NUR 288 Final

Priority assessment for pancreatitis

BS (decreased), abd distention, jaundice, nausea, vomiting, presence of flatus (excess), last BM (constipation) assess location, nature, duration, & precipitating factor of pain, pain that radiates to the back or pain that is relieved by sitting up/leaning forward ask about alcohol consumption, dietary intake, and family hx of pancreatitis VS (decreased BP, elevated temp, tachycardia, bruising in the flanks (Turner's sign), bruising around the umbilicus (Cullen's sign) anorexia, weight loss, steatorrhea, previous illness, surgery, & current meds

Burn injury: Resuscitation Phase

Begins at onset of injury til diuresis begins (48-72 hrs post injury) Shock most common cause of death at this phase Priorities: - prevent shock - secure airway - support circulation (fluids) - manage pain - prevent infection - maintain body temp - emotional support

For a patient with acute exacerbation of heart failure, which laboratory test would the nurse expect to be ordered as an indication of heart failure and fluid volume status?

Brain natriuretic peptide (BNP)

The nurse is providing diet teaching to a patient with a history of heart failure. Which of the following statements made by the patient indicates they understood the diet teaching?

" I will limit my consumption of frozen meals"

The mother of a preadolescent client is concerned because the client often reports non-specific "bone pain." Which response by the nurse is appropriate?

"Bone pain in children is caused from the pulling of muscles when bones grow quickly."

A client with a history of hypertension, is diagnosed with chronic renal disease. When the client asks the nurse how this occurred, which response by the nurse is most appropriate?

"High blood pressure reduces renal blood flow and harms the kidney tissue causing this diagnosis."

A client with end-stage liver disease is talking to you about being on the transplant list. Which statement by the client concerns you the most?

"I am going to cut down on my drinking very soon"

A nurse teaches a patient being treated for a full-thickness burn. Which is the best statement that the nurse should include in this patient's discharge teaching?

"I will demonstrate how to change your wound dressing"

After teaching a male client with a spinal cord injury at the T4 level with some sensation below the injury. The nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply)

"I will explore other ways besides intercourse to please my partner." "Ejaculation may not be as predictable as before." "I may urinate with ejaculation but this will not cause infection." "I should be able to have an erection with stimulation."

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home?

"I'll use my incentive spirometer every 2 hours while I'm awake."

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement indicates that the attendees understand the risk factors and prevention methods associated with spinal cord injury?

"I'm going to spend extra time discussing this talk with my Boy Scout troop because of their higher risk for spinal cord injury." Feedback: The highest-risk population for spinal cord injuries is males between 16 and 30 years old.

A patient receiving a blood transfusion develops anxiety and complains of lower back pain. The nurse's best response is which of the following statements?

"I'm going to stop the transfusion and notify your physician."

The nurse is caring for a school-age client who will be discharged from the hospital after receiving a ventriculoperitoneal (VP) shunt as treatment for increased intracranial pressure (IICP). The nurse has taught the parents to monitor the child for shunt malfunction. Which statement by the parents regarding when to notify the healthcare provider indicates that learning goals have been met?

"If our child develops an altered level of consciousness, we will notify the doctor." Feedback: An altered level of consciousness would be a symptom of shunt malfunction and increasing intracranial pressure. In most children, by age 8, the cranial suture lines have fused, and the fontanelles are closed, so a bulging soft spot, expanding head size, or sunset eyes would not be common symptoms of shunt malfunction and an increase in intracranial pressure.

The home care nurse is teaching a client with Heart Failure and a history of falls to safely assess for weight gain. Which of the following suggestions would best meet the needs of the patient?

"If your shoes or waistband feel tighter than usual, you should call your doctor"

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications?" How should the nurse respond?

"Once you start Corticosteroids, you have to be weaned off them"

The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement?

"Patients must be moved correctly in bed to prevent shearing"

The nurse is teaching the client and family about the reason for taking calcium acetate tablets with each meal. Which explanation about this medication is the most appropriate?

"The calcium acetate will lower your serum phosphate levels."

The nurse is caring for a client with a potassium level of 5.9 mEq/L. The health care provider prescribes both glucose and insulin for the client. The client's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate?

"The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood."

A client with renal failure is receiving peritoneal dialysis. The nurse is explaining the process to the client. Which statement would the nurse include in a discussion with the client and family?

"The peritoneum acts as a semipermeable membrane through which wastes move by diffusion and osmosis."

The nurse instructs a client with chronic renal disease on the prescribed medication epoetin (Epogen). Which statement by the client indicates that teaching has been effective?

"This medication will make sure I have enough red blood cells in my body."

The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client's discharge teaching?

"Use a soft-bristled toothbrush."

A young school-age client is in the hospital with acute kidney injury following a streptococcus infection. The parents are Spanish-speaking and speak little English. The parents, through an interpreter, ask the nurse what mistake they made that caused the child to be so sick. Which response by the nurse is most appropriate?

"Your child's recent infection may have caused the renal failure."

The nurse is caring for a client admitted with a diagnosis of acute renal failure. The client asks the nurse, "Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is most appropriate?

"Your condition may be reversed with prompt treatment and usually will not harm the kidney."

An assessment findings of a patient admitted to the emergency room with a deep partial-thickness burn after a fire in the workplace would be documented by the nurse as:

'necrotic tissue through all of the epidermis and most of the dermis'

Cognitive-Behavioral Therapy

(CBT) focuses on skill training and problem solving to help clients reorient patterns of negative thinking and negative behaviors

Electroconvulsive Therapy

(ECT) is a treatment procedure that passes an electric current through the brain to induce a seizure. It is given 2-3 times a week for 12 treatments.

Priority problems for long-term management

- Difficulty breathing --- pneumonia --- area of injury - Impaired physical mobility (safety issue) --- worried about burns, pressure sores - Spastic bowel & bladder - Impaired judgment

A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the PACU, in what order from first to last, should the nurse provide care?

1. Monitor the pulses 2. Inspect the dressing 3. Ensure the IV infusion rate is as ordered 4. Administer pain medication 5. Draw blood for laboratory studies

The nurse's assignment consists of the following four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? The client:

1. with cirrhosis who became confused and disoriented during the night 2. with acute pancreatitis who is requesting pain medication 3. who is one day postoperative following a cholecystectomy and has a t-tube inserted 4. with hepatitis B who has questions about discharge instructions

sodium (Na+)

136-145 mEq/L

The clotting process can be impaired in two ways:

1: when clotting factors are not available and patients bleed excessively 2: if blood clots form when they are not physiologically indicated, then a thrombus may obstruct blood vessels and impair blood flow

Burn injury: Acute Phase

36-48 hrs after burn injury when diuresis begins Lasts until wounds are closed (can take weeks-months) % TBSA burned determines # of days in hospital Infection most common cause of death Goals: pain control, infection prevention, wound care, pain control

The nurse has a prescription to administer two ounces of lactulose to a client who has cirrhosis. How many tablespoons of lactulose should the nurse administer? (Whole Number Only)

4

The nurse knows that according to the Parkland formula for fluid replacement, a 65 kg patient with a burn of 40% Total Body Surface Area (TBSA) would receive a total of how many cc's of Lactated Ringer's solution in the first 8 hours of replacement?

4 mL x % BSA x weight (kg) ..... Then half of it in the first 8 hours and the other half in the following 16 hours 1040 (520 + 520)

During change of shift report, the nurse learns about the following four patients. Which patient will the nurse assess first?

45 year old with cirrhosis and severe ascites who has an oral temperature of 102 F

Parkland formula

4mL x weight (kg) x % TBSA burned = volume (mL)

Which patient does the charge nurse know is best assigned to a float nurse who has come from the post anesthesia care unit (PACU)?

52 year old patient with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy

The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time?

60 seconds

The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock?

68-year-old woman who is being treated with chemotherapy

Calcium (Ca+)

9-11 mg/dL

Burn criteria for hospitalization

>/= 20% TBSA >/= 10% TBSA in peds or geriatrics >/= 5% full thickness burns Burns to hands, face, feet, groin Burns to eyes/ears

deep vein thrombosis (DVT)

A blood clot in a deep vein, most often an extremity. Causes: ■ common causes are immobilization, hospitalization, and surgery ■ other causes include; pregnancy, trauma, certain cancers, use of oral contraceptives or hormone replacement Presentation: ■ Calf pain (dull, aching) especially when walking ■ tenderness, swelling, warmth, redness, edema

A school-age client loses consciousness after being hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, blood pressure 148/74 mmHG, and respiratory rate 28 and irregular. Based on this data, which conclusion by the nurse is the most appropriate?

A sign of increased intracranial pressure Feedback: These vital signs show increased blood pressure with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Normal sleeping pulse at this age is 60-90.

Glascow coma scale

A system used to measure the level of consciousness in a person following a traumatic brain or spinal cord event. 3 is the lowest (and the worst) score while 15 is the highest (and the best) score. The three parts of the glascow coma scale are eye opening, verbal, and motor.

Polycythemia:

A systemic disease state in which bone marrow produces too many RBCs. The blood is thickened, having very high hematocrit, increasing risk of clots or stroke.

chronic kidney disease (ckd)

A type of renal failure that progresses slowly with few symptoms until the kidneys are severely damaged and unable to meet the excretory needs of the body.

SCI (spinal cord injury)

Above C5: difficulty breathing GCS: best score is 15 --increasing score means they are improving neurological-wise

Meds: pancreatitis

Acute pancreatitis: analgesics like hydromorphone (dilaudid) or prophylactic antibiotics for severe or necrotizing pancreatitis to prevent infection Chronic pancreatitis: pancrelipase (pancreatic enzyme replacement) enhances the digestion of starches & fats in the GI tract by supplying an exogenous source of protease, amylase, & lipase

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: INR of 8; Hgb, 11g/L; and Hct, 33%. In which order should the nurse implement the following HCP orders?

Administer IV dextrose 5% in 0.45% normal saline solution Obtain one unit of fresh frozen plasma (FFP) from Blood Bank Administer vitamin K 2.5 mg by mouth Give polyethylene glycol-electrolyte solution in preparation for sigmoidoscopy

The nurse receives new prescriptions for a patient with severe burn injuries in the emergent phase of injury who is receiving fluid resuscitation per the Parkland formula. The patent's urine output continues to range from 10 to 15 mL/hr. Which prescription should the nurse question?

Administer lasix

What actions by the nurse indicates understanding of the nutritional needs of the client with Chronic Kidney Disease (CKD) ? (select all four that apply) .

Administer parenteral nutrition as prescribed Monitor serum albumin and BUN values Serve small meals Encourage oral care

Common risk factors for hormonal imbalances

Age Autoimmune conditions Cancer treatment / destruction of tissues Chromosomal deficiency Chronic medical conditions Family History Genetics Lifestyle Hormonal supplement therapy Obesity Sedentary lifestyle Stress Trauma

Mobility lab diagnostics

Alkaline phosphatase (ALP): ALP is produced by the bone and other organs. Increased ALP may indicate bone disease, bone fracture, bone tumors, osteomalacia, Paget disease, rickets. Decreased ALP may indicate Wilson Disease. Calcitonin/parathyroid hormone: These have opposite actions in the regulation of blood calcium levels, which is vital for bone and muscle strength and function. Increases calcitonin may indicate a thyroid tumor. PTH may be increased in osteoporosis that does not respond to therapy. Increased PTH may suggest kidney disease, parathyroid gland tumors, lack of calcium, or vitamin D deficiency. Calcium: increased blood calcium levels could indicate the presence of metastatic bone tumors, Paget disease, bone fractures, or hyperthyroidism. Decreased blood calcium levels could indicate hypothyroidism, osteomalacia, or vitamin D deficiency. Creatine Kinase (CK): Used to detect muscle damage, muscle inflammation, rhabdomyolysis, polymyositis, and muscular dystrophy. CPK-MM is specific for skeletal muscle. Growth Hormone (GH): High levels of growth hormone may indicate acromegaly or gigantism. Low levels of growth hormone may result in dwarfism. Human leukocyte antigen-B27: The presence of HLA-B27 indicates an increased risk for ankylosing spondylitis and arthritis. Phosphorus (P): Increased levels may indicate hypothyroidism. Decreased levels may indicate hyperparathyroidism or lack of vitamin D, which increases the risk of rickets and osteomalacia. Rheumatoid Factor (RF): Elevated level may indicate rheumatoid arthritis, scleroderma, lupus, and adult Still disease. Uric Acid: Increased uric acid levels may indicate gout, excessive exercise, and a variety of non-related disorders.

The nurse is caring for a group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for impaired urinary elimination?

An 80-year-old male reporting frequent urination at night

A patient diagnosed with Hyperthyroidism will receive Radioactive Iodine as indicated for treatment of this condition. The Nurse should include which teaching in this patient's plan of care?

An additional dose may be needed Feedback: If thyroid production remains too high a second dose may be needed

Burn meds

Analgesia: Morphine is drug of choice, avoid PO until hemodynamic stability has occurred and there is normal gastric emptying, IV/ IM provide faster pain relief Antianxiety (midazolam or lorazepam): helpful when given one hour before wound care Antimicrobials can be applied on the surface of the skin (as a topical agent), is not applied until the patient has reached the burn unit, are used to decrease the risk of a systemic infection Tetanus prophylaxis: if patient's immunization status is not sure, administered IM in the acute phase Antacids (histamine H2 blockers, proton pump inhibitors): control hyperacidity if gastric pH is below 5, given IV, after bowel sounds become audible, start to administer antacids

The nurse is aware that patients who are experiencing immobility often have which of the following emotions? (Select all answers)

Anger Helplessness Anxiety

A client is hospitalized for suicidal ideations as a response to complicated grief. Which collaborative interventions would be appropriate for this client's care? Select all 3 that apply.

Antidepressants Group therapy Social Service Consult

Bone Marrow Suppression:

Any suppression of bone marrow activity. Can reduce platelets, erythrocytes, and leukocytes. When platelets are low, abnormal bleeding happens.

An adult client is diagnosed with bone spurs of the vertebral column. Which is the priority action by the nurse?

Assess pain management.

A nurse is caring for a patient with Diabetes Insipidus. Which of the following interventions should the nurse implement?

Assess skin turgor every four hours.

A nurse educator is teaching a group of nursing students about the feelings associated with losing a client. The educator suggests which activity as the most helpful when a nurse is coping with feelings of grief?

Attending the wake or funeral of the client

A unconscious patient is admitted to the ER following a fire that was managed quickly. Physical exam shows cherry-red mucous membranes, nail beds and skin. The nurse interprets these findings as indicative of which of the following?

Carbon monoxide poisoning

A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient?

Cardiac dysrhythmia

Patients who have decreased mobility may suffer from many complications:

Cardiovascular system: orthostatic hypertension, the formation of blood clots, decreased cardiac capacity, decreased cardiac contraction, and decreased cardiac output Respiratory system: decreased lung expansion, atelectasis, decreased capacity for gas exchange, and possible development of stasis pneumonia Integumentary system: tissue hypoxia and pressure ulcers Gastrointestinal system: decreased peristalsis motility, reduced appetite, anorexia, and constipation Urinary system: renal calculi, urinary stasis, infection, loss of bladder tone

A patient is receiving transcutaneous pacing for symptomatic bradycardia. The ECG tracing shows 100% 'pace and capture' . To ensure there is actual adequate perfusion, what should the nurse assess next?

Carotid pulse

CNS functions

Cerebrum- frontal (speech, thought, learning, emotion, voluntary movement), parietal (sensory, like temperature, shapes, and pain), occipital (vision), temporal (hearing) Cerebellum- muscule movement, control, posture, and balance Diencephalon- thalamus, hypothalamus (regulates heart rate, blood pressure, respiratory rate and depth, pain, pleasure, fear, body temperature, sleep cycles, and digestive motility) Brainstem- controls reflexes, breathing, blood pressure, and heart rate Also assess for decorticate posturing (rigid flexion that is associated with lesions that exist above the brainstem) and decerebrate posturing (rigid extension that is associated with lesions that exist at or below the brainstem)

A health care provider informs the nurse that a patient is to be started on a platelet inhibitor. Education about which of the following drugs, does the nurse plan to teach the patient?

Clopidogrel (Plavix)

Which of the following processes does the nurse know have the strongest links to intracranial regulation? (Select all that apply)

Cognition Oxygenation Perfusion

Circumferential burns complications

Compartment syndrome = edema & swelling --> excessive pressure builds up inside an enclosed muscle space, impeding blood flow --treatment: procedure escharotomy (treat full thickness burns) or fasciotomy (fascia cut to relieve pressure) -- most common symptom is severe pain Might have respiratory complications, pain with breathing (atelactasis) Malnutrition (eating issues) Visual complications ABG abnormality: -- Metabolic acidosis w/ hypoxemia ---- ph low ---- HCO3 low ---- PaCO2 low -- Remember: 0.9% vs LR - LR brings body more basic Assess pt for perfusion: skin color, temp, pulses, spo2

The nurse is assigned to a 4-month-old infant with vomiting and diarrhea who is brought to the pediatric clinic. The infant's vital signs are temperature: 37° C, apical HR: 130, R: 40/min. The abdominal assessment reveals a soft, concave abdomen, 10 gurgles auscultated in 1 minute in all four quadrants, and tympani to percussion. Which collaborative care action does the nurse anticipate?

Complete a thorough digestion assessment interview with the mother. Feedback: The assessment data for this pediatric client indicates a non-emergent alteration in digestion that requires additional interview information from the mother. Nothing in the assessment indicates a surgical emergency.

A nurse is preparing to administer a blood transfusion. What action is most important?

Correctly identifying the patient using two identifiers.

The nurse cares for a client who has facial burns. The patient asks, "Will I ever look the same?" How should the nurse respond?

Cosmetic surgery

The nurse in a rheumatology clinic is managing care for clients who receive non-steroid anti-inflammatory drugs (NSAIDs) for the treatment of their disease processes. Which are the primary laboratory tests the nurse will assess prior to initiation of this type of therapy? Select all 3 that apply.

Creatine clearance Complete blood count (CBC) Liver function tests

Labs/Diagnostics for elimination

Creatinine level: muscle breakdown; solely filtered from blood via the glomerulus, is NOT reabsorbed or secreted in the nephron (normal is about 0.6-1.2 mg/dL) Creatinine clearance: amount of blood kidneys make per minute that is free of creatinine (normal is about 85-125 mL/min in females and about 95-140 mL/min in males) Glomerular filtration rate: rate of blood flow through kidneys in which waste, ions, and water is filtered (normal is >90 mL/min) BUN: breakdown of protein in the liver, secreted in the blood and filtered by the kidneys (normal is 6-20 mg/dL) Electrolytes (Potassium, sodium, phosphorus, calcium, magnesium) Urinalysis: bacteria in the urine indicates infection while blood in the urine may indicate infection or trauma. Renal function tests: Blood levels of urea and creatinine are tested Culture: if there is bacteria, a culture will determine what type of bacteria is present Occult blood Biopsy: Used in obtaining tissue for diagnosing or monitoring kidney disease

The rehab nurse is planning care for a client with a late-stage burn wound to promote healing and minimize scarring. Which of the following is the most important intervention for the nurse to include in the plan?

Custom-fitted pressure garments

HypOthyroidism

Cytomel (Liothyronine sodium) Thyrolar (Liotrix) Synthroid (Levothyroxine): the most common medication. Older adults may require a lower amount of the medication due to an age related decrease in albumin and renal excretion which causes an increase in the amount of medication that is available which means that a smaller amount of medication would cause a larger effect on an adult

Meds linked to the potential development of cirrhosis

DAMP TRIM didanozine -- HIV antiviral med amiodarone -- antiarrhythmic methyldopa -- antihypertensive agent propylthiouracil -- treatment of hyperthyroidism tamoxifen -- breast cancer treatment retinol -- high dose vitamin a isoniazid -- TB treatment methotrexate -- immunosuppression TPN can also lead to cirrhosis, along with high-dose, repeated acetaminophen

Labs/Diagnoses in Clotting

DIC: CBC and platelet count, coag studies, fibrin degradation prods/fibrin split prods (these would be increased), fibrinogen levels (decreased or normal), d-dimer (elevated) DVT: PT (11-12.5 secs is normal), INR (1.5-2.0 is preferred for prophylaxis for DVT, 2.0-3.0 when treating DVT, 3.0-4.0 when treating A-fib), PTT (norm is 60-70 secs), fibrinogen (200-400), platelet count (150-400), d-dimer, erythrocytes/hgb/hct, bone marrow exam, noninvasive venous studies, arteriograms, venograms, CBC

The nurse caring for a patient with a primary diagnosis of Diabetes Insipidus (DI). What would be expected findings on physical exam? (Select all that apply).

Decreased skin turgor Dry mucous membranes Tachycardia

The nurse is preparing an infusion of Magnesium Sulfate for a patient with preeclampsia. What baseline assessment data should the nurse obtain? (Select all that apply).

Deep tendon reflexes Respiratory rate Urine output Blood pressure

The nurse reviews the client's medical history. Which condition(s) place the client at risk for developing acute renal failure? (Select all three that apply).

Dehydration Renal calculi Hypertension

Match The following type of closed traumatic head Injury with the correct description.

Diffuse Axonal Injury: Diffuse damage to brain tissue but no test to give a definitive diagnosis Mild Traumatic Brain Injury ( Mild Concussion): LOC up to 30 min, amnesia just before and after event, neurological deficits that may be transient Moderate Traumatic Brain Injury ( Moderate Concussion): LOC 30 min - 6 hrs, Glasgow Coma Scale 9-12, focal or diffuse neurological deficits Severe Traumatic Brain Injury ( Severe Concussion): LOC > 6 hours, Glasgow Coma Scale 3-8 and diffuse neurological deficits

A patient arrives at the emergency room after a spill of a known chemical liquid (commercial bleach) over both hands. What is the priority intervention that the nurse should perform next?

Dilute the burns

Spinal Cord injury

Direct damage to the spinal cord or indirect damage due to diseases of surrounding tissues. Medical emergencies that may result in permanent disability or paralysis. Can result from motor vehicle accidents, assault, gunshot wounds, sports injuries and falls. Manifestations include: weakness/numbness below the injury, muscle spasticity, loss of bladder and bowel control, pain, paralysis, and/or difficulty breathing. Interventions and therapies include: immobilization of the spine, pharm. Therapy to reduce pain and swelling and prevent further damage, surgery to remove tissue, fluid or objects pressing on the spinal cord, bed rest, spinal traction, and/or physical and occupational therapy

The hospice nurse reviews the care provided to a dying client. Which observations indicate that outcomes have been reached for this client? Select all 4 that apply.

Discusses fears Resting comfortably Medicated for pain Informed of any changes

The client states to the nurse, "I have been having trouble sleeping since my boyfriend died unexpectedly 3 weeks ago." The client also confides that the boyfriend was married and they were seeing each other secretly. For which reason is the client most likely experiencing sleeping difficulty when grieving?

Disenfranchised grief

Nursing Considerations/Interventions for Clotting disorders

Disseminated intravascular coagulation: promote effective tissue perfusion, monitor gas exchange, manage pain, manage fear, avoid unnecessary needle sticks; educate on the items that can cause an increase in bleeding (hard toothbrush, use of a straight razor) Deep vein thrombosis: manage pain, promote effective peripheral perfusion, promote effective protection, encourage physical mobility, promote effective cardiopulmonary perfusion Apply pressure over punctures for a much longer time (5-15 minutes/ as long as it takes) in pts who have longer clotting time or bleeding disorders.

Elimination meds

Diuretics: remove excess fluid Antihypertensives: decrease high blood pressure that is associated with glomerulonephritis Kayexalate (sodium polystyrene sulfonate): removes excess potassium from the body by exchanging sodium for potassium in the large intestine

Physiologic adaptation (DIC)

During DIC, the clotting cascade is stimulated which leads to an increase in thrombi formation and the clotting activates the fibrinolytic process (in which the thrombi are broken down) which contributes to the excess bleeding

The nurse is providing care to a client with a compromised immune system. Which independent nursing intervention is appropriate for the nurse to include in the client's plan of care?

Educating on the importance of a nutritious diet

More mobility assessments

Education (mobility): instruct about body mechanics and proper posture, simple modifications in turning, lifting and bending, importance of regular exercise and good nutrition, discussion of medications added to the client's regimen, including safe administration, actions, side effects, and precautions. Promote comfort: client positioning and proper padding of joints and bony prominences, helping with braces and support devices. When a splint or brace is in place, routinely assess the surrounding area for signs & symptoms of circulatory impairment, including skin pallor and blanching, weak or absent pulses, and impaired sensation. Prevent injury: encourage client to perform exercises and stretches, and to utilize splints and braces as prescribed by the primary HCP, PT, and OT, environmental screening for potential hazards such as loose floor coverings, inadequate lighting, and obstructed walkways, and ensure the patient is properly using any assistive devices.

The nurse assesses bilateral wheezes in a patient with burn injuries inside the mouth. Four hours later the wheezing is no longer heard and the 02 saturation is 89% with 100% O2 via a non-re-breather mask. Which is the best next action by the nurse?

Emergency airway

The nurse identifies the diagnosis of Interrupted Family Processes for a child who sustained a brain injury during an automobile accident. Which nursing intervention would support this diagnosis?

Encourage the family to express feelings.

Prostatic hyperplasia

Enlargement of the prostate. Enlarged prostate gland can cause difficulty with urination and a feeling of urinary urgency, frequency, and incomplete bladder emptying. Only seen in men, most often older men.

The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question?

Enoxaparin (Lovenox) 40 mg subcutaneous twice daily

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?

Evaluate respiratory status.

A client with acute renal failure has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on5this data, which nursing diagnosis is the most appropriate?

Excess fluid volume

The nurse is assessing a client who has a factor VIII deficiency. Which clinical manifestation does the nurse expect to assess in this client?

Excessive bleeding from a cut

A hospice nurse is caring for a client who has been given 6 months to live. Which nursing intervention would address the anxiety of the client and family associated with receiving a terminal diagnosis?

Explore the client and family's history with other stressful life events and how successful coping was at that time.

Mood & affect assessment

FIRST establish a therapeutic relationship based on mutual trust-ask open-ended questions and allow time for a response. Use self reporting scales. Adult-the Beck Depression Inventory- questionnaire for the patient to fill out. The Center for Epidemiological Studies Depression Scale-Revised (20 item self-rating scale rating their past week).

Hormonal Regulation has five overarching functions

Fetal differentiation of the reproductive and central nervous systems Growth and development during childhood/ adolescence Reproduction Metabolic activity Adaptive responses

Nursing dx for pts w significant burns

Fluid Volume Deficit Disturbed Body Image Impaired Gas Exchange Ineffective Tissue Perfusion Risk for Infection

The nurse caring for a patient with a primary diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH). What would be expected findings on physical exam on physical exam? (Select all that apply)

Full and bounding peripheral pulses Decrease in serum sodium level 2+ pitting edema of bilateral ankles

A client diagnosed with chronic pancreatitis, asks if there are any alternative therapies that might help with treating the condition. The nurse teaches the client that which complementary and alternative therapies can be safely used in conjunction with traditional treatment? Select all 3 that apply.

Gentle, low-impact exercise Low-salt, low-fat vegetarian diet Magnetic field therapy

A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse rate is 120 and the central venous pressure is measured at 2 mmHg. Which of these orders by the health care provider will the nurse question?

Give furosemide (Lasix) 40 mg IV

A client is complaining of frequent headaches, chest tightness, palpitations, and menstrual irregularities. The client also reports having lost weight and experiencing difficulty eating and sleeping. The nurse notes that the client is tearful, sad, and lacks energy. Which question is most appropriate when assessing the source of the client's symptoms?

Have you experienced the loss of a loved one?

HIT Syndrome

Heparin-induced thrombocytopenia (and thrombosis)

The HCP 's order says to administer Lasix 40 mg IV twice a day. The patient has the following morning labs: Na+ 148, BNP 900, K+ 2.0 and BUN 8. Which of the following is a nursing priority action?

Hold the dose and notify the HCP about the K+ level

A patient who is prescribed furosemide (Lasix) as part of a regimen for chronic heart failure should have periodic laboratory monitoring due to the potential for which laboratory abnormality?

Hypokalemia

With a diagnosis of Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the nurse would be most concerned about which laboratory abnormality that is due to the altered level of antidiuretic hormone (ADH)?

Hyponatremia

The nurse is aware that the management of Diabetes Insipidus (DI) includes all of the following:

Identification and correction of the underlying cause Administration of desmopressin Administration of intravenous fluid resuscitation You would NOT administer hypertonic solution (such as 3% NS).

Blood transfusions

If the patient is receiving a transfusion of some sort, monitor for anaphylaxis reactions, nurses must remain in the patient's room for the first 15 minutes of a blood transfusion, monitoring vitals-checking for any change in temperature and have normal saline ready in case of a reaction to the blood product. Act as if all blood products are contaminated and wear the appropriate PPE during nursing interventions/ procedures Blood infusions must be verified by a second nurse, and must be discarded if not used quickly. Ask the patient if they have allergies, or if they have ever had a reaction to a blood product. Check their MAR and wristband for allergies as well.

Relationship b/t immunity & inflammation

Immunity is the body's natural or induced response to infection. The immune system will respond to antigens such as foreign substances, infectious agents, and abnormal cells. Inflammation is the body's nonspecific immune response. Inflammation brings fluid, dissolved substances and blood cells into the interstitial tissues where the injury or infection is. Inflammation is characterized by redness, pain, swelling, warmth and sometimes loss of function. Therefore, inflammation is what the body looks and feels like in the place where it is having an immune response.

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with the rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis?

Ineffective Breathing Pattern

Relationship b/t immunity, inflammation, & infection

Infection is a colonization of the body by harmful microorganisms. When an infection occurs, the body's immune system will detect the cells or substances and mount an immune response, sending white blood cells to the site of infection. The infected site will possibly be red, warm, painful, swollen, and possibly not working properly because of inflammation.

Paracentesis puts people at risk for

Infection: bc you're entering the body, they may have immunity issues, may be repeated procedure Bladder damage by needle: make sure they empty their bladder before procedure Hypotension Hemorrhage

Urinary elimination assessments

Inspect abdomen for abdominal or bladder distention inspect genitalia for redness, lesions, discharge, inspect perianal area, inspect stool and urine for color, characteristics (especially the elements that are within the stool or urine), odor, auscultate the abdomen in all four quadrants, auscultate lungs, palpate abdomen (should be soft and nontender), percuss over the costovertebral angle (should not be painful) if percussion causes pain the kidneys may be infected, monitor for edema, monitor vital signs, especially blood pressure, I&O, neurological assessment, signs of anemia like pale, tired, shortness of breath, and confused; monitor daily weight, monitor EKG

The nurse is conducting a gait and posture assessment for a client who is experiencing mobility issues. Which action by the nurse is appropriate during this assessment?

Inspect the spine for curvature.

The nurse is caring for a female client with a history of urinary tract infections (UTIs). Which action by the nurse would decrease the risk of the client experiencing future UTIs?

Instruct the client to completely empty the bladder.

The nurse is providing care for a client who is experiencing an alteration in mobility. Which independent nursing intervention is appropriate?

Instructing on the importance of proper nutrition and an active life style

Symptoms/assessment of cirrhosis

Jaundice: eyes, under tongue distended belly (ascites), heavy breathing may have really thin extremities, red palms of hands neuro assessment, safety fall risk: balance may be off, confusion, O2 levels may be a little lower, bleeding beta blockers given sometimes to help with variceal bleeding

Care of pts with hepatitis

Labs - LFTs, albumin, PT, INR, platelets, serum protein Avoid acetaminophen & NSAIDs, meds metabolized by the hepatic system Assessment: jaundice, petechiae, ecchymosis, redness of palms, spider angiomas, ascites (same as cirrhosis) Past-exposure prophylaxis: antiretrovirals, interferons Harvoni: treats and cures Hep C

The nurse is aware that the American Heart Association recommends for cardiac health promotion, daily sodium intake should be limited to which of the following amounts?

Less than or equal to 1500 mg/day

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. What actions should the nurse take to support this client's care need? (Select all that apply)

Limit the client's visitors. Keep the room dark and quiet. Teach family to speak softly and minimize touching.

Labs for liver disease

Liver enzymes (ALT) BUN Coagulation factors (PTT, INR, CBC) -- these are not produced as well with a person w/ liver disease

Anterior cord syndrome

Location and cause of injury: Injury to the anterior two thirds of the spinal cord, especially the anterior spinal artery Symptoms: paraplegia below the level of injury (or tetraplegia for injuries higher than C7) bilateral loss of pain & temperature sensations w preservation of proprioception & vibratory senses below the injury Prognosis: clients w this have the worst prognosis for recovery of neurological function and require long periods of rehabilitation. Only 10-20% of clients experience motor recovery

Symptoms of active dying

Long pauses in breathing/irregular breathing. Urinary/Bowel incontinence/decrease in urine/discolored urine. Significant drop in blood pressure Weakness, pale, cool extremities, decreased interest in food/ fluids, dyspnea, decreased oxygen saturation levels, gurgling sounds in the back of the throat from excess secretions, possible decrease in the amount of comfort and pain, agitation, restless, confused, sleepy, disoriented, pupils fixed or dilated

reason why pts w/ severe liver disease develop ascites

Low albumin level (protein produced by the liver) albumin is a major plasma protein in the bloodstream necessary for maintaining pressure of the vascular system with low albumin, fluid leaks out from interstitial spaces into the peritoneal cavity, which produces ascites

thrombocytopenia

Low level of platelets (thrombocytes), caused by medication (chemo/radiation), pregnancy, or altitude.

what scoring tool is used to prioritize pts in the liver transplant list?

MELD score - Model for End-Stage Liver Disease -serum bilirubin -- assesses how well the liver excretes bile -serum creatinine -- measures kidney function; impaired function is often associated w/ severe liver disease -INR -- measures ability to make blood clotting factors -predicts 3-month mortality rates for pts with chronic liver disease; the higher the MELD score, the higher the likelihood of mortality

Transcranial Magnetic Stimulation

Magnetic field passes through the skull, causing cells in the cerebral cortex to fire. It is thought that the magnets cause a disruption in depression.

Care of pts with acute heart failure exacerbation

Maintain cardiac output: monitor vital signs and oxygen saturation, monitor BNP levels (indicate severity of heart failure), auscultate heart and breath sounds (S3 and S4 sounds are an early sign of heart failure as well as crackles in the base of the lungs), administer O2 as needed, administer medications as ordered, encourage bed rest, elevate the head of the bed, provide bedside commode, instruct to avoid Vulsalva maneuver Monitor fluid volume: assess respiratory status and auscultate lung sounds, monitor I&O (decrease in urine output of less than 30mL/ hour indicates reduced cardiac output and renal ischemia), weight daily, record abdominal girth, record and monitor patient's hemodynamic measurements, restrict fluids as needed, offer ice chips and mouth care frequently as well as provide hard candies Monitor activity: organize nursing care to allow for rest periods, assist patient with performance of ADLs as needed, use active and passive movements, provide written and verbal education materials Provide low sodium diet: explain rationale for sodium restriction, consult with dietician

SCI nursing interventions

Manage emergent and urgent problems: immobilize spine, provide adequate airway, monitor vital signs, ABGs, and machines that are being used to help stabilize the patient, once patient is stabilized focus on skin wounds, bone fractures, loss of bladder and bowel control, encourage fluid and fiber intake, assess the client for complications like blood clots, infections, pressure sores, and distended bladder

HypERthyroidism Meds

Methimazole (Tapazole) is the most common med given bc it has fewer side effects and is the treatment option for Graves disease. Propylthiouracil is the med given if a women is pregnant because it is safer in the first trimester than Tapazole. Side effects of both medications are agranulocytosis and aplastic anemia. Educate on the items that were mentioned above as well as they will not see improvement right away because the medication's therapeutic effects will not be seen for a few weeks Beta blockers: Inderal to decrease heart rate, blood pressure, and heat intolerance. Educate patient to monitor their heart rate and to follow parameters if there are any that exist from their doctor Radioactive iodine: is a pill that destroys the thyroid gland overtime, is a permanent cure, do not give to pregnant or nursing women, side effects are a metal taste in the mouth, nausea, and swollen saliva glands

care of pts with aneurysms

Monitor circulation, temperature, color, edema, vital signs, respiratory status, fluid balance, and monitor for arrhythmias

The nurse is caring for a post-op Craniotomy patient. What special precautions should the nurse take? (Select all that apply)

Monitor for CSF leaks Keep neck in midline position Provide a quiet environment

A pediatric client is receiving IV antibiotics for the treatment of a Staphylococcus aureus infection. Which nursing interventions are appropriate when providing care to this client? Select all 4 that apply.

Monitor for allergic reaction. Assess renal and liver function. Monitor vital signs. Encourage adequate fluid intake.

The nurse is caring for a patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What is the nurse's best action?

Monitor for changes in level of consciousness

A client with terminal lung cancer is experiencing shortness of breath. The nurse notes bilateral crackles and wheezes, despite oxygen at 4 liters per minute via nasal cannula and diuretic therapy. What nursing interventions are most appropriate for this client? Select all 3 that apply.

Morphine Elevate HOB Use of fan

The nurse cares for a patient with burn injuries. Which intervention should the nurse implement to appropriately reduce the patient's pain?

Morphine sulfate

SIRS criteria

Must meet 2 or more of the following: Temp >38C or <36C HR >90 beats/min RR >20 breaths/min or PaCO2 <32 torr WBC >12,000, <4,000, or >10% immature (band) form 2+ SIRS + suspected infection = sepsis severe sepsis can lead to septic shock

Nephritis and glomerulonephritis

Nephritis is an inflammation of the kidney. Glomerulonephritis is specifically inflammation of the glomerular capillary membrane.

During a home visit, the nurse is concerned that an older adult client is developing renal failure. The client has no history of cardiovascular disease. Which data in the client's assessment caused the nurse to have this concern? (Select all two that apply).

New onset of hypertension 2+ Pitting Edema

A hospice nurse is critically evaluating various models of grief used for terminally ill clients and their families. Which should the nurse recognize when applying these models to individual client cases?

No clear timetables exist, nor are there clear-cut stages of grief.

Management of SCI

Nonsurgical management Immobilization Drug therapy (look out for resp. depression) Surgical management -- halo = pins all around the spine Community resources -- social work: getting medical equipment, support groups

Other notes - elimination

Normal urine output (1,500mLs daily for adults) Normal adult fluid intake: 2,150-2,450 mL/day, including food and water Fluid and electrolyte values Sodium (Na+) Most abundant cation in ECF. 135-145 mEq/L serum Potassium (K+) Major cation in ICF. 3.5-5.3 mEq/L serum. 125-140 mEq/L ICF Calcium (Ca²+) 9-11 mg/dL serum. 4.25-5.25 mg/dL normal ionized/unbound. Magnesium (Mg²+) 1.5-2.5 mEq/L Chloride (Cl-) Major anion of ECF 95-105 mEq/L serum Phosphate (PO4-) Major anion of ICF 2.5-4.5 mg/dL serum Bicarbonate (HCO³-) In ECF and ICF, regulates acid base balance. Age, sex, and body fat affect total body water. Infants have the highest proportion of water (70-80% of body weight), and highest proportionate body surface

The nurse is planning education for an adolescent client recently diagnosed with hepatitis B. The client recently moved back in with his parents. Which recommendation to the client's parents will best prevent them from acquiring hepatitis B (HBV) if they do come into contact with contaminated blood or body fluids?

Obtain post exposure prophylaxis.

The nurse on a medical-surgical unit is in charge of making nurse-patient assignments at the beginning of the shift. Which task should the nurse delegate to the licensed practical nurse (LPN)?

Obtaining vital signs on a patient who is 2 hours post-operative after a cardiac catheterization.

Which are typical signs and symptoms of left-sided heart failure? (Select all that apply.)

Orthopnea (SOB when lying flat) Crackles Persistent cough

Intracranial regulation meds

Osmotic Diuretics: Reduce ICP by reducing Fluid --Mannitol Sedatives: Reduce metabolic demand to reduce ICP --Propofol, lorazepam Analgesics: Pain control to reduce oxygen demand --Fentanyl, morphine Antiepileptics: seizure control --Phenytoin, valproic acid Glucocorticoids: Cerebral edema assoc. With pathogenesis ==Dexamethasone Antipyretics: Fever control to reduce metabolic demand --Acetaminophen Antihypertensives: Reduce BP in hemorrhagic stroke --Labetalol, transdermal nitroglycerine paste, nicardipine Antiparkinsonian agents: Restore balance of dopamine in brain --Levodopa. Etc. Cholinesterase inhibitors: Dementia --Donepezil, rivastigmine, galantamine, memantine

Lab values:

PT normal: 11-12.5 seconds INR normal: 2.0-3.0 (therapeutic for people taking warfarin), if not taking warfarin the value should be 0.9-1.1 PTT normal: 60-70 seconds aPTT normal: 30-40 seconds (but double for a therapeutic range when discussing warfarin (60-80 seconds)) Fibrinogen normal: 200-400 mg/dL Platelet normal: 150,000-400,000 per microliter

Assessing amount of burn

Palmar surface area Wallace Rule of Nines: note that the arm includes the hand, leg includes the foot/buttock Lund & Bowner: used for children

During the emergent phase of a burn injury, the nurse should monitor the patient for which of the following gastrointestinal complication that may lead to a bowel obstruction?

Paralytic ileus

The Nurse knows that the group at highest risk of developing an Aneurysm are which of the following?

Patients with atherosclerosis

The novice nurse accepts a job working on a long-term care unit. Nursing care that is required includes caring for clients at the end of life. Which behavior by the nurse indicates a healthy response to the dying client and family?

Paying close attention to details regarding the pain and comfort measures for the client

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply)

Performs gloved dressing changes Frequent handwashing Patients room at warm temp

Meds & Nurs Considerations (for clotting disorders)

Pharmacotherapy- Clotting factor replacement, Stimulating agents, Anticoagulants, Antiplatelets, Direct thrombin inhibitors, and Thromobolytic agents. Disseminated intravascular coagulation: ● Heparin- controversial because it may exacerbate bleeding in addition to prevent further clotting; heparin interferes with clotting cascade and prevents even more clotting consumption; it is used when bleeding cannot be controlled with the use of platelets or plasma and when there are signs and symptoms of thrombotic problems Deep venous thrombosis: ● Low molecular weight heparin ● Oral anticoagulation ● Heparin: aPTT needs to be around 2x the control (so about 60-80) ● Warfarin: given with the IV heparin for at least 4-5 days; needs to be taken for at least 5 days to see the full effects of the medication; adjust dose so that INR is around 2.0- 3.0; continue medication for at least a total of 3 months Nursing Prevention: Position to promote venous blood flow, elevate feet with knees slightly bent, avoid pillows under knees, avoid sharply flexed hips and knees, use recliner, footstool, early ambulation, teach ankle flexion and extension exercises, apply elastic stockings, PCD, avoid crossing legs, possible prophylaxis with heparin or warfarin (high risk clients) and assess IV site (change location with evidence of inflammation)

The nurse is planning care for the client with acute kidney injury. The nurse plans the client's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis?

Pitting edema in the lower extremities

A client agrees to receive long-term hemodialysis. The nurse anticipates developing a teaching plan for which surgical procedure?

Placement of an arteriovenous fistula

A preadolescent client who fell from a balance beam in physical education is diagnosed with an ankle fracture. Which action by the nurse is appropriate?

Placing an ice pack on the ankle Feedback: An appropriate intervention for a client who experiences an ankle fracture is placing ice on the ankle to limit swelling

The nurse is caring for an adult client who sustained a right distal radial fracture and a left tibia fracture. Which mobility aid is appropriate for this client?

Platform crutches Feedback: Platform crutches are used for clients who are unable to bear weight on their wrists. A walker, axillary crutches, and Lofstrand crutches all require the use of the wrists.

Risk factors: clotting/perfusion

Preeclamsia/ ecclampsia risk factors: african american, older than 30 or 35 years old, suffer from chronic hypertension, obesity, coagulation disorders, diabetes mellitus, kidney disease, family history or personal history, nulliparity, twin pregnancy (or more), fetal development abnormalities Aneurysm risk factors: male, over the age of 60, smoke, suffer from hypertension Pulmonary embolism risk factors: prolonged immobility, smoke, are a women who is pregnant, going through childbirth, uses oral contraceptives or estrogen therapy, MI, obesity, heart failure, surgery (orthopedic)/ trauma (hip/ femur fracture), Virchow's Triad (stasis of blood, blood vessel wall damage, altered coagulation- increased), advanced age Heart failure risk factors: 65 years old or older, African Americans, obesity, clients with a history of MI, men, smoke, suffer from substance abuse, hypertension, diabetes mellitus, cardiomyopathy, heart valve disease, arrhythmias, congenital heart defects, history of heart attacks, severe lung disease, sleep apnea

The nurse is planning care for a male client admitted with heart failure. Based on this diagnosis, which type of renal failure is the client at an increased risk for experiencing?

Prerenal low cardiac output

The nurse in the emergency department is preparing to administer methylprednisolone to a client with a spinal cord injury. Which effect will this medication have on the client?

Prevent cord damage from ischemia and edema

Burns

Prevent hypovolemia: give lots of fluids (LR) Pts w electrical burns are most at risk for arrhythmias: -- also want to put on tele -- risk for SCI Tetanus shot -- everyone should get it if they have not received in the past 5 yrs -- give early and ASAP -- given to people w burns to prevent infection, & will be given through burns if needed Thermal burns -- heat related, scalding, fire -- can go all the way to the bone -- most common -- radiation, chemo, sun related Chemical burns -- precautions while addressing these: identify the agent & dilute the burn -- alkalize are worse as far as causing damage than acidizing

A burn patient has survived the emergent phase of a burn injury. The nurse is preparing to to care for the patient in the acute phase going forward. The nurse anticipates the most important focus of the patient's care is which of the following?

Preventing infection

You are providing orientation to a novice RN who is preparing to administer packed red blood cells (PRBC's) to a patient who had blood loss during surgery. Which action by the novice RN requires that you intervene immediately?

Priming the transfusion set using 5% dextrose in Lactated Ringer's solution

Disseminated Intravascular Coagulation (DIC)

Process: ■ inflammation activates clotting factors, this causes uncontrolled thrombi formation which then leads to a depletion of clotting factors leading to a massive hemorrhage Causes: ● epithelial damage ● severe tissue damage (burns, trauma, head injury) ● recent surgery ● sepsis ● cancer ● pregnancy complications ● shock ● blood transfusion reactions Presentation: ■ Hemorrhage stage: ● Bruising, pericheia, epistaxis, hemorrhage, decrease in BP ■ Clotting stage: ● clots in CNS: headache, weakness, seizure, coma ● renal clotting: poor urine output, renal failure ● PE/MI: cough, SOB, chest pain, respiratory distress Interventions: ■ Treat cause ■ treat the stage they are in (clotting or hemorrhage). ■ often treated with heparin but depends where in the disease process ■ Manage fluids

Manifestations of Graves disease

Proptosis: forward displacement of the eye Also known as exophthalmos Results from accumulation of inflammation by-products in the retro-orbital tissues

A client with acute kidney injury is complaining of a metallic taste in the mouth and has no appetite. Based on this data, which intervention by the nurse is most appropriate?

Provide mouth care before meals.

Which of the following nursing actions included in the plan of care for a client with cirrhosis can the RN delegate to the unlicensed assistive personnel (UAP)?

Providing oral hygiene before meals

A client with a 2-month-old child is experiencing insomnia, mood swings, and crying. Based on this data, which would the nurse anticipate the client would benefit from receiving? Select all 2 that apply.

Psychosocial therapy Antidepressants

Burn diagnostics

Pulse oximetry: allows for continuous assessment of O2 saturation levels, except in clients with carbon monoxide poisoning (in this, oxygen saturation levels are falsely elevated) Carboxyhemoglobin measurement: used venous and arterial blood to measure the % of hgb that is bound to carbon monoxide Serial ABGs: will show the presence of hypoxia, acid-base disturbances, and help measure the client's response to the past treatments (patient with a burn may show elevated or lowered pH, decreased PCO2 and PO2, and low to normal HCO3 levels) Serial 12 lead ECG: monitor dysrhythmias development Serial chest x-ray: will evaluate the development of atelectasis, pulmonary edema, or ARDS Urinalysis: will evaluate renal perfusion and client's nutritional status CBC: hematocrit will be elevated and hemoglobin will be decreased and WBCs will be elevated Serum electrolytes: sodium levels are generally decreased, potassium levels will be initially elevated and then decreased after burn shock resolves Renal function: BUN and creatinine are elevated Total protein, albumin, transferrin, prealbumin, retinol binding protein, alpha one-acid glycoprotein, and C-reactive protein levels: evaluated during the rehabilitation phase Creatinine phosphokinase: elevated following an electrical burn

The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP). Which assessment data indicates that the nurse is successful? (Select all that apply)

Pupils equal and reactive to light Oxygen saturation 93% via pulse oximetry

The nurse is concerned that an older adult client is at risk for developing acute kidney injury. Which information in the client's history supports the nurse's concern? (Select all three that apply).

Recent aortic valve replacement surgery Prescribed high doses of intravenous antibiotics Diagnosed with hypotension

The nurse is planning care for a client with chronic kidney disease and osteoporosis. After reviewing the client's medical record, which is the priority nursing diagnosis for this client?

Risk for Injury

The nurse assesses a young adult client who was involved in a swimming accident, resulting in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this data, which nursing diagnosis is the most appropriate for this client?

Risk for Post-Trauma Syndrome Feedback: The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome

A patient has a Traumatic Brain Injury and a positive halo sign. The patient is in the ICU, sedated and on a ventilator. The patient's is in critical but stable condition. What collaborative problem does the nurse know takes priority at this time?

Risk for acquiring an infection

An older adult client tells the nurse about rarely going outdoors in the winter because of a lack of energy or desire. Based on this data, which does the nurse suspect the client is experiencing?

SAD

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which possible classifications of medications might the nurse prepare to administer to this client? (Select all that apply)

Sedatives Antiepileptic drugs Opioids Loop Diuretics Osmotic Diuretics

Burn manifestations

Skin loss, sensory loss, decreased temp, decreased BP, increased pulse, decreased RBCs, decreased cardiac output, decreased tissue perfusion, hypoxia, increased respirations, rhonchi, airway obstruction, hyperacidity in the GI, hematemesis, increased abdominal girth, decreased GFR, increased creatinine and BUN, myoglobinuria, decreased T and B-Cells, increased WBCs, decreased proteins, acidosis, and hyperglycemia

The Rehab nurse is caring for a patient who has suffered a recent T12 spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action?

Speak with the patient about past elimination habits

The nurse is caring for a heart failure patient with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition?

Speech alterations

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What should the nurse ensure while caring for this client?

Stabilization of the neck and spinal cord

Burn injury: Rehab Phase

Starts w/ wound closure & ends when pt returns to highest functional level Priorities: psychosocial adjustment, prevention of scars/contractures, return to preburn activities, achieve max function and independence

Virchow's Triad:

Stasis of blood, vessel damage, and increased blood coagulability are the three factors associated with thrombophlebitis.

Stridor

Strained shrill heard during inspiration due to an airway obstruction

The nurse is concerned that a client whose spouse died 2 years ago is experiencing complicated grief. Which should the nurse consider when planning care for the client? Select all 4 that apply.

Substance abuse assessment Alcohol abuse assessment Psychotherapy Monitoring for suicidal behavior

Burn classifications

Superficial burns: Involves only the epidermal layer Most often results from sunburn, UV light, minor flash injury, or mild radiation Pink - bright red in color May be accompanied by slight edema Usually heals in 3-6 days Partial-thickness burns: Deeper than superficial burns Involves both the epidermis and dermis Superficial partial thickness burn: Extends from the skin's surface into the papillary layer of the dermis Often bright red, have a most, glistening appearance with blister formation Typically heal in 21 days with no or minimal scarring BLANCHABLE Deep partial-thickness burn: Involves the dermis but extends deeper into a superficial partial-thickness burn, past the papillae & into the reticular layer Hair follicles, sebaceous glands, & epidermal sweat glands remain intact The surface appears pale and waxy; may be moist or dry Often require more than 21 days of healing NONBLANCHABLE Full-thickness burn: Involve all layers of the skin' May extend into subcutaneous fat, connective tissue, muscle, and bone Caused by prolonged contact with flames, steam, chemicals, or high-voltage electric current May appear pale, waxy, yellow, brown, mottled, charred, or non-blanching red Surface is dry, leathery, and firm to the touch Thrombosed blood vessels may be visible No sensation of pain or light touch at the site bc pain & touch receptors have been destroyed Singed nostrils, black mucous: looking for resp issue

Staging of burns

Superficial/1st degree Partial thickness/2nd degree Deep partial thickness/3rd degree Full thickness/4th degree

Categories of clotting problems:

Systemic- Problem extends throughout the entire body and is usually a result of a significant hematologic event. Localized- Problem in a specific area, usually a vein or artery.

procedure that can be done to improve portal HTN & reduce the likelihood of acute variceal bleeding

TIPS procedure -- Transjugular Intrahepatic Portosystemic Shunt -invasive procedure to reroute blood flow in the liver & therefore reduce pressure in surrounding veins -stent is placed b/t portal vein & one of the hepatic veins -often is very successful at controlling bleeding, but the new connection may narrow & cause re-bleeding at a later time -can also cause worsening hepatic encephalopathy bc blood flow to the liver is reduced, & toxic substances in blood are no longer metabolized by the liver

The nurse is caring for a client with severe inflammation. Which assessment findings would indicate a systemic reaction to inflammation? Select all 2 that apply.

Tachycardia Tachypnea

The nurse is caring for a client who is diagnosed with dysfunctional grieving after the loss of a child. Which treatment approaches are appropriate for the nurse to include in the plan of care for this client? Select all 3 that apply.

Talk therapies Antidepressants Cognitive therapy

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply)

Tape a halo wrench to the client's vest. Assess the pin sites for signs of infection. Assess the chest, back of neck and back for skin breakdown.

The nurse identifies the nursing diagnosis of grieving as appropriate for the family of a terminally ill client. Which family behavior supports this diagnosis?

Tearful and sad

Parkland formula

The Parkland formula for the total fluid requirement in 24 hours is as follows: 4ml x TBSA (%) x body weight (kg); 50% given in first eight hours; 50% given in next 16 hours.

A client was discharged after hospitalization for acute pancreatitis. Discharge instructions included: the use of analgesics, the importance of avoiding alcohol and smoking, and recommendations for a low-fat diet. Which outcomes would indicate that the client has implemented the recommendations? Select all 4 that apply.

The client experiences reduction or elimination of pain. The client is free from alterations in nutritional status. The client remains free from alterations in fluid balance. The client is free from nausea.

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that the interventions have been successful?

The client is improving in ability to perform self-urinary catheterization. Feedback: An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits.

During a home care visit, an older adult client states to the nurse, "my wife died 3 years ago." Which client action is a possible indicator that the client is experiencing complicated grief?

The client shows the nurse his wife's craft room and states that it remains just as she left it before she died.

A nurse is assigned to care for the following four patients on a medical floor. Which patient does the nurse know should be assessed first?

The client with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. Feedback: muscle twitching is a sign of early sodium imbalance. if an immediate intervention isnt made, the client could begin to seize

A school-age client is experiencing photophobia, a sore neck, chills, and fever. During a physical assessment, the nurse uses the technique in the Exhibit. Why did the nurse use this technique when assessing the client?

The client's symptoms indicated meningitis.

The nurse is caring for a homosexual client who has just died due to complication associated with acquired immune deficiency syndrome (AIDS). The client's partner is still in the room and is dry-eyed and exhibiting somber behavior. The nurse offers condolences to the partner, realizing that the partner expects which to occur?

The community will not allow the partner to grieve openly.

A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the nurse, "I'm getting worse. It's harder to breathe." Based on this data, which does the nurse suspect?

The extent of injury cannot yet be determined. Feedback: With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days.

The nervous system

The nervous system works with the skeletal, muscular, and circulatory systems by making red and white blood cells. The blood provides oxygen, calcium, and other nutrients to strengthen the bones and transports electrolytes which are used with muscle movement. The nerves innervate the muscles to provide the electrical stimulus needed to stimulate contraction.

Types of burns

Thermal burns: exposure to heat (dry: flames, wet: steam, hot liquids) Chemical burns: direct contact between skin and cerin acids, alkaline agents, or organic compounds Electrical burns Radiation burns: sunburn or radiation treatment for cancer or a nuclear power accident

An older adult client in the terminal phases of a debilitating muscular disease believes the healthcare team has "failed" and "given up" and "aren't trying as hard." On which belief should the nurse plan interventions for this client?

This is a common fear in the terminally ill client.

Mood and affect diagnostics

Thyroid function tests since thyroid disorders may mimic depression or hypomania. Electrolyte panel, urinalysis, toxicology to rule out substance abuse. Liver function tests-antidepressant medications are metabolized in the liver. Pregnancy Test-females of reproductive age since antidepressants may affect fetal development

A 75 year-old patient presents to the ED with a Heart rate of 30 BPM, B/P 85/40 and complaints of dizziness. The nurse observes that the patient is sweating profusely. The patient is given an IV dose of Atropine without improvement. What would be the next intervention?

Transcutaneous Pacing

Pacing

Transcutaneous: used in a code situation/ emergency ● Is painful, make sure that patient is sedated, considered short term treatment Temporary transvenous: used for trauma, malfunction of permanent pacers, drugs, and electrolyte imbalances ● Temporary pacing wires inserted through a sheath in a large vessel typically in the internal jugular vein, into the heart, can pace atrial or ventricular Temporary epicardial: primarily used after cardiac surgery ● Electrodes are placed during cardiac surgery on epicardium, able to provide pacing to atrial or ventricular, hooked to an external energy pulse generator Permanent: used when a patient has a bradyarrhythmia, AV conduction block, or suppression of ectopy, heart block, 3rd or advanced 2nd degree block, bradycardia ● Wires are implanted surgically, pocket is made for pacemaker to sit usually in the left infraclavicular region (or right side if patient is left handed-but place on opposite side in which the person is dominant), battery lasts about 8-10 years

Antidepressants

Tricyclic antidepressants: three-ring chemical structure. Inhibits the reuptake of norepinephrine and serotonin into presynaptic nerve terminals. Used for major depression. Side effects: orthostatic hypotension and cardiac arrhythmias, dry mouth, constipation, urinary retention, excessive perspiration, blurred vision, and tachycardia. Monitor clients condition and provide education. Monitor for suicide ideations Selective serotonin reuptake inhibitors: reuptake of serotonin into presynaptic nerve terminals. Increases the availability of serotonin into the synaptic cleft for postsynaptic receptors. First-line therapy. Nurses need to obtain baseline liver function tests and baseline height and weight. Monitor clients condition and provide education. Monoamine oxidase inhibitors: inhibits monoamine oxidase which is the enzyme that terminates the actions of neurotransmitters such as dopamine, norepinephrine, epinephrine, and serotonin. Prescribed if clients don't respond to TCA's or SSRIs. Side effects include orthostatic hypotension, headache, insomnia, and diarrhea. Hypertensive crisis and cardiac problems can occur. Monitor client's condition and provide education, especially on foods containing tyramine. Assess cardiovascular status and obtain a CBC because of platelet function. May lower seizure threshold. Atypical antidepressants: (examples: Cymbalta and Effexor). Inhibit reabsorption of serotonin and norepinephrine and elevate mood by increasing levels of serotonin and norepinephrine and dopamine in the CNS.

2 classic "signs" seen in pts with hypocalcemia

Trousseau sign: spasms of hands & feet Chovstek's sign: facial twitching

Diagnostic tests for pancreatitis

US: identify gallstones, a pancreatic mass, or pseudocyst ● Endoscopic US: changes indicative of chronic pancreatitis ● Contrast enhanced CT scan: identify pancreatic enlargement, ductal calcifications, fluid collections in or around the pancreas, and perfusion deficits ● Magnetic resonance cholangiopancreatography: allows visualization of the bile and pancreatic ducts ● Endoscopic retrograde cholangiopancreatography: diagnoses chronic pancreatitis and differentiates inflammation and fibrosis from carcinoma ● Percutaneous fine needle aspiration: differentiate chronic pancreatitis from pancreatic cancer

The nurse is caring for a client who is experiencing a systemic infection after a total knee replacement. Which diagnostic tests will be used to validate the presence of this infection? Select all 4 that apply.

Urinalysis Wound culture White blood cell differential White blood cell count

A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply)

Urine osmolality is increased. Urine output is decreased Specific gravity is increased.

A make patient has a platelet count of 42,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Use a lift sheet when needed to re-position the patient. Shave the male client with an electric razor Help the patient choose soft foods from the menu.

The nurse is teaching a class on infection control. Which nursing measure is most appropriate in breaking a link in the chain of infection?

Use personal protective equipment (PPE).

Priority assessment for cirrhosis

VS (hypertension), mental status, color & condition of skin and mucous membranes (look for jaundice), peripheral pulses (bonding), presence of peripheral edema, listen to lung sounds. discuss eating habits (is likely to cause nausea, anorexia), abdominal assessment (appearance, shape and contour, bowel sounds, abdominal girth. percussion for liver borders, and palpation for tenderness and liver size), characteristics of bowel movements (clay-colored or brown colored or blood in the stool or diarrhea or constipation), weight. assess for JVD, maintain skin integrity (warm water rather than hot when bathing patient, apply an emollient or lubricant to keep skin moist, turn client at least every 2 hours, administer prescribed antihistamine if needed).

A client is assessed at being in the Progressive stage of Hypovolemic shock. Which parameters does the nurse correlate with this stage of shock? (Select all that apply)

Vital organs develop hypoxia Patient has a change in MAP of greater than 20 mm Hg. decreased cardiac output Patient expresses feelings of impending doom.

Postdialysis care (peritoneal)

Vital signs ii. Time meals to correspond with dialysis outflow (meals while the abdomen is empty of dialysis enhances intake and reduces nausea) iii. Teach the client and family about the procedure

Predialysis care (peritoneal)

Vital signs ii. weight daily or in-between dialysis runs iii. Note BUN, serum electrolyte, creatinine, pH, & hematocrit levels before peritoneal dialysis iv. measure & record abdominal girth v. fluid and dietary restrictions as ordered vi. have client empty their bladder vii. warm the dialysate solution to body temp using a warm water bath or heating pad on low setting

The nurse is caring for a client who is at risk for developing an alteration in mobility. Which modifiable risk factor will the nurse focus in order to decrease the risk?

Weight

Mobility diagnostic tests

X-rays: can reveal major vertebral fractures or other bone problems, useful for determining both the location of the injury and if the spinal cord is being compressed CT scans/ MRIs: more sensitive at detecting abnormalities than X-rays, especially when damage is done to the soft tissue and small fractures, useful for determining both the location of the injury and if the spinal cord is being compressed Myelogram: contrast dye is used to study the spinal cord and nerve, used when patients have back pain Arthrography: injection of a radiopaque substance into the joint cavity which allows for evaluation of the bones, cartilage, and ligaments (most commonly performed on the knee and shoulder joints) ABGs: evaluate oxygenation and ventilation Hemoglobin: detect major blood loss Hematocrit: detect major blood loss

A nurse prepares to administer intravenous ranitidine (Zantac) to a patient who has a new burn injury. The patient asks, "Why am I taking this medication?" How should the nurse respond?

Zantac helps prevent stomach ulcers

The nurse is aware that Cardiac output is a calculation of

___heart rate__ multipled by __stroke volume___.

Adjustment Disorders with Depressed Mood / Situational Depression

a change in mood and affect following a stressor, such as the end of a relationship or any life-altering event. It typically begins 3 months after the event and lasts about 6 months

Cellulitis

a common, bacterial skin infection (staph or strep usually) that is potentially serious. Inflammation is evident, with typical signs of pain, redness, swelling and warmth. It usually occurs in lower legs, but can occur in arms, face, or other areas of the body. Risk factors for cellulitis include skin injury, a weakened immune system, chronic skin conditions such as eczema or shingles, lymphedema (chronic swelling of arms or legs), a history of cellulitis, and obesity

SIADH - Syndrome of Inappropriate Antidiuretic Hormone

a condition in which the body makes too much antidiuretic hormone (ADH). This hormone helps the kidneys control the amount of water your body loses through the urine. SIADH causes the body to retain too much water

Postpartum Depression

a depressive disorder associated with pregnancy, now recognized as starting during pregnancy approx. 50% of the time, is also called major depressive disorder with peripartum onset

Bipolar Disorders

a group of mood disorders that include manic, hypomanic, and depressive episodes

Contact dermatitis

a hypersensitivity/ allergic reaction to contact with a substance like soap, metals, cosmetics, or paint. An uncomfortable red rash develops, but is not life threatening.

Hemodialysis

a small amount of blood is taken out of the body and put into a filter in the dialyzer, cleaned and put back into the body. This is normally done over and over through a period of 3-4 hours, 3 times a week. Requires one tube/needle to take the blood out of the body and one tube/needle for blood to be put back into the body

Venous ligation

a surgical tying of veins to prevent pooling of blood

Cerebral edema

a symptom common to many conditions of impaired intracranial regulation. Regardless of the cause, it results in an increase in brain size, negatively affecting oxygenation and perfusion of the brain. Causes include -Mass lesions --- Brain abscess --- Brain tumor --- Hematoma --- Hemorrhage -Head injuries and brain surgery --- Contusion --- Hemorrhage --- Post-traumatic brain swelling -Cerebral infection --- Meningitis --- Encephalitis -Vascular insult --- Anoxic and ischemic episodes --- Hemorrhagic stroke --- Ischemic stroke (thrombotic or embolic) --- Venous sinus thrombosis -Toxic or metabolic encephalopathic conditions --- Lead or arsenic intoxication --- Hepatic encephalopathy --- Uremia

most common cause of cirrhotic death

acute variceal bleeding

common complications of cirrhosis

acute variceal bleeding portal HTN hepatic encephalopathy: disturbance in brain function due to liver disease coagulation disorders hepatorenal syndrome: renal failure due to liver failure; changes in blood circulation in the portal venous system and the arterial system lead to changes in blood flow to kidneys causing renal disease and potential failure ascites and spontaneous bacterial peritonitis (most common organism is E. coli)

common causes of cirrhosis

alcohol consumption meds autoimmune disorder chronic viral hepatitis metabolic liver disease budd-chiari syndrome: rare occlusion of the hepatic vein that drains the liver (a type of vascular disease)

hepatic encephalopathy

ammonia builds up & stays in blood, makes its way to the brain; causes loss of brain function/neuro changes ammonia is a toxic product from protein digestion

Diabetes Insipidus

an uncommon disorder of salt and water metabolism characterized by intense thirst (polydipsia) and excessive urination (polyuria)

signs of cirrhosis

ascites jaundice confusion/altered mental status fetorhepaticus: musky breath caputmedusa: distended & enlarged superficial veins across the abdomen hepatic encephalopathy

Burn assessment

assess for airway, breathing, circulation, disability, & exposure assess for the time of the injury, the cause of the injury determine if the patient needs first aid treatment assess what type of medications the patient takes regularly determine the patient's age and their body weight.

A patient with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). which interventions should the nurse implement?

assess for nausea and vomiting and weigh daily

The Unlicensed Assistive Personel (UAP) reports to the nurse that the water pitcher was refilled 4 times during the shift for a patient with a closed head injury and the client has asked for the pitcher to be filled again. which intervention should the nurse implement first?

assess the client for polyuria and polydipsia Feedback: the first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabetes insipidus, a complication of the head trauma

Arterial Thrombus:

associated with conditions that increase platelets or erythrocyte production or create turbulent blood flow with platelet adhesion.

Which instructions should the nurse include when developing a teaching plan for an elderly client being discharged from the hospital on anticoagulant therapy after having a DVT? (Select all that apply.)

avoiding surface bumps because the skin is prone to injury checking urine for bright blood and a dark smoky color walking daily as a good exercise preventing DVT because of risk of pulmonary emboli performing foot/leg exercises and walking around the airplane cabin when on long flights

Cirrhosis NC

balance fluid volume: daily weight, assess for JVD, measure abd girth daily, check for peripheral edema, monitor I & O, assess urine specific gravity, & provide a low-sodium diet maintain mental status: assess neuro status, LOC, mental status, observe for signs of early encephalopathy (asterixis and changes in handwriting and speech), avoid hepatotoxic meds & drugs that depress the CNS, administer meds or enemas as ordered to reduce nitrogenous products, monitor bowel function, orient client to surroundings, person, and place minimize bleeding: monitor VS, report tachycardia or hypotension, implement bleeding precautions, monitor coag studies and platelet count maintain skin integrity: Warm water rather than hot water while bathing client, apply an emollient or lubricant to keep skin moist, turn client at least every 2 hours, administer prescribed antihistamine promote balanced nutrition: provide small meals with between-meal snacks, promote nutrient and protein intake by providing nutritional supplements, such as Ensure or instant breakfasts manage complications

procedure used to temporarily stabilize acute variceal bleeding

balloon tamponade (temporary fix) w/ Sengstaken-Blakemore tube or Minnesota Tube -tube is placed through nose or mouth & balloons are inflated to put pressure onto esophageal and/or gastric varices -is a temporary measure -always secure pt's airway through endotracheal intubation endoscopic variceal ligation banding -upper GI endoscopy after identification of esophageal varices; that applies "rubber band" type device around the area to tie them off & prevent blood flow & subsequent rupture; the banded varices eventually slough off & the esophagus is less likely to bleed at this area

gold standard test for assessing liver damage

biopsy liver biopsy results are reported in: stage 0-4 (fibrosis/scarring) grade 1-4 (inflammation)

Hemophilia:

bleeding disorder caused by mutated gene resulting in the absence of or ineffective production of clotting protein factors. Severity determined by the level of clotting factor. Hem A and Hem B=most common. Affects the X chromosome in males but females can carry the gene.

Hemiarthrosis

blood into joint spaces, as from an injury to a person with hemophilia.

Sepsis

body's response to a critical illness that can result from an infectious cause precipitating a whole body inflammatory process, SIRS is a precursor to sepsis, vasodilation, increased capillary permeability, and hypercoagulability all occur.

Pressure ulcers

breakdown of skin and underlying tissue as a result of sitting or lying on one area for a prolonged time, as in the case of immobility. Constant pressure disrupts perfusion to the area, leading to hypoxia and tissue breakdown

A patient is suspected of having a Hormonal Imbalance. What should the nurse expect to be monitored?

caloric Intake Serum Electrolyte levels Thyroid Studies

Quadraplegia

can't move/feel all 4 limbs

Depression

characterized by a sad or despondent mood or loss of interest in usual activities. One of the most common mental health disorders. Many symptoms including lack of energy, sleep disturbances, anxious distress, abnormal eating patterns, psychomotor retardation or agitation, and/or feelings of despair, guilt, or hopelessness

Atherosclerosis:

condition in which fatty deposits called plaque build up on the inner walls of the arteries. begins with injury to the endothelium, (from HTN from increased pressure of blood in the arteries creating a shearing force) and exogenous chemical agents such as toxins from cigarette smoke and endogenous agents such as cholesterol.

pt with a sengstaken-blakemore tube suddenly develops respiratory distress. the nursing action should be to:

cut the tube.

After a client has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective?

decrease in episodes of variceal bleeding

Hypothyroidism

decreased amount of thyrotropin releasing hormone, decreased amount of thyroid stimulating hormone, and decrease amount of thyroid hormone triiodothyronine (T3) and thyroxine (T4)

1st line of treatment for ascites

diuretics: lasix, spironolactone & sodium restriction given in morning

Blakemore tube

emergent procedure for esophageal varices that remains in the esophagus until going into OR

Cirrhosis

end stage of liver disease that is progressive, irreversible, and eventually leads to liver failure. The most common type is alcoholic cirrhosis. Three primary effects occur in cirrhosis that cause the manifestations that are seen within patients, disrupted liver cell function, impaired bilirubin conversion and excretion leading to jaundice, and disrupted blood flow through the liver with resulting portal hypertension.

Caput medusa

engorged periumbilical veins these veins are engorged often due to portal HTN; inability of the blood to flow through its normal pathway through the portal venous system, due to scarring within the liver; therefore, blood flows into small veins not designed to carry large amounts of blood, causing engorgement seen in pregnant & postpartum women

Nursing interventions for intracranial regulation

ensure airway patency, assess LOC, monitor fluid intake and output, reduce environmental stimuli, position client, take precautions for seizures, monitor ICP, perform neurological exam, measure vital signs

Hyperthyroidism

excessive amount of thyrotropin releasing hormone, excessive amount of thyroid stimulating hormone, and excessive amount of thyroid hormone triiodothyronine (T3) and thyroxine (T4)

Thyroid storm (a.k.a thyroid crisis)

extreme state of hyperthyroidism Hyperthermia; body temps 102-106 Tachycardia, systolic hypertension, GI symptoms Agitation, restlessness, tremors, progressing to confusion, psychosis, delirium, & seizures Treatment: aspirin, replacing fluids, glucose & electrolytes, relieve respiratory distress, stabilizing cardiovascular function, reducing TH synthesis & secretion

Hep A

fecal-oral route flu-like sx much more severe for immunocompromised & elderly incubation is 15-50 days

functions of the liver

filters toxins out (such as ammonia) bilirubin - liver gets rid of bilirubin fluid volume

ECG changes in hypokalemia

flattened t waves

Venous Thrombosis:

formation of a blood clot in a vein, usually from inflammation. This obstructs blood flow and may lead to deep venous thrombosis (DVT) when the thrombosis is located in a deep vein of the body.

A patient with a diagnosis of SIADH secondary to lung cancer tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. which action by the nurse is an example of the ethical principle of autonomy?

give the patient fluids as desired notify the health care provider of the patient's wishes

Prevention of bleeding

have the patient use an electric razor, a soft toothbrush, no anal temps/enema, and avoid activities that may cause bleeding such as contact or extreme sports.

Care of pt with AKI

i. Careful history is essential ii. Exposure to nephrotoxins and drugs iii. Anuria may indicate post-renal causes iv. Skin rashes may indicate allergic nephritis v. Evidence of volume depletion: diarrhea, bleeding vi. Ischemia or trauma to the legs or arms may indicate rhabdomyolysis vii. History of prostatic disease, nephrolithiasis viii. Recent surgical or radiologic procedures ix. Past and present use of medications x. Family history of renal diseases xi. physical examination should be focused to rule out possible differential diagnoses

Care of pt with CRF (CKD)

i. Dietary restrictions ii. Uremic frost -- bathing, taking care of skin iii. Muscle strength, energy iv. Family members -- education v. Excess fluid volume -- monitor I&O, fluid restriction as ordered vi. Monitor for decreased cardiac output vii. Recombinant human erythropoietin may be administered viii. Interdisciplinary team ix. Mouth care before meals

Assessment of fistula

i. Every shift at least ii. Auscultate for a bruit (whooshing of blood) iii. Palpate for thrill (little bit of vibration under skin) iv. You want to feel a big pulse

Intradialysis care (peritoneal)

i. Use a strict aseptic technique ii. add meds to dialysate iii. instill dialysate into the abdominal cavity over a period of 10 minutes iv. Clamp tubing and allow the dialysate to remain in the abdomen for the prescribed dwell time v. Observe for signs of respiratory distress vi. Place in Fowler or semi-Fowler position vii. Open tubing clamps and allow the dialysate to drain by gravity viii. Record the amount and type of dialysate instilled, dwell time, and amount and character of the drainage ix. Monitor BUN, serum electrolyte, and creatinine levels

Care of pt with nephrolithiasis

i. monitor for signs of infection, including fever, increased malaise, and an elevated WBC count ii. Avoid/minimize invasive procedures; if catheterization is needed, use sterile intermittent straight catheter or maintain a closed drainage system for an indwelling catheter iii. educate family on good hand hygiene iv. screen family members for presence of strep infection v. protect skin integrity (turn frequently, make sure skin is clean and dry) vi. Monitor vital signs, fluid and electrolyte status, intake and output vii. Prevent unnecessary fatigue -- assist with ADLs, reduce energy demands

Hashimoto thyroiditis (hypo)

in this autoimmune disease antibodies that develop destroy thyroid tissue, the tissue is replaced with fibrous tissue and thyroid hormone levels decrease

Superficial thickness wound

includes redness with mild edema, pain and increased sensitivity to heat.

Hepatitis

inflammation of the liver, usually caused by a virus or infectious agent. Liver function is disrupted from the inflammatory immune response. When the flow of bile is impeded, the patient experiences a yellow color called jaundice.

Thyroiditis (hyper)

inflammation of the thyroid gland Most often the result of a viral infection of the thyroid gland

Decreased mobility assessment

inspection and palpation of bones, muscles, and joints for deformities, tenderness, or pain. Perform range of motion (either active or passive) to determine the patient's ability to move muscle/ bone. Assess the 5 P's neurovascular assessment (pain, pulses, pallor, paresthesia, paralysis/ paresis). Assess the patient's gait, flexion and rotation of the spine, shoulders, elbows, wrists, fingers, hips, kness, ankles, and toes

Persistent vegatative state

irreversible coma; patient is unaware of self and their environment; patient loses all of their cognitive function; this is caused by the death of cerebral hemispheres; during this the patient's homeostatic regulatory functions remains intact

A client with advanced cirrhosis is receiving lactulose. Which finding by the nurse indicates that the medication is effective? The patient:

is alert and oriented

albumin can be used to help treat burns because

it helps hold fluid in intravascularly

treatment options for hyperkalemia

kayexalate acute dialysis insulin (facilitates uptake of glucose into the cell, which causes intracellular shift of K+)/calcium (stabilizes cardiac cell membranes to reduce likelihood of lethal ventricular arrhythmias like VT)/dextrose (to counteract blood glucose lowering effects of insulin)

HypERthyroidism Nursing interventions

keep the patient comfortable in a cool and quiet environment; obtain daily weights monitor EKG, heart rate, and BP values educate about medication and treatment options, monitor for thyroid storm. Nurse should educate to not stop taking medication suddenly, take medication at the same time every day educate the pt on the s & sx of a thyroid storm educate pt to avoid foods that are high in iodine like seaweed, dairy, and eggs do not take aspirin bc it increases the thyroid hormone Promote visual health, monitor for difficulty focusing, double vision, visual loss, dryness, trouble blinking, closing eyes. Promote balanced nutrition. Have client check weight daily, keep a record of weights, and consult a dietician for a diet to maintain a healthy weight. More Small meals may be preferable to a Few Large meals.

hemophilia A

lacking clotting factor 8

hemophilia B

lacking clotting factor 9

first line pharmacologic treatment for hepatic encephalopathy

lactulose -- cathartic med (accelerates defecation) absorbs the ammonia and pushes it out

Myxedema Coma

life-threatening complication of long-standing, untreated hypothyroidism Hypothermia, shallow edema, cardiovascular collapse, impaired mentation, and coma

Purpura

like petechiae only slightly larger spots

Pancreatitis NC

manage pain, restore nutritional status, meet fluid and electrolyte needs

Iodine deficiency (hypo)

may result from certain goitrogenic drugs; lithium carbonate & antithyroid drugs Iodine is necessary for synthesis & secretion of TH

priority assessment for sepsis

monitor VS (decreased BP, rapid, weak, thready pulse), hemodynamic status, CVP pressure (decreased <2mmHg) listen to lungs (crackles, wheezes, dyspnea) check capillary refill (prolonged), neck veins (flattened neck veins that cannot be seen) Adequacy of ventilation, perfusion, renal function. Monitor skin color,temp, turgor, & moisture monitor BP, rate/depth of respirations, pulse ox, peripheral pulses. Monitor for JVD, urine output, LOC.

Sepsis NC

monitor client's skin color, temp, turgor, & moisture (sepsis can lead to decreased perfusion which is evidenced by pale, cool, moist skin) monitor BP, rate & depth of respirations, lung sounds, pulse oximetry, peripheral pulses (monitors cardiopulmonary function) monitor client's jugular vein, CVP, temp, urinary output, assess mental status and LOC

HypOthyroidism nursing interventions

monitor for myxedema coma, monitor VS like HR, BP, as well as EKG, monitor weight, and keep patient warm. Nurse should educate pt to not stop taking medication suddenly, to take the medication at the same time every day in the MORNING WITHOUT food (one hour before eating breakfast), don't take with multivitamins or GI medications bc both decrease the absorption, & watch for signs and symptoms of toxicity developing (signs and symptoms of hyperthyroidism). Pts should not take narcotics or other sedatives because these pts are very sensitive to the meds Prevent constipation - encourage fluid intake, a high fiber diet, and activity as tolerated. Maintain skin integrity, monitor for redness or lesions, especially in sedentary clients. Promote circulation through turning, shifting body weight, using pillows or pads. Teach and implement range of motion exercises. Bathe using gentle soaps, oils, and techniques.

A nurse is plans the care of a patient with a diagnosis of SIADH. Which interventions should be implemented? (select all that apply)

monitor urine and serum osmolality restrict fluids per health care provider order assess level of consciousness every 2 hours

A client is admitted with a diagnosis of deep vein thrombosis (DVT) of the right leg. A loading dose of heparin has been given in the ED and IV heparin drip will be continued over the next several days. The nurse should develop a plan of care for this client that will involve:

monitoring the activated partial thromboplastin time

Graves disease

most common type of hyperthyroidism, is an autoimmune disorder in which an antibody in the individual's serum binds to thyroid stimulating hormone receptors and cause the thyroid cells to hyperfunction. When the antibody binds the thyroid gland stimulates hormone synthesis and secretion which causes the gland to grow larger

aldosterone and antidiuretic hormone

need to be secreted and regulated in the appropriate amounts to keep the amount of fluids and electrolytes balanced

which assessment is crucial for a pt with significant hyponatremia?

neuro checks every 1-2 hours they are at risk for seizures, coma, death

Hep C

no vaccine for this transmitted through blood (IV drug use, sexual contact, needle sticks) incubation period 7 weeks typically leads to chronic infection, w/ potential for cirrhosis

Ecchymoses

non-raised skin discoloration, bruising, a sign of escape of blood from ruptured vessels into tissues. (>1cm)

meds for primary & secondary prevention of acute variceal bleeding

noncardio-selective beta blockers -- decrease portal venous inflow through beta 1 adrenergic blockade & beta 2 adrenergic blockade propranolol 20 mg TID nadolol 40 mg daily titrated to a goal HR 55-65 bpm

Hep D

only occurs if you had Hep B typically develops into chronic disease spread through sexual contact, IV drug use changes in liver cells, liver ca

The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client's septic shock is trending towards disseminated intravascular coagulation (DIC)?

oozing of blood at the IV site

Pancreatitis

pancreatic enzymes are activated too early and digest the pancreas and surrounding tissues, also known as autodigestion, can be acute or chronic. There is inflammation of the pancreas.

Locked in syndrome

patient is alert, fully aware, and has intact cognitive function but can only communicate with the use of their eyes; patient cannot speak or move any part of their body, besides their eyes; the cause is hemorrhage of the pons which disrupts outgoing nerve tracts

ECG changes in hyperkalemia

peaked T wave premature ventricular contractions (excitability)

The nurse has given Morphine sulfate 4 mg IV as ordered to a patient with acute exacerbation of Heart Failure. When the nurse evaluates the client's response after giving the medication, which finding indicates a need for immediate further action?

persistent chest pain at a level of 5 (on a scale of 0 to 10)

meds administered for CRD pts to prevent high phosphorus levels

phosphate binders: renvela/sevelamer

Petechiae

pinpoint, round, red/purplish spots just under skin (<3mm)

Interventions for burns

promote fluid balance, provide effective pain management, protect skin integrity, prevent infection, maintain physical mobility, promote balanced nutrition remove clothing or jewelry apply cool water soaks (tepid) NO ICE flush chemical burns with a lot of water cover with a clean cloth obtain tetanus vaccine no greasy lotions/butters

testing for asterixis

put hands out, flipping them up

paracentesis procedure

removing fluid. voiding is encouraged prior to the procedure to prevent puncture of the bladder; pt positioned in an upright position typically about 2 liters are removed, but up to 4-6 liters can be removed in severe cases

To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which assessment test should the nurse initiate with the patient ?

request the patient extend both arms to the front and dorsiflex the wrists

Which laboratory value should the nurse monitor for the client with a diagnosis of Diabetes Insipidus?

serum sodium

A nurse admits a patient wiht a diagnosis of SIADH. Which clinical manifestations should be reported to the Health Care Provider immediately?

serum sodium of 112 mEq/L and a headache. Feedback: A serum sodium level of 112 is dangerously low, and the client is at risk for seizures. a headache is a symptom of a low sodium level

Hep A

should be most alert for FATIGUE. it is one of the 1st symptoms other symptoms include: anorexia, RUQ pain, & jaundice

Hep B

spread through blood & bodily fluids (sex, IV drug use, needle sticks) sx w/in 25-180 days of exposure: anorexia, N/V, fever, fatigue, RUQ pain, dark urine, jaundice most clear the virus and develop immunity, some become carriers babies get vaccination right after birth if on dialysis, at higher risk avoid sharing personal items

The UAP reports to the nurse that a patient with a diagnosis of Heart Failure is "feeling short of breath." The patient's blood pressure was 124/78 two hours ago with a heart rate of 82; the UAP reports that blood pressure is now 84/44 with a heart rate of 54 and the client stated, "I just don't feel good." Which of the following interventions should the nurse initiate?

stay with the client and reassure the client inform the charge nurse of the change in condition and initiate the hospital's rapid emergency response team confirm the client's vital signs and complete a focused assessment call the PHCP and report the situation using SBAR format position client in semi-Fowler's position

A client with cirrhosis and esophageal varices has a new prescription for propranolol. Which assessment finding is the best indicator that the medicaton has been effective?

stool for occult blood is negative

Increased intracranial pressure

sustained elevated pressure in the cranial cavity. ICP increases and decreases throughout the day depending on the type of activities in which the client is engaged. Coughing, sneezing, and straining increase ICP.

Brain death

the brain stops working and this is irreversible; the criteria for this are - Unresponsive coma with the absent of motor and reflex movements - Apnea - Fixed and dilated pupils - Absent ocular responses to head turning and caloric stimulation - Flat EEG - No cerebral blood circulation present on angiography These manifestations last for 30 minutes-1 hour and for 6 hours after onset of coma and apnea

Grief

the combination of various psychological, biological and behavioral responses to a loss Biological responses include weight loss, sleep disturbances, and decreased appetite. Psychological responses: anger, denial and depression. Behavioral responses: personality changes and decreased socialization. Anticipatory grief: the grief that is experienced, by the pt and the pt's loved ones, before the pt passes Disenfranchised grief: when an individual is unable to recognize a loss to others, usually because the grief is not a socially acceptable behavior Complicated grief: a longer lasting grief or more intensified grief which causes an individual to struggle to more through all of the stages of grief

Acute renal failure (ARF)

the kidneys suddenly lose their ability to filter waste from the blood. It is usually caused by trauma, sepsis, poor perfusion, or medications. Can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Excretion of excess electrolytes by urinary elimination helps maintain health

Peritoneal dialysis

the peritoneal cavity can be used as a filter and includes a catheter, in which warm, sterile dialysate is instilled. The waste products diffuse in the dialysate while it remains in the abdomen. The fluid is then drained out of the peritoneal cavity into the sterile bag. This is used with a manual bag, four times a day or exchanges automatically when a patient is sleeping.

following a liver biopsy, the pt should be positioned on:

their right side. this keeps a seal on the site of the biopsy to reduce the risk of bleeding/hemorrhage

Toxic multinodular goiter (hyper)

there are small, independently functioning nodules that secrete excessive amounts of thyroid hormone

Addison's Disease

too little cortisol in bloodstream

Cushing's Disease

too much cortisol in bloodstream

Smoking contributes to the formation of blood clots.

true

Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ pitting edema of the feet/legs?

use a pressure-relieving mattress

The prognosis of a patient with an altered LOC

varies, the underlying cause, pathophysiology, patients age, and general medical condition all play a role in the patient's outcome. Typically younger patients recover fully and/or more quickly. A patient's prognosis is poor if they lack pupillary reaction or reflex eye movement 6 hours after the onset of coma.

Hep E

waterborne infection typically seen in other countries fecal-oral route typically self-limiting

Quadriparesis

weakness/no sensation in all 4 limbs

Arterial Embolism:

when a clot forms in an artery, causing complete or partial blockage of blood flow. Most three common places : vessels in the heart (leading to cardiac ischemia or infarction), the brain (leading to ischemic stroke), or vessels in the legs (DVT).

Neomycin

works in gut, cuts down chemical that produces ammonia

Stages of Septic Shock

○ Initial ■ Oxygen perfusion is maintained ■ Compensatory mechanisms are effective ■ Reversible in this stage ■ Subtle changes make it difficult to detect ● Slight increase in HR or RR ● Slight increase in diastolic BP ○ Nonprogressive (compensatory) ■ Kidney and hormonal compensatory mechanisms kick in since cardiovascular system cannot sustain adequate perfusion. ■ Acidosis, tissue hypoxia ■ Begin to see signs and symptoms: ● Thirst ● Anxiety ● Restlessness ● Tachycardia and Tachypena ● Decreased urine output ● Falling BP ○ Progressive ■ Sustained decrease in BP ■ Compensatory mechanisms can no longer deliver sufficient CO2 ■ Organ hypoxia ■ Anorexia and ischemia ■ Signs and symptoms: ● Confusion ● Weak pulses ● Cyanosis/pallor ● Anuria ● Cool skin ○ Refractory and MODS ■ Vital organs have sustained severe damage and can no longer respond to interventions ■ There is a massive release of metabolites and enzymes that further block perfusion ■ Cellular ischemia and tissue necrosis ■ Death is inevitable ○ Mods= multiple organ dysfunction syndrome ■ affects CNS, pulmonary, cardiovascular, integumentary, GI, renal

Meds: sepsis

● Antimicrobial: if infection is caused by a bacteria or fungi, broad spectrum antibiotics are used, may be placed on several antibiotics to ensure adequate coverage of the pathogen until it has been determined by the culture what is specifically causing the infection ● Vasoactive and inotropic drugs: used when fluid replacement has not been enough: increased venous return through vasoconstriction by facilitating myocardial contractility and dilate coronary arteries to increase the perfusion of the myocardium ● Oxygen therapy ● Fluid replacement: the most effective treatment for septic shock, administer fluids or blood (whole blood or blood products increase the oxygen carrying capacity of the blood and increase the oxygenation of cells), crystalloid and colloid solutions increase circulating blood volume and tissue perfusion; are administered in large amounts

Meds: cirrhosis

● Diuretics (spironolactone & furosemide): reduce fluid retention and ascites ● Lactulose: used for manifestations related to hepatic encephalopathy, reduce the nitrogenous load and lower serum ammonia levels, draws ammonia from the blood to the colon where it is converted to ammonia which is excreted in the feces ● Neomycin: used for manifestations related to hepatic encephalopathy, reduce the nitrogenous load and lower serum ammonia levels, is a locally acting antibiotic that reduces the number of ammonia forming bacteria ● Beta blocker: nadolol prevent rebleeding of esophageal varices and lowers hepatic venous pressure ● Isosorbide mononitrate: prevent rebleeding of esophageal varices and lowers hepatic venous pressure ● Ferrous sulfate & folic acid: treat anemia ● Vitamin K: reduce the risk of bleeding

Diagnostics for sepsis

● Hgb/ hct: if the result of sepsis is from intravascular fluid loss then these would be increased ● ABG: decrease in pH, decrease in PaO2 or total oxygen saturation, increase in PaCO2 ● Serum electrolytes: glucose (<100) and sodium (<135) would be decreased, while potassium levels are increased (>5.3) ● BUN, creatinine, urine specific gravity and osmolality: increased ● Blood cultures: identify causative organism ● WBC: may be increased or decreased

Diagnostics for cirrhosis

● LFTs: alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma glutamyltrasferase would all be elevated if cirrhosis were to develop, these levels would not be as elevated as they are in hepatitis ● CBC: decreased RBC, WBC, and platelet count ● Coagulation studies: prolonged prothrombin time occurs due to decreased production of clotting factors and decreased vitamin K ● Serum electrolytes: hyponatremia, hypokalemia, hypomagnesemia, hypophosphatemia ● Bilirubin (direct and indirect): increased ● Serum albumin: decreased ● Serum ammonia (increased)