pediatric cardiovascular problems: interventions for cardiovascular defects

1. monitor for signs of a defect in an infant or child 2. monitor vitals 3. monitor respiratory status for the presence of nasal flaring, the use of accessory muscles, and for signs of impending respiratory distress, and notify the pediatrician if any changes occur 4. auscultate breath sounds for crackles, rhonchi, and wheezes 5. if respiratory effort is increased, place the child in a reverse trendelenburg's position, elevating the head and upper body to decrease the work of breathing 6. administer humidified O2 as prescribed 7. provide endotracheal tube and ventilator care if needed and prescribed 8. monitor for hypercyanotic spells and intervene immediately if they occur 9. assess for signs of HF, such as periorbital edema or dependent edema in the hands or feet 10. assess peripheral pulses 11. maintain fluid restriction if prescribed 12. monitor I&O and notify the Dr. if a decrease in urine output occurs 13. obtain daily weight 14. provide adequate nutrition (high calorie requirements) as prescribed 15. administer meds as prescribed 16. administer meds as prescribed 17. plan interventions to allow maximum rest for the child, and keep the child as stress-free as possible 18. prepare the child and parents for cardiac catheterization if appropriate

Oncological emergencies

1. sepsis and DIC: - the client with cancer has an increased risk of infection and DIC which is associated with sepsis. - interventions: prevent the complication through early identification of the client at risk risk of sepsis and DIC, maintain strict aseptic technique and monitor closely for signs of infection and bleeding, administer antibiotics as prescribed, administer anticoagulants as prescribed during the early stages of DIC, administer cryoprecipitated clotting factors when DIC progresses and hemorrhage is the primary problem, 2. Syndrome of Inapproprite antidiuretic hormone (SIADH): - tumors produce secrete or stimulate substances that mimic ADH. symptoms are weakness, muscle cramps, loss of appetite, fatigue, and sodium levels can be 115-120. more serious symptoms are water intoxication and weight gain, personality changes, confusion, and extreme muscle weakness. as the sodium levels reach 110 the patient is at risk for seizures, come, and death. - interventions: initiate fluid restriction and increased sodium intake as prescribed, administer an antagonist to ADH as prescribed, monitor sodium levels, and treat the underlying cause with chemo or radiation to achieve tumor regression. 3. spinal cord compression: - can occur when a tumor directly enters the spinal cord or when the vertebral column collapses from tumor entry. it causes back pain, progressing to neurological deficits such as numbness, tingling, loss of urethral, vaginal, and rectal sensation, and muscle weakness. - interventions: assess for back pain and neurological deficits, administer high-dose corticosteroids to reduce swelling around the spinal cord and relieve symptoms, prepare the client for immediate radiation / chemo to reduce the size of the tumor and relieve compression, surgery may be needed to remove the tumor and relieve the pressure on the spinal cord, and instruct the client in the use of neck or back braces if they are prescribed. 4. Hypercalcemia: - is a late manifestation of extensive malignancy that occurs most often with bone metastasis, when the bone releases calcium into the blood stream. decreased physical mobility contributes to or worsens it. early signs are fatigue, anorexia, nausea, vomiting, constipation, and polyuria. severe signs and symptoms are severe muscle weakness, diminished deep tendon reflexes, paralytic ileus, dehydration, and changes in the ECG. - interventions: monitor serum calcium level and ECG changes, administer oral or parenteral fluid as prescribed, give meds that lower the calcium level and control nausea and vomiting as prescribed, prepare the client for dialysis if the condition becomes life-threatening or is accompanied by renal impairment, and encourage walking to prevent breakdown of the bone. 5. Superior vena cava syndrome: - occurs when the SVC is compressed or obstructed by tumor growth (commonly associated with lung cancer and lymphoma). signs and symptoms result from blockage of blood flow in the venous system of the head, neck, and upper trunk. early symptoms generally occur in the morning and include edema of the face, especially around the eyes, and tightness of the shirt or or blouse collar (Stokes' sign). as the condition worsens, edema in the arms and hands, erythema of the upper body, dyspnea, swelling of the veins in the chest and neck, and epistaxis occur. life-threatening signs and symptoms are airway obstruction, hemorrhage, cyanosis, mental status changes, decreased CO, and hypotension. - interventions: assess for early signs and symptoms of SVC, place the client in semi-fowler's position and give corticosteroids and diuretics as prescribed, prepare the client for high-dose radiation therapy to the mediastinal area and possible surgery to insert a metal stent in the vena cava. 6. Tumor lysis syndrome: - occurs when large quantities of tumor cells are destroyed rapidly and intracellular components are released into the blood faster than the body can eliminate them. it can indicate that cancer treatment is destroying tumor cells, however if left untreated, it can cause severe tissue damage and death. hyperkalemia, hyperphosphatemia with resulting hypocalcemia, and hyperuricemia occur, hyperuricemia can lead to acute kidney injury. - interventions: encourage oral hydration; IV fluids may be prescribed, monitor renal function and I&O, and ensure that the client is on a renal diet low in K+ and phosphorus. Administer diuretics to increase the urine flow through the kidneys as prescribed. administer meds that increase the excretion of purines (such as allopurinol) as prescribed. Prepare to give an IV infusion of glucose and insulin to treat hyperkalemia. Prepare the client for dialysis if hyperkalemia and hyperuricemia persist despite treatment.

Management of dysrhythmias

1. vagal maneuvers: - induce vagal stimulation of the cardiac conduction system and are used to terminate supraventricular tachydysrhythmias 2. carotid sinus massage: - the PHCP instructs the client to turn their head away from the side to be massaged - the PHCP massages over 1 carotid artery for a few seconds to determine if a change in cardiac rhythm occurs - the client must be on a cardiac monitor; an ECG rhythm strip before during and after the procedure - have a defibrillator and resuscitative equipment available - monitor vitals, cardiac rhythm, and LOC following the procedure 3. Valsava maneuver: - the PHCP instructs the client to bear down or induces a gag reflex in the client to stimulate a vagal response - monitor the HR, rhythm, and BP - observe the ECG for a change in rhythm - provide an emesis basin if a gag reflex is stimulated, and initiate precautions to prevent aspiration - have a defibrillator and resuscitative equipment available 4. cardioversion: - is synchronized countershock to convert an undesirable rhythm to a stable one - can be an elective procedure performed by the PHCP for stable tachydysrhythmias resistant to medical therapies or an emergent procedure for hemodynamically unstable ventricular or supraventricular tachydysrhythmias - uses less energy than defibrillation - the defibrillator is synchronized to the client's R wave to avoid discharging the shock during the vulnerable period (T wave) - if the defibrillator is not synchronized, it can discharge on the T wave and cause VF - pre-op interventions: 1. is it's an elective procedure, make sure you get informed consent signed 2. administer sedation as prescribed 3. if an elective procedure, hold digoxin for 48 hours before the procedure as prescribed to prevent postcardioversion ventricular irritability 4. if an elective procedure for atrial fibrillation or atrial flutter, the client should receive anticoagulant therapy for 4-6 weeks preprocedure, and a transesophageal echocardiogram (TEE) should be performed to rule out clots in the atria prior to the procedure - during the procedure: 1. ensure the skin is clean and dry in the area where the electrode pads/hands-off pads will be placed 2. stop the O2 during the procedure to avoid a fire hazard 3. be sure that no one is touching the bed or the client when delivering the counter-shock - post-procedure interventions: 1. priority assessment includes ability of the client to maintain O2 administration as prescribed 2. resume O2 administration as prescribed 3. assess vitals 4. assess LOC 5. monitor cardiac rhythm 6. monitor for indications of successful response, such as cardioversion to sinus rhythm, strong peripheral pulses, an adequate BP, and adequate urine output 7. assess the skin on the chest for evidence of burns from the edges of the pads 5. defibrillation: - used to terminate pulseless VT or VF - after a shock CPR is resumed immediately and continued for 5 cycles or 2 minutes - reassess the rhythm after 2 minutes, and if the VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level as previously used - resume CPR after the shock, and continue with the life support protocol ** before defibrillating the client, be sure that the O2 is shut off to avoid a fire and be sure no one is touching the client or bed** 6. use of pad electrodes: - one pad is placed at the 3rd intercostal space to the right of the sternum, the other is placed at the 5th intercostal space on the left midaxillary line - apply firm pressure of at least 25 lbs to each of the pads - be sure no one is touching the client or bed when delivering the shock - placement directly over breast tissue should be avoided 7. automated external defibrillator (AED): - is used for cardiac arrest that does not occur in the hospital - place the client on a firm dry surface - turn on the AED and follow the voice prompts - place the electrode patches in the correct positions on the client's chest - stop the CPR - ensure no one is touching the client to avoid motion artifact during rhythm analysis - the machine will advise whether a shock is needed - shocks are recommended for pulseless VT or VF inly (usually 3 shocks are delivered) - if unsuccessful, CPR is continued for 1 minute and then another series of shocks is delivered 8. automated implanted cardioverter-defibrillator (AICD): - monitors cardiac rhythm and detects and terminated episodes of VF or VT - the generator is most commonly implanted in the left pectoral region - instruct the client on the basic functions of the AICD - know the rate cutoff of the AICD and the # of consecutive shocks that it will deliver - wear loose-fitting clothing over the AICD generator site - instruct the client on activities to avoid, including contact sports, to prevent trauma to the generator and its wires - report any fever, redness, swelling, or drainage from the site - report symptoms of fainting, nausea, weakness, blackouts, and rapid pulse rates to the PHCP - during shock discharge the client may feel faint or SOB - instruct the client to sit or lie down is they feel a shock and to notify the PHCP - advise the client to maintain a log of the date, time, and activity preceding the shock; the symptoms preceding the shock, and post-shock sensations - instruct the client and family on how to access the emergency medical system - encourage the family to learn CPR - instruct the client on how to avoid electromagnetic fields directly over the AICD, because they can inactivate the device - instruct the client to move away from the magnetic field immediately if beeping tones are heard, and notify the PHCP - keep an AICD identification card in the wallet and wear a Medi-alert bracelet - inform all PHCPs that an AICD has bee inserted, certain diagnostic tests such as MRI an procedures using diathermy or electrocautery interfere with AICD function

normal FHR at term

110 - 160 beats per minute

ACE inhibitors and Angiotensin II receptor blockers

ACE inhibitors: "pril" remember APRIL ... Ace inhibitors end in PRIL! - benazepril - captopril - fosinopril - enalapril - lisinopril - moexipril - perindopril - quinapril - ramipril - trandolapril Angiotensin II receptor blockers: "sartan" remember satan blocks angels... (Sartans block angiotensins) - candesartan - eprosartan - Irbesartan - Losartan - olmesartan - telmisartan - valsartan - ACE inhibitors prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II - ARBs prevent peripheral vasoconstriction and secretion of aldosterone and block the binding of angiotensin II to their receptors - these meds are used to treat HTN and HF; also, ACE-inhibitors are administered for their cardio-protective effect after a MI - avoid use with K+-retaining diuretics or K+ supplements adverse effects: 1. nausea, vomiting, diarrhea 2. persistent dry cough (ACE inhibitors) 3. hypotension 4. hyperkalemia 5. tachycardia 6. headache 7. dizziness, fatigue 8. insomnia 9. hypoglycemic reaction in the client with DM 10. bruising, petechiae, bleeding 11. diminished taste (ACE inhibitors) **a persistent dry cough is a common complaint for those taking an ACE inhibitor, but this often subsides after a few weeks. Instruct the client to contact the PHCP if this occurs and persists** interventions: 1. monitor vitals 2. monitor WBCs, protein, albumin, BUN, creatinine, and K+ levels 3. monitor for hypoglycemia reactions in the client with DM 4. if captopril is prescribed, instruct the client to take the med 20-60 minutes before a meal 5. monitor for bruising, petechiae, or bleeding with captopril 6. instruct the client not to discontinue meds because rebound HTN can occur 7. instruct the client not to take OTC medications 8. instruct the client in how to take the BP 9. inform the client that taste of food may be diminished during the first month of therapy 10. instruct the client to report adverse effects to the PHCP

Cranial nerve 6

Abducens - controls lateral eye movement

Cranial nerve 8

Acoustic - controls hearing - assess the client's ability to hear and observe their balance

Recommended childhood and adolescent immunizations

Birth: - hepatitis B vaccine: given within 12 hours of birth, administered IM, contraindicated if they have an allergy, precautions with infant weighing less than 2000 g or if they have a moderate or severe acute illness. - if the mother is hepatitis B surface antigen +, the baby should get the hepatitis B immunoglobulin along with the hep B vaccine. 1 month: - HepB 2 months: - inactivated poliovirus vaccine (IPV): given sub q or IM, contraindicated with a severe allergy to vaccine components (formalin, neomycin, streptomycin, or polymyxin B). - diptheria, tetanus, acellular pertussis (DTaP): given IM - Haemophilus influenzea type b conjugate vaccine (Hib): protects against infections caused by H. influenzea type b, including bacterial meningitis, epiglottis, bacterial pneumonia, septic arthritis, and sepsis. Given IM, contraindicated with severe allergy - pneumococcal conjugate vaccine (PVC): prevents infections caused by streptococcus pneumoniae, such as meningitis, pneumonia, septicemia, sinusitis, and otitis media. given IM, contraindicated with severe allergy. - rotavirus (RV): administered orally so vaccine replicates in infant's gut , it may be withheld if infant has severe vomiting and diarrhea and may be given as soon as infant recovers. 4 months: - DTaP: second dose of series - Hib: second dose of series - IPV: second dose of series - PCV: second dose of series - RV: second dose of series 6 months: DTaP, Hib, HepB, IPV, PCV, RV. - HepB: second dose of series, first was given at birth 12-15 months: - Hib, PVC, MMR, HepA first dose (2nd is given 6-18 months after 1st dose), varicella vaccine - MMR: given sub q HepA: given IM 15-18 months: - DTaP 18-33 months: - HepA 4-6 years: - DTaP, IPV, MMR, varicella vaccine 11-12 years: - MMR, diptheria, tetanus, acellular pertussis adolescent preparation (Tdap), meningococcal vaccine (MCV4) with a booster at age 16, and HPV given to girls at age 11-12, again 2 months later, and again 6 months after 1st dose.

Physiological maternal changes during pregnancy

Cardiovascular system: - blood volume increases, plasma increases, and # of RBCs increases. - anemia occurs as the plasma increases more than the # of RBCs - iron requirements are increased - heart size increases, and the heart is elevated slightly upwards and to the left because of the displacement of the diaphragm as the uterus enlarges - retention of Na+ and water may occur Respiratory system: - O2 consumption increases by 15 - 20 % - diaphragm is elevated - shortness of breath may be experienced GI system: - nausea and vomiting may occur and subsides by the 3rd month - poor appetite may occur due to decreased gastric motility - alterations in taste and smell may occur - constipation, flatulence, and heartburn may occur - hemorrhoids may occur due to increased venous pressure - gum tissue may become swollen and easily bleed, and excessive secretion of saliva may occur due to increasing levels of estrogen Renal system: - frequency of urination increases - bladder capacity increases - bladder tone decreases - renal threshold for glucose may be decreased Endocrine system: - BMR increases and metabolic function decreases - pituitary produces prolactin needed for breast feeding - pituitary produces oxytocin needed for contractions - thyroid enlarges slightly and its activity increases - parathyroid increases in size - aldosterone levels increase - body weight increases - water retention is increased which can contribute to weight gain Reproductive system: - the uterus enlarges from 60 to 1000g, size and # of blood vessels and lymphatics increase, irregular contractions occur after 16 weeks gestation - cervix becomes shorter, more elastic, and larger in diameter; endocervical glands secrete a thick mucus plug which is expelled once dilation begins; increased vascularization and an increase in estrogen causes softening and a violet discoloration (Chadwick's sign) at around 6 weeks of gestation - the ovaries secrete progesterone for the first 6 - 7 weeks of pregnancy, the maturation of new follicles is blocked, the ovaries cease ovum production - hypertrophy and thickening of the vagina muscle occurs - increased vaginal secretions occur - increased estrogen and progesterone cause the breasts to change, they increase in size and may be tender, nipples become more pronounced, the areolae become darker in color, superficial veins become prominent, hypertrophy of Montgomery's follicles occur, and colostrum may leak from the breasts Skin: - increased pigmentation - dark streak down the midline of the abdomen called linea nigra - chloasma is the "mask of pregnancy" which is a blotchy brownish hyperpigmentation of the forehead cheeks and nose - striae gravidarum are stretch marks that appear on the breasts, abdomen, thighs, and upper arms - vascular spider nevi may occur on the neck, chest, face, arms, and legs - rate of hair growth may increase Musculoskeletal system: - changes in the center of gravity begin in the 2nd trimester and are caused by relaxin and progesterone - the lumbosacral curve increases - aching, numbness, and weakness may result; walking becomes more difficult, and the woman develops a waddling gait and is at risk for falls - relaxation and increased mobility of pelvic joints occur, which permit enlargement of pelvic dimensions - abdominal wall stretches with loss of tone and is regained postpartum - umbilicus flattens or protrudes

Fluid volume excess assessment findings

Cardiovascular: - bounding, increased pulse rate - elevated bp - distended neck and hand veins - elevated central venous pressure - dysrhythmias Respiratory: - increased RR and shallow respirations - dyspnea - crackles on auscultation Neuromuscular: - altered LOC - headache - visual disturbances - skeletal muscle weakness - paresthesias Renal: - increased output if kidneys can compensate, decreased output if kidneys are damaged Integumentary: - pitting edema - pale, cool skin GI: - increased motility - diarrhea - increased body weight - liver enlargement - ascites Lab findings: - decreased serum osmolality - decreased hematocrit - decreased BUN - decreased Na+ - decreased urine specific gravity

Cranial nerve 7

Facial - controls movement of face and taste sensation - client should be able to taste salty and sweet, smile, frown, and show teeth, puff out their cheeks, and attempt to close eyes during resistance.

use of GTPAL to estimate pregnancy outcomes

G: the number of pregnancies T: the number of births born at term (37+ weeks) P: the number of preterm births A: the number of abortions or miscarriages L: the number of live or living children

Cranial nerve 12

Hypoglossal - controls tongue movements involved in swallowing and speech - observe the movement of the tongue for symmetry and ask the client to push tongue against resistance.

Physiological changes that occur in older adult clients that increase their risk of accidents

Musculoskeletal changes: - strength and function of muscles decrease - joints become less mobile and bones more brittle - postural changes and limited range of motion occur Nervous system changes: - voluntary and autonomic reflexes become slower - decreased ability to respond to multiple stimuli occur - decreased sensitivity to touch occur Sensory changes: - decreased vision and lens accommodation and cataracts develop - delayed transmission of hot and cold impulses occur - impaired hearing develops with high-frequency tones less perceptible Genitourinary changes: - increased nocturia and occurrences of incontinence may occur

Cranial nerve 3

Oculomotor - controls pupillary constriction, upper eyelid elevation, and most eye movement - inspect eyelids for drooping, asses eye movements and note any deviation, test accommodation with light reflexes

Physical care of the dying client

Pain: - administer pain meds - do not delay or deny pain meds Dyspnea: - elevate the head of the bed or position the client on his or her side - administer supplemental O2 for comfort - suction fluids from the airway as needed - administer meds as prescribed Skin: - assess color and temp - assess for breakdown - implement measures to prevent breakdown Dehydration: - maintain regular oral care - encourage taking ice chips and sips of fluids - do not force the client to eat or drink - use moist cloths to provide moisture to the mouth - apply lubricant to the lips and oral mucous membranes Anorexia, nausea, and vomiting: - give antiemetics before meals - have family members give the client their favorite foods - provide frequent small portions of their favorite foods Elimination: - monitor urinary and bowel elimination - place absorbent pads under the client and check frequently Weakness and fatigue: - provide rest periods - assess tolerance for activities - provide assistance and support as needed for maintaining bed or chair positions Restlessness: - maintain a calm, soothing environment - do not restrain - limit the # of visitors at the client's bedside - allow a family member to stay with the client

The "RACE" acronym in the event of a fire

R: Rescue the clients who are in immediate danger A: activate the fire alarm C: confine the fire E: extinguish the fire

Cranial nerve 11

Spinal accessory - controls strength of neck and shoulder muscles - push the chin and shrug shoulders against resistance

Normal vitals for a 1 year old infant

Temp: 97-99 HR: 90-130 RR: 20-40 BP: 90/56

Normal vital sign values

Temperature: 97.5 - 99.5 degrees F. - to convert F to C: F - 32 x 5 divided by 9 = C - to convert C to F: C x 9 divided by 5 + 32 = F - do not take a temp rectally in cardiac clients, clients who have undergone rectal surgery, those who have diarrhea, fecal impaction, rectal bleeding, or who is at risk for bleeding. HR: 60 - 100 bpm - grading scale for pulses: 4+ = strong and bounding 3+ = full pulse, increased 2+ = normal, easily palpable 1+ = weak, barely palpable 0 = absent, not palpable RR: 12-20 breaths per minute BP: normal BP is a systolic below 120 and a diastolic below 80 - hypertensive crisis: a systolic over 180 and/or a diastolic over 120. Pulse oximetry: - is normally 95 - 100%

Leukemia

There are 4 types: - acute lymphocytic leukemia (ALL): affects kids, mostly lymphoblasts present in the bone marrow. - acute myelogenous leukemia (AML): mostly myeloblasts present in the bone marrow, age of onset is between 15 and 39 - chronic myelogenous leukemia (CML): mostly granulocytes present in bone marrow, age of onset is in the 40s - chronic lymphocytic leukemia (CLL): mostly lymphocytes present in the bone marrow, age of onset is after age 50 - leukemia affects the bone marrow, causing anemia, leukopenia, and the production of immature cels, thrombocytopenia, and a decline in immunity. - the cause is unknown, appears to involve genetically damaged cells, leading to the transformation of cells from a normal to a malignant state - risk factors include genetic, viral, immunological, and environmental factors and exposure to radiation, chemicals, and meds such as previous chemotherapy. assessment: - anorexia, fatigue, weakness, weight loss, anemia - overt bleeding and occult bleeding - ecchymoses, petechiae - prolonged bleeding after minor abrasions and lacerations - elevated temp - enlarged lymph nodes, spleen, and liver - palpitations, tachycardia, orthostatic hypotension - pallor and dyspnea on exertion - headache - bone pain and joint swelling - normal, elevated, or reduced WBC count - decreased Hgb and Hct levels - decreased platelets - positive bone marrow biopsy identifying leukemic blast-phase cells infection: - the WBC count may be extremely low during the period of greatest bone marrow suppression, called nadir - common sites of infections are the skin, respiratory tract, and GI tract - initiate protective isolation procedures - ensure frequent and thorough hand washing - staff and visitors with known infections or exposure to communicable diseases should avoid contact with the client - use strict aseptic technique for all procedures - keep separate supplies for the client - limit the number of staff entering the client's room to reduce the risk of cross-infection - maintain the client in a private room with the door closed - place the client in a room with high-efficiency particulate air filtration or a laminar airflow system if possible - reduce exposure to environmental organisms by eliminating fresh or raw fruits and veggies from the diet, eliminate fresh flowers and live plants from their room, and avoid leaving standing water in their room - make sure their room is cleaned daily - assist the client with daily bathing, using an anti-microbial soap - assist them to perform oral hygiene often - initiate a bowel program to prevent constipation and rectal trauma - avoid invasive procedures like injections, insertion of rectal thermometers, and urinary catheterization - change wound dressings daily, and inspect the wounds for redness, swelling, or drainage - assess the urine for cloudiness and other characteristics of infection - assess the skin and oral mucous membranes for signs of infection - auscultate lung sounds, and encourage the client to cough and deep breathe - monitor temp, pulse, respirations, blood pressure, and for pain - monitor WBC and neutrophil counts - notify the dr is signs of infection are present, and prepare to obtain specimens for culture of the blood, open lesions, urine, sputum, and a chest radiograph may also be prescribed - administer prescribed antibiotic, anti-fungal, and antiviral meds - instruct the client to avoid crowds and those with infections - instruct the client on a low-bacteria diet - instruct the client to avoid activities that expose them to infection - instruct them and their household contacts not to receive immunization with a live vaccine such as MMR, polio, varicella, shingles, and some influenza bleeding: - during the period of greatest bone marrow suppression, the platelet count may be very low - the client is at risk for bleeding when the platelet count falls below 50,000 and spontaneous bleeding occurs when the platelet level falls below 20,000 - clients with platelet counts below 20,000 may need a platelet transfusion - for clients with anemia and fatigue, packed RBCs may be prescribed - monitor lab values - examine the client for signs and symptoms of bleeding, and examine all body fluids and excretions for blood - handle the client gently, using caution when taking BP measurements to prevent skin injury - monitor for signs of internal hemorrhage such as pain, rapid and weak pulse, increased abdominal girth, abdomen guarding, and change in mental status - provide soft foods that are cool to warm to avoid oral mucosal damage - avoid injections to prevent damage to the skin and apply firm and gentle pressure to the site for at least 5 minutes - pad side rails and sharp corners of furniture - avoid rectal suppositories, enemas, and thermometers - if the female client is menstruating, count the number of pads or tampons used - administer blood products as prescribed - instruct the client to use a soft toothbrush and avoid dental floss - instruct the client to only use an electric razor for shaving - instruct the client to avoid blowing the nose - discourage the client from engaging in activities involving the use of sharp objects and contact sports - instruct the client to avoid using NSAIDs and products that contain aspirin fatigue and nutrition: - assist the client in selecting a well-balanced diet - provide small, frequent meals (high calorie, high protein, high carb) that require little energy to eat - assist the client in self-care and mobility activities - do not perform activities unless they are essential, assist the client in scheduling important or pleasurable activities during periods of highest energy - administer blood products for anemia as prescribed additional interventions: - chemotherapy: induction therapy is aimed at achieving a rapid, complete remission of all manifestations of the disease. - consolidation therapy is administered early in remission with the aim of curing - maintenance therapy may be prescribed for months or years after successful induction and consolidation therapy, the aim is to maintain remission - administer antibiotic, anti-bacterial, anti-viral, and anti-fungal meds as prescribed - administer colony-stimulating factors as prescribed - administer blood replacements as prescribed - maintain infection and bleeding precautions - prepare the client for transplantation if indicated - instruct the client in appropriate home care measures - provide psychosocial support and support services for home care

Cranial nerve 5

Trigeminal - controls sensation in the cornea, nasal and oral mucosa, and facial skin - ask client to clench teeth, lightly touch the cornea of eye with cotton, and ask client to close eyes while gently touching their face.

Cranial nerve 4

Trochlear - controls downward and inward eye movement

Pediatric GI Problems: Ingestion of poisons

priority actions for treatment in the ED: 1. assess the child 2. terminate exposure to the poison 3. identify the poison 4. take measures to prevent the absorption of the poison 5. document the occurrence, assessment findings, poison ingested, treatment measures, and the child's response 1. for lead poisoning, Chelation therapy is used which removes lead from the circulating blood and some organs and tissues. meds include calcium disodium edetate used with succimer, and British anti-lewisite used with ethylenediamine tetraacetic acid (EDTA) - the function of the renal, hepatic, and hematological systems must be monitored closely - ensure adequate urinary output before administering, and monitor the output and pH of the urine closely during and after therapy - provide adequate hydration and monitor kidney function for nephrotoxicity when the med is given because it's excreted through the kidneys - follow-up of lead levels need to be done to monitor progress - provide instructions to parents about safety from lead hazards, med administration, and the need for follow-up - confirm that the child will be discharged to a home without lead hazards 2. for acetaminophen poisoning: toxic dose is 150 mg or higher for kids - assessment during the first 2-4 hours = malaise, nausea, vomiting, sweating, pallor and weakness - assessment for the latent period, 24 hours - 36 hours = child improves - hepatic involvement may last 7 days and may be permanent, RUQ pain, jaundice, confusion, stupor, elevated liver enzymes, elevated bilirubin levels, and prolonged prothrombin time - interventions: - administer antidote N-acetylcysteine - dilute antidote in juice or soda because it has an offensive odor - loading dose is followed by maintenance doses - in an unconscious child, prepare to administer gastric lavage with activated charcoal to decrease the absorption of acetaminophen - if using activated charcoal with lavage, do not also use N-acetylcysteine because activated charcoal inactivates the antidote 3. Acetylsalicylic acid (Aspirin): acute toxicity is ingestion of 300-500 mg/kg, chronic toxicity is ingestion of more than 100 mg/kg for 2+ days - assessment findings = nausea, vomiting, thirst, hyperpnea, confusion, tinnitus, seizures, coma, respiratory failure, circulatory collapse, oliguria, bleeding tendencies, diaphoresis, fever, hyponatremia, hypokalemia, dehydration, hypoglycemia, and metabolic acidosis - interventions: - prepare to give activated charcoal to decrease its absorption - emesis or cathartic measures may be used - administer IV fluids; sodium bicarb may be prescribed to correct metabolic acidosis - external cooling, anti-convulsants, vitamin K if bleeding, and O2 are other interventions - prepare dialysis for the child as prescribed if they are unresponsive to therapy 4. Corrosives: other household items that can cause poisoning - assessment = severe burning of the mouth, throat, or stomach - edema of mucous membranes, lips, tongue, and pharynx - vomiting - drooling and inability to clear secretions - interventions: - dilute corrosive with water or milk as prescribed - inducing vomiting is contraindicated because it damages the mucous membranes - neutralization of the ingested corrosive is not done because it can cause a reaction producing heat and burns

Cranial nerve 10

Vagus - controls swallowing and sensation behind the ear

Gravidity

the number of pregnancies

Naegele's rule

used to estimate the date of delivery. add 7 days and 9 months to the day of the woman's last period.

infant skills 14-15 months

walks alone, can crawl up stairs, shows emotion like anger and affection, will explore away from mother in familiar surroundings

infant skills 12-13 months

walks with 1 hand held, can take a few steps without falling, can drink from a cup

medications to avoid in the older client

analgesics: - indomethacin - ketorolac - NSAIDs - meperidine antidepressants - first generation tricyclic antidepressants antihistamines: - first-generation anti-histamines antihypertensives - alpha1-blockers - centrally acting alpha2- agonists urine incontinence meds - oxybutynin - tolterodine muscle relaxants - carisoprodol - cyclobenzaprine - metaxalone - methocarbamol sedative-hypnotics - barbituates - benzodiazepines

amnion

ancloses the amniotic cavity, inner membrane that forms the 2nd week of development, forms a fluid-filled sac that surrounds the embryo

purulent drainage

yellow, gray, or green drainage that is due to infection of the wound

Newborn initial physical examination

body measurement: - length: 18-22 inches - weight: 2500-4000 g - head circumference: 33-35 cm Head: - should be 1/4 of the body's length - bones of the skull are not fused - sutures (connective tissues between the skull bones) are palpable and may be overlapping because of head molding but should not be widened - fontanels are un-ossified membraneous tissue at the junction of the sutures: - anterior fontanel: is soft, flat, diamond-shaped, closes between 12 and 18 months of age - posterior fontanel: triangular, located between occipital and parietal bones, closes between 2-3 months of age Ears: - low-set ears are associated with Down syndrome, renal anomalies, or other genetic or chromosomal syndromes Birthmarks: - Telangiectatic nevi (Stork bites): pale pink or red, flat, dilated capillaries on eyelids, nose, lower occipital bone, or nape of neck, blanch easily, more noticeable during crying periods, and disappear by 2 years old - Nevus flammeus (port-wine stain): cluster of capillaries directly below epidermis, non-elevated, sharp edges, red-purple color, commonly appear on face, will not fade, may require future surgery. - Nevus vasculosus (strawberry mark): bright red birth mark made of capillaries, raised, clearly shaped, dark red with rough surface, common on head, disappears by 7-9 years old. - Mongolian spots: bluish-black pigmentation, on lumbar dorsal area and buttocks, gradually fade at age 1-2, common in Asian and dark-skinned individuals Umbilical cord: - should have 2 arteries and 1 vein, if not notify the PHCP - cord should be clamped for at least 1 day after birth, can remove clamp once the cord is dried and occluded and no longer bleeding - note any bleeding or drainage from the cord - cleansing of the cord is done based on hospital's and PHCP's preferences - signs of infection are moistness, oozing, discharge, or a reddened base, notify the PHCP if these occur, antibiotics will be prescribed - first stool meconium should occur within 24 hours after birth Female genitals: - labia may be swollen, clitoris may be enlarged - smegma (thick, white mucous discharge) may be present - pseudomenstruation (blood-tinged mucous) caused by the withdrawal of the maternal estrogen may appear - hymen tag may be visible - first voiding should occur within 24 hours after birth Male genitals: - prepuce (foreskin) covers glans penis - scrotum may be swollen - meatus should be at tip of penis - testes are descended but may retract when cold - assess for hernia or hydrocele - first voiding should occur within 24 hours after birth Spine: - assess for hair tufts and dimples along the spinal column; they may indicate a possible opening Extremities: - assess for fractures of the clavicle or hip dislocations - assist the PHCP to assess for developmental dysplasia of the hip, when thighs are rotated outwards no clicks should occur (Ortolani's sign and Barlow's sign are the 2 assessment tools for developmental dysplasia of the hip) Respiratory system: - signs of respiratory distress and hypoxemia are nasal flaring, increasingly severe retractions, grunting, cyanosis, bradycardia, and periods of apnea lasting longer than 15 seconds. Hepatic system: - normal or physiological jaundice appears in a full term newborn after the first 24 hours and in a pre-term newborn after the first 48 hours. pathological jaundice is jaundice that occurs before this time, it must be reported to the PHCP and may indicate early hemolysis of RBCs. - normal jaundice peaks on the 5th day of life, with bilirubin levels of 6-7. - feed early to stimulate intestinal activity and to keep the bilirubin level low. - prevent chilling, hypothermia can cause acidosis which interferes with bilirubin conjugation and excretion. - the liver stores iron and glycogen - the newborn is at risk for hemorrhagic disorders; coagulation factors synthesized in the liver depend on vitamin K which is not synthesized until intestinal bacteria are present. - administer phytonadione to the newborn as prescribed to prevent hemorrhagic disorders, usually the dose is 0.5-1mg and it is given in the lateral aspect of the middle 1/3 of the vastus lateralis muscle. Renal system: - signs of dehydration are dry mucous membranes, sunken eyes, poor skin turgor, and sunken fontanels. GI system: - assist the mother with breast-feeding or formula feeding, breast-feeding should be done every 2-3 hours and formula feeding should be done every 3-4 hours - burp the newborn during and after the feeding

hemorrhaging drainage

frank blood from a leaking blood vessel, may require emergency treatment to control the bleeding

infant skills at 4-5 months

grasps objects, switches objects from hands, rolls over, enjoys social interaction, begins to show memory, aware of unfamiliar surroundings