leadership, mental health, peds, maternity, medsurg, pharmacology, fundamentals

Catheter Thrombosis/Emboli - Blood can coagulate and cause an occlusion

Nursing Actions -Flush the line per facility protocol. -Do not force fluid if resistance is encountered (may dislodge thrombosis). -Use a 10 mL or larger syringe to avoid excess pressure per square inch (PSI) that could cause catheter fracture/rupture.

cognitive disorders (Alzheimers and delerium)

Nursing Care ◯Perform self-assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients who have progressive cognitive decline. ◯Nursing interventions are focused on protecting the client from injury, as well as promoting client dignity and quality of life. ◯Provide for a safe and therapeutic environment ■Assign the client to a room close to the nurse's station for close observation. ■Provide a room with a low level of visual and auditory stimuli. ■Provide for a well-lit environment, minimizing contrasts and shadows. ■Have the client sit in a room with windows to help with time orientation. ■Have the client wear an identification bracelet; use monitors and bed alarm devices as needed. ■Use restraints only as an intervention of last resort. ■Monitor client's level of comfort and assess for non-verbal indications of discomfort. ■Use caution when administering medications PRN for agitation or anxiety. ■ Assess client's risk for injury and ensure safety in the physical environment, such as a lowered bed and removal of scatter rugs to prevent falls. ■Provide compensatory memory aids, such as clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects. Reorient as necessary. ■Provide eyeglasses and assistive hearing devices as needed. ■Keep a consistent daily routine. ■Maintain consistent caregivers. ■Ensure adequate food and fluid intake. ■Allow for safe pacing and wandering. ■Cover or remove mirrors to decrease fear and agitation. ◯Communication ■Communicate in a calm, reassuring tone. ■Speak in positive rather than negatively worded phrases. Do not argue or question hallucinations or delusions. ■Reinforce reality. ■Reinforce orientation to time, place, and person. ■Introduce self to client with each new contact. ■Establish eye contact and use short, simple sentences when speaking to the client. Focus on one item of information at a time. ■Encourage reminiscence about happy times; talk about familiar things. ■Break instructions and activities into short timeframes. ■Limit the number of choices when dressing or eating. ■Minimize the need for decision making and abstract thinking to avoid frustration. ■Avoid confrontation. ■Encourage family visitation as appropriate Home safety measures to be implemented may include: ■Removing scatter rugs ■Installing door locks that cannot be easily opened ■Locking water heater thermostat and turning water temperature down to a safe level ■Providing good lighting, especially on stairs ■Installing a handrail on stairs, and marking step edges with colored tape. ■Placing mattresses on the floor ■Removing clutter, keeping clear, wide pathways for walking through a room ■Securing electrical cords to baseboards ■Storing cleaning supplies in locked cupboards ■Installing handrails in bathrooms

admissions, transfers, and discharge

admission Process ●Equipment ◯Prior to arrival of the client, bring necessary equipment into the room. This should include appropriate documentation forms, equipment to measure vital signs, a pulse oximeter, and hospital attire for the client. ●Procedure ◯Introduce yourself. ◯Explain the roles of other care delivery staff. ◯If in a semiprivate room, introduce the client to his roommate. ◯Provide hospital attire and assist as necessary. ◯Position the client comfortably. ◯Apply the identification bracelet and allergy band, if needed. ◯Provide facility-specific brochures and informational material. ◯Provide information about advance directives. ◯Document the client's advance directives status in the medical record. Place a copy in the medical record if it is available. ◯Assess/collect the following data. ■Baseline data - Vital signs, height, weight, allergy status, medications ■Biographical information ■The client's reason for seeking health care ■Present illness and symptoms ■Health history ☐Current illness ☐Current medications (prescription and over-the-counter) ☐Prior illnesses, chronic diseases ☐Surgeries ☐Previous hospitalizations ☐Other relevant data ■Family history (hypertension, cancer, heart disease, diabetes mellitus) ■Psychosocial assessment ☐Alcohol, tobacco, drug, and caffeine use ☐History of mental illness ☐History of abuse or homelessness ☐Home situation/significant others ■Nutrition ☐Current diet, any chewing or swallowing problems ☐Recent weight gain/loss ■Spiritual health/quality-of-life concerns ☐Religion ☐Advance directives, living will ■Review of systems ■Safety assessments ☐History of falls ☐Sensory deficits (vision, hearing) ☐Use of assistive devices (walker, cane, crutches, wheelchair) ■Discharge information ☐Family members in the home ☐Transportation for discharge ☐Any relevant phone numbers ☐Inventory any personal items. ■Examples are clothing, jewelry, money, credit cards, assistive devices (hearing aids, cane, dentures), medications, and religious articles. ■Document leaving items at the bedside, storing items in the room closet, sending items home with family, and locking up valuables in the facility's safe. Discourage keeping valuables at the bedside. ◯Orient the client and family to the room and the facility. Share information, including the following: ■Call light operation ■Electric bed operation ■Telephone services/television controls ■Overhead lighting operation ■Smoking policy ■Restroom locations ■Waiting areas ■Meal times ■Usual time for providers' visits ■Dining/vending services ■Visiting policies transfer and discharge Process ●Indications for Transfer and Discharge ◯The level of care has changed. For example, health status has improved so a client no longer needs intensive care. ◯Another setting is required to provide necessary care, for example, a transfer from the medical unit to the surgical suite. ◯The facility does not offer the type of care a client now requires. For example, after the acute phase of a stroke, the client now requires care in a skilled facility. ◯The client no longer needs inpatient care and is ready to return home. ●Discharge Planning ◯This should begin on admission, unless it is long-term care. ◯Assess whether or not the client will be able to return to his previous residence. ◯Determine whether or not the client will need and/or have someone to assist him at home. ◯Assess the residence to see if the client will need adaptations or specific equipment. ◯Make a referral to the social worker to arrange for community services. ◯Communicate health status and needs to community service providers. ◯The provider documents that the client may be discharged. However, a client who is legally competent has the right to leave the facility at any time. The nurse notifies the client's provider, has the client sign the proper forms if possible, and provides discharge teaching. ●Discharge Education ◯The nurse discusses the discharge instructions with the client and provides a printed copy. ◯Instructions should use clear, concise language that the client will understand. ◯Standards for discharge education ■Identifying safety concerns at home ■Reviewing signs and symptoms of potential complications and when to contact either emergency care or the provider ■Providing the phone number of the provider ■Providing names and phone numbers of community resources that give care at the client's residence ■Step-by-step instructions for performing continuing treatments, such as dressing changes ■Dietary restrictions and guidelines, including those that pertain to medication administration ■Amount and frequency of therapies to perform to support continued independence at home ■Directions on how to take medications and explanations for why adherence is important ●Equipment ◯Items to transfer/discharge with the client ■Personal belongings at the bedside (flowers, books, clothing, personal care items) ■Valuables from the safe (if leaving the facility) ■Medications (especially those belonging to the client or those that cannot be returned to the pharmacy for credit) ■Assistive devices ■Medical records or a transfer form ◯Transfer documentation ■Medical diagnosis and care providers ■Demographic information ■Overview of health status, plan of care, and recent progress ■Any alterations that may precipitate an immediate concern ■Notification of any assessments or care essential within the next few hours ■Most recent vital signs and medications, including PRN ■Allergies ■Diet and activity orders ■Special equipment or adaptive devices (oxygen, suction, wheelchair) ■Advance directives and emergency code status ■Family involvement in care and health care proxy, if applicable ◯Discharge documentation ■Type of discharge (provider prescription or against medical advice [AMA]) ■Date and time of discharge, who went with the client, and transportation (wheelchair to car, gurney to ambulance) ■Where the client went (home, long-term care facility) ■A summary of the client's condition at discharge (steady gait, ambulating independently, in no apparent distress) ■A description of any unresolved difficulties and procedures for follow up ■Disposition of valuables, medications brought from home, and prescriptions ■Discharge instructions ◯Discharge instructions ■Step-by-step instructions for procedures at home ■Precautions to take when performing procedures or administering medications ■Signs and symptoms of complications to report ■Names and numbers of health care providers and community services to contact ■Plans for follow-up care and therapies

Appropriate activities (1-3 yr)

■Filling and emptying containers ■Playing with blocks ■Looking at books ■Push-pull toys ■Tossing balls ■Finger paints ■Large-piece puzzles ■Thick crayons

medications to support withdrawal abstinence from nicotine Burpropion (zyban) nicotine replacement therapy varenicline (chantix)

●Abstinence syndrome is evidenced by irritability, nervousness, restlessness, insomnia, and difficulty concentrating

Diagnostic Procedures

-Urinalysis - ruling out of infection -Blood type and cross match - transfusion readiness -CBC - infection/immune status -Hgb and Hct - fluid status, anemia -Pregnancy test - fetal risk of anesthesia -Clotting studies (PT, INR, aPTT, platelet count) -Electrolyte levels - electrolyte imbalances -Serum creatinine and BUN - renal status -ABGs - oxygenation status -Chest x-ray - heart and lung status -12-lead ECG - baseline heart rhythm, dysrhythmias, history of cardiac disease, performed on all clients older than 40 year

Hypermagnesemia Hypermagnesemia is a serum magnesium level greater than 2.1 mEq/L.

Assessment *Risk Factors Decreased magnesium output -Kidney failure -Adrenal insufficiency Increased magnesium intake and absorption -Laxatives or antacids containing magnesium *Subjective and Objective Data -Neuromuscular Diminished DTRs Muscle paralysis Shallow respirations, decreased respiratory rate -Cardiovascular Bradycardia, hypotension Dysrhythmias, cardiac arrest -Central nervous system Lethargy *Laboratory Findings -Calcium level greater than 10.5 mg/dL *Diagnostic Procedures ECG - Shortened QT interval and ST segment Nursing Care - Perform frequent focused assessments (vital signs, level of consciousness, reflexes). Notify the provider of changes or absent reflexes.

chest tube

A patient air leak is confirmed when air bubbles are observed going from right to left in the air leak monitor.

Rectocele

A rectocele is a protrusion of the anterior rectal wall through the posterior vaginal wall. It is caused by a defect of the pelvic structures, a difficult delivery, or a forceps delivery subjective ■Constipation and/or the need to place fingers in the vagina to elevate the rectocele to complete evacuation of feces ■Sensation of a mass in the vagina ■Pelvic/rectal pressure or pain ■Dyspareunia ■Fecal incontinence ■Uncontrollable flatus ■Hemorrhoid objective ☐A pelvic examination reveals a bulging of the posterior wall when the client is instructed to bear down. ☐A rectal examination and/or barium enema reveals the presence of a rectocele.

Vitamin K (Aquamephyton)

Administered to prevent hemorrhagic disorders. Vitamin K is not produced in the gastrointestinal tract of the newborn until around day 8. Vitamin K is produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn. ■Nursing Considerations and Client Education ☐Administer 0.5 to 1 mg intramuscularly into the vastus lateralis (where muscle development is adequate) within 1 hr after birth.

car seat safety

Car Seat Safety ◯Use an approved rear-facing car seat in the back seat, preferably in the middle, (away from air bags and side impact) to transport the newborn. Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat. Do not use a used or secondhand car seat.

HEMODYNAMIC MONITORING EXPECTED REFERENCE RANGES

Central venous pressure (CVP)- 1 to 8 mm Hg Pulmonary artery systolic (PAS)- 15 to 26 mm Hg Pulmonary artery diastolic (PAD)- 5 to 15 mm Hg Pulmonary artery wedge pressure (PAWP)- 4 to 12 mm Hg Cardiac output (CO)- 4 to 7 L/min Mixed venous oxygen saturation (SvO2)- 60% to 80%

Cholecystitis

Cholecystitis is characterized by inflammation of the gallbladder. Clinical manifestations include pain, tenderness, and rigidity in upper right abdomen. Pain can radiate to the right shoulder or midsternal area. Nausea, vomiting, and anorexia also can occur. If the gallbladder becomes filled with pus or becomes gangrenous, perforation can result. ◯Fat intake should be limited to reduce stimulation of the gallbladder ◯Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. ◯The diet is individualized to the client's needs and tolerance. ◯Diet modifications are not necessary for healthy people with asymptomatic gallstones.

Circumcision Care

Circumcision is the surgical removal of the foreskin of the penis. ■Circumcision is a personal choice made by the newborn's family for reasons of hygiene, religious conviction (Jewish male on eighth day after birth), tradition, culture, or social norms. Parents should make a well-informed decision in consultation with the provider. ■Contraindications for circumcision include newborns born with hypospadias (abnormal positioning of urethra on ventral undersurface of the penis) and epispadias (urethral canal terminates on dorsum of penis) because the prepuce skin may be needed for surgical repair of the defect. Familiar history of bleeding disorders is also a contraindication. ■Circumcision should not be done immediately following birth because the newborn's level of vitamin K is at a low point, and the newborn would be at risk for hemorrhage. ■Advocates of circumcision state that circumcision promotes a penis with clean glans, minimizes the risk of phimosis later in life, and reduces the risk of penile cancer and cervical cancer in sexual partners. ◯Diagnostic and therapeutic procedures and management ■Anesthesia is required for circumcision. Types of anesthesia include a ring block, dorsal-penile nerve block, and topical anesthetic (eutectic mixture of local anesthetics). Oral sucrose, oral acetaminophen, and nonpharmacologic methods, such as swaddling and nonnutritive sucking, may be employed prior to the procedure. ■Surgical methods for removing the foreskin include the Yellen, Mogen, and Gomco clamps, and Plastibell. ☐The provider applies the Yellen, Mogen, or Gomco clamp to the penis, loosens the foreskin, and inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis. The wound is covered with sterile petroleum gauze to prevent infection and control bleeding. ☐The provider slides the Plastibell device between the foreskin and the glans of the penis. The provider ties a suture tightly around the foreskin at the coronal edge of the glans. This applies pressure as the excess foreskin is removed from the penis. After 5 to 7 days, the Plastibell drops off, leaving a clean, healed excision. No petroleum is used for circumcision with the Plastibell. ◯ Nursing assessments ■Preprocedure - The newborn should be assessed for: ☐A history of bleeding tendencies in the family (hemophilia and clotting disorders). ☐Hypospadias or epispadias. ☐Ambiguous genitalia (when the newborn has genitalia that may include both male and female characteristics). ☐Illness or infection. ■Postprocedure - The newborn should be assessed for: ☐Bleeding every 15 min for the first hour and then every hour for at least 12 hr. ☐The first voiding. Postprocedure parent teaching ■Teach the parents to keep the area clean. Change the newborn's diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. ■Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. ■A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis. ■Notify the provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the newborn. ■Tell the parents that a film of yellowish mucus may form over the glans by day 2 and it is important not to wash it off. ■Teach the parents to avoid using premoistened towelettes to clean the penis because they contain alcohol. ■Inform the parents that the newborn may be fussy or may sleep for several hours after the circumcision. Provide comfort measures for 24 to 48 hr, to include acetaminophen (Tylenol) as prescribed. ■Inform the parents that the circumcision will heal completely within a couple of weeks

partial rebreather mask (low flow)

Covers the client's nose and mouth It delivers an FiO2 of 40% to 70% at flow rates of 6 to 11 L/min. -The mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3 of exhaled air together with room air

Nursing Interventions to Promote Successful Breastfeeding

Place the newborn skin-to-skin on the mother's abdomen immediately after birth. Initiate breastfeeding as soon as possible or within the first 30 min following delivery. ◯Explain breastfeeding techniques to the mother. Have the mother wash her hands, get comfortable, and have caffeine-free, nonalcoholic fluids to drink during breastfeeding. ◯Explain the let-down reflex (stimulation of maternal nipple releases oxytocin that causes the let-down of milk). ◯Reassure the mother that uterine cramps are normal during breastfeeding, resulting from oxytocin, which also promote uterine involution. ◯Express a few drops of colostrum or milk and spread it over the nipple to lubricate the nipple and entice the newborn. ◯Show the mother the proper latch-on position. Have her support the breast in one hand with the thumb on top and four fingers underneath. With the newborn's mouth in front of the nipple, the newborn can be stimulated to open his mouth by tickling his lower lip with the tip of the nipple. The mother pulls the newborn to the nipple with his mouth covering part of the areola as well as the nipple. ◯Explain to the mother that when her newborn is latched on correctly, his nose, cheeks, and chin will be touching her breast. ◯Demonstrate the four basic breastfeeding positions: football, cradle or modified cradle, across the lap, and side-lying. ◯Encourage the mother to breastfeed at least 15 to 20 min/breast to ensure that her newborn receives adequate fat and protein, which is richest in the breast milk as it empties the breast. ◯Avoid educating mothers regarding the duration of newborn feedings. Mothers should be instructed to evaluate when the newborn has completed the feeding, including slowing of newborn suckling, a softened breast, or sleeping. ◯Explain to the mother that newborns will nurse on demand after a pattern is established. ◯Show the mother how to insert a finger in the side of the newborn's mouth to break the suction from the nipple prior to removing the newborn from the breast to prevent nipple trauma. ◯Show the mother how to burp the newborn when she alternates breasts. The newborn should be burped either over the shoulder or in an upright position with his chin supported. The mother should gently pat the newborn on his back to elicit a burp. ◯Tell the mother to begin the newborn's next feeding with the breast she stopped feeding him with in the previous feeding. ◯Tell the mother how to tell if her newborn is receiving adequate feeding (gaining weight, voiding 6 to 8 diapers a day, and contentedness between feedings). ◯Explain to the mother that the newborn may have loose, pale, and/or yellow stools during breastfeeding, and that this is normal. ◯Tell the mother to avoid nipple confusion in the newborn by not offering supplemental formula, pacifier, or soothers. Supplementation can be provided using a small feeding or syringe feeding, if needed. ◯Tell the mother to always place her newborn on his back after feedings. ◯Promote rooming-in efforts. ◯Offer referral to breastfeeding support groups. ◯Contact a lactation consultant to offer additional recommendations and support, especially to mothers who have concerns about adequate breast milk or mothers who have been unsuccessful with breastfeeding in the past. ◯Herbal products, such as fenugreek, and prescription medications, such as metoclopramide (Reglan), have been reported to increase breast milk production. There is insufficient data to confirm or deny their effect on lactation. Mothers should check with the provider before taking over-the-counter or prescription medications.

acute glomerulonephritis

a streptococcal infection precedes the majority of cases of acute glomerulonephritis. Other infections that can cause glomerulonephritis include pneumococcal infections and viral infections.

Preoperative instructions

(avoid cigarette smoking for 24 hr preoperatively, medications to hold, bowel preparation) -Clients who are taking acetylsalicylic acid (Aspirin) should stop taking it for 1 week before an elective surgery to decrease the risk of bleeding. -Clients who take herbal medications (e.g., ginkgo biloba, ginseng, feverfew) should stop taking them 2 to 3 weeks before surgery to prevent hemorrhage or adverse affects to the anesthetic. -Medications for cardiovascular disease, pulmonary disease, seizures, and diabetes mellitus, certain antihypertensive medications, and eye drops for glaucoma may be taken prior to surgery or a procedure. -Teach the client how to use a pain scale to rate pain level postoperative

magnesium sulfate toxicity.

Absence of patellar deep tendon reflexes ☐Urine output less than 30 mL/hr ☐Respirations less than 12/min ☐Decreased level of consciousness ☐Cardiac dysrhythmias If magnesium toxicity is suspected: ■Immediately discontinue infusion. ■Administer antidote calcium gluconate. ■Prepare for actions to prevent respiratory or cardiac arrest. Discharge instructions ■Maintain the client on bed rest, and encourage side-lying position. ■Promote diversional activities. ■Have the client avoid foods that are high in sodium. ■Have the client avoid alcohol and limit caffeine. ■Instruct the client to increase her fluid intake to 8 glasses/day. ■Maintain a dark quiet environment to avoid stimuli that may precipitate a seizure. ■Maintain a patent airway in the event of a seizure. ■Administer antihypertensive medications as prescribed.

cord care

Cord Care ◯Before discharge, the cord clamp is removed. ◯Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it. ◯Sponge baths are given until the cord falls off, which occurs around 10 to 14 days after birth. Tub bathing and submersion can follow. ◯Cord infection (complication of improper cord care) can result if the cord is not kept clean and dry. ■Monitor for symptoms of a cord that is moist and red, has a foul odor, or has purulent drainage. ■Notify the provider immediately if findings of cord infection are present.

Clinical manifestations of hypoxemia

EARLy ›Tachypnea ›Tachycardia ›Restlessness, anxiety ›Pale skin, mucous membranes ›Elevated blood pressure ›Use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds LAtE ›Confusion, stupor ›Cyanotic skin, mucous membranes ›Bradypnea ›Bradycardia ›Hypotension ›Cardiac dysrhythmias

hyPeReMesis gRaviDaRuM

Hyperemesis gravidarum is excessive nausea and vomiting (possibly related to elevated hCG levels) that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis. Discharge instructions ■Advance the client to clear liquids after 24 hr if no vomiting. ■Advance the client's diet, as tolerated, with frequent, small meals. Start with dry toast, crackers, or cereal; then move to a soft diet; and finally to a normal diet as tolerated. ■In severe cases, or if vomiting returns, enteral nutrition per feeding tube or total parental nutrition (TPN) may be considered.

injection needle size

Intradermal- tuberculin syringe with a fine-gauge needle (26 to 27) Subcutaneous- short, fine-gauge needle (3/8- to 5/8-inch, 25- to 27-gauge) Intramuscular- needlee size 18 to 27 (1- to 1 ½-inch, 22- to 25-gauge) Intravenous- 24-gauge catheters appropriate for most adults, smaller-gauge catheters appropriate for infants and children

Postrenal acute kidney injury

Occurs as a result of bilateral obstruction of structures leaving the kidney. ■Causes ☐Stone, tumor, bladder atony ☐Prostate hyperplasia, urethral stricture ☐Spinal cord disease or injury

Hepatitis B Immunization

Provides protection against hepatitis B. ■Nursing Considerations and Client Education ☐Recommended to be given to all newborns; informed consent must be obtained. ☐For newborns born to healthy women, recommended dosage schedule is at birth, 1 month, and 6 months. ☐For women infected with hepatitis B, hepatitis B immunoglobulin (HBIG) and the hepatitis B vaccine is given within 12 hr of birth. The hepatitis B vaccine is given alone at 1 month, 2 months, and 12 months. ☐It is important NOT to give the vitamin K and the hepatitis B injections in the same thigh. Sites should be alternated.

Generalized anxiety disorder (GAD)

The client exhibits uncontrollable, excessive worry for more than 3 months. ■GAD causes significant impairment in one or more areas of functioning, such as work-related duties. ■Manifestations of GAD include the following: ☐Restlessness ☐Muscle tension ☐Avoidance of stressful activities or events ☐Increased time and effort required to prepare for stressful activities or events ☐Procrastination in decision-making ☐Seeks repeated reassurance

Leaders

Transformational leaders empower followers to assume responsibility for a communal vision, and personal development is a secondary outcome. ●Transactional leaders focus on immediate problems, maintaining the status quo and using rewards to motivate followers.

Heel stick blood samples

Warm the newborn's heel first to increase circulation. ■Cleanse the area with an appropriate antiseptic, and allow for drying. ■A spring-activated lancet is used so that the skin incision is made quickly and painlessly. ■The outer aspect of the heel should be used, and the lancet should go no deeper than 2.4 mm to prevent necrotizing osteochondritis resulting from penetration of bone with the lancet. ■Follow facility protocol for specimen collection, equipment to be used, and labeling of specimens. ■Apply pressure with dry gauze (do not use alcohol because it will cause bleeding to continue) until bleeding stops, and cover with an adhesive bandage. ■Cuddle and comfort the newborn when the procedure is completed to reassure the newborn and promote feelings of safety.

Seclusion and Restraints

●In general, seclusion and/or restraints should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient. It is for the physical protection of the client or the protection of other clients or staff. ●A client may voluntarily request temporary seclusion in cases in which the environment is disturbing or seems too stimulating. ●Restraints can be either physical or chemical, such as sedatives and neuroleptic or psychotropic medications to calm the client. ●Seclusion and/or restraint must never be used for the following: ◯Convenience of the staff ◯Punishment for the client ◯Clients who are extremely physically or mentally unstable ◯Clients who cannot tolerate the decreased stimulation of a seclusion room ●Restraints should ◯Never interfere with treatment ◯Restrict movement as little as is necessary to ensure safety ◯Fit properly and be as discreet as possible ◯Be easily removed or changed to decrease the chance of injury and to provide for the greatest level of dignity ●When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur in order for seclusion or restraint to be used: ◯The treatment must be prescribed by the provider in writing, based on a face-to-face assessment of the client. ■In an emergency situation in which there is immediate risk to the client or others, the nurse may place a client in restraints. The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually within 1 hr). ◯The prescription must include the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint may be used, and the type of behaviors demonstrated by the client that warrant use of the restraint. ◯The prescription and the renewal are limited to 4 hr for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Prescriptions may be renewed, if needed, with a maximum of 24 consecutive hours. ◯PRN prescriptions for restraints are not allowed. ◯Nursing responsibilities ■Assess skin integrity, and provide skin care per facility protocol, usually every 2 hr. ■Offer food and fluid. ■Provide with means for hygiene and elimination. ■Monitor for vital signs. ■Offer range of motion of extremities. ◯Always explain the need for the restraint to the client and family, emphasizing that the restraint is needed to ensure the safety of the client and will be used only as long as it is necessary. ◯Obtain signed consent from client or guardian, if required. ◯Review the manufacturer's instructions for correct application. ◯Remove or replace restraints frequently to ensure good circulation to the area and allow for full range of motion to the limb that has been restricted. ◯Pad bony prominences. ◯Use a quick-release knot to tie the restraint to the bed frame (loose knots that are easily removed) where it will not tighten when the bed is raised or lowered. ◯Ensure that the restraint is loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury. ◯Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring the client's safety. ◯Never leave the client unattended without the restraint. ◯Document ■Precipitating events and behavior of the client prior to seclusion or restraint ■Alternative actions taken to avoid seclusion or restraint ■The time restraints were applied and removed (if discontinued) ■Type of restraint used and location ■Client's behavior while restrained ■Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) ■Condition of the body part being restrained ■Client's response when the restraint is removed ■Medication administration ◯An emergency situation must be present for the nurse to use seclusion or restraints without first obtaining a provider's written prescription. If this treatment is initiated, the nurse must obtain the written prescription within a specified period of time (usually within 1 hr).

Endometritis

☐Uterine tenderness and enlargement ☐Dark, profuse lochia ☐Lochia that is either malodorous or purulent ☐Temperature greater than 38° C (100.4° F) typically on the third to fourth postpartum day ☐Tachycardia Nursing interventions for endometritis ■Collect vaginal and blood cultures. ■Administer IV antibiotics as prescribed. ■Administer analgesics as prescribed. ■Teach the client hand hygiene techniques. ■encourage client to maintain interaction with her infant to facilitate bonding.

candida albicans

A fungal infection caused by Candida albicans. Risk Factors ●Diabetes mellitus ●Oral contraceptives ●Recent antibiotic treatment Subjective Data ◯Vulvar itching ●Objective Data ◯Physical Assessment Findings ■Thick, creamy, white vaginal discharge ■Vulvar redness ■White patches on vaginal walls ■Gray-white patches on the tongue and gums (neonate) ◯Laboratory Tests ■Wet prep ◯Diagnostic Procedures ■Potassium hydroxide (KOH) prep ■Presence of hyphae and pseudohyphae indicates positive findings. ●Nursing Care ◯Medications ■Fluconazole (Diflucan) ☐Antifungal agent ☐Fungicidal action ☐Over-the-counter treatments, such as clotrimazole (Monistat), are available to treat candidiasis. However, it is important for the provider to diagnosis candidiasis initially. ●Health Promotion and Disease Prevention ◯Client Education ■Instruct the client to avoid tight-fitting clothing. ■Instruct the client to wear cotton-lined underpants. ■Instruct the client to limit wearing damp clothing. ■Instruct the client to void before and after intercourse and avoid douching. ■Instruct the client to increase dietary intake of yogurt with active cultures

diuretics

A. Therapeutic Uses ●Used when there is an emergent need for rapid mobilization of fluid ●Pulmonary edema caused by heart failure ●Liver, cardiac, or kidney disease ●Hypertension ●Kidney stone formation B. Adverse Effects ●Dehydration ●Hypotension ●Ototoxicity ●Hypokalemia C. Nursing Interventions/Client Education ●Dehydration - Assess for dry mouth, increased thirst, low urine output, weight loss. ●Hypotension - Monitor orthostatic blood pressure and pulse; monitor for signs of postural hypotension. ●Ototoxicity - Assess for tinnitus; avoid administering ototoxic medications. ●Hypokalemia - Monitor laboratory values; offer potassium-rich foods; assess for general weakness, nausea, and vomiting

aMNioiNfusioN

An amnioinfusion of 0.9% sodium chloride or lactated Ringer's solution, as prescribed, is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation will reduce the severity of variable decelerations caused by cord compression. ●Indications ◯Potential diagnoses ■Oligohydramnios (scant amount or absence of amniotic fluid) caused by any of the following: ☐Uteroplacental insufficiency ☐Premature rupture of membranes ☐Postmaturity of the fetus ■Fetal cord compression secondary to: ☐Postmaturity of fetus (macrosomic, large body), which places the fetus at risk for variable deceleration from cord compression Nursing Actions Interventions ■Assist with the amniotomy if membranes have not already ruptured. Membranes must have ruptured to perform an amnioinfusion. ■Warm fluid using a blood warmer prior to infusion. ■Perform nursing measures to maintain comfort and dryness because the infused fluid will leak continuously. ■Monitor the client to prevent uterine overdistention and increased uterine tone, which can initiate, accelerate, or intensify uterine contractions and cause nonreassuring FHR changes. ■Continually assess intensity and frequency of the client's uterine contractions. ■Continually monitor FHR. ■Monitor fluid output from vagina to prevent uterine overdistention.

aMNiotoMy

An amniotomy is the artificial rupture of the amniotic membranes (AROM) by the provider using an Amnihook or other sharp instrument. ◯Labor typically begins within 12 hr after the membranes rupture. ◯The client is at an increased risk for cord prolapse or infection. Indications ◯Labor progression is too slow and augmentation or induction of labor is indicated. ◯An amnioinfusion is indicated for cord compression. ●Nursing Actions ◯Ongoing care ■Ensure that the presenting part of the fetus is engaged prior to an amniotomy to prevent cord prolapse. ■Monitor FHR prior to and following AROM to assess for cord prolapse as evidenced by variable or late decelerations. ■Assess and document characteristics of amniotic fluid including color, odor, and consistency. ◯Interventions ■Document the time of rupture. ■Obtain temperature every 2 hr.

newborn bathing

Bathing ◯After the initial bath, the newborn's face, diaper area, and skin folds are cleansed daily. Complete bathing is performed 2 to 3 times a week using a mild soap that does not contain hexachlorophene. ◯Bathing by immersion is not done until the newborn's umbilical cord has fallen off and the circumcision has healed on males. Wash the area around the cord, taking care not to get the cord wet. Move from the cleanest to dirtiest part of the newborn's body, beginning with his eyes, face, and head; proceed to the chest, arms, and legs; and wash the groin area last. ◯Teach the parents proper newborn bathing techniques by a demonstration. Have the parents return the demonstration. ◯Bathing should take place at the convenience of the parents, but not immediately after feeding to prevent spitting up and vomiting. ◯Organize all equipment so that the newborn is not left unattended. Never leave the newborn alone in the tub or sink. ◯Make sure the hot water heater is set at 49° C (120.2° F) or less. The room should be warm, and the bath water should be 36.6° to 37.2° C (98° to 99° F). Test the water for comfort on inner wrist prior to bathing the newborn. ◯Avoid drafts or chilling of the newborn. Expose only the body part being bathed, and dry the newborn thoroughly to prevent chilling and heat loss. ◯The newborn's eyes should be cleaned using a clean portion of the wash cloth. Clear water should be used to clean each eye, moving from the inner to the outer canthus. ◯Each area of the newborn's body should be washed, rinsed, and dried, with no soap left on the skin. ◯Wrap the newborn in a towel, and swaddle him in a football hold to shampoo his head. Rinse shampoo from the newborn's head, and dry to avoid chilling. ◯In male newborns, to cleanse an uncircumcised penis, wash with soap and water and rinse the penis. The foreskin should not be forced back or constriction may result. ◯In female newborns, wash the vulva by wiping from front to back to prevent contamination of the vagina or urethra from rectal bacteria. ◯Do not use lotions, oils, or powders, because they can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic reaction. Powder should be avoided because it can cause respiratory problems if inhaled by the newborn.

Bladder perforation

Bladder perforation is a rare but possible complication. Manifestations of bladder perforation include hematuria, low or no urine output, suprapubic pain and/or distention, symptoms of cystitis, and fever. Nursing Actions - If a bladder perforation is suspected, notify the provider immediately. Client Education - Inform the client to report manifestations of bladder perforation as described above

newborn nutrition

Breastfeeding is the optimal source of nutrition for newborns. Breastfeeding is recommended exclusively for the first 6 months of age by the American Academy of Pediatrics. Newborns should be breastfed every 2 to 3 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr during the night until the newborn is feeding well and gaining weight adequately. Breastfeeding should occur 8 to 12 times within a 24-hr window. Then, a feed-on-demand schedule may be followed. ●Colostrum is secreted from the mother's breasts during postpartum days 1 to 3. It contains the IgA immunoglobulin that provides passive immunity to the newborn. ●Nursing interventions can help a new mother be successful in breastfeeding. This includes the provision of adequate calories and fluids to support breastfeeding. The practice of rooming-in, allowing mothers and newborns to remain together, should be encouraged as part of baby-friendly initiatives. Lactation consultants can improve the mother's efforts and success in breastfeeding. ●Advantages of breastfeeding - Parents should be presented with factual information about the nutritional and immunological needs of their newborn. The nurse should present information about both breastfeeding and bottle feeding in a nonjudgmental manner. The optimal time to provide newborn nutritional information is during pregnancy, so that the parents make a decision prior to hospital admission

ChlaMydia

Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It is the most common STI. The infection is often difficult to diagnose because it is typically asymptomatic. According to current guidelines from the Centers for Disease Control and Prevention, all women and adolescents ages 20 to 25 who are sexually active should be screened for STIs Subjective Data ◯Vaginal spotting ◯Vulvar itching ◯Postcoital bleeding and dysuria ●Objective Data ◯Physical Assessment Findings ■White, watery vaginal discharge ◯Laboratory Tests ■Endocervical culture Nursing Care ◯Instruct the client to take the entire prescription as prescribed. ◯Identify and treat all sexual partners. ◯Clients who are pregnant should be retested 3 weeks after completing the prescribed regimen. ●Medications ◯Azithromycin (Zithromax) and amoxicillin (Amoxil) are prescribed during pregnancy. ■Broad-spectrum antibiotic ■Bactericidal action ■Nursing Care ☐Administer erythromycin (Romycin) to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. ■Client Education ☐Instruct the client to take all prescriptions as prescribed. ☐Educate the client about the possibility of decreasing effectiveness of oral contraceptives.

non-rebreather mask (low flow)

Covers the client's nose and mouth It delivers an FiO2 of 60% to 80% at flow rates of 10 to 15 L/min to keep the reservoir bag 2/3 full during inspiration and expiration. It delivers the highest O2 concentration possible (except for intubation). ›A one-way valve situated between the mask and reservoir allows the client to inhale maximum O2 from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask.

Hypocalcemia and Tetany

Damage to parathyroid gland causes hypocalcemia and tetany. Nursing Actions -Monitor for indications of hypocalcemia (tingling of the fingers and toes, carpopedal spasms, convulsions). -Assess for Chvostek's and Trousseau's signs, which are indicators of neuromuscular irritability from hypocalcemia. -Have IV calcium gluconate available for emergency administration. -Maintain seizure precautions. Client Education -Advise the client to notify the nurse of any tingling sensation of the mouth, tingling of distal extremities, or muscle twitching

Deep-vein thrombosis (DVT)

Deep-vein thrombosis is the most common complication following trauma, surgery, or disability related to immobility. ◯Nursing Actions ■Encourage early ambulation. ■Apply antiembolism stockings, sequential compression device (SCD). ■Administer anticoagulants as prescribed. ■Encourage intake of fluids to prevent hemoconcentration. ■Instruct the client to rotate feet at the ankles and perform other lower extremity exercises as permitted by the particular immobilization device

Phlebitis

Erythema at the site (usual initial sign) Pain or burning at the site and the length of the vein Discomfort when the skin over the tip is palpated Warmth over the site Edema at the site Vein indurated (hard), red streak, and/or cordlike Slowing infusion rate Temperature elevation of 1° F or more Infection appearing 7 to 10 days after insertion treatment: Discontinue the IV. Apply warm compresses Restart with new tubing/infusate.

Aerosol mask (high flow)

Face tent (fits loosely around the face and neck) ›Tracheostomy collar (a small mask that covers the surgically created opening of the trachea) They deliver an FiO2 of 24% to 100% at flow rates of at least 10 L/min. ›They provide high humidification with oxygen delivery. Use with clients who do not tolerate masks well. ›Useful for clients who have facial trauma, burns, and thick secretions.

Palliative care is a multidisciplinary approach that focuses on the process of dying rather than prolonging life in cases in which cures are no longer possible.

Focus on control of managing the client's manifestations and offering supportive care.

A nurse is reviewing a client's medication history and notes an allergy to sulfonamides. Which of the following medications are contraindicated due to this allergy? (Select all that apply.) A nurse is planning discharge teaching for a female client who has a new prescription for sulfamethoxazole-trimethoprim (Septra). Which of the following information should the nurse include in the teaching? A nurse is providing teaching to a client who has a new prescription for nitrofurantoin (Furadantin). Which of the following information should the nurse include in the teaching? (Select all that apply.) A nurse is teaching about ciprofloxacin (Cipro) to a female client who has a severe urinary tract infection. Which of the following information about adverse reactions should the nurse include in the teaching? (Select all that apply.) A nurse is planning to administer ciprofloxacin (Cipro) IV to a client who has cystitis. Which of the following is an appropriate action by the nurse?

Hydrochlorothiazide (Microzide) Tolbutamide (Orinase) Furosemide (Lasix) Take the medication on an empty stomach Observe for bruising on the skin. Take the medication with milk or meals. Expect brownish discoloration of urine. Observe for pain and swelling of the Achilles tendon. Monitor for a vaginal yeast infections Inspect the mouth for cottage cheese-like lesions. Infuse medication over 60 min.

Hypercalcemia

Hypercalcemia is a serum calcium level greater than 10.5 mg/dL. Assessment *Risk Factors Decreased calcium output -Thiazide diuretics Increased calcium intake and absorption Calcium shift from bone to extracellular fluid -Hyperparathyroidism -Bone cancer -Paget's disease -Chronic immobility *Subjective and Objective Data -Neuromuscular Decreased reflexes Bone pain Flank pain if renal calculi develop -Cardiovascular -Dysrhythmias -GI - anorexia, nausea, vomiting, constipation -Central nervous system-Weakness, lethargy -Confusion, decreased level of consciousness *Laboratory Findings - Calcium level greater than 10.5 mg/dL *Diagnostic Procedures ECG - shortened QT interval and ST segment Nursing Care -Increase client activity level. -Limit dietary calcium. -Encourage fluids to promote urinary excretion. -Encourage fiber to promote bowel elimination. -Implement safety precautions if client is confused. -Monitor for pathologic fractures. -Encourage acid-ash fluids such as prune or cranberry juice to decrease the risk for renal calcium stone formation.

anemias

Increased hemolysis ■Defective Hgb (sickle-cell disease) - RBCs become malformed during periods of hypoxia and obstruct capillaries in joints and organs ■Impaired glycolysis - glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia ■Immune disorder or destruction (transfusion reactions, autoimmune diseases) ■Mechanical trauma to RBCs (mechanical heart valve, cardiopulmonary bypass) ◯Inadequate dietary intake or malabsorption ■Iron deficiency ■Vitamin B12 deficiency - pernicious anemia due to deficiency of intrinsic factor produced by gastric mucosa, which is necessary for absorption of vitamin B12 ■Folic acid deficiency ■Pica, or a persistent eating of substances not normally considered food (nonnutritive substances), such as soil or chalk, for at least 1 month, may limit the amount of healthy food choices a client makes ◯Bone-marrow suppression ■Exposure to radiation or chemicals (such as insecticides or solvents) ■Aplastic anemia results in a decreased number of RBCs as well as decreased platelets and WBCs. ◯Older adult clients are at risk for nutrition-deficient anemias (iron, vitamin B12, folate). ◯Anemia may be misdiagnosed as depression or debilitation in older adult clients. ◯Gastrointestinal bleeding is a common cause of anemia in older adult clients. ●Subjective Data ◯May be asymptomatic in mild cases ◯Pallor ◯Fatigue ◯Irritability ◯Numbness and tingling of extremities ◯Dyspnea on exertion ◯Sensitivity to cold ◯Pain and hypoxia with sickle-cell crisis ●Objective Data ◯Physical Assessment Findings ■Shortness of breath/fatigue, especially upon exertion ■Tachycardia and palpitations ■Dizziness or syncope upon standing or with exertion ■Pallor with pale nail beds and mucous membranes ■Nail bed deformities ■Smooth, sore, bright-red tongue (vitamin B12 deficiency)

venturi mask (high flow)

It delivers an FiO2 of 24% to 60% at flow rates of 4 to 12 L/min via different size adaptors. It delivers the most pr ecise oxygen concentration. ›Humidification is not required. ›It is best for clients who have chronic lung disease.

CesaReaN biRth

Indications ◯Potential diagnoses ■Malpresentation, particularly breech presentation ■Cephalopelvic disproportion ■Fetal distress ■Placental abnormalities ☐Placenta previa ☐Abruptio placenta ■High‑risk pregnancy ☐Positive HIV status ☐Hypertensive disorders such as preeclampsia and eclampsia ☐Diabetes mellitus ☐Active genital herpes lesions ■Previous cesarean birth ■Dystocia ■Multiple gestations ■Umbilical cord prolapse

Implanted port

Insertion location - Port is surgically implanted into chest wall pocket; the catheter is inserted into the subclavian vein with the tip in the superior vena cava. Preprocedure -To access an implanted port: -Apply local anesthetic to skin if indicated. Palpate skin to locate the port body septum to ensure proper insertion of the needle. -Clean the skin with alcohol for at least 3 seconds and allow to dry prior to insertion of the needle. -Access with a noncoring (Huber) needle. Postprocedure -Flush (with 10 mL 0.9% sodium chloride or per facility protocol) after every use and at least once per month.

injection needle size

Intradermal- tuberculin syringe with a fine-gauge needle (26 to 27) Subcutaneous-

laRge foR gestatioNal age NewboRN (lga)/MacRosoMic

Large for gestational age (LGA) occurs in neonates who weigh above the 90th percentile or more than 4,000 g (8 lb, 12 oz). ●Neonates who are LGA may be preterm, postterm, or full-term. LGA does not necessarily mean postmature. ●Newborns who are macrosomic are at risk for birth injuries (shoulder dystocia, clavicle fracture or a cesarean birth, asphyxia, hypoglycemia, polycythemia and Erb-Duchenne paralysis due to birth trauma). ●Uncontrolled hyperglycemia during pregnancy (leading risk factor for LGA) can lead to congenital defects with the most common being congenital heart defects, tracheoesophageal fistula, and CNS anomalies.

phototherapy

Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. ■Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ■Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ■Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ■Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ■Check the lamp energy with a photometer per facility protocol. ■Turn off the phototherapy lights before drawing blood for testing. Check the newborn's axillary temperature every 4 hr during phototherapy because temperature may become elevated. ◯Feed the newborn early and frequently - every 3 to 4 hr. This will promote bilirubin excretion in the stools. ◯Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. ◯Maintain adequate fluid intake to prevent dehydration. ◯Reassure the parents that most newborns experience some degree of jaundice. ◯Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. ◯Explain that the newborn's stool contains some bile that will be loose and green.

Dehiscence

Manifestations of dehiscence -A significant increase in the flow of serosanguineous fluid on the wound dressings -Immediate history of sudden straining (coughing, sneezing, vomiting) -The client reporting a change or "popping" or "giving way" in the wound area. -Visualization of viscera

home safety older adults

Modifications that can be made to improve home safety include: ☐Removing items that could cause the client to trip, such as throw rugs and loose carpets. ☐Placing electrical cords and extension cords that against a wall behind furniture. ☐Monitoring gait and balance, and providing aids as needed. ☐Making sure that steps and sidewalks are in good repair. ☐Placing grab bars near the toilet and in the tub or shower, and installing a stool riser. ☐Using a nonskid mat in the tub or shower. ☐Placing a shower chair in the shower and bedside commode if needed. ☐Ensuring that lighting is adequate both inside and outside of the home.

newborn elimination

Monitor elimination habits. ■Newborns should void once within 24 hr of birth. They should void 6 to 10 times a day after 4 days of life. ■Meconium should be passed within the first 24 hr after birth. The newborn will then continue to stool 3 to 4 times a day depending on whether he is being breast- or bottle-fed. ■The stools of newborns who are breastfed may appear yellow and seedy. These stools are lighter in color and looser than the stools of newborns who are formula-fed

respiratory complications newborn

Monitor for signs and symptoms of respiratory complications. ■Bradypnea - respirations less than 25/min ■Tachypnea - respirations greater than 60/min ■Abnormal breath sounds - expiratory grunting, crackles, and wheezes ■Respiratory distress - nasal flaring, retractions, grunting, and labored breathing

upper respiratory meds A nurse is caring for a client who states she has been taking phenylephrine (Neo-Synephrine) nasal drops for the past 10 days for her upper respiratory symptoms. For which of the following adverse effects should the nurse assess? A nurse is teaching a client to self-administer nasal drops for allergic rhinitis symptoms. The nurse should teach the client to lie in which of the following positions to obtain the best effect of the medication? A preschool child recently diagnosed with cystic fibrosis has a new prescription for acetylcysteine (Mucomyst). The nurse teaches the client and her family that the purpose of this medication is to do which of the following? An adult client is taking diphenhydramine (Benadryl) for symptoms of allergic rhinitis. For which of the following adverse reactions should the nurse teach the client to watch? (Select all that apply.) A nurse is evaluating a client's understanding of the teaching about the use of fluticasone (Flonase) to treat perennial rhinitis. Which of the following statements by the client indicate he understands the teaching? guaifenesin (Mucinex). A.Adverse Effects: Identify two adverse effects of this medication. B.Medication Effectiveness: Identify two findings that indicate that the medication is effective.

Nasal congestion Lateral with head in low position Loosen secretions Dry mouth Urinary hesitation "It may take as long as 3 weeks before the medication takes a maximum effect." Adverse Effects ●GI upset ●Drowsiness ●Dizziness ●Rash B.Medication Effectiveness ●Cough is more productive, mucous is easier to expectorate. ●Chest congestion is decreased.

contraction stress test

Nipple stimulated CST consists of a woman lightly brushing her palm across her nipple for 2 min, which causes the pituitary gland to release endogenous oxytocin, and then stopping the nipple stimulation when a contraction begins. The same process is repeated after a 5-min rest period. ◯Analysis of the FHR response to contractions (which decrease placental blood flow) determines how the fetus will tolerate the stress of labor. A pattern of at least three contractions within a 10-min time period with duration of 40 to 60 seconds each must be obtained to use for assessment data. ◯Hyperstimulation of the uterus (uterine contraction longer than 90 seconds or more frequent than every 2 min) should be avoided by stimulating the nipple intermittently with rest periods in between and avoiding bimanual stimulation of both nipples unless stimulation of one nipple is unsuccessful. Interpretation of findings ◯A negative CST (normal finding) is indicated if within a 10-min period, with three uterine contractions, there are no late decelerations of the FHR. ◯A positive CST (abnormal finding) is indicated with persistent and consistent late decelerations on more than half of the contractions. This is suggestive of uteroplacental insufficiency. Variable deceleration may indicate cord compression, and early decelerations may indicate fetal head compression. Based on these findings, the provider may determine to induce labor or perform a cesarean birth.

Chronic kidney disease care

Nursing Care ◯Abnormal findings to be reported and monitored ■Urinary elimination patterns (amount, color, odor, and consistency) ■Vital signs (blood pressure may be increased or decreased) ■Weight - 1 kg (2.2 lb) daily weight increase is approximately 1 L of fluid retained. ◯Assess and monitor vascular access or peritoneal dialysis insertion site. ◯Obtain a detailed medication and herb history to determine the client's risk for continued kidney injury. ◯Control protein intake based on the client's stage of chronic kidney disease and type of dialysis prescribed. ◯Restrict the client's dietary sodium, potassium, phosphorous, and magnesium. ◯Provide the client a diet that is high in carbohydrates and moderate in fat. ◯Restrict the client's intake of fluids (based on urinary output). ◯Monitor for weight gain trends. ◯Adhere to meticulous cleaning of areas on skin not intact and access sites to control infections. ◯Balance the client's activity and rest. ◯Prepare the client for hemodialysis, peritoneal dialysis, and hemofiltration if indicated. ◯Provide skin care to the client in order to increase comfort and prevent breakdown. ◯Protect the client from injury. ◯Provide emotional support to the client and family. ◯Encourage the client to ask questions and discuss fears. ◯Administer medications as prescribed.

A nurse is caring for a client who is receiving daily doses of oprelvekin (Interleukin-11). Which of the following laboratory values should the nurse monitor to determine effectiveness of this medication? A nurse is preparing to administer filgrastim (Neupogen) for the first time to a client who has just undergone a bone marrow transplant. Which of the following interventions is appropriate? A nurse is monitoring a client who is receiving epoetin alfa (Epogen) for adverse effects. Which of the following is an adverse effect of this medication? A nurse is assessing a client who has chronic neutropenia and who has been receiving filgrastim (Neupogen). Which of the following actions should the nurse take to assess for an adverse effect of filgrastim?

Platelet count Discard vial after removing one dose of the medication. Hypertension Assess for bone pain.

skin biopsy types

Punch biopsy ■A small plug of tissue approximately 2 to 6 mm is removed with a special cutting instrument, with or without sutures to close the site. ◯Shave biopsy ■Removal of only the part of the lesion that is raised above the surrounding tissue using a scalpel or razor blade with no suturing. ◯Excisional biopsy ■A larger and deeper specimen is obtained, and suturing is required. Client Education ■Teach the client to report excessive bleeding and/or evidence of infection (redness, warmth, drainage, fever) to the provider. ■Teach the client to check the incision daily. The incision should be clean, dry, and intact. ■May remove dressings after 8 hr, and may use tap water or 0.9% sterile sodium chloride to clean the biopsy site of dried blood or crusts. ■If prescribed by the provider, may apply an antibacterial topical medication to prevent infection. ■If sutures are used, return to the provider for removal in 7 to 10 days. ■Report excessive bleeding to the provider

Delegation Factors

RNs cannot delegate the nursing process, client education, or tasks that require clinical judgment to LPNs or AP. LpNs: ›Monitoring client findings (as input to the RN's ongoing assessment of the client) ›Reinforcement of client teaching from a standard care plan ›Tracheostomy care ›Suctioning ›Checking nasogastric tube patency ›Administration of enteral feedings ›Insertion of a urinary catheter ›Medication administration (excluding intravenous medications in several states) uap: ›Activities of daily living (ADLs) »Bathing »Grooming »Dressing »Toileting »Ambulating »Feeding (without swallowing precautions) »Positioning »Bed making ›Specimen collection ›Intake and output (I&O) ›Vital signs (on stable clients)

Refeeding syndrome

Refeeding syndrome is the potentially fatal complication that can occur when fluids, electrolytes, and carbohydrates are introduced to a severely malnourished client.

Pancreatitis

The islets of Langerhans in the pancreas secrete insulin and glucagon. The pancreatic tissues secrete digestive enzymes that break down carbohydrates, proteins, and fats. ●Pancreatitis is an autodigestion of the pancreas by pancreatic digestive enzymes that activate prematurely before reaching the intestines. The mechanism of action is unknown. Pancreatitis can result in inflammation, necrosis, and hemorrhage. Subjective Data ◯Sudden onset of severe, boring pain ■Epigastric, radiating to back, left flank, or left shoulder ■Worse when lying down or while eating ■Worse after consumption of alcohol or high-fat foods ■Not relieved with vomiting ◯Pain relieved somewhat by fetal position ◯Nausea and vomiting ◯Weight loss ●Objective Data ◯Physical Assessment Findings ■Seepage of blood-stained exudates into tissue as a result of pancreatic enzyme actions ☐Ecchymoses on the flanks (Turner's sign) ☐Bluish-grey periumbilical discoloration (Cullen's sign) Generalized jaundice ■Absent or decreased bowel sounds (possible paralytic ileus) ■Warm, moist skin; fruity breath (evidence of hyperglycemia) ■Ascites ■Tetany ☐Trousseau's sign (hand spasm when blood pressure cuff is inflated) ☐Chvostek's sign (facial twitching when facial nerve is tapped) ◯Laboratory Tests ■Serum amylase (increases within 12 hr, remains increased for 4 days) and serum lipase (increases slowly but remains increased for up to 2 weeks) ☐Urine amylase remains increased for up to 2 weeks. ☐Increases in enzymes indicate pancreatic cell injury. ☐Memory aid: In pancreatitis, the "ases" (aces) are high. ☐for amylase and lipase to be considered positive, the enzyme increases must be significant (two to three times greater than the expected value for amylase, and three to five times greater than the expected value for lipase). The degree of enzyme elevation does not directly correlate with the severity of the disease. ■WBC count: increased due to infection and inflammation ■Platelets: decreased ■Serum calcium and magnesium: decreased due to fat necrosis with pancreatitis ■Serum liver enzymes and bilirubin: increased with associated biliary dysfunction ■Serum glucose: increased due to a decrease in insulin production by the pancreas Nursing care: Rest the pancreas. ■NPO - no food until pain-free ■Total parenteral nutrition (TPN) or jejunal feedings (less risk of hyperglycemia) ■When diet is resumed: bland, low-fat diet with no stimulants (caffeine); small, frequent meals ■Administer antiemetic as needed, as prescribed ■Nasogastric tube - gastric decompression ■No alcohol consumption ■No smoking ■Limit stress ■Pain management ◯Position the client for comfort (fetal, side-lying, the head of the bed elevated, sitting up or leaning forward). ◯Administer analgesics and other medications as prescribed. ◯Monitor blood glucose and provide insulin as needed (potential for hyperglycemia). ◯Monitor hydration status (orthostatic blood pressure, intake and output, laboratory values). ◯Administer IV fluids and electrolyte replacement as prescribed.

12-step program

X-Abstinence is necessary for recovery. X-A higher power is needed to assist in recovery. X-They are not responsible for their disease but are responsible for their recovery. X-Others cannot be blamed for their addictions, and they must acknowledge their feelings and problems.

first-pass effect

after an oral medication has been absorbed, most of the medication is inactivated as the blood initially passes through the liver, producing little therapeutic effect.

CoUntertransferenCe

description ›Countertransference occurs when a health care team member displaces characteristics of people in her past onto a client. example ›A nurse may feel defensive and angry with a client for no apparent reason if the client reminds her of a friend who often elicited those feelings. Nursing implications ›A nurse should be aware that clients who induce very strong personal feelings may become objects of countertransference.

Age affects nutritional requirements

infants (Birth to 1 year) ›High energy requirements. ›Breast milk (preferred) or formula to provide: »108 kcal/kg of weight the first 6 months. »98 kcal/kg of weight the second 6 months. ›Solid food starting after 6 months of age. ›No cow's milk or honey for the first year. toddlers (12 months to 3 years) and preschoolers (3 to 6 years) ›Toddlers and preschoolers need fewer calories per kg of weight than infants. ›Toddlers and preschoolers need increased protein from sources other than milk. ›Calcium and phosphorus are important for bone health. school-age children (6 to 12 years) ›School-age children need supervision to consume adequate protein and vitamins C and A. ›School-age children tend to eat foods high in carbohydrates, fats, and salt. adolescents (12 to 20 years) ›Metabolic demands are high and require more energy. ›Protein, calcium, iron, iodine, folic acid, and vitamin B needs are high. ›One fourth of dietary intake comes from snacks. ›Increased water consumption is important for active adolescents. young adults (20 to 35 years) and middle adults (35 to 65 years) ›There is a decreased need for most nutrients (except during pregnancy). ›Calcium and iron are essential minerals for women. ›Good oral health is important. older adults (over 65 years) ›A slower metabolic rate requires fewer calories. ›Thirst sensations diminish. ›Older adults need the same amount of most vitamins and minerals as younger adults. ›Calcium may be necessary and is important for both men and women. ›Many older adults require carbohydrates that provide fiber and bulk to enhance gastrointestinal function

Chest physiotherapy (CPT)

involves the use of chest percussion, vibration, and postural drainage to help mobilize secretions. Chest percussion and vibration facilitate movement of secretions into the central airways. For postural drainage, one or more positions allow gravity to assist with the removal of secretions from specific areas of the lung.

Management

is the process of planning, organizing, directing, and coordinating the work within an organization.

Prerenal acute kidney injury

occurs as a result of volume depletion and prolonged reduction of blood flow to the kidneys, which leads to ischemia of the nephrons. Occurs before damage to the kidney. Early intervention restoring fluid volume deficit can reverse AKI and prevent chronic kidney disease (CKD). Causes ☐Renal vascular obstruction ☐Shock ☐Decreased cardiac output causing decreased renal profusion ☐Sepsis ☐Hypovolemia ☐Peripheral vascular resistance

oxygen safety measures

■Using and storing oxygen equipment according to the manufacturer's recommendations. ■Placing a "No Smoking" sign in a conspicuous place near the front door of the home. A sign may also be placed on the door to the client's bedroom. ■Informing the client and family of the danger of smoking in the presence of oxygen. Family members and visitors who smoke should do so outside the home. ■Ensuring that electrical equipment is in good repair and well grounded. ■Replacing bedding that can generate static electricity (wool, nylon, synthetics) with items made from cotton. ■Keeping flammable materials, such as heating oil and nail polish remover, away from the client when oxygen is in use. ■Following general measures for fire safety in the home, such as having a fire extinguisher readily available and an established exit route if a fire occurs.

medications to support withdrawal/abstinence from opioids methadone (dolophine) Clonidine (catapres) Buprenorphine (subutex)

●Characteristic withdrawal syndrome occurs within 1 hr to several days after cessation of substance use. ●Clinical findings include agitation, insomnia, flulike manifestations, rhinorrhea, yawning, sweating, and diarrhea. ●Manifestations are non-life-threatening, although suicidal ideation may occur.

A nurse receives a change-of-shift report at 0700 for an assigned caseload of clients. Number the following clients in the order in which they should be seen.

1-The first action the nurse should take is to attend to the client who is receiving blood. It has been 3 hr since the transfusion was initiated, and it should be completed within 4 hr. The client is also at risk for a transfusion reaction; therefore, this is the first action the nurse should take. 2-The next action the nurse should take is to administer the insulin, which is scheduled to be administered before 0800. 3-Next the nurse should administer PRN pain medication to the client who was last medicated at 0430. 4-Then the nurse should verify that the informed consent is completed in sufficient time to take any actions needed prior to the scheduled colonoscopy. 5-Finally, the nurse should reinforce teaching for the client who is to be discharged and has a prescription for dressing changes.

Drowning

Asphyxiation while child is submerged in fluid may occur in any standing body of water that is at least 1 inch deep (bathtub, toilet, bucket, pool, pond, lake). ●Submersion injury (near-drowning) incidents are those in which children have survived for 24 hr after being submerged in fluid. ●Families should be taught preventive measures. ◯Administer oxygen, may need mechanical ventilation. ◯Monitor vital signs. ◯Administer medications, IV fluids, and emergency medications as prescribed. ◯Provide chest physiotherapy. ◯Monitor for complications that can occur 24 hr after incident (cerebral edema, respiratory distress). ◯Use a calm approach with the child and family. ◯Keep the family informed of the child's status. ◯Client Education ■Encourage parents of toddlers to lock toilet seats when their child is at home. ■Instruct parents to not leave the child unattended in the bathtub. ■Inform parents to not leave the child unattended in a swimming pool, even if the child can swim. ■Instruct parents to make sure private pools are fenced with locked gates to prevent children from wandering into the pool area. ■Encourage parents to provide life jackets when boating.

Priority ABCD

First *Airway ›Identify an airway concern (obstruction, stridor). ›Establish a patent airway if indicated. ›Recognize that 3 to 5 min without oxygen causes irreversible brain damage secondary to cerebral anoxia. second *Breathing ›Assess the effectiveness of the client's breathing (apnea, depressed respiratory rate). ›Intervene as appropriate (reposition, administer naloxone [Narcan]). third *Circulation ›Identify circulation concern (hypotension, dysrhythmia, inadequate cardiac output, compartment syndrome). ›Institute appropriate actions to reverse or minimize circulatory alteration. Fourth *Disability ›Assess for current or evolving disability (neurological deficits, stroke in evolution). ›Implement action to slow down development of disability

Disciplinary action

First ›Informal reprimand ›Manager and employee meet »Discuss the issue »Suggestions for improvement/correction second ›Written warning ›Manager meets with employee to distribute written warning »Review of specific rules/policy violations »Discussion of potential consequences if infractions continue third ›Employee placed on suspension with or without pay. Time away from work gives the employee opportunity to: »Examine the issues »Consider alternatives Fourth ›Employee termination »Follows after multiple warning have been given and employee continues to violaterules and policies

hemophilia

Hemophilia is a group of disorders characterized by difficulty controlling bleeding Management of bleeding in the hospital ■Avoid taking temperature rectally. ■Avoid unnecessary skin punctures and use surgical aseptic technique. ■Apply pressure for 5 min after injections, venipuncture, or needle sticks. ■Monitor urine, stool, and nasogastric fluid for occult blood. ■Control localized bleeding. ☐Administer factor replacement. ☐Observe for adverse effects, which include headache, flushing, low sodium, and alterations in heart rate and blood pressure. ☐Encourage the child to rest and immobilize the affected joints. ☐Elevate and apply ice to the affected joints. Teach parents to prevent bleeding at home. ☐Place the infant or child in a padded crib. ☐Provide a safe home and a play environment that is free of clutter. Place padding on corners of furniture. ☐Dress toddlers in extra layers of clothing to provide additional padding. ☐Set activity restrictions to avoid injury. Acceptable activities include low-contact sports (tennis, swimming, golf). While participating in these activities, children should wear protective equipment. ☐Encourage the use of soft-bristled toothbrushes. ■Encourage regular exercise and physical therapy after active bleeding is controlled. ■Encourage the family to maintain up-to-date immunizations. ■Teach the importance of wearing a medical identification wristband or medical identification tags. ■Teach manifestations of internal bleeding and hemarthrosis. ■Teach to control bleeding episodes using the RICE (rest, ice, compression, elevation) method. ■Encourage the family to participate in a support group.

NephRotiC syNdRome

In nephrotic syndrome, alterations in the glomerular membrane allow proteins (especially albumin) to pass into the urine, resulting in decreased serum osmotic pressure Physical Assessment Findings ■Weight gain over a period of days or weeks ■Facial and periorbital edema - decreased throughout the day ■Ascites ■Edema in the ankles ■Anorexia ■Diarrhea ■Irritability ■Lethargy ■Decreased frothy urine ■Blood pressure within expected reference range or slightly below ◯Laboratory Tests ■Urinalysis/24-hr urine collection ☐proteinuria - protein greater than 2+ on dipstick ☐Hyaline casts ☐Few RBCs ☐Oval fat bodies Serum chemistry ☐Hypoalbuminemia - reduced serum protein and albumin ☐Hyperlipidemia - elevated serum lipid levels ☐Hemoconcentration - elevated Hgb, Hct, and platelets ☐Possible hyponatremia - reduced sodium level ☐Glomerular filtration rate - normal or high

HIV in children

Nursing Care ◯Encourage a balanced diet that is high in calories and protein. Obtain the child's preferred food and beverages. Give nutritional supplements. ◯Administer total parental nutrition (TPN) if prescribed. ◯Provide good oral care and report abnormalities for treatment. ◯Keep the child's skin clean and dry. ◯Provide nonpharmacological methods of pain relief. ◯Assess the child for pain and provide adequate pain management. Use of medications may include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol), opioids, muscle relaxants, and/or a eutectic mixture of local anesthetics (EMLA cream) for numerous diagnostic procedures. Protect/prevent infection using standard precautions. ■Encourage deep breathing and coughing. ■Maintain good hand hygiene. ■Teach the child and parents to avoid individuals who have colds/infections/viruses. ■Encourage immunizations, such as pneumococcal vaccine (PCV) and yearly seasonal influenza vaccine. ■Monitor for signs of opportunistic infections.

epistaxis

Nursing Care ◯Maintain a calm demeanor with the child and family. ◯Have the child sit up with the head tilted slightly forward to prevent aspiration of blood. ◯Apply pressure to the lower nose with the thumb and forefinger for at least 10 min. ◯If needed, cotton or tissue can be packed into the side of the nose that is bleeding. ◯Encourage the child to breathe through her mouth while her nose is bleeding. ◯Apply ice across the bridge of the nose if bleeding continues. ◯Water-soluble jelly or petroleum can be inserted after a nose bleed to prevent crusting of the blood and possible recurrence of bleeding episode. ●Care After Discharge ◯Client Education ■Keep fingernails short. ■Use a cool-mist humidifier during the dry winter months. ■For recurrences, remind the child to sit up and slightly forward so blood does not flow down the throat and cause coughing. ■Inform the family that bleeding usually stops within 10 min.

maltReatmeNt of iNfaNts aNd ChildReN

Physical - causing pain or harm to a child (shaken baby syndrome [due to violent shaking of infants], fractures, Munchausen syndrome by proxy) ■Sexual - occurring when sexual contact takes place without consent, whether or not the victim is able to give consent (includes any sexual behavior toward a minor and dating violence among adolescents) ■Emotional - humiliating, threatening, or intimidating a child (includes behavior that minimizes an individual's feelings of self-worth) ■Neglect - includes failure to provide: ☐Physical care (feeding, clothing, shelter, medical or dental care, safety, education) ☐Emotional care and/or stimulation to foster normal development (nurturing, affection, attention)

Physical Development (1 month to 1 year)

Physical Development ◯The infant's posterior fontanel closes by 6 to 8 weeks of age. ◯The infant's anterior fontanel closes by 12 to 18 months of age. ◯Weight, height, and head circumference measurements are used to track the size of infants. ■Weight - Infants gain approximately 150 to 210 g (about 5 to 7 oz) per week the first 6 months of life. Birth weight is at least doubled by the age of 6 months, and tripled by the age of 12 months. ■Height - Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life. Growth occurs in spurts after the age of 6 months, and the birth length increases by 50% by the age of 12 months. ■Head circumference - The circumference of infants' heads increases approximately 1.5 cm (0.6 in) per month for the first 6 months of life, and then approximately 0.5 cm (0.2 in) between 6 and 12 months of age. ◯Dentition - Six to eight teeth should erupt in infants' mouths by the end of the first year of age. The first teeth typically erupt between the ages of 6 and 10 months. ■Teething pain can be eased using cold teething rings and over-the-counter teething gels. Acetaminophen (Tylenol) and/or ibuprofen (Advil) are appropriate if irritability interferes with sleeping and feeding, but should not be used for more than 3 days. Ibuprofen should be used only in infants over the age of 6 months. ■Clean infants' teeth using cool, wet washcloths. ■Bottles should not be given to infants when they are falling asleep because prolonged exposure to milk or juice can cause early childhood caries.

coNFLict resoLutioN

Problem Solving ◯Open communication among staff and between staff and clients can help defray the need for conflict resolution. ◯When potential sources of conflict exist, the use of open communication and problem-solving strategies can be effective tools to de-escalate the situation. Actions the nurse can take to promote open communication and de-escalate a conflict include the following: ■Use "I" statements, and remember to focus on the problem, not on personal differences. ■Listen carefully to what the other people are saying, and try to understand their perspective. ■Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. ■Share ground rules with participants. For example, everyone is to be treated with respect, only one person can speak at a time, and everyone should have a chance to speak. ◯Steps of the problem-solving process ■Identify the problem - State it in objective terms, minimizing emotional overlay. ■Discuss possible solutions - Brainstorming solutions as a group may stimulate new solutions to old problems. Encourage individuals to "think outside the box." ■Analyze identified solutions - The potential pros and cons of each possible solution should be discussed in an attempt to narrow down the number of viable solutions. ■Select a solution - Based on this analysis, select a solution for implementation. ■Implement the selected solution - A procedure and time line for implementation should accompany the implementation of the selected solution. ■Evaluate the solution's ability to resolve the original problem. The outcomes surrounding the new solution should be evaluated according to the predetermined time line. The solution should be given adequate time to become established as a new routine before it is evaluated. If the solution is deemed unsuccessful, the problem-solving process will need to be reinstituted and the problem discussed again.

Cystic fibrosis

Respiratory findings ☐Early signs X-Wheezing X-Dry, nonproductive cough ☐Increased involvement X-Dyspnea X-Paroxysmal cough X-Mucus plugs and atelectasis on x-ray ☐Advanced involvement X-Cyanosis X-Barrel-shaped chest X-Clubbing of fingers and toes X-Multiple episodes of bronchitis or bronchopneumonia Gastrointestinal findings ☐Large, loose, fatty, sticky, foul-smelling stools ☐Voracious appetite (early), loss of appetite (late) ☐Failure to gain weight or weight loss ☐Delayed growth patterns ☐Distended abdomen ☐Thin arms and legs ☐Deficiency of fat-soluble vitamins ☐Anemia ■Integumentary findings ☐Sweat, tears, and saliva are abnormally salty ■Endocrine and reproductive system findings ☐Viscous cervical mucus ☐Decreased or absent sperm Provide a well-balanced diet that's high in protein and calories. ■Give three meals a day with snacks. ■Encourage oral fluid intake. ■Administer pancreatic enzymes as prescribed 30 min within eating. ■Administer vitamin supplements as prescribed: multivitamin; vitamins A, D, E, and K. ■Administer polyethylene-glycol electrolyte solution (GoLYTELY) via nasogastric tube for constipation as prescribed. ■Administer histamine-receptor antagonist and motility medications for GERD as prescribed. ■Administer possible formula supplements via gastric tube. ■Consult dietitian. ◯Endocrine management ■Monitor blood glucose. ■Administer insulin as prescribed

psychotic disorders

Schizophrenia - The client has psychotic thinking or behavior present for at least 6 months. Areas of functioning, including school or work, self-care, and interpersonal relationships, are significantly impaired. ◯Schizotypal personality disorder - The client has impairments of personality (self and interpersonal) functioning. However, impairment is not as severe as with schizophrenia. ◯Delusional disorder - The client experiences delusional thinking for at least 1 month. Self or interpersonal functioning is not markedly impaired. ◯Brief psychotic disorder - The client has psychotic manifestations that last between 1 day to 1 month in duration. ◯Schizophreniform disorder - The client has manifestations similar to those of schizophrenia, but the duration is from 1 to 6 months, and social/occupational dysfunction may or may not be present. ◯Schizoaffective disorder - The client's disorder meets both the criteria for schizophrenia and depressive or bipolar disorder. ◯Substance-induced psychotic disorder - The client experiences psychosis within 1 month of substance intoxication or withdrawal. May be caused by medications intended for therapeutic use.

Suicide

Sense of hopelessness ■Intense emotions, such as rage, anger, or guilt ■Poor interpersonal relationships at home, school, and work ■Developmental stressors, such as those experienced by adolescents *Subjective Data ◯Assess carefully for verbal and nonverbal clues. It is essential to ask the client if he is thinking of suicide. This will not give the client the idea to commit suicide. ◯Suicidal comments usually are made to someone that the client perceives as supportive. ◯Comments or signals may be overt or covert. ■Overt comment - "There is just no reason for me to go on living." ■Covert comment - "Everything is looking pretty grim for me." ◯Assess the client's suicide plan: ■Does the client have a plan? ■How lethal is the plan? ■Can the client describe the plan exactly? ■Does the client have access to the intended method? ■Has the client's mood changed? A sudden change in mood from sad and depressed to happy and peaceful may indicate a client's intention to commit suicide. ●Objective Data ◯Lacerations, scratches, and scars that could indicate previous attempts at self-harm Suicide precautions include milieu therapy within the facility. ■Initiate one-on-one constant supervision around the clock, always having the client in sight and close. ■Document the client's location, mood, quoted statements, and behavior every 15 min or per facility protocol. ■Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, and plastic bags from the client's room and vicinity. ■Allow the client to use only plastic eating utensils. ■Check the environment for possible hazards (such as windows that open, overhead pipes that are easily accessible.) ■During observation periods, always check the client's hands, especially if they are hidden from sight. ■Do not assign to a private room if possible and keep door open at all times. ■Ensure that the client swallows all medications. ■Identify whether or not the client's current medications can be lethal with overdose. If so, collaborate with the provider to have less dangerous medications substituted if possible. ■Restrict the visitors from bringing possibly harmful items to the client.

Phobias

Social phobia - The client has a fear of embarrassment, is unable to perform in front of others, has a dread of social situations, believes that others are judging him negatively, and has impaired relationships. ■Agoraphobia - The client avoids being outside and has an impaired ability to work or perform duties. ■Specific phobias ☐The client has a fear of specific objects, such as spiders, snakes, strangers. ☐The client has a fear of specific experiences, such as flying, being in the dark, riding in an elevator, being in an enclosed space.

Audits

Structure audits evaluate the influence of elements that exist separate from or outside of the client-staff interaction. X-Process audits review how care was provided and assume a relationship exists between nurses and the quality of care provided. X-Outcome audits determine what results, if any, occurred as a result of the nursing care provided. X-Some outcomes are influenced by aspects of care such as the quality of medical care, the level of commitment of managerial staff, and the characteristics of facility's policies and procedures. X-Nursing-sensitive outcomes are those that are directly affected by the quality of nursing care. Examples include client fall rates and the incidence of nosocomial infections.

autism speCtRum disoRdeR

Subjective and Objective Data ◯Delays in at least one of the following: social interaction, social communication, imaginative play prior to the age of 3 years ◯Distress when routines are changed ◯Unusual attachments to objects ◯Cannot start or continue conversation ◯Uses gestures instead of words ◯Delayed language development ◯Unable to adjust gaze to look at something else ◯Does not refer to self correctly ◯Withdrawn ◯Lack of empathy ◯Spends time alone rather than play with others ◯Avoids eye contact ◯Withdraw from physical contact ◯Heightened or lowered senses ◯Does not imitate actions of others ◯Minimal pretend play ◯Short attention span ◯Intense temper tantrums ◯Shows aggression ◯Exhibits repetitive movements Nursing Care/Client Teaching ◯Assist with screening assessment tools. ◯Refer to early intervention, physical therapy, occupational therapy, and speech and language therapy. ◯Assist with behavior modification program. ■Promote positive reinforcement. ■Increase social awareness. ■Teach verbal communication. ■Decrease unacceptable behaviors. ■Set realistic goals. ■Structure opportunities for small successes. ■Set clear rules. ◯Decrease environmental stimulation. ◯Assist with nutritional needs. ◯Introduce the child to new situations slowly. ◯Monitor for behavior changes. ◯Encourage age appropriate play. ◯Communicate at an age-appropriate level. ◯Provide support to the family. ◯Encourage support groups.

Anger/ aggression

Subjective and Objective Data ◯Hyperactivity such as pacing, restlessness ◯Defensive response when criticized, easily offended ◯Eye contact that is intense, or no eye contact at all ◯Facial expressions, such as frowning or grimacing ◯Body language, such as clenching fists, waving arms ◯Rapid breathing ◯Aggressive postures, such as leaning forward, appearing tense ◯Verbal clues, such as loud, rapid talking ◯Drug or alcohol intoxication Nursing Care ◯Provide a safe environment for the client who is aggressive, as well as for the other clients and staff on the unit. ◯Follow policies of the mental health setting when working with clients who demonstrate aggression. ◯Assess for triggers or preconditions that escalate client emotion. ◯Steps to handle aggressive and/or escalating behavior in a mental health setting include the following: ■Responding quickly ■Remaining calm and in control ■Encouraging the client to express feelings verbally, using therapeutic communication techniques (reflective techniques, silence, active listening) ■Allowing the client as much personal space as possible ■Maintaining eye contact and sitting or standing at the same level as the client ■Communicating with honesty, sincerity, and nonaggressive stance ■Avoiding accusatory or threatening statements ■Describing options clearly and offering the client choices ■Reassuring the client that staff are present to help prevent loss of control Setting limits for the client: ☐Tell the client calmly and directly what he must do in a particular situation, such as, "I need you to stop yelling and walk with me to the day room where we can talk." ☐Use physical activity, such as walking, to deescalate anger and behaviors. ☐Inform the client of the consequences of his behavior, such as loss of privileges. ■Use pharmacological interventions if the client does not respond to calm limit setting. ■Plan for four to six staff members to be available and in sight of the client as a "show of force" if appropriate.

failuRe to thRive (ftt)

Subjective and Objective Data ◯Less than the fifth percentile on the growth chart for weight ◯Malnourished appearance ◯No fear of strangers ◯Minimal smiling ◯Decreased activity level ◯Withdrawal behavior ◯Developmental delays ◯Feeding disorder ◯Wide-eyed gaze ◯Stiff or flaccid body Nursing Care ◯Obtain a nutritional history. ◯Observe parent-child interactions. ◯Obtain accurate baseline height and weight. Observe for low weight, malnourished appearance, and signs of dehydration. ◯Weigh the child daily without clothing or a diaper. ◯Maintain I&O and calorie counts as prescribed. ◯Teach parents to recognize and respond to the infant's cues of hunger. ◯Establish a routine for eating that encourages usual times, duration, and setting. ◯Reinforce proper positioning, latching on, and timing for mothers who are breastfeeding. ◯Provide 24 kcal/oz formula as prescribed. ◯Provide high-calorie milk supplements for children. ◯Administer multivitamin supplements including zinc and iron ◯Teach parents how to mix formula properly and provide step by step written instructions. ◯Limit juice to 4 oz/day. ◯Provide developmental stimulation. ◯Encourage parents to: ■Maintain eye contact and face-to-face posture during feedings. ■Talk to the infant while feeding. ■Burp the infant frequently. ■Keep the environment quiet and avoid distractions. ■Be persistent, remaining calm during 10 to 15 min of food refusal. ■Introduce new foods slowly. ■Never force the infant to eat.

tRaNscRaNial MagNetic stiMulatioN (tMs)

TMS is a noninvasive therapy that uses magnetic pulsations to stimulate specific areas of the brain. Educate the client about TMS. ◯TMS is commonly prescribed daily for a period of 4 to 6 weeks. ◯TMS can be performed as an outpatient procedure. ◯The TMS procedure lasts 30 to 40 min. ◯A noninvasive electromagnet is placed on the client's scalp, allowing the magnetic pulsations to pass through. ◯The client is alert during the procedure.

Glasgow Coma Scale (GCS)

The best possible GCS score is 15. In general, total scores of the GCS correlate with the degree or level of coma. Less than 8 - Associated with severe head injury and coma 9 to 12 - Indicate a moderate head injury Greater than 13 - Reflect minor head trauma The GCS is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the client's response in three areas. Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. E + V + M = Total GCS

Acute glomerulonephritis (AGN)

The glomeruli are inflamed, which impairs the kidney to filter the urine properly. Acute poststreptococcal glomerulonephritis (APSGN) is an antibody-antigen disease that occurs as a result of certain strains of the Group A ß-hemolytic streptococcal infection and is most commonly seen in children between the ages of 2 and 7 years. Subjective Data ◯Recent upper respiratory infection or streptococcal infection ●Objective Data ◯Physical Assessment Findings ■Cloudy, tea-colored urine ■Decreased urine output ■Irritability ■Ill appearance ■Lethargy ■Anorexia ■Vague reports of discomfort (headache, abdominal pain, dysuria) ■Periorbital edema ■Facial edema that is worse in the morning but then spreads to extremities and abdomen with progression of the day ■Mild to severe hypertension Encourage adequate nutritional intake. ■Possible restriction of sodium and fluid. ■Restrict foods high in potassium during periods of oliguria. ■Provide small, frequent meals of favorite foods due to a decrease in appetite. ■Refer the child for dietary consultation if indicated. ■Avoid added salt and salty foods such as chips. ◯Manage fluid restrictions as prescribed. Fluids may be restricted during periods of edema and hypertension.

toddler nutrition

Toddlers should consume 24 to 30 oz of milk per day, and may switch from drinking whole milk to drinking low-fat milk after 2 years of age. ◯Juice consumption should be limited to 4 to 6 oz per day. ◯Trans fatty acids and saturated fats should be avoided. ◯Diet should include 1 cup of fruit daily. ◯Food serving size should be 1 tbsp for each year of age, or ¼ to 1/3 of an adult portion. ◯Toddlers generally prefer finger foods because of increasing autonomy. ◯Regular meal times and nutritious snacks best meet nutrient needs. ◯Snacks or desserts that are high in sugar, fat, or sodium should be avoided. ◯foods that are potential choking hazards (nuts, grapes, hot dogs, peanut butter, raw carrots, tough meats, popcorn) should be avoided.

SEDATIVES/HYPNOTICS

general information ›Such as benzodiazepines like diazepam (Valium) or barbiturates like pentobarbital (Nembutal) can be taken orally or injected. intended effects ›Decreased anxiety, sedationeffects of intoxication ›Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea, vomiting ›Respiratory depression and decreased level of consciousness, which may be fatal ›An antidote, flumazenil (Romazicon), available for IV use for benzodiazepine toxicity ›No antidote to reverse barbiturate toxicity Withdrawal Manifestations ›Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea or vomiting, hallucinations or illusions, psychomotor agitation, and sometimes seizure activity

opioiDs

general information ›Such as heroin, morphine, hydromorphone (Dilaudid) can be injected, smoked, and inhaled intended effects ›A rush of euphoria (extreme well-being), relief from pain effects of intoxication ›Slurred speech, impaired memory, pupillary changes, and decreased respirations and level of consciousness, which may cause death ›Maladaptive behavioral or psychological changes, including impaired judgment or social functioning ›An antidote, naloxone (Narcan), available for IV use to relieve effects of overdoseWithdrawal Manifestations ›Abstinence syndrome begins with sweating and rhinorrhea progressing to piloerection (gooseflesh), tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea and vomiting, pain in the muscles and bones, and muscle spasms. ›Withdrawal is very unpleasant but not life-threatening, and it is self-limiting to 7 to 10 days.

hallUCinogens

general information ›Such as lysergic acid diethylamide (LSD), mescaline (peyote), and phencyclidine piperidine (PCP) are usually ingested orally, can be injected or smoked intended effects ›Heightened sense of self and altered perceptions (colors being more vivid while under the influence) effects of intoxication ›Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks Withdrawal Manifestations ›Hallucinogen Persisting Perception Disorder - Visual disturbances or flashback hallucinations can occur intermittently for years

delusions

ideas of reference ›Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about him. persecution ›Feels singled out for harm by others (e.g., being hunted down by the FBI). grandeur ›Believes that she is all powerful and important, like a god. somatic delusions ›Believes that his body is changing in an unusual way, such as growing a third arm. Jealousy ›May feel that her spouse is sexually involved with another individual. being controlled ›Believes that a force outside his body is controlling him. thought broadcasting ›Believes that her thoughts are heard by others. thought insertion ›Believes that others' thoughts are being inserted into his mind. thought withdrawal ›Believes that her thoughts have been removed from her mind by an outside agency. Religiosity ›Is obsessed with religious beliefs.

Rheumatic fever

is an inflammatory disease that occurs as a reaction to Group A β-hemolytic streptococcus (GABHS) infection of the throat Risk Factors ◯Rheumatic fever usually occurs within 2 to 6 weeks following an untreated or partially treated upper respiratory infection (strep throat) with GABHS. ●Subjective and Objective Data ◯History of recent upper respiratory infection ◯Fever ◯Tachycardia, cardiomegaly, prolonged PR interval, new or changed heart murmur, muffled heart sounds, pericardial friction rub, and report of chest pain, which may indicate carditis ◯Nontender, subcutaneous nodules over bony prominence ◯Large joints (knees, elbows, ankles, wrists, shoulders) with painful swelling, indicating polyarthritis ■Findings may be present for a few days and then disappear without treatment, frequently returning in another joint. ◯Pink, nonpruritic macular rash on the trunk and inner surfaces of extremities that appears and disappears rapidly, indicating erythema marginatum ◯CNS involvement (chorea) including involuntary, purposeless muscle movements; muscle weakness; involuntary facial movements; difficulty performing fine motor activities; labile emotions; and random, uncoordinated movements of the extremities ◯Irritability, poor concentration, and behavioral problems Nursing Care ◯Encourage bed rest during the acute illness. ◯Administer antibiotic as prescribed. ◯Encourage nutritionally balanced meals. ◯Assess for chorea

torts

unintentional torts eXampLe: Negligence ›A nurse fails to implement safety measures for a client who has been identified as at risk for falls. Malpractice (professional negligence) ›A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. quasi-intentional torts example: Breach of confidentiality ›A nurse releases the medical diagnosis of a client to a member of the press. defamation of character ›A nurse tells a coworker that she believes a client has been unfaithful to the spouse. intentional tort example: assault ›The conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat). Battery ›Intentional and wrongful physical contact with a person that involves an injury or offensive contact (restraining a client and administering an injection against his wishes). false imprisonment ›A person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility).

Cholinergic crisis (excessive muscarinic stimulation and respiratory depression from neuromuscular blockade)

›Muscarinic effects (increased salivation, increased gastric secretions and GI motility, urinary urgency, eye spasms, and bradycardia) can be treated with atropine. ›Provide respiratory support through mechanical ventilation and oxygen.

congenital heart defects

›Patent ductus arteriosus (PDA) - a condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left‑to‑right shunt) ›Murmur (machine hum) ›Wide pulse pressure ›Bounding pulses ›Asymptomatic (possibly) ›Heart failure ›Pulmonary stenosis - a narrowing of the pulmonary valve or pulmonary artery that results in obstruction of blood flow from the ventricles ›Systolic ejection murmur ›Asymptomatic (possibly) ›Cyanosis varies with defect, worse with severe narrowing ›Cardiomegaly ›Heart failure ›Ventricular septal defect (VSD) - a hole in the septum between the right and left ventricle that results in increased pulmonary blood flow (left‑to‑right shunt) ›Loud, harsh murmur auscultated at the left sternal border ›Heart failure ›Many VSDs close spontaneously ›Atrial septal defect (ASD) - a hole in the septum between the right and left atria that results in increased pulmonary blood flow (left‑to‑right shunt) ›Loud, harsh murmur with a fixed split second heart sound ›Heart failure ›Asymptomatic (possibly) ›Aortic stenosis - a narrowing of the aortic valve ›Infants »Faint pulses »Hypotension »Tachycardia »Poor feeding tolerance ›Children »Intolerance to exercise »Dizziness »Chest pain »Possible ejection murmur ›Coarctation of the aorta - a narrowing of the lumen of the aorta, usually at or near the ductus arteriosus, that results in obstruction of blood flow from the ventricle ›Elevated blood pressure in the arms ›Bounding pulses in the upper extremities ›Decreased blood pressure in the lower extremities ›Cool skin of lower extremities ›Weak or absent femoral pulses ›Heart failure in infants ›Dizziness, headaches, fainting, or nosebleeds in older children ›Transposition of the great arteries - a condition in which the aorta is connected to the right ventricle instead of the left, and the pulmonary artery is connected to the left ventricle instead of the right a septal defect or a PDA must exist in order to oxygenate the blood ›Murmur depending on presence of associated defects ›Severe to less cyanosis depending on the size of the associated defect ›Cardiomegaly ›Heart failure ›Tricuspid atresia - A complete closure of the tricuspid valve that results in mixed blood flow. An atrial septal opening needs to be present to allow blood to enter the left atrium. ›Infants - cyanosis, dyspnea, tachycardia ›Older children - hypoxemia, clubbing of fingers ›Tetralogy of Fallot - four defects that result in mixed blood flow »Pulmonary stenosis »Ventricular septal defect »Overriding aorta »Right ventricular hypertrophy ›Cyanosis at birth - progressive cyanosis over the first year of life ›Systolic murmur ›Episodes of acute cyanosis and hypoxia (blue spells) ›Truncus arteriosus - failure of septum formation, resulting in a single vessel that comes off of the ventricles ›Heart failure ›Murmur ›Variable cyanosis ›Delayed growth ›Lethargy ›Fatigue ›Poor feeding habits ›Hypoplastic left heart syndrome - Left side of the heart is underdeveloped. An ASD or patent foramen ovale allows for oxygenation of the blood. ›Mild cyanosis ›Heart failure ›Lethargy ›Cold hands and feet ›Once PDA closes, progression of cyanosis and decreased cardiac output result in eventual cardiac collapse

Tonsillectomy

›Place in side-lying position or on abdomen to facilitate drainage. ›Elevate head of bed when child is fully awake. ›Assess for evidence of bleeding, which includes frequent swallowing, clearing the throat, restlessness, bright red emesis, tachycardia, and/or pallor. ›Assess the airway and vital signs. ›Monitor for difficulty breathing related to oral secretions, edema, and/or bleeding. ›Administer analgesics (acetaminophen and codeine) as prescribed. ›Provide an ice collar. ›Offer ice chips or sips of water to keep throat moist. ›Administer pain medication on a regular schedule. ›Discourage coughing, throat clearing, and nose blowing in order to protect the surgical site. ›Refrain from placing pointed objects in the back of the mouth. ›Alert parents that there may be clots or blood-tinged mucus in vomitus. Client Education ■Instruct the parents to contact the provider if the child experiences difficulty breathing, lack of oral intake, increase in pain, and/or indications of infection. ■Tell the parents to ensure that the child does not put anything sharp (ice-cream stick, straw, pointed object) in the mouth. ■Teach the parents to administer pain medications for discomfort. ■Encourage fluid intake and diet advancement to a soft diet with no spicy foods or hard, sharp foods like corn chips until full recovery. ■Instruct the child and family to limit strenuous activity and physical play with no swimming for 2 weeks as prescribed. ■Instruct the child and family that full recovery usually occurs in approximately 14 days. ■Teach the family of clinical manifestations of hemorrhage, dehydration, and infection, and when to notify the provider.

transferenCe

›Transference occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life. example ›A client may see a nurse as being like his mother, and thus may demonstrate some of the same behaviors with the nurse as he demonstrated with his mother. Nursing implications ›A nurse should be aware that transference by a client is more likely to occur with a person in authority.

Leadership Styles

■Authoritative ☐Makes decisions for the group. ☐Motivates by coercion. ☐Communication occurs down the chain of command. ☐Work output by staff is usually high - good for crisis situations and bureaucratic settings. ☐Effective for employees with little or no formal education. ■Democratic ☐Includes the group when decisions are made. ☐Motivates by supporting staff achievements. ☐Communication occurs up and down the chain of command. ☐Work output by staff is usually of good quality - good when cooperation and collaboration are necessary. ■Laissez-faire ☐Makes very few decisions, and does little planning. ☐Motivation is largely the responsibility of individual staff members. ☐Communication occurs up and down the chain of command and between group members. ☐Work output is low unless an informal leader evolves from the group. ☐Effective with professional employees.

Immunizations newborn

■Birth - Hepatitis B (Hep B) ■2 months - Diphtheria and tetanus toxoids and pertussis (DTaP), rotavirus vaccine (RV), inactivated poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B ■4 months - DTaP, RV, IPV, Hib, PCV ■6 months - DTaP, IPV (6 to 18 months), PCV, and Hep B (6 to 12 months); RV; Hib ■6 to 12 months - Seasonal influenza vaccination yearly (the trivalent inactivated influenza vaccine (TIV) is available as an intramuscular injection)

Specific therapies

■Cognitive behavioral therapy - The anxiety response can be decreased by changing cognitive distortions. This therapy uses cognitive reframing to help the client identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk. ■Behavioral therapies teach clients ways to decrease anxiety or avoidant behavior and allow an opportunity to practice techniques. ☐Relaxation training is used to control pain, tension, and anxiety. Refer to the chapter on Stress Management, which covers relaxation training techniques. ☐Modeling allows a client to see a demonstration of appropriate behavior in a stressful situation. The goal of therapy is that the client will imitate the behavior. ☐Systematic desensitization begins with mastering of relaxation techniques. Then, a client is exposed to increasing levels of an anxiety-producing stimulus (either imagined or real) and uses relaxation to overcome the resulting anxiety. The goal of therapy is that the client is able to tolerate a greater and greater level of the stimulus until anxiety no longer interferes with functioning. This form of therapy is especially effective for clients who have phobias. ☐Flooding involves exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response. This therapy is most useful for clients who have phobias. ☐Response prevention focuses on preventing the client from performing a compulsive behavior with the intent that anxiety will diminish. ☐Thought stopping teaches a client to say "stop" when negative thoughts or compulsive behaviors arise, and substitute a positive thought. The goal of therapy is that with time, the client uses the command silently. ■Group and family therapy is beneficial, especially for clients who have trauma- and stressor-related disorders. ■Eye movement desensitization and reprocessing (EMDR) is a therapy for clients who have PTSD. EMDR encourages eye focus on a separate stimuli while thinking of or talking about the traumatic event.

Age-Appropriate Activities 1mo-1yr

■Rattles ■Teething toys ■Nesting toys ■Playing pat-a-cake ■Playing with balls ■Reading books ■Mirrors ■Brightly colored toys ■Playing with blocks

Least Restrictive/Least Invasive

■Select interventions that maintain client safety while posing the least amount of restriction to the client. For example, if a client with a high fall risk index is getting out of bed without assistance, move the client closer to the nurses' work area rather than choosing to apply restraints. ■Select interventions that are the least invasive. For example, bladder training for the incontinent client is a better option than an indwelling urinary catheter.

Mandatory Reporting

●Health care providers have a legal obligation to report their findings in accordance with state law in the following situations: ◯Abuse ■Nurses must report any suspicion of abuse (child or elder abuse, domestic violence) following facility policy. ◯Communicable Diseases ■Nurses must report communicable disease diagnoses to the local or state health department. ■For a complete list of reportable diseases and a description of the reporting system diseases to report in that state. Reporting allows officials to: ☐Ensure appropriate medical treatment of diseases (tuberculosis). ☐Monitor for common-source outbreaks (foodborne, hepatitis A). ☐Plan and evaluate control and prevention plans (immunizations). ☐Identify outbreaks and epidemics. ☐Determine public health priorities based on trends

impaired Coworkers

●Impaired health care providers pose a significant risk to client safety. ●A nurse who suspects a coworker of using alcohol or drugs while working has a duty to report the coworker to appropriate management personnel as specified by institutional policy. At the time of the infraction, the report may need to be made to the immediate supervisor, such as the charge nurse, to ensure client safety. ●Health care facility policies should provide guidelines for handling employees who have a chemical dependency issue, and many provide peer assistance programs that facilitate the health care provider's entry into a treatment program. ●Each state board of nursing has laws and regulations that govern the disposition of nurses who have been reported secondary to chemical dependency. Depending on the individual case, the boards may have the option to require the nurse to enter a treatment program, during which time the nurse's license may be retained, suspended, or revoked. If a nurse is allowed to maintain licensure, there usually are work restrictions put in place, such as working in noncritical care areas and being restricted from administering controlled medications. ●Health care providers who are found guilty of misappropriation of controlled substances also can be charged with a criminal offense consistent with the infraction. ●Behaviors consistent with chemical dependency that should be considered suspicious include: ◯Smell of alcohol on breath or frequent use of strong mouthwash or mints ◯Impaired coordination, sleepiness, shakiness, and/or slurred speech ◯Bloodshot eyes ◯Mood swings and memory loss ◯Neglect of personal appearance ◯Excessive use of sick leave, tardiness, or absences after a weekend off, holiday, or payday ◯Frequent requests to leave the unit for short periods of time or to leave the shift early ◯Frequently "forgetting" to have another nurse witness wasting of a controlled substance ◯Frequent involvement in incidences where a client assigned to the nurse reports not receiving pain medication or adequate pain relief (impaired nurse provides questionable explanations) ◯Documenting administration of pain medication to a client who did not receive it or documenting a higher dosage than has been given by other nurses ◯Preferring to work the night shift where supervision is less or on units where controlled substances are more frequently given Behaviors may be difficult to detect if the impaired nurse is experienced at masking the addiction.

types of advance Directives

●Living Will ◯A living will is a legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. ◯Most state laws include provisions that protect health care providers who follow a living will from liability. ●Durable Power of Attorney for Health Care ◯A durable power of attorney for health care is a document in which clients designate a health care proxy to make health care decisions for them if they are unable to do so. The proxy may be any competent adult the client chooses. ●Provider's Orders ◯Unless a provider writes a "do not resuscitate" (DNR) or "allow natural death" (AND) prescription in the client's medical record, the nurse initiates cardiopulmonary resuscitation (CPR) when the client has no pulse or respirations. The provider consults the client and the family prior to administering a DNR or AND

haNdLiNg iNfectious aNd hazardous MateriaLs

●Members of the health care team must clean and maintain equipment that is shared by several clients on a unit (blood pressure cuffs, thermometers, pulse oximeters). ●Keep designated equipment in the rooms of clients who are on contact precautions. ●Use standard precautions at all times. ●Employ proper hand hygiene techniques. ●Use needlestick precautions when handling needles and sharps. ●Maintain knowledge of rules and regulations and proper procedures for handling infectious/hazardous materials (use of red biohazard bag for disposal of contaminated materials, proper use of puncture-proof containers for sharps).

Status asthmaticus

◯A life-threatening episode of airway obstruction that is often unresponsive to common treatment ◯Manifestations include wheezing, labored breathing, nasal flaring, lack of air movement in lungs, use of accessory muscles, distended neck veins, and risk for cardiac and/or respiratory arrest. ◯Nursing Actions ■Monitor oxygen saturations continuously. ■Place on continuous cardiorespiratory monitoring. ■Position the child sitting upright, standing, or leaning slightly forward. ■Administer humidified oxygen. ■Administer three nebulizer treatments of a beta2-agonist, 20 to 30 min apart or continuously. Ipratropium bromide may be added to the nebulizer to increase bronchodilation. ■Obtain IV access. ■Monitor ABGs and serum electrolytes. ■Administer corticosteroid. ■Prepare for emergency intubation. ●Respiratory failure ◯Persistent hypoxemia related to asthma can lead to respiratory failure. ◯Nursing Actions ■Monitor oxygenation levels and acid-base balance. ■Prepare for intubation and mechanical ventilation as indicated.

Defense Mechanisms Used in Cognitive Disorders

◯Assess for defense mechanisms used by the client to preserve self-esteem and to compensate when cognitive changes are progressive: ■Denial - Both the client and family members may refuse to believe that changes, such as loss of memory, are taking place, even when those changes are obvious to others. ■Confabulation - The client may make up stories when questioned about events or activities that she does not remember. This may seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that she does not remember the occasion. ■Perseveration - The client avoids answering questions by repeating phrases or behavior. This is another unconscious attempt to maintain self-esteem when memory has failed.

Ethical principles are standards of what is right or wrong with regard to important social values and norms. Ethical principles pertaining to the treatment of clients include:

◯Autonomy - the ability of the client to make personal decisions, even when those decisions may not be in the client's own best interest ◯Beneficence - the care that is in the best interest of the client ◯Fidelity - keeping one's promise to the client about care that was offered ◯Justice - fair treatment in matters related to physical and psycho social care and use of resources ◯Nonmaleficence - the nurse's obligation to avoid causing harm to the client ◯Veracity - the nurse's duty to tell the truth

Time Management and Teamwork

◯Be cognizant of assistance needed by other health care team members. ◯Offer to help when unexpected crises occur. ◯Assist other team members with provision of care when experiencing a period of "down time."

When a nurse receives an inappropriate assignment, she should take the following actions:

◯Bring the inappropriate assignment to the attention of the scheduling/charge nurse and negotiate a new assignment. ◯If no resolution is arrived at, take the concern up the chain of command. ◯If a satisfactory resolution is still not arrived at, an unsafe staffing complaint in the form of an Assignment Despite Objection (ADO) or Document of Practice Situation (DOPS) should be filed with the appropriate administrator. ◯Failure to accept the assignment without following the proper channels may be considered abandonment

toddler dental health

◯Children should have an established dental home by the age of 1 year. ◯Flossing and brushing should be performed by the adult caregiver, and is the best method of removing plaque. ◯Brushing should occur after meals and at bedtime. Nothing to eat or drink, except water, is given to the child after the bedtime cleaning. ◯Fluoride is supplemented for children living in areas without adequate levels in drinking water. ◯Early childhood caries is a form a tooth decay that develops in toddlers, and is more common in children who are put to bed with a bottle of juice or milk. ◯Consumption of cariogenic foods should be eliminated if possible. If not, the frequency of consumption should be limited.

Pneumothorax - accumulation of air in the pleural space

◯Clinical Manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen saturations, and tachycardia ◯Nursing Interventions ■Prepare client for an emergent needle aspiration with insertion of chest tube to closed drainage. ■Provide for chest tube management. ■Assess respiratory status. ■Administer oxygen as prescribed

Pleural effusion - accumulation of fluid in the pleural space

◯Clinical manifestations - dyspnea, chest pain, back pain, labored respirations, decreased oxygen saturations, and tachycardia ◯Nursing Interventions ■Prepare the client for an emergent needle aspiration with insertion of chest tube to closed drainage. ■Provide for chest tube management. ■Assess respiratory status. ■Administer oxygen as prescribed.

codes

◯Code Red (fire) ◯Code Pink (newborn abduction) ◯Code Orange (chemical spill) ◯Code Blue (mass casualty incident) ◯Code Gray (tornado)

Hospice care specializes in the care of a client who is dying.

◯Family members are the primary caregivers. ◯Nursing focus is on pain control and comfort. ◯Family and client needs are equal. ◯Provide support for the family grieving process, which can continue after the client's death.

Incident reports

◯Medication errors ◯Procedure/treatment errors ◯Equipment-related injuries/errors ◯Needlestick injuries ◯Client falls/injuries ◯Visitor/volunteer injuries ◯Threat made to client or staff ◯Loss of property (dentures, jewelry, personal wheelchair) In the event of an incident that involves a client, employee, volunteer, or visitor, the nurse's priority is to assess the individual for injuries and institute any immediate care measures necessary to decrease further injury. If it was a client-related incident, the provider should then be notified, and additional tests or treatment should be carried out as prescribed. Incident Reports ◯Should be completed by the person who identifies that an unexpected event has occurred. (This may or may not be the individual most directly involved in the incident.) ◯Should be completed as soon as possible and within 24 hr of the incident. ◯Are considered confidential and are not shared with the client. (Nor is it acknowledged to the client that one was completed.) ◯Are not placed in the client's health care record nor mentioned in the client's health care record. However, a description of the incident itself should be documented factually in the client's record. ◯Include an objective description of the incident and actions taken to safeguard the client, as well as assessment and treatment of any injuries sustained. ◯Are forwarded to the risk management department or officer (varies from facility to facility), possibly after being reviewed by the nurse manager. ◯Provide data that may be used in performance improvement studies regarding the incidence of client injuries and care-related errors. When completing an incident report, the nurse should include the following: ◯The client's name and hospital number (or visitor's name and address if visitor injury), along with the date, time, and location of the incident ◯A factual description of the incident and injuries incurred, avoiding any assumptions as to the cause of the incident ◯Names of any witnesses to the incident and any client or witness comments regarding the incident ◯Corrective actions that were taken, including notification of the provider and any referrals ◯The name and dose of any medication or identification number of any piece of equipment that was involved in the incident

Pharmacological therapy for drug use

◯Medications ■Alcohol withdrawal - Diazepam (Valium), lorazepam (Ativan), carbamazepine (Tegretol), clonidine (Catapres), chlordiazepoxide (Librium) ■Alcohol abstinence - Disulfiram (Antuse), naltrexone (Revia), acamprosate (Campral) Opioid withdrawal - methadone (Dolophine) substitution, clonidine (Catapres), buprenorphine (Subutex) ■Nicotine withdrawal from tobacco use - Bupropion (Zyban), nicotine replacement therapy (nicotine gum [Nicorette] and nicotine patch [Nicotrol])

Bone and Soft Tissue Cancers symptoms

◯Osteosarcoma usually occurs in the metaphysis of long bones, most often in the femur. Treatment frequently includes amputation or limb salvage procedure of the affected extremity as well as chemotherapy. ◯Ewing's sarcoma (a primitive neuroectodermal tumor [PNET]) occurs in the shafts of long bones and of trunk bones. Treatment includes surgical biopsy, intensive radiation therapy to tumor site, and chemotherapy, but not amputation.

Warning signs of abuse

◯Physical evidence of abuse ◯History of injury incompatible with the findings ◯Vague explanation of injury ◯Other injuries are discovered that are not related to the original client concern ◯Delay in seeking care ◯Multiple fractures at different stages of healing ◯Bruising in a nonmobile client ◯Caregivers/client report conflicting histories ◯Statement of possible abuse from a caregiver or client

Physical manifestations of death

◯Sensation of heat when the body feels cool ◯Decreased sensation and movement in the lower extremities ◯Loss of senses (hearing is the last to be lost) ◯Confusion or loss of consciousness (LOC) ◯Decreased appetite and thirst ◯Swallowing difficulties ◯Loss of bowel and bladder control ◯Bradycardia, hypotension ◯Cheyne-Stokes respirations

Dietary sources of iron

☐Infants - iron-fortified cereals and formula ☐Older children - dried beans and lentils; peanut butter; green, leafy vegetables; iron-fortified breads and flour; poultry; and red meat

viral infections, hiv and aids A nurse is caring for a client who has a new diagnosis of HIV infection and is beginning combination oral NRTIs (abacavir, lamivudine, and zidovudine [Trizivir]). The client asks how medications work to treat HIV. Which of the following responses by the nurse is appropriate? A nurse is teaching a client who is beginning highly active antiretroviral therapy (HAART) for HIV infection about ways to prevent medication resistance. Which of the following should the nurse teach the client about resistance? A nurse is caring for a client who takes several antiretroviral medications, including the NRTI zidovudine, to treat HIV infection. For which of the following adverse effects of zidovudine should the nurse monitor? (Select all that apply A nurse is caring for a client who is taking ritonavir (Norvir), a protease inhibitor, to treat HIV infection. For which of the following abnormalities in laboratory values should the nurse monitor? A nurse is caring for a client who is starting enfuvirtide (Fuzeon) to treat HIV infection. For which of the adverse reactions should the nurse monitor? (Select all that apply.) A nurse is administering IV acyclovir (Zovirax) to a client who has varicella and is immunocompromised. Which of the following nursing actions is appropriate?

"These medications work by inhibiting enzymes to prevent HIV replication." Taking medication at the same times daily without skipping doses minimizes resistance. Fatigue Hyperventilation Vomiting Hyperlipidemia Breath sounds for pneumonia Injection site for erythema blood pressure for hypersensitive reaction Administer acyclovir infusion over at least 1 hr

Hemodynamic Monitoring

*Arterial lines are placed in the radial (most common), brachial, or femoral artery. -Arterial lines provide continuous information about changes in blood pressure and permit the withdrawal of samples of arterial blood. Intra-arterial pressures can differ from cuff pressures. -The integrity of the arterial waveform should be assessed to verify the accuracy of blood pressure readings. -Monitor circulation in the limb with the arterial line (capillary refill, temperature, color). -Arterial lines are not used for IV fluid administration. *Pulmonary Artery (PA) Catheters -The PA catheter is inserted into a large vein (internal jugular, femoral, subclavian, brachial) and threaded through the right atria and ventricle into a branch of the pulmonary artery. -PA catheters have multiple lumens, ports, and components that allow for various hemodynamic measurements, blood sampling, and infusion of IV fluids. -----Proximal lumen can be used to measure right atrial ---pressure (CVP), infuse IV fluids, and obtain venous blood samples. -----Distal lumen can be used to measure pulmonary artery pressures (PA systolic, PAdiastolic, mean PA pressure, and PA wedge pressure). This lumen is not used for IV fluid administration. -----Balloon inflation port is intermittently used for PAWP measurements. When not in use, it should be left deflated and in the "locked" position. ----Thermistor measures the temperature differences between the right atrium and the pulmonary artery in order to determine cardiac output. ----Additional infusion ports may be available, depending on the brand.

Basic Nutrients the Body Requires

*Carbohydrates provide most of the body's energy and fiber. Each gram produces 4 kcal. Sources include whole grain breads, baked potatoes, and brown rice. ●Fats provide energy and vitamins. No more than 30% of caloric intake should be from this source. Each gram produces 9 kcal. Sources include olive oil, salmon, and egg yolks. ●Proteins contribute to the growth and repair of body tissues. Each gram produces 4 kcal. Sources include ground beef, whole milk, and poultry. ●Vitamins are necessary for metabolism. The fat-soluble vitamins are A, D, E, and K. The water-soluble vitamins include C and B complex (eight vitamins). ●Minerals complete essential biochemical reactions in the body (calcium, potassium, sodium, iron). ●Water replaces fluids lost through perspiration, elimination, and respiration.

abstinence maintenance (following detox)

*Disulfiram (antabuse) *intended Effects›Disulfiram is a daily oral medication that is a type of aversion (behavioral) therapy. ›Disulfiram used concurrently with alcohol will cause acetaldehyde syndrome to occur. ›Effects include nausea, vomiting, weakness, sweating, palpitations, and hypotension. ›Acetaldehyde syndrome can progress to respiratory depression, cardiovascular suppression, seizures, and death. *Nursing interventions/ client Education ›Inform clients of the potential dangers of drinking any alcohol. ›Advise clients to avoid any products that contain alcohol (cough syrups, mouthwash, aftershave lotion). ›Monitor frequent liver function tests to detect hepatotoxicity. ›Encourage clients to wear a medical alert bracelet. ›Encourage clients to participate in a 12-step self-help program. ›Advise clients that medication effects (potential for acetaldehyde syndrome with alcohol ingestion) persist for 2 weeks following discontinuation of disulfiram. *naltrexone (vivtrol) *intended Effects ›Naltrexone is a pure opioid antagonist that suppresses the craving and pleasurable effects of alcohol (also used for opioid withdrawal). *Nursing interventions/client Education ›Take an accurate history to determine whether clients are also dependent on opioids. Concurrent use of naltrexone and opiates increases the risk for an opiate overdose. ›Advise clients to take the medication with meals to decrease gastrointestinal distress. ›Suggest monthly IM injections for clients who have difficulty adhering to regimen *acamprosate (campral) *intended Effects ›Acamprosate decreases unpleasant effects resulting from abstinence (anxiety, restlessness). *Nursing interventions/client Education ›Inform clients that diarrhea may result. ›Advise clients to maintain adequate fluid intake and to receive adequate rest. ›Advise clients to avoid use in pregnancy.

Reporting Communicable Diseases

*Ensure appropriate medical treatment of diseases (tuberculosis). ■Monitor for common-source outbreaks (foodborne - hepatitis A). ■Plan and evaluate control and prevention plans (immunizations for preventable diseases). ■Identify outbreaks and epidemics. ■Determine public health priorities based on trends. Anthrax† Arboviral diseases, neuroinvasive and nonneuroinvasive California serogroup virus Eastern equine encephalitis virus Powassan virus St. Louis encephalitis virus West Nile virus Western equine encephalitis virus Botulism foodborne infant other (wound and unspecified) Brucellosis† Chancroid infection Cholera Cryptosporidiosis Cyclosporiasis† Dengue Virus Infection Dengue fever Dengue hemorrhagic fever Dengue shock syndrome Diphtheria Ehrlichiosis/Anaplasmosis† Undetermined Giardiasis Gonorrhea Haemophilus influenzae, invasive disease† Hansen disease (leprosy) Hantavirus pulmonary syndrome† Hemolytic uremic syndrome, post-diarrheal Hepatitis, viral Hepatitis A, acute Hepatitis B, acute Hepatitis B virus, perinatal infection Hepatitis B, chronic Hepatitis C, acute Hepatitis C, chronic§ Human Immunodeficiency Virus (HIV) infection** Influenza-associated pediatric mortality Legionellosis Listeriosis Lyme disease Malaria† Measles Meningococcal disease Mumps Novel influenza A virus infections Pertussis Plague Poliomyelitis, paralytic Poliovirus infection, nonparalytic Psittacosis† Q fever† Acute Chronic Rabies Animal Human† Rubella Rubella, congenital syndrome Salmonellosis Severe acute respiratory syndrome-associated coronavirus (SARS-CoV) disease Shiga toxin-producing (STEC) Shigellosis Smallpox Spotted fever rickettsiosis†¶ Streptococcal toxic-shock syndrome† Streptococcus pneumoniae, invasive disease Syphilis Syphilis, congenital Tetanus Toxic-shock syndrome (other than streptococcal) Trichinellosis Tuberculosis† Tularemia Typhoid fever Vancomycin-intermediate (VISA) infection Vancomycin-resistant (VRSA) infection Varicella (morbidity) Varicella (mortality) Vibriosis Viral hemorrhagic fevers New World Arenavirus Crimean-Congo hemorrhagic fever virus Ebola virus Lassa virus Marburg virus Yellow fever

Intracranial pressure (ICP)

*Four methods are used to monitor. -Use a thin tube inserted into the lateral ventricle (intraventricular). -Use a bolt or screw placed in the subarachnoid area (subarachnoid). -Place a sensor in the epidural space (epidural). -Place a fiberoptic transducer-tipped catheter into the subdural or subarachnoid space, ventricle, or brain tissue. ☐Expected reference range for ICP level is 10 to 15 mm Hg. *ICP may be increased by -Hypercarbia, which leads to cerebral vasodilation -Endotracheal or oral tracheal suctioning -Coughing -Blowing the nose forcefully -Extreme neck or hip flexion/extension -Maintaining the head of the bed at an angle less than 30° -Increasing intra-abdominal pressure (restrictive clothing, Valsalva maneuver). ☐Implement actions that will decrease ICP. -Elevate head at least 30° to reduce ICP and to promote venous drainage. -Avoid extreme flexion, extension, or rotation of the head, and maintain the body in a midline neutral position. -Maintain a patent airway. Provide mechanical ventilation as indicated. -Administer oxygen as indicated to maintain an oxygen saturation level of greater than 92%. -Hyperventilate clients on mechanical ventilation to keep the PaCO2 between 35 to 38 mm Hg. This reduces cerebral blood flow. -Maintain cervical spine stability until cleared by an x-ray. -Report presence of cerebrospinal fluid (CSF) from nose or ears to the provider. -Provide a calm, restful environment (limit visitors, minimize noise). -Implement measures to prevent complications of immobility (turn every 2 hr, footboard, and splints). Specialty beds can be used. -Monitor fluid and electrolyte values and osmolarity to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia. -Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema. When a large amount of IV fluids are prescribed, monitor for excess fluid volume which could increase ICP. -Maintain safety and seizure precautions (side rails up, padded side rails, call light within the client's reach). -Even if the level of consciousness is decreased, explain to the client the actions being taken and why. -Hearing is the last sense affected by a head injury

Nasogastric Intubation

*Indications Decompression -Removal of gases or stomach contents to relieve distention, nausea, or vomiting -Tube types - Salem sump, Miller-Abbott, Levin Feeding -Alternative to oral route for administering nutritional supplements -Tube types - Duo, Levin, Dobhoff Lavage -Washing out the stomach to treat active bleeding, ingestion of poison, gastric dilation -Tube types - Ewald, Levin, Salem sump Compression -Applied pressure using an internal balloon to prevent hemorrhage -Tube type - Sengstaken-Blakemore

Fluid volume deficits (FVDs)

*Isotonic FVD is the loss of water and electrolytes from the ECF. -Isotonic FVD is often referred to as hypovolemia because intravascular fluid is also lost. *Dehydration is the loss of water from the body without the loss of electrolytes. -This hemoconcentration results in increases in Hct, serum electrolytes, and urine specific gravity. *Compensatory mechanisms include sympathetic nervous system responses of increased thirst, antidiuretic hormone (ADH) release, and aldosterone release

nasal cannula (low flow)

*It delivers an FiO2 of 24% to 44% at a flow rate of 1 to 6 L/min *Provide humidification for flow rates of 4 L/min and above.

hypernatremia

*Risk Factors -Water deprivation (NPO) -Heat stroke -Excessive sodium intake - dietary sodium intake, hypertonic IV fluids, hypertonic tube feedings, bicarbonate intake -Excessive sodium retention - kidney failure, Cushing's syndrome, aldosteronism, some medications (glucocorticosteroids) -Fluid losses - fever, diaphoresis, burns, respiratory infection, diabetes insipidus, hyperglycemia, watery diarrhea -Age-related changes, specifically decreased total body water content and inadequate fluid intake related to an altered thirst mechanism -Compensatory mechanisms - increased thirst and increased production of ADH *Subjective and Objective Data Vital signs - hyperthermia, tachycardia, orthostatic hypotension Neuromusculoskeletal - restlessness, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased level of consciousness, reduced to absent DTRs GI - thirst, dry mucous membranes, dry and swollen tongue that is red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea Other clinical findings - edema, warm flushed skin, oliguria *Laboratory Findings Serum sodium Increased - greater than 145 mEq/L Serum osmolarity Increased - greater than 300 mOsm/kg

pulmonary edema

*Risk Factors Acute MI Fluid volume overload Hypertension Valvular heart disease Postpneumonectomy Postevacuation of pleural effusion Acute respiratory failure Left-sided heart failure High altitude exposure or deep-sea diving Trauma Sepsis Drug overdose *Subjective Data Anxiety Inability to sleep *Objective Data Persistent cough with pink, frothy sputum (cardinal sign) Tachypnea, dyspnea, and orthopnea Hypoxemia (SaO2 expected reference range greater than 95%) Cyanosis (later stage) Crackles tachycardia Reduced urine output Confusion, stupor S3 heart sound (gallop) Increased pulmonary artery occlusion pressure *Nursing Care Monitor vital signs every 15 min until stable. Monitor intake and output. Monitor hemodynamic status (pulmonary wedge pressures, cardiac output). Check ABGs, electrolytes (especially potassium if on diuretics), SaO2, and chest x-ray findings. Maintain a patent airway. Suction as needed. Position the client in high-Fowler's position with feet and legs dependent or sitting on the side of the bed to decrease preload. Administer oxygen using a high-flow rebreather mask. BiPAP or intubation/ventilation can become necessary. Be prepared to intervene quickly. Restrict fluid intake (slow or discontinue infusing IV fluids). Monitor hourly urine output. Watch for intake greater than output or hourly urine less than 30 mL/hr.

hyponatremia

*Subjective and Objective Data Physical assessment findings - vary with a normal, decreased, or increased ECF volume Vital signs - hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension Neuromusculoskeletal - headache, confusion, lethargy, muscle weakness with possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, coma GI - increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, nausea, vomiting *Laboratory Findings Serum sodium Decreased - less than 136 mEq/L Serum osmolarity Decreased - less than 280 mOsm/kg Nursing Care -Report abnormal laboratory findings to the provider. -Fluid overload - Restrict water intake as prescribed. Acute hyponatremia: -Administer hypertonic oral and IV fluids as prescribed. -Encourage foods and fluids high in sodium (cheese, milk, condiments). -Restoration of normal ECF volume - Administer isotonic IV therapy (0.9% sodium chloride, lactated Ringer's). -Monitor I&O and weigh the client daily. -Monitor vital signs and level of consciousness, reporting abnormal findings. -Encourage the client to change positions slowly. -Follow any prescribed fluid restrictions.

Torch infections

*Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. The symptoms are similar to influenza or lymphadenopathy. Other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella-zoster. These are some of the most common and can be associated with congenital anomalies. ●Rubella (German measles) is contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy. ●Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal. ●The herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions. Subjective Data ◯Toxoplasmosis findings similar to influenza or lymphadenopathy ◯Malaise, muscle aches, (flulike symptoms) ◯Rubella joint and muscle pain ◯Cytomegalovirus has asymptomatic or mononucleosis-like manifestations ●Objective Data ◯Physical assessment findings ■Manifestations of toxoplasmosis include fever and tender lymph nodes. ■Manifestations of rubella include rash, mild lymphedema, fever, and fetal consequences, which include miscarriage, congenital anomalies, and death. ■Herpes simplex virus initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. ◯Laboratory Tests ■For herpes simplex, obtain cultures from women who have HSV or are at or near term. ◯Diagnostic Procedures ■A TORCH screen is an immunologic survey that is used to identify the existence of these infections in the mother (to identify fetal risks) or in her newborn (detection of antibodies against infections). ■Prenatal screenings Client Education ■For rubella, vaccination of women who are pregnant is contraindicated because rubella infection may develop. These women should avoid crowds of young children. Women with low titers prior to pregnancy should receive immunizations. ■Because no treatment for cytomegalovirus exists, tell the client to prevent exposure by frequent hand hygiene before eating, and avoiding crowds of young children. ■Emphasize to the client the importance of compliance with prescribed treatment. ■Provide client with emotional support.

routes of administration

*Transdermal - medication stored in a skin patch and absorbed through the skin producing systemic effects *Instructions to the client should include: ›Apply patches as provided to ensure proper dosing. ›Wash the skin with soap and water, and dry it thoroughly before applying a new patch. ›Place the patch on a hairless area of the skin and rotate sites to prevent skin irritation *instillation (drops, ointments, sprays) - generally used for eyes, ears, and nose ›Eyes »Use medical aseptic technique when instilling medications in eyes. »Have the client sit upright or lie supine with the head tilted slightly and looking up at the ceiling. »Rest the dominant hand on the client's forehead, hold the dropper above the conjunctival sac about 1 to 2 cm, drop the medication into the center of the sac, and have the client close the eye gently. »Apply gentle pressure with the finger and a clean tissue on the nasolacrimal duct for 30 to 60 seconds to prevent systemic absorption of the medication. ›Ears »Use medical aseptic technique when administering medications into the ears. »Have the client sit upright or maintain a side-lying position. »Straighten the ear canal by pulling the auricle upward and outward for adults or down and back for children. Hold the dropper 1 cm above the ear canal, instill medication, and then gently apply pressure with finger to tragus of ear unless contraindicated due to pain. »Do not press a cotton ball deep into the ear canal. If needed, gently place it into the outermost part of the ear canal. »Have the client remain in the side-lying position if possible for 2 to 3 min after installation of ear drops. ›Nose »Use medical aseptic technique when administering medications into the nose. »Have the client supine with the head positioned to allow the medication to enter the appropriate nasal passage. »Use the dominant hand to instill drops, supporting the head with the non-dominant hand. »Instruct the client to breathe through the mouth, stay in a supine position, and not to blow the nose for 5 min after drop insertion.

magnesium sulfate

*adverse effects Muscle weakness, flaccid paralysis, painful muscle contractions, cardiac disorders, and respiratory depression, Diarrhea

herbal supplements

*black cohosh Increases effects of antihypertensive medications ›May increase effect of estrogen medications ›Increases hypoglycemia in clients taking insulin or other medications for diabetes ›Some products contain St. John's wort and should be avoided because of drug interactions related to St. John's wort. *Echinacea action-Stimulates the immune system ›Decreases inflammation ›Topically heals skin disorders, wounds, and burns ›Possibly treats viruses (common cold, herpes simplex) ›Used to increase T-lymphocyte, tumor necrosis factor, and interferon production *interactions ›With chronic use (more than 6 months), echinacea can decrease positive effects of medications for tuberculosis, HIV, or cancer *Garlic action ›When crushed forms the enzyme allicin ›Blocks LDL cholesterol and raises HDL cholesterol; lowers triglycerides ›Suppresses platelet aggregation and disrupts coagulation ›Acts as a vasodilator (may lower BP) interactions ›Due to antiplatelet qualities, can increase risk of bleeding in clients taking NSAIDs, warfarin, and heparin ›Can increase hypoglycemic effects of diabetes medications ›Decreases levels of saquinavir, a medication for HIV treatment *Ginko biloba action ›Promotes vasodilation - Decreases leg pain caused from occlusive arterial disorders ›Decreases platelet aggregation - May decrease risk of thrombosis ›Decreases bronchospasm ›Increases blood flow to the brain - Improves memory (dementia, Alzheimer's disease interactions ›May interact with medications that lower the seizure threshold, such as antihistamines, antidepressants, and antipsychotics ›Can interfere with coagulation *st johns wort action ›Affects serotonin, producing antidepressant effects - Used for mild depression ›Used orally as an analgesic to relieve pain and inflammation ›Applied topically for infection interactions ›May cause serotonin syndrome when combined with other antidepressants, amphetamine, and cocaine ›Decreases effectiveness of oral contraceptives, cyclosporine, warfarin, digoxin, calcium-channel blockers, steroids, HIV protease inhibitors, and some cancer chemotherapy medications

thyroidectomy

-A thyroidectomy is the surgical removal of part or all of the thyroid gland. *A subtotal thyroidectomy may be performed for the treatment of hyperthyroidism when medication therapy fails or radiation therapy is contraindicated. It may also be used to correct diffuse goiter and thyroid cancer. After a subtotal thyroidectomy, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function. *If a total thyroidectomy is performed, the client will need thyroid hormone replacementtherapy.

preoperative medication administration

-Administer preoperative medications (prophylactic antimicrobials, antiemetics, sedatives) as prescribed. -Prophylactic antibiotics are administered 1 hr prior to surgical incision. -If the client previously took a beta-blocker, administer a beta-blocker prior to surgery to prevent a cardiac event and mortality. -Have the client void prior to administration. -Monitor the client's response to the medications. -Raise side rails following administration to prevent injury.

Evisceration and dehiscence require emergency treatment.

-Call for help. -Stay with the client. -Cover the wound and any protruding organs with sterile towels or dressings soaked with sterile normal saline solution. Do not attempt to reinsert the organs. -Position the client supine with the hips and knees bent. -Observe for signs of shock. -Maintain a calm environment. -Keep the client NPO in preparation for returning to surgery.

heart failure

-Left-sided heart (ventricular) failure results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion. Forms include the following: *Systolic heart (ventricular) failure (ejection fraction below 40%, pulmonary and systemic congestion) *Diastolic heart (ventricular) failure (inadequate relaxation or "stiffening" prevents ventricular filling) -Right-sided heart (ventricular) failure results in inadequate right ventricle output and systemic venous congestion (peripheral edema) *Subjective and Objective Data -Left-sided failure Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop) Pulmonary congestion (dyspnea, cough, bibasilar crackles) Frothy sputum (can be blood-tinged) Altered mental status Manifestations of organ failure, such as oliguria (decrease in urine output -Right-sided failure Jugular vein distention Ascending dependent edema (legs, ankles, sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (nocturnal) Liver enlargement (hepatomegaly) and tenderness Weight gain

Poisoning is considered a medical emergency and requires rapid management therapy.

-Obtain a client history to identify the toxic agent. ◯Implement supportive care. ◯Determine type of poison. Prevent further absorption of the toxin. ◯Extract or remove the poison. ◯Administer antidotes when necessary. ■Antivenin based on the type and severity of a snake bite within 4 to 12 hr. ■For ingested poison, three procedures are available: activated charcoal, gastric lavage and aspiration, or whole-bowel irrigation. (Syrup of ipecac is no longer recommended.) ●Interventions to manage the clinical status of the client exposed to or who ingested a toxic agent: ◯Provide measures for respiratory support (oxygen, airway management, mechanical ventilation). ◯Monitor compromised circulation (resulting from excess perspiration, vomiting, diarrhea). ◯Restore fluids with IV fluid therapy. ◯Monitor blood pressure, cardiac monitoring, ECG. ◯Assess for tissue edema every 15 to 30 min if bitten by a snake or spider. ◯Administer opioid medications for pain due to snake or spider bite. ◯Monitor ABGs, blood glucose levels, coagulation profile. ◯Administer IV diazepam (Valium) if seizures occur. ◯Reverse heroin and other opiate toxicity with naloxone (Narcan). ◯Implement dialysis and an exchange blood transfusion as a nonpharmacologic technique to remove toxic agent

Thyroid Storm/Crisis

-Precipitating factors include infection, trauma, emotional stress, diabetic ketoacidosis, and digitalis toxicity, all of which increase demands on body metabolism. It also can occur following a surgical procedure or a thyroidectomy as a result of manipulation of the gland during surgery. -Findings are hyperthermia, hypertension, delirium, vomiting, abdominal pain, hyperglycemia, and tachydysrhythmias. Additional findings include chest pain, dyspnea, and palpitations. Nursing Actions -Maintain a patent airway. -Provide continuous cardiac monitoring for dysrhythmias. -Administer acetaminophen to decrease the client's temperature. ***Caution - Salicylate antipyretics are contraindicated because they release thyroxine from protein-binding sites and increase free thyroxine levels. -Provide cool sponge baths, or apply ice packs to decrease fever. If fever continues, obtain a prescription for a cooling blanket for hyperthermia. -Administer thionamides - methimazole or propylthiouracil (PTU) - to prevent further synthesis and release of thyroid hormones. -Administer propranolol to block sympathetic nervous system effects. -Administer glucocorticoids to treat shock. -Administer IV fluids to provide adequate hydration and prevent vascular collapse. Fluid volume deficit may occur because of increased fluid excretion by the kidneys or excessive diaphoresis. Monitor intake and output hourly to prevent fluid overload or inadequate replacement. -Administer sodium iodide as prescribed, 1 hr after administering PTU. ****Caution - If given before PTU, sodium iodide can exacerbate manifestations in susceptible clients. -Administer small doses of insulin as prescribed to control hyperglycemia, which can occur because of the hypermetabolic state. -Administer supplemental O2 to meet increased oxygen demands.

Preoperative Assessment

-Preoperative nursing assessments -Detailed history (including medical history, medication use, substance use, psychosocial history, and cultural considerations) -Allergies to medications, latex related to a sensitivity to bananas and other fruits, -betadine related to an allergen to shellfish, -propofol related to an allergy to eggs or soybean oil. -Anxiety level regarding the procedure, support systems, and coping mechanisms. -Older adult clients may be more fearful due to financial concerns and lack of social support.

Accidental Decannulation and trachea damage

Accidental Decannulation ◯Accidental decannulation in the first 72 hr after surgery is an emergency because the tracheostomy tract has not matured, and replacement may be difficult. ■Ventilate the client with a BVM. Call for assistance. ◯Nursing Actions ■Always keep the tracheostomy obturator and two spare tracheostomy tubes at the bedside. ■If accidental decannulation occurs after the first 72 hr: ☐Immediately hyperextend the neck and with the obturator inserted into the tracheostomy tube, quickly and gently replace the tube and remove the obturator. ☐Secure the tube. ☐Assess tube placement by auscultating for bilateral breath sounds. ■If unable to replace the tracheostomy tube, administer oxygen through the stoma. If unable to administer oxygen through the stoma, occlude the stoma and administer oxygen through the nose and mouth. ●Damage to the Trachea ◯Tracheal wall necrosis is tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall. ◯Tracheal stenosis is the narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff. ■Keep the cuff pressure between 14 and 20 mm Hg. ■Check the cuff pressure at least once every 8 hr. ■Keep the tube in the midline position and prevent pulling or traction on the tracheostomy tube.

Acute and chronic gastritisursing Interventions .

Acute gastritis occurs with excessive use of NSAIDs, bile reflux, ingestion of a strong acid or alkali substance, as a complication of radiation therapy, or as a complication of trauma (burns; food poisoning; severe infection; liver, kidney, or respiratory failure; major surgery). Chronic gastritis occurs in the presence of ulcers (benign or malignant), Helicobacter pylori, autoimmune disorders (pernicious anemia), poor diet (excessive caffeine, excessive alcohol intake), medications (alendronate [Fosamax], perindopril [Aceon]), and reflux of pancreatic secretions and bile into stomach. Clinical manifestations include abdominal pain or discomfort (may be relieved by eating), headache, lassitude, nausea, anorexia, hiccupping (lasting a few hours to days), heartburn after eating, belching, sour taste in mouth, vomiting, bleeding, and hematemesis (vomiting of blood) nursing Interventions ■Suggest that the client avoid eating frequent meals and snacks, as they promote increased gastric acid secretion. ■Tell the client to avoid alcohol, cigarette smoking, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), coffee, black pepper, spicy foods, and caffeine. ■Monitor the client for vitamin deficiency, especially of vitamin B12.

KawasaKi disease

Acute systemic vasculitis Subjective and Objective Data ◯Acute phase: onset of high fever that is unresponsive to antipyretics, with development of other clinical manifestations ■Fever greater than 38.9° C (102° F) lasting 5 days to 2 weeks and unresponsive to antipyretics ■Irritability ■Red eyes without drainage ■Bright red, chapped lips ■Strawberry tongue with white coating or red bumps on the posterior aspect ■Red oral mucous membranes ■Swelling of hand and feet with red palms and soles ■Nonblistering rash ■Bilateral joint pain ■Enlarged lymph nodes ◯Subacute phase: resolution of the fever and gradual subsiding of other clinical manifestations ■Irritability ■Peeling skin around the nails, on the palms and soles

.A nurse is providing teaching to a client who has anemia and has a new prescription for an iron supplement. Which of the following should be included in the teaching? (Select all that apply.) A nurse is evaluating a group of clients at a health fair in relation to the need for folic acid therapy. Which of the following clients may benefit from folic acid therapy? (Select all that apply.) A nurse is preparing to administer potassium chloride IV to a client who has hypokalemia. Which of the following are appropriate actions by the nurse? (Select all that apply.) A nurse is caring for a client who has increased liver enzymes and is taking herbal supplements. The use of which of the following herbal supplements should be reported to the provider? A client requests information from a nurse on the use of the herbal supplement feverfew. Which of the following is an appropriate response by the nurse? A nurse is completing an assessment of a client's current medications. The client states she also takes gingko biloba. Which of the following medications is contraindicated for a client taking gingko biloba?

Add foods that are high in fiber to the diet. Rinse the mouth after taking the liquid formulation. Expect stools to be green or black in color Add additional red meat to the diet. A 24-year-old female with no health problems A 55-year-old female with alcohol use disorder Infuse medication no faster than 10 mEq/hr. Implement cardiac monitoring Administer the infusion using an IV pump. Kava- Chronic use of kava or high doses can cause liver damage, including severe liver failure. It decreases the frequency of migraine headaches. Warfarin (Coumadin)

Echocardiogram

An echocardiogram is an ultrasound of the heart, which is used to diagnose valve disorders and cardiomyopathy. *Indications Cardiomyopathy Heart failure Angina Myocardial infarction *Preprocedure - Explain the reason for the test to the client. This is a noninvasive test and takes up to 1 hr. *Intraprocedure - Instruct the client to lie on left side and remain still. *Postprocedure - Provider reviews test results and a plan for follow-up care with the client.

A nursing is planning care for a client who is receiving furosemide (Lasix) IV for peripheral edema. Which of the following should the nurse include in the plan of care? (Select all that apply.) A nurse is providing information to a client who has a new prescription for hydrochlorothiazide (Hydrodiuril). Which of the following information should the nurse include? A nurse is monitoring a client who is receiving spironolactone (Aldactone). Which of the following findings should the nurse report to the provider? A client who has increased intracranial pressure is receiving mannitol (Osmitrol). Which of the following findings should the nurse report to the provider? A nurse is reviewing a client's medication history and notes that the client is taking digoxin (Lanoxin), an antihypertensive medication, and NSAIDs. The client has a new prescription for torsemide (Demadex). The nurse should plan to monitor for which of the following medication interactions? (Select all that apply.)

Assess for tinnitus. Monitor serum potassium levels. Elevate the head of bed slowly before ambulation. Recommend eating a banana daily. Take the medication with food Serum potassium 5.2 mEq/L Dyspnea Hypokalemia Hypotension Low urine output Ventricular dysrhythmias

Hypokalemia

Assessment *Risk Factors -Abnormal GI losses - vomiting, nasogastric suctioning, diarrhea, inappropriate laxative use -Renal losses - excessive use of potassium-excreting diuretics such as furosemide (Lasix), corticosteroids -Skin losses - diaphoresis, wound losses -Hyperaldosteronism -Insufficient potassium -Inadequate dietary intake (rare) -Prolonged administration of non-electrolyte-containing IV solutions such as 5% dextrose in water -ICF - metabolic alkalosis, after correction of acidosis (treatment of diabetic ketoacidosis), during periods of tissue repair (burns, trauma, starvation), total parenteral nutrition *Subjective and Objective Data -Vital signs - hyperthermia, weak irregular pulse, hypotension, respiratory distress -Neuromusculoskeletal - ascending bilateral muscle weakness with respiratory collapse and paralysis, muscle cramping, decreased muscle tone and hypoactive reflexes, paresthesias, mental confusion -ECG - premature ventricular contractions (PVCs), bradycardia, blocks, ventricular tachycardia, flattening T waves, and ST depression -GI - decreased motility, hypoactive bowel sounds, abdominal distention, constipation, ileus, nausea, vomiting, anorexia -Other clinical findings - polyuria (excretion of dilute urine) *Laboratory Findings -Serum potassium Decreased - Less than 3.5 mEq/L Arterial blood gases -Metabolic alkalosis - pH greater than 7.45 Diagnostic Procedures -Electrocardiogram (ECG) shows findings of dysrhythmias, such as PVCs, ventricular tachycardia, flattening T waves, and ST depression. Nursing Care -Report abnormal findings to the provider. -Treat the underlying cause. -Replace potassium. -Provide dietary education and encourage foods high in potassium (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach). -Provide oral potassium supplementation. IV potassium supplementation --Mixed by a pharmacist and double-checked by two nurses prior to administration. --The maximum recommended rate is 10 to 20 mEq/hr. --Never IV bolus (high risk of cardiac arrest) --Monitor for phlebitis (tissue irritant). --Monitor for and maintain an adequate urine output. --Monitor for shallow, ineffective respirations and diminished breath sounds. --Monitor the client's cardiac rhythm and intervene promptly as needed. --Monitor clients receiving digoxin. Hypokalemia increases the risk for digoxin toxicity. --Monitor level of consciousness and ensure safety. --Monitor bowel sounds and abdominal distention and intervene as needed

Hyperkalemia

Assessment *Risk Factors -Increased total body potassium - IV potassium administration, salt substitutes, blood transfusion -ECF shift - decreased insulin, acidosis (diabetic ketoacidosis), tissue catabolism (sepsis, trauma, surgery, fever, myocardial infarction) -Hypertonic states - uncontrolled diabetes mellitus -Decreased excretion of potassium - kidney failure, severe dehydration, potassium-sparing diuretics, ACE inhibitors, adrenal insufficiency -Older adult clients - at greater risk due to decreased kidney function and medical conditions resulting in the use of salt substitutes, angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics *Subjective and Objective Data -Vital signs - slow, irregular pulse; hypotension -Neuromusculoskeletal - irritability, confusion, weakness with ascending flaccid paralysis, paresthesias, lack of reflexes -ECG - ventricular fibrillation, peaked T waves, widened QRS, cardiac arrest -GI - increased motility, diarrhea, abdominal cramps, hyperactive bowel sounds -Other clinical findings - oliguria *Laboratory Findings Serum potassium Increased - Greater than 5 mEq/L Arterial blood gases Metabolic acidosis - pH less than 7.35 Diagnostic Procedures ECG will show dysrhythmias (ventricular fibrillation, peaked T waves, widened QRS). Nursing Care -Report abnormal findings to the provider. -Decrease potassium intake: -Stop infusion of IV potassium. -Withhold oral potassium. -Provide a potassium-restricted diet. -If potassium levels are extremely high, dialysis may be required. -Promote the movement of potassium from ECF to ICF: -Administer IV fluids with dextrose and regular insulin. -Monitor the client's cardiac rhythm and intervene promptly as needed. Medications to increase potassium excretion: -Administer loop diuretics, such as furosemide (Lasix), if kidney function is adequate. Loop diuretics increase the excretion of potassium from the renal system. -Sodium polystyrene sulfonate (Kayexalate) is given orally or as an enema. Kayexalate increases the excretion of potassium from the gastrointestinal system. -Maintain IV access. -Prepare the client for dialysis if prescribed.

hypocalcemia

Assessment *Risk Factors Increased calcium output -Chronic diarrhea -Steatorrhea as with pancreatitis (binding of calcium to undigested fat) Inadequate calcium intake or absorption: -Malabsorption syndromes, such as Crohn's disease -Vitamin D deficiency (alcohol use disorder, kidney failure) -Calcium shift from extracellular fluid into bone or to an inactive form: Repeated blood transfusion -Post-thyroidectomy -Hypoparathyroidism *Subjective and Objective Data Muscle twitches/tetany -Numbness and tingling (extremities, circumoral) -Frequent, painful muscle spasms at rest that can progress to tetany -Hyperactive DTRs -Positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) -Positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) Cardiovascular -Decreased myocardial contractility (decreased heart rate and hypotension) -GI - hyperactive bowel sounds, diarrhea, abdominal cramping -Central nervous system - seizures due to overstimulation of the CNS *Laboratory Findings -Calcium level less than 9 mg/dL Diagnostic Procedures -ECG - Prolonged QT interval and ST segments Nursing Care -Administer oral or IV calcium supplements. (Carefully monitor respiratory and cardiovascular status.) -Initiate seizure precautions. -Keep emergency equipment on standby. -Encourage foods high in calcium, including dairy products and dark green vegetables.

FVD assesment

Assessment Risk Factors -Causes of isotonic FVD (hypovolemia) *Abnormal gastrointestinal (GI) losses - vomiting, nasogastric suctioning, diarrhea *Abnormal skin losses - diaphoresis *Abnormal renal losses - diuretic therapy, diabetes insipidus, kidney disease, adrenal insufficiency, osmotic diuresis *Third spacing - peritonitis, intestinal obstruction, ascites, burns *Hemorrhage *Altered intake - impaired swallowing, confusion, nothing by mouth (NPO) -Causes of dehydration *Hyperventilation *Prolonged fever *Diabetic ketoacidosis *Enteral feeding without sufficient water intake -Subjective and Objective Data *Vital signs - hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea (increased respirations), hypoxia *Neuromusculoskeletal - dizziness, syncope, confusion, weakness, fatigue *GI - thirst, dry mucous membranes, dry furrowed tongue, nausea/vomiting, anorexia, acute weight loss *Renal - oliguria (decreased production of urine) *Other clinical findings - diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor -----Assessment of skin turgor in the older adult may not provide reliable findings due to a natural loss of skin elasticity.

FVE assessment

Assessment Risk Factors *Causes of hypervolemia -Chronic stimulus to the kidney to conserve sodium and water (heart failure, cirrhosis, increased glucocorticosteroids) -Abnormal kidney function with reduced excretion of sodium and water (kidney failure) -Interstitial to plasma fluid shifts (hypertonic fluids, burns) -Age-related changes in cardiovascular and kidney function -Excessive sodium intake from IV fluids, diet, or medications (sodium bicarbonate antacids, hypertonic enema solutions) *Causes of overhydration -Water replacement without electrolyte replacement (strenuous exercise with profuse diaphoresis) -Syndrome of inappropriate antidiuretic hormone (SIADH), which is the excess secretion of ADH -Head injuries -Barbiturates -Anesthetics *Subjective and Objective Data -Vital signs - tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure -Neuromusculoskeletal - confusion, muscle weakness -GI - weight gain, ascites -Respiratory - dyspnea, orthopnea, crackles -Other clinical findings - edema, distended neck veins *Laboratory Findings -Hct Hypervolemia - decreased Hct -Overhydration - decreased Hct = hemodilution -Serum osmolarity Overhydration - osmolarity less than 280 mOsm/kg -Serum sodium Hypervolemia - sodium within expected reference range -Electrolytes, BUN, and creatinine Overhydration/hypervolemia - decreased electrolytes, BUN, and creatinine -Arterial blood gases Respiratory alkalosis - decreased PaCO2 (less than 35 mm Hg), increased pH (greater than 7.45) *Diagnostic Procedures Chest x-rays may indicate pulmonary congestion.

detoxification (alc)

BENzodiAzEPiNEs *Examples ›Chlordiazepoxide (Librium), diazepam (Valium),lorazepam (Ativan) *intended Effects ›Maintenance of the client's vital signs within normal limits ›Decrease in the risk of seizures ›Decrease in the intensity of withdrawal manifestations Nursing interventions/client Education ›Administer around the clock or PRN. ›Use chlordiazepoxide only if the client is able to tolerate oral intake. Otherwise, use IV route for diazepam and lorazepam. The client may continue with diazepam and lorazepam orally. ›Obtain the client's baseline vital signs. ›Monitor the client's vital signs and neurological status on an ongoing basis. ›Provide for seizure precautions (padded side rails and suction equipment at bedside).

Bowel Elimination Needs and Specimen Collection

Bowel Elimination Needs and Specimen Collection ●Collect stool specimens for serial fecal occult blood (guaiac) testing three times from three different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. ●Bowel diversions through ostomies are temporary or permanent openings (stomas) in the abdominal wall to allow fecal matter to pass. ●End stomas are a result of colorectal cancer or some types of bowel disease. Colostomies end in the colon, and ileostomies end in the ileum. ●Loop colostomies help resolve a medical emergency and are temporary. ●Double-barrel colostomies consist of two abdominal stomas - one proximal and one distal.

therapeutic diets

Clear liquid - liquids that leave little residue (clear fruit juices, gelatin, broth) ◯Full liquid - clear liquids plus liquid dairy products, all juice, pureed vegetables ◯Pureed - clear and full liquids plus pureed meats, fruits, scrambled eggs ◯Mechanical soft - clear and full liquids plus diced or ground foods ◯Soft/low-residue - foods that are low in fiber and easy to digest ◯High-fiber (whole grains, raw and dried fruits) ◯Low sodium - no added salt or 1 to 2 g of sodium ◯Low cholesterol - no more than 300 mg/day of dietary cholesterol ◯Diabetic - balanced intake of protein, fats, and carbohydrates of about 1,800 calories ◯Dysphagia - pureed food and thickened liquids ◯Regular - no restrictions

Nasogastric Decompression

Clients who have an intestinal obstruction require NG decompression. An NG tube is inserted, then suction is applied to relieve abdominal distention. Treatment continues until the obstruction resolves or is removed. The obstruction can be mechanical (tumors, adhesions, fecal impaction) or functional (paralytic ileus). Indications -Diagnoses - Any disorder that causes a mechanical or functional intestinal obstruction -Client Presentation *Vomiting (begins with stomach contents and continues until fecal material is also being regurgitated) *Bowel sounds may be absent (paralytic ileus) or hyperactive and high-pitched (obstruction). *Intermittent, colicky abdominal pain and distention; hiccups Preprocedure Nursing Actions - Gather necessary equipment and supplies. Client Education - Instruct the client on the purpose of the NG tube and the client's role in its placement. Postprocedure -Nursing Actions *Assess and maintain proper function of the NG tube and suction equipment. *Maintain accurate I&O. *Assess bowel sounds and abdominal girth; return of flatus. *Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). *Client Education - Instruct the client to maintain NPO status. Complications Fluid/electrolyte imbalance Skin breakdown Nursing Actions Monitor for fluid and electrolyte imbalance (metabolic acidosis - low obstruction; alkalosis - high obstruction). Monitor I&O, observing for discrepancies. Assess nasal skin for irritation.

Fat embolism

Clinical manifestations include: ■Dyspnea, chest pain, decreased oxygen saturation ■Decreased mental acuity related to low arterial oxygen level (earliest sign) ■Respiratory distress ■Tachycardia ■Tachypnea ■Fever ■Cutaneous petechiae - pinpoint-sized subdermal hemorrhages that occur on the neck, chest, upper arms, and abdomen (from the blockage of the capillaries by the fat globules). This is a discriminating finding from pulmonary embolism and is a late sign. Nursing Actions ■Maintain the client on bed rest. ■Prevention includes immobilization of fractures of the long bones and minimal manipulation during turning if immobilization procedure has not yet been performed. ■Treatment includes oxygen for respiratory compromise, corticosteroids for cerebral edema, vasopressors, and fluid replacement for shock, as well as pain and antianxiety medications as needed.

Compartment syndrome

Compartment syndrome usually affects extremities and occurs when pressure within one or more of the muscle compartments (an area covered with an elastic tissue called fascia) of the extremity compromises circulation, resulting in an ischemia-edema cycle. Clinical Manifestations ■Compartment syndrome (ACS) is assessed by using the five P's (pain, paralysis, paresthesia, pallor, and pulselessness). ■Increased pain unrelieved with elevation or by pain medication. ☐Intense pain when passively moved. ■Paresthesia or numbness, burning, and tingling are early signs. ■Paralysis, motor weakness, or inability to move the extremity indicate major nerve damage and are late signs. ■Color of tissue is pale (pallor), and nail beds are cyanotic. ■Pulselessness is a late sign of compartment syndrome. ■Palpated muscles are hard and swollen from edema.

Bowel Elimination Complications

Complications ●Constipation ◯Bowel pattern of difficult and infrequent evacuation of hard, dry feces. ◯May be the result of improper diet, decreased fluid intake, lack of exercise, or side effects of medications. ◯Increase fiber and water consumption before treating constipation with laxatives. ◯Give bulk-forming products before stool softeners, stimulants, or suppositories to promote bowel elimination. ◯Enemas are a last resort for stimulating defecation. ●Impaction ◯Stool that is wedged into the rectum with diarrhea fluid leaking around the impacted stool. ◯Use a gloved, lubricated finger for digital removal of stool. ◯Loosen the stool around the edges and then remove it in small pieces, allowing the client to rest as necessary. ◯When evacuating the rectum, be careful to avoid stimulating the vagus nerve. ●Diarrhea ◯Frequent, liquid stools caused by various disorders. ◯Help determine and treat the cause. ◯Administer medications to slow peristalsis. ◯Provide perineal care after each stool and apply a moisture barrier. ◯Clients and caregivers should perform hand hygiene frequently. ●Fecal Incontinence ◯Inability to control defecation, often caused by diarrhea. ◯Assess for causes, such as medications, infections, or impaction. ◯Provide perineal care after each stool and apply a moisture barrier. ●Flatulence ◯Distention of the bowel from gas accumulation (may cause cramping or a feeling of fullness) ■Assess for abdominal distention and the ability to pass gas through the anus. ■Encourage ambulation to promote the passage of flatus. ■Notify the provider if the problem continues. ●Hemorrhoids ◯Engorged, dilated blood vessels in the rectal wall from difficult defecation, pregnancy, liver disease, and heart failure. ■Hemorrhoids may be itchy, painful, and bloody after defecation. ■Use moist wipes for cleansing the perianal area. ■Apply ointments or creams.

thermoregulation

Conduction - Loss of body heat resulting from direct contact with a cooler surface. Preheat a radiant warmer, warm a stethoscope and other instruments, and pad a scale before weighing the newborn. The newborn should be placed directly on the mother's abdomen and covered with a warm blanket. X Convection - Flow of heat from the body surface to cooler environmental air. Place the bassinet out of the direct line of a fan or air conditioning vent, swaddle the newborn in a blanket, and keep the head covered. Any procedure done with the newborn uncovered should be performed under a radiant heat source. X Evaporation - Loss of heat as surface liquid is converted to vapor. Gently rub the newborn dry with a warm sterile blanket (adhering to standard precautions) immediately after delivery. If thermoregulation is unstable, postpone the initial bath until the newborn's skin temperature is 36.5° C (97.7° F). When bathing, expose only one body part at a time, washing and drying thoroughly. X Radiation - Loss of heat from the body surface to a cooler solid surface that is close to, but not in direct contact. Keep the newborn and examining tables away from windows and air conditioners.

dverse effects of opioid use

Constipation - Use a preventative approach (monitoring of bowel movements, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas). ■Orthostatic hypotension - Advise clients to sit or lie down if symptoms of light-headedness or dizziness occur. Instruct clients to avoid sudden changes in position by slowly moving from a lying to a sitting or standing position. Provide assistance with ambulation. ■Urinary retention - Monitor I&O, assess for distention, administer bethanechol (Urecholine), and catheterize. ■Nausea/vomiting - Administer antiemetics, advise clients to lie still and move slowly, and eliminate odors. ■Sedation - Monitor level of consciousness and take safety precautions. Sedation usually precedes respiratory depression. ■Respiratory depression - Monitor respiratory rate prior to and following administration of opioids (especially for clients who are opioid-naïve). Initial treatment of respiratory depression and sedation is generally a reduction in opioid dose. If necessary, slowly administer diluted naloxone (Narcan) to reverse opioid effects.

simple face mask (low flow)

Covers the client's nose and mouth It delivers an FiO2 of 40% to 60% at flow rates of 5 to 8 L/min. ›The minimum flow rate is 5 L/min to ensure flushing of CO2 from the mask. ›A face mask is easy to apply and may be mor e comfortable than a nasal cannula. ›It is a simple delivery method. ›It is more comfortable than a nasal cannula. ›It provides humidified oxygen.

VaCuuM-assisted deliVeRy

Description of Procedure ◯A vacuum‑assisted birth involves the use of a cuplike suction device that is attached to the fetal head. Traction is applied during contractions to assist in the descent and birth of the head, after which, the vacuum cup is released and removed preceding delivery of the fetal body. ◯Recommendations by the manufacturer should be followed for product use to ensure safety. ◯Conditions for use of a vacuum‑assisted birth ■Vertex presentation ■Absence of cephalopelvic disproportion ■Ruptured membranes ◯Risks associated with vacuum‑assisted births ■Scalp lacerations ■Subdural hematoma of the neonate ■Cephalohematoma ■Maternal lacerations to the cervix, vagina, or perineum ●Indications ◯Maternal exhaustion and ineffective pushing efforts ◯Fetal distress during second stage of labor Nursing Actions ◯Preparation of the client ■Provide the client and her partner with support and education regarding the procedure. ■Assist the client into the lithotomy position to allow for sufficient traction of the vacuum cup when it is applied to the fetal head. ■Assess and record FHR before and during vacuum assistance. ■Assess for bladder distention, and catheterize if necessary. ◯Ongoing care ■Prepare for a forceps‑assisted birth if a vacuum‑assisted birth is not successful. ◯Interventions ■Alert postpartum care providers that vacuum assistance was used. ■Observe the neonate for lacerations, cephalohematomas, or subdural hematomas after delivery. ■Check the neonate for caput succedaneum. Caput succedaneum is a normal occurrence and should resolve within 24 hr.

urinary diagnostic tests

Diagnostic Tests -Bedside sonography/bladder scanner - Portable ultrasound scanner noninvasively measures bladder volume to measure residual volume after voiding. -Kidneys/ureters/bladder (KUB) - X-ray to determine size, shape, and position of these structures. -Intravenous pyelogram (IVP) - Injecting contrast media (iodine) allows for viewing of ducts, renal pelvis, ureters, bladder, and urethra. Determine whether the client has an allergy to shellfish. -Renal scan - View of renal blood flow and anatomy of the kidneys - no contrast. -Renal ultrasound - View of gross renal structures. -Cystoscopy - Uses an endoscope to visualize the bladder and urethra. -Urodynamic testing - Tests bladder muscle function by filling the bladder with CO2 or 0.9% sodium chloride and comparing pressure readings with the client's reported sensations.

Bowel Elimination Diagnostic Tests

Diagnostic Tests ◯Visualization of the bowel ■Colonoscopy - the provider visualizes and may collect tissue for biopsy or remove polyps from the colon and sometimes a portion of the lower small bowel. ■Sigmoidoscopy - the provider visualizes and may collect tissue for biopsy or remove polyps from the sigmoid colon and rectum. ◯Preparation ■Protocols vary with the provider and the facility, but generally include clear liquids only and a bowel cleanser. ■Clients receive moderate (conscious) sedation and may not drive home afterwards.

Coagulopathies (iDiopathiC thRoMboCytopeNiC puRpuRa aND DisseMiNateD iNtRaVasCulaR CoagulatioN)

Disseminated intravascular coagulation (DIC) is a coagulopathy in which clotting and anticlotting mechanisms occur at the same time. Objective Data ◯Physical assessment findings ■Unusual spontaneous bleeding from the client's gums and nose (epistaxis) ■Oozing, trickling, or flow of blood from incision, lacerations, or episiotomy ■Petechiae and ecchymoses ■Excessive bleeding from venipuncture, injection sites, or slight traumas ■Tachycardia, hypotension, and diaphoresis ■Oliguria ●Laboratory Tests ◯CBC with differential ◯Blood typing and crossmatch ◯Clotting factors ■Platelet levels (thrombocytopenia) ■Fibrinogen levels (decreased) ■PT (increased) ■Fibrin split product levels (increased) Nursing assessments for ITP and DIC ■Skin, venipuncture, injection sites, lacerations, and episiotomy for bleeding. ■Vital signs and hemodynamic status. ■Urinary output usually by insertion of an indwelling urinary catheter. ■Transfuse platelets. ■Assist in preparing the client for a splenectomy if ITP does not respond to medical management and provide postsurgical care. ■Nursing interventions for DIC focus on assessing for and correcting the underlying cause (removal of dead fetus or placental abruption, treatment of infection, preeclampsia, or eclampsia). ☐Administer fluid volume replacement, which may include blood and blood products. ☐Administer pharmacologic interventions including antibiotics, vasoactive medications, and uterotonic agents as prescribed. ☐Administer supplemental oxygen. ☐Provide protection from injury.

dumping syndrome

Dumping syndrome is a group of manifestations that occur following eating. A shift of fluid to the abdomen is triggered by rapid gastric emptying or high-carbohydrate ingestion. symptoms- decrease in circulating volume, resulting in vasomotor symptoms (syncope, pallor, palpitations, dizziness, headache) Client Education ■Lying down after a meal slows the movement of food within the intestines. ■Limit the amount of fluid ingested at one time. ■Eliminate liquids with meals, for 1 hr prior to, and following a meal. ■Consume a high-protein, high-fat, low-fiber, and low- to moderate-carbohydrate diet. ■Avoid milk, sweets, or sugars (fruit juice, sweetened fruit, milk shakes, honey, syrup, jelly). ■Consume small, frequent meals rather than large meals

Human B-type natriuretic peptides (hBNP)

Elevated in heart failure. In clients who have dyspnea, elevated hBNP confirms a diagnosis of heart failure rather than a problem originating in the respiratory system. hBNP levels direct the aggressiveness of treatment interventions. A level below 100 pg/mL indicates no heart failure. Levels between 100 to 300 pg/mL suggest heart failure is present. A level above 300 pg/mL indicates mild heart failure. A level above 600 pg/mL indicates moderate heart failure. A level above 900 pg/mL indicates severe heart failure.

AdjUNCt MEdiCAtioNs (alc)

Examples ›Carbamazepine (Tegretol), clonidine (Catapres), propranolol (Inderal) intended Effects ›Decrease in seizures - carbamazepine ›Depression of autonomic response (decrease in blood pressure, heart rate) - clonidine and propranolol ›Decrease in craving - propranolol Nursing interventions/client Education ›Provide for seizure precautions (padded side rails, suction equipment at bedside). ›Obtain the client's baseline vital signs, and continue to monitor on an ongoing basis.

specimen collection and diagnostic testing

Fecal occult blood test - obtain a fecal sample using medical asepsis while wearing disposable gloves. Some foods (red meat, fish, poultry, raw vegetables) and medications can cause false positive results. Bleeding can be a sign of cancer, which can be a contributing factor for constipation. ◯Digital rectal examination for impaction - position on the left side with the knees flexed. The examiner inserts a gloved, lubricated index finger gently into the rectum. During the procedure, monitor vital signs and response. ◯Specimens for stool cultures - obtain using medical asepsis while wearing disposable gloves. Label the specimen and promptly send it to the laboratory. Intestinal bacteria can cause diarrhea

newborn feeding/elimination

Feeding/Elimination ◯Mothers who are breastfeeding should be seen by the lactation consultant. ◯The newborn is offered the breast immediately after birth and frequently thereafter. Newborns who are breastfed will average 15 to 20 min per breast and 30 to 40 min for the total feeding. Feedings should be 8 to 12 times in a 24-hr period. Feeding for a newborn who is breastfeeding should be on demand or every 2 to 3 hr. Newborns who are formula fed also should be fed on demand or every 3 to 4 hr. ◯Inform parents that adhering to specific timing of feedings is to be avoided. Parents should be instructed to recognize when the newborn has completed the feeding. No other fluids are offered ◯The mother's milk supply is equal to the demand of the newborn. Eventually, the newborn will empty a breast within 5 to 10 min, but may need to continue to suck to meet comfort needs. ◯Frequent feedings (every 2 hr may be indicated), and manual expression of milk to initiate flow may be needed. ◯Most newborns spit up a small amount after feedings. Keep the newborn upright and quiet for a few minutes after feedings. ◯Newborns should have 6 to 8 wet diapers a day with adequate feedings and may have 3 to 4 stools per day.

Antilipemic Agents Classifications •HMG CoA reductase inhibitors (statins) •Cholesterol absorption inhibitors •Bile -acid sequestrants •Nicotinic acid

Fibrates •Prototype- Gemfibrozil •Other medications-Fenofibrate •Expected action-Decrease in triglyceride levels, Increase in HDL levels •Therapeutic uses •Reduction of plasma triglycerides (VLDL) •Increase levels of HDL HMG CoA Reductase Inhibitors (Statins) •Prototype- Atorvastatin •Other medications Simvastatin Lovastatin Pravastatin sodium Rosuvastatin Fluvastatin •Expected action Decrease LDL cholesterol Decrease (VLDL) Increase (HDL) •Therapeutic uses Hypercholesterolemia Prevention of coronary events Protection against MI, stroke for clients who have diabetes mellitus *Adverse Effects Hepatotoxicity Increase in serum transaminase •Nursing interventions/client education Obtain baseline liver function. Monitor liver function test after 12 weeks and then every 6 month. Monitor for symptoms of liver dysfunction. (Anorexia, vomiting, nausea, jaundice) Avoid alcohol. Medications may be discontinued if tests are abnormal. **Grapefruit juice suppresses CYP3A4 and can increase levels of statins Nursing administration •Administer statins by oral route •Administer lovastatin with evening meal. •Other statins can be taken without food intake, but evening dosing is best •Advise clients to obtain baseline cholesterol levels, HDL, LDL, and triglycerides. Monitor periodically while taking medication

FLUID VOLUME EXCESSES

Fluid volume excesses include *Fluid volume excess (FVE) is the isotonic retention of water and sodium in abnormally high proportions. -FVE is often referred to as hypervolemia because of the resulting increased blood volume. *Overhydration, or hypoosmolar fluid imbalance, is the gain of more water than electrolytes. --This hemodilution results in decreases in Hct, serum electrolytes, and protein. *Severe hypervolemia can lead to pulmonary edema and heart failure. *Compensatory mechanisms include an increased release of natriuretic peptides, resulting in increased excretion of sodium and water by the kidneys, and a decreased release of aldosterone

ostomy

Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Yogurt can be ingested to decrease gas. After an ostomy involving the small intestine is placed, the client should be instructed to avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluid intake, and evaluate for evidence of blockage when slowly adding high-fiber foods to the diet. Proper appliance fit and maintenance prevent odor when pouch is not open. Filters, deodorizers, or placement of a breath mint in the pouch can minimize odor while the pouch is open.

gestatioNal Diabetes Mellitus

Gestational diabetes mellitus is an impaired tolerance to glucose with the first onset or recognition during pregnancy. The ideal blood glucose level during pregnancy should fall between 70 and 110 mg/dL. Gestational diabetes mellitus causes increased risks to the fetus including the following: ◯Spontaneous abortion, which is related to poor glycemic control. ◯Infections (urinary and vaginal), which are related to increased glucose in the urine and decreased resistance because of altered carbohydrate metabolism. ◯Hydramnios, which can cause overdistention of the uterus, premature rupture of membranes, preterm labor, and hemorrhage. ◯Ketoacidosis from diabetogenic effect of pregnancy (increased insulin resistance), untreated hyperglycemia, or inappropriate insulin dosing. ◯Hypoglycemia, which is caused by overdosing in insulin, skipped or late meals, or increased exercise. ◯Hyperglycemia, which can cause excessive fetal growth (macrosomia). Laboratory Tests ■Routine urinalysis with glycosuria ■A glucola screening test/1-hr glucose tolerance test (50 g oral glucose load, followed by plasma glucose analysis 1 hr later performed at 24 to 28 weeks of gestation - fasting not necessary; a positive blood glucose screening is 130 to 140 mg/dL or greater; additional testing with a 3-hr oral glucose tolerance test [OGTT] is indicated) ■An OGTT (following overnight fasting, avoidance of caffeine, and abstinence from smoking for 12 hr prior to testing; a fasting glucose is obtained, a 100 g glucose load is given, and serum glucose levels are determined at 1, 2, and 3 hr following glucose ingestion) ■Presence of ketones in urine is tested to assess the severity of ketoacidosis

gestatioNal hyPeRteNsioN

Gestational hypertension (GH), which begins after the 20th week of pregnancy, describes hypertensive disorders of pregnancy whereby the woman has an elevated blood pressure at 140/90 mm Hg or greater recorded at least twice, 4 to 6 hr apart, and within a 1-week period. There is no proteinuria. The presence of edema is no longer considered in the definition of hypertensive disease of pregnancy. The client's blood pressure returns to baseline by 6 weeks postpartum Mild preeclampsia is GH with the addition of proteinuria of greater than 1+. Report of transient headaches may or may not occur along with episodes of irritability. Edema may be present. Severe preeclampsia consists of blood pressure that is 160/100 mm Hg or greater, proteinuria greater than 3+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or visual disturbances (headache and blurred vision), hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia. Subjective Data ◯Severe continuous headache ◯Nausea ◯Blurring of vision ◯Flashes of lights or dots before the eyes ●Objective Data ◯Physical assessment findings ■Hypertension ■Proteinuria ■Periorbital, facial, hand, and abdominal edema ■Pitting edema of lower extremities ■Vomiting ■Oliguria ■Hyperreflexia ■Scotoma ■Epigastric pain ■Right upper quadrant pain ■Dyspnea ■Diminished breath sounds ■Seizures ■Jaundice ■Signs of progression of hypertensive disease with indications of worsening liver involvement, renal failure, worsening hypertension, cerebral involvement, and developing coagulopathies

iron dextran is to be administered by IM injection

If iron dextran is to be administered by IM injection, the nurse should use the Z-track method into a deep, large muscle to prevent staining and injuring tissue. The deltoid muscle is not a large enough muscle mass for administration of an irritating medication. Massaging the injection site should be avoided to prevent permanent skin staining with the dark- colored iron product. No more than 2 mL (1 mL when injecting into the deltoid) should be injected when administering an IM injection into a large muscle. Dried fruit, chicken, and ground beef are good sources of iron. Low-fat yogurt and grapes are not good sources of iron.

FVD Labs

Laboratory Findings *Hct - Increased in both hypovolemia and dehydration unless the fluid volume deficit is due to hemorrhage. *Serum osmolarity Dehydration - increased hemoconcentration osmolarity (greater than 300 mOsm/kg) - increased protein, BUN, electrolytes, glucose *Urine specific gravity and osmolarity Dehydration - increased concentration (urine specific gravity greater than 1.030) *Serum sodium Dehydration - increased hemoconcentration

goNoRRhea

Neisseria gonorrhoeae is the causative agent of gonorrhea. Gonorrhea is a bacterial infection that is primarily spread by genital-to-genital contact. However, it also can be spread by anal-to-genital contact or oral-to-genital contact. It can also be transmitted to a newborn during delivery. Women are frequently asymptomatic. Subjective Data (Male) ◯Urethral discharge ◯Painful urination ◯Frequency ●Subjective Data (Female) ◯Lower abdominal pain ◯Dysmenorrhea Objective Data - Male/Female ◯Physical Assessment Findings ■Urethral discharge ■Yellowish-green vaginal discharge ■Reddened vulva and vaginal walls ■If gonorrhea is left untreated, it can cause pelvic inflammatory disease, heart disease, and arthritis. ◯Laboratory Tests ■Urethral and vaginal cultures ■Urine culture Medications ◯Ceftriaxone (Rocephin) IM and azithromycin (Zithromax) PO for gonorrhea ■One dose prescription ■Broad-spectrum antibiotic ■Bactericidal action ◯Client Education ■Instruct the client to take entire prescription as prescribed. ■Instruct the client to repeat the culture to assess for medication effectiveness. ■Educate the client regarding safe sex practices.

Home Safety infant

Never leave the newborn unattended with pets or other small children. ◯Keep small objects (coins) out of the reach of newborns due to choking hazard. ◯Never leave the newborn alone on a bed, couch, or table. Newborns move enough to reach the edge and fall off. ◯Never place the newborn on his stomach to sleep during the first few months of life. The back-lying position is the position of choice. The newborn can be placed on his abdomen when awake and being supervised. ◯Never provide a newborn with a soft surface to sleep on (pillows and waterbed). The newborn's mattress should be firm. Never put pillows, toys, bumper pads, or loose blankets in a crib. Crib linens should be tight-fitting. ◯Do not tie anything around the newborn's neck. ◯Monitor the safety of the newborn's crib. The space between the mattress and sides of the crib should be less than 2 fingerbreadths. The slats on the crib should be no more than 5.1 cm (2.25 in) apart. ◯The newborn's crib or playpen should be away from window blinds and drapery cords. Newborns can become strangled in them. ◯The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation. ◯If an infant carrier is placed on a high place, such as a table, always be within arm's reach. ◯Smoke detectors should be on every floor of a home and should be checked monthly to ensure that they are working. Batteries should be changed yearly. (Change batteries when daylight savings time occurs or on a child's birthday.) ◯Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if they come into contact with heat sources. ◯Control the temperature and humidity of the newborn's environment by providing adequate ventilation. ◯Avoid exposing the newborn to cigarette smoke in a home or elsewhere. Secondhand exposure increases the newborn's risk of developing respiratory illnesses. ◯All visitors should wash their hands before touching the newborn. Any individual who has an infection should be kept away from the newborn. ◯Carefully handle the newborn. Do not toss the newborn up in the air or swing him by his extremities. ◯Provide community resources to clients who may need additional and ongoing assessment and instruction on newborn care (adolescent parents

Dumping syndrome

Normally, the stomach controls the rate in which nutrients enter the small intestine. When a portion of the stomach is surgically removed, the contents of the stomach are rapidly emptied into the small intestine, causing dumping syndrome. ■Early manifestations typically occur 15 to 30 min after eating. Late manifestations occur 1 to 3 hr after eating. ◯Early manifestations include a sensation of fullness, faintness, diaphoresis, tachycardia, palpitations, hypotension, nausea, abdominal distention, cramping pain, diarrhea, weakness, and syncope. ◯Manifestations resolve after intestine is emptied. However, there is a rapid rise in blood glucose and increase in insulin levels immediately after the intestine empties. This leads to hypoglycemia. ◯The client experiences vasomotor symptoms, such as dizziness, sweating, palpitations, shakiness, and confusion. ◯Nursing Interventions ■Recommend small, frequent meals. ■Recommend consumption of protein and fat at each meal. ■Tell the client to avoid food that contains concentrated sugars and to restrict lactose intake. ■Suggest that the client consume liquids 1 hr before or after eating instead of during meals (dry diet). ■Instruct client to lie down for 20 to 30 min to after meals to delay gastric emptying. If reflux is a problem, assume a reclining position. ■Monitor clients receiving enteral tube feedings and report clinical manifestations of dumping syndrome to the provider. ■Monitor the client for vitamin and mineral deficits, such as iron and vitamin B12

A nonreassuring FHR is noted.

Notify the provider. ■Position the client in a side‑lying position to increase uteroplacental perfusion. ■Keep the IV line open and increase the rate of IV fluid administration to 200 mL/hr unless contraindicated. ■Administer O2 by a face mask at 8 to 10 L/min as prescribed. ■Administer the tocolytic terbutaline (Brethine) 0.25 mg subcutaneously as prescribed to diminish uterine activity. ■Monitor FHR and patterns in conjunction with uterine activity. ■Document responses to interventions. ■If unable to restore reassuring FHR, prepare for an emergency cesarean birth.

anesthesia

Nursing Actions ◯Ensure that consent has been signed by the client, because legal consent cannot be given by a adult who is medicated. ◯Have the client void before the medication is administered so he will not need to get out of bed. ◯Ensure that the bed is in the low position and that the side rails are raised for safety. ◯Monitor airway and oxygen saturation. ◯Monitor and report laboratory values (ABGs, CBC, and electrolytes) as appropriate. ◯Monitor cardiac status (rhythm, heart rate, blood pressure). ◯Monitor temperature. ◯Monitor drains, tubes, catheters, and IV access throughout anesthesia and surgery. ◯Assess level of sedation and anesthesia (level of consciousness, vital signs). ◯If hypotension occurs as an adverse effect of medication or dehydration, lower the head of bed, administer a prescribed IV fluid bolus, and monitor. ◯Notify the surgeon and anesthesiologist if abnormalities are noted

Accidental disconnection, system breakage, or removal

Nursing Actions ☐If the tubing separates, the client is instructed to exhale as much as possible and to cough to remove air from the pleural space. The nurse should cleanse the tips and reconnect the tubing. ☐If the chest tube drainage system breaks, the nurse should immerse the end of the tube in sterile water to restore the water seal. ☐If a chest tube is accidentally removed, an occlusive dressing taped on only three sides should be immediately placed over the insertion site. This allows air to escape and reduces the risk for development of a tension pneumothorax. ◯Tension pneumothorax ■Sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause a tension pneumothorax. A nurse is assessing the functioning of a client's chest drainage system. Which of the following are expected client findings? (Select all that apply.) -Gentle constant bubbling in the suction control chamber -Rise and fall in the level of water in the water seal chamber with inspiration and expiration

Cast care

Nursing Actions ☐Monitor neurovascular status and assess pain. ☐Apply ice for 24 to 48 hr. ☐Handle a plaster cast with the palms, not fingertips, until the cast is dry to prevent denting the cast. ☐Avoid setting the cast on hard surfaces or sharp edges. ☐Prior to casting, the area is cleaned and dried. Tubular cotton web roll is placed over the affected area to maintain skin integrity. The casting material is then applied. ☐After cast application, position the client so that warm, dry air circulates around and under the cast (support the casted area without pressure under or directly on the cast) for faster drying and to prevent pressure from changing the shape of the cast. Use gloves to touch the cast until it is completely dry. ☐Elevate the cast above the level of the heart during the first 24 to 48 hr to prevent edema of the affected extremity. ☐If any drainage is seen on the cast, it should be outlined, dated, and timed, so it can be monitored for any additional drainage. ☐Older adult clients have an increased risk for impaired skin integrity due to the loss of elasticity of the skin and decreased sensation (comorbidities). Client Education ☐Clients are instructed not to place any foreign objects under the cast to avoid trauma to the skin. Itching under the cast can be relieved by blowing cool air from a hair dryer under the cast. ☐Plastic coverings over the cast can be used to avoid soiling from urine or feces. ☐Demonstrate how plastic bags can be used during baths and showers to keep the cast dry. ☐Report any areas under the cast that become painful, have a "hot spot," have increased drainage, are warm to the touch, or have odor, which may indicate infection. ☐Instruct the client to report immobility and complications such as shortness of breath, skin breakdown, and constipation.

FVE nursing interventions

Nursing Care -Assess respiratory rate, symmetry, and effort. -Assess breath sounds in all lung fields. Lung sounds may be diminished with crackles. -Monitor for shortness of breath and dyspnea. -Check ABGs, SaO2, CBC, and chest x-ray results. -Position the client in semi-Fowler's position. -Measure the client's weight daily. -Monitor and document edema (pretibial, sacral, periorbital). -Monitor I&O. -Implement prescribed restrictions for fluid and sodium intake. -Provide fluids in small glass to promote the perception of a full glass of fluid. -Set 1- to 2-hr short-term goals for the fluid restriction to promote client control and understanding. -Administer supplemental oxygen as needed. -Reduce IV flow rates. -Administer diuretics (osmotic, loop) as prescribed. -Monitor and document circulation to the extremities. -Reposition the client at least every 2 hr. -Support arms and legs to decrease dependent edema as appropriate.

suddeN iNfaNt death syNdRoMe (sids)

Nursing Care ◯Teach the family how to reduce the risks of SIDS. ■Place infant on back for sleep. ■Avoid exposure to tobacco smoke. ■Prevent overheating. ■Use a firm, tight-fitting mattress in the infant's crib. ■Remove pillows, quilts, and sheepskins from the crib during sleep. ■Ensure that the infant's head is kept uncovered during sleep. ■Offer pacifier at naps and night. ■Encourage breastfeeding. ■Avoid cosleeping. ■Maintain immunizations up to date. ◯Provide support. ◯Allow the infant's family an opportunity to express feelings. ◯Plan a home health visit to follow a death. ◯Refer to support groups, counseling, or community groups.

pRolapsed uMbiliCal CoRd

Nursing Care ◯Call for assistance immediately. ◯Notify the provider. ◯Use a sterile‑gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. ◯Reposition the client in a knee‑chest, Trendelenburg, or a side‑lying position with a rolled towel under the client's right or left hip to relieve pressure on the cord. ◯Apply a warm, sterile, saline‑soaked towel to the visible cord to prevent drying and to maintain blood flow. ◯Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia. ◯Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. ◯Initiate IV access, and administer IV fluid bolus. ◯Prepare for a cesarean birth if other measures fail. ◯Inform and educate the client and her partner about the interventions.

MeCoNiuM-staiNed aMNiotiC Fluid

Nursing Care ◯Document color and consistency of stained amniotic fluid. ◯Notify neonatal resuscitation team to be present at birth. ◯Gather equipment needed for neonatal resuscitation. ◯Follow designated suction protocol. ■Assess neonate's respiratory efforts, muscle tone, and heart rate. ■Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. ■Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min.

erythropoeitic growth factors ●Select Prototype Medication: epoetin alfa (Epogen, Procrit) ●Other Medications ◯Darbepoetin alfa (Aranesp) - long-acting erythropoietin ◯Methoxy polyethylene glycol (MGEG)-epoetin beta (Mircera) - very long-acting erythropoietin

Nursing administration ●Obtain baseline blood pressure. In clients who have chronic kidney injury, control hypertension before the start of treatment. ●Monitor blood pressure frequently, because adjustments in antihypertensive medication may also be required as treatment progresses. ●Administer by subcutaneous or IV bolus injection. Dosage is based on client's weight. ●Do not agitate the vial of medication. Use each vial for one dose, and do not put the needle back into the vial when withdrawing the medication. ●Do not mix medication with any other medication in syringe. ●Dosing is usually three times/week, but may be once per week with some types of chemotherapy. ●Monitor iron levels, and implement measures to ensure a normal iron level. RBC growth is dependent upon adequate quantities of iron, folic acid, and vitamin B12. Without adequate levels of these, erythropoietin is significantly less effective. ●Monitor Hgb and Hct twice a week until target range is reached. ●The longer-acting forms are administered less frequently (weekly or monthly), but can be prescribed for clients who have chronic kidney failure only.

Obsessive-compulsive and related disorders

OCD - Persistent thoughts or urges that the client attempts to suppress through compulsive or obsessive behaviors. Obsessions or compulsions are time consuming and result in impaired social and occupational functioning. ■Hoarding disorder - Client has obsessive desire to save items regardless of value. Experiences extreme stress with thoughts of discarding or getting rid of items. Client's hoarding behavior results in social and occupational impairment and often leads to an unsafe living environment.

poisoning in children

Objective data ◯Physical response will depend on specific poison ■Acetaminophen (Tylenol) ☐2 to 4 hr after ingestion - nausea, vomiting, sweating, and pallor ☐24 to 36 hr after ingestion - improvement in the child's condition ☐36 hr to 7 days or longer (hepatic stage) - pain in upper right quadrant, confusion, stupor, jaundice, and coagulation disturbances ☐Final stage - death or gradual recovery ■Acetylsalicylic acid (aspirin) ☐Acute poisoning - nausea, vomiting, disorientation, diaphoresis, tachypnea, tinnitus, oliguria, lightheadedness, and seizures ☐Chronic poisoning - subtle version of acute manifestations, bleeding tendencies, dehydration, and seizures more severe than acute poisoning ■Supplemental iron ☐Initial period (30 min to 6 hr after ingestion) - vomiting, hematemesis, diarrhea, gastric pain, and bloody stools ☐Latency period (2 to 12 hr after ingestion) -improvement of condition ☐Systemic toxicity period (4 to 24 hr after ingestion) - metabolic acidosis, hyperglycemia, bleeding, fever, shock, and possible death ☐Hepatic injury period (48 to 96 hr after ingestion) - seizures or coma ■Hydrocarbons (gasoline, kerosene, lighter fluid, paint thinner, turpentine) ☐Gagging, choking, coughing, nausea, and vomiting ☐Lethargy, weakness, tachypnea, cyanosis, grunting, and retractions ■Corrosives (household cleaners, batteries, denture cleaners, bleach) ☐Pain and burning in mouth, throat, and stomach ☐Edematous lips, tongue, and pharynx with white mucous membranes ☐Violent vomiting with hemoptysis ☐Drooling ☐Anxiety ☐Shock ■Lead ☐Low-dose exposure - easily distracted, impulsive, hyperactive, hearing impairment, and mild intellectual difficulty ☐High-dose exposure - cognitive delays varying in severity, blindness, paralysis, coma, seizures, and death ☐Other manifestations - kidney impairment, impaired calcium function, and anemia Assist with gastric decontamination if indicated. ■Activated charcoal ■Gastric lavage ■Increasing bowel motility ■Syrup of ipecac is contraindicated for routine poison control treatment ◯Keep the family informed of the child's condition.

Intrarenal acute kidney injury

Occurs as a result of direct damage to the kidney from lack of oxygen (acute tubular necrosis). ■Causes ☐Physical injury - trauma ☐Hypoxic injury - renal artery or vein stenosis or thrombosis ☐Chemical injury - acute nephrotoxins (e.g. antibiotics, NSAIDs, contrast dye, heavy metal, blood transfusion reaction) ☐Immunologic injury - infection, vasculitis, acute glomerulonephritis

Osteomyelitis

Osteomyelitis is an infection of the bone that begins as an inflammation within the bone secondary to penetration by infectious organisms (virus, bacteria, or fungi) following trauma or surgery. ◯Clinical Manifestations ■Bone pain that is constant, pulsating, localized, and worse with movement ■Erythema and edema at the site of the infection ■Fever ☐Older adults may not have an elevated temperature. ■Leukocytosis and possible elevated sedimentation rate ■Many of these manifestations will disappear if the infection becomes chronic. Treatment ■Long course (3 months) of IV and oral antibiotic therapy. ■Surgical debridement may also be indicated. If a significant amount of the bone requires removal, a bone graft may be necessary. ■Hyperbaric oxygen treatments may be needed to promote healing in chronic cases of osteomyelitis. ■Surgically implanted antibiotic beads in bone cement are packed into the wound as a form of antibiotic therapy. ■Unsuccessful treatment can result in amputation.

fibrocystic breat condition

Overview ●Fibrocystic breast condition is a noncancerous breast condition. ●It is most common in younger women. It occurs less frequently in postmenopausal women. ●The condition is thought to occur due to cyclic hormonal changes. ●Fibrosis (of connective tissue) and cysts (fluid-filled sacs) develop. Risk Factors ◯Premenopausal status ◯Hormone therapy ◯Caffeine consumption Subjective Data ◯Breast pain ◯Tender lumps, commonly in upper, outer quadrant Objective Data ◯Physical Assessment Findings ■Palpable rubberlike lumps, usually in the upper, outer quadrant ◯Diagnostic/Therapeutic Procedures ■Breast ultrasound is used to confirm the diagnosis. ■Fine needle aspiration is also used to confirm the diagnosis or to reduce pain due to fluid build-up. Patient-centered care Medications ◯Over-the-counter analgesics such as acetaminophen (Tylenol) or ibuprofen (Motrin) ◯Oral contraceptives to suppress estrogen/progesterone secretion. ◯Diuretics to decrease breast engorgement. ◯Danazol (Danocrine) and androgen/anabolic steroid to suppress ovarian function. Use of this medication is limited to clients who have severe fibrocystic breast condition due to its many adverse effects. ◯Vitamin E to reduce pain. Nursing Actions ◯Suggest that the client reduce the intake of salt before menses, wear a supportive bra, and use apply either local heat or cold to temporarily reduce pain. ◯Encourage the client to follow the provider's recommendations and to journal the effectiveness of the treatment plan.

PET and SPECT Scans

PET and SPECT scans are nuclear medicine procedures that produce three-dimensional images of the head. These images can be static (depicting vessels) or functional (depicting brain activity). A glucose-based tracer is injected into the blood stream prior to the PET scan. This initiates regional metabolic activity, which is then documented by the PET scanner. A radioisotope is used for SPECT scanning. A CT scan may be performed after a PET/SPECT scan, as this provides information regarding brain activity and pathological location (e.g., brain injury, death, neoplasm)

informed consentt

PROVIDER -Once surgery has been discussed as treatment with the client and significant other, family member, or friend, it is the responsibility of the primary care provider to obtain consent after discussing the risks and benefits of the procedure. The nurse is not to obtain the consent for the provider in any circumstance. NURSE -The nurse can clarify any information that remains unclear after the provider's explanation of the procedure. The nurse may not provide any new or additional information not previously given by the provider. -The nurse's role is to witness the client's signing of the consent form after the client acknowledges understanding of the procedure. **The nurse should determine if the client is: -18 years of age. -Mentally capable of understanding the risks, reason, and options for surgery and anesthesia. -Under the influence of medication that affects decision-making or judgment (opioids, benzodiazepines, sedatives). -Do not have the client sign the informed consent if medications have been administered. --A legal guardian may need to sign the surgical consent form if the client is not capable of providing consent or if there is no family. --Two witnesses are required if the client is able to only sign with an "X", blind, deaf, or English is a second language. Informed consent is required for surgical procedures, invasive procedures (biopsy, paracentesis, scopes), and any procedure requiring sedation or anesthesia, or involving radiation.

FVD nursing interventions

Patient-Centered Care Nursing Care -Assess respiratory rate, symmetry, and effort. -Monitor for shortness of breath and dyspnea. -Check urinalysis, oxygen saturation (SaO2), CBC, and electrolytes. -Administer supplemental oxygen as prescribed. -Measure the client's weight daily at same time of day using the same scale. -Observe for nausea and vomiting. -Assess and monitor the client's vital signs (check for hypotension and orthostatic hypotension). -Check neurological status to determine level of consciousness. -Assess heart rhythm (may be irregular or tachycardic). -Initiate and maintain IV access. -Place the client in shock position (on the back with the legs elevated). -Fluid replacement: Administer IV fluids as prescribed (isotonic solutions such as lactated Ringer's or 0.9% sodium chloride; blood transfusions). -Monitor I&O. Encourage fluids as tolerated. Alert the provider to a urine output less than 30 mL/hr. -Monitor level of consciousness and ensure client safety. -Assess level of gait stability. -Encourage the client to use the call light and ask for assistance. -Encourage the client to change positions slowly (rolling from side to side or standing up). -Check capillary refill (expected reference range less than 2 seconds). -Provide frequent oral care. -Prevent skin breakdown.

Iron preparations

Patient-Centered Care ●Instruct clients to take iron on an empty stomach, such as 1 hr before meals to maximize absorption. Stomach acid increases absorption. ●Instruct clients to take with food if GI adverse effects occur. This may increase adherence to therapy even though absorption is also decreased. ●Instruct clients to space doses at approximately equal intervals throughout day to most efficiently increase red blood cell production. Inform clients to anticipate a harmless dark green or black color of stool. ●Teach clients to dilute liquid iron with water or juice, drink with a straw, and rinse the mouth after swallowing. ●Instruct clients to increase water and fiber intake (unless contraindicated) and to maintain an exercise program to counter the constipation effects. ●Advise clients that therapy may last 1 to 2 months. Usually, dietary intake will be sufficient after Hgb has returned to an appropriate level. ●Encourage concurrent intake of appropriate quantities of foods high in iron (liver, egg yolks, muscle meats, yeast, grains, green leafy vegetables).

Central Catheters

Peripherally inserted central catheter -Insertion location - basilic or cephalic vein at least one finger's breadth below or above the antecubital fossa; the catheter should be advanced until the tip is positioned in the lower one-third of the superior vena cava Postprocedure -Apply an initial dressing of gauze and replace with a transparent dressing within 24 hr. -An initial x-ray should be taken to ensure proper placement. -Care of a PICC line includes: ----Assessing the site at least every 8 hr. Note redness, swelling, drainage, tenderness, and condition of the dressing. ---Changing the tube and positive pressure cap per facility protocol (usually a minimum of every 3 days for the hospitalized client). -----Using 10 mL or larger syringe to flush the line. ----Cleaning the insertion port with alcohol for 3 seconds and allowing it to dry ----completely prior to accessing it. ----Performing flush for intermittent medication administration per facility protocol, usually with 10 mL of 0.9% sodium chloride before, between, and after medications. ----Obtaining blood samples by withdrawing 10 mL of blood and discarding; taking a second syringe and withdrawing 10 mL of blood for sample; taking a third syringe and flushing with 10 mL of 0.9% sodium chloride (follow facility protocol for specific flushing guidelines). -----Using transparent dressing. Follow facility protocol for dressing changes, usually every 7 days and when indicated (wet, loose, soiled). ----Advising the client not to immerse his arm in water. To shower, cover dressing site to avoid water exposure. ----Educating the client not to have blood pressure taken in arm with PICC line

Peritonitis

Peritonitis can occur as a result of injury to the intestines during needle insertion. Manifestations of peritonitis include sharp, constant abdominal pain, fever, nausea, vomiting, and diminished or absent bowel sounds.

NeoNatal substaNce withdRawal

Physical assessment findings ■Monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following: ☐CNS - increased wakefulness, a high-pitched, shrill cry, incessant crying, irritability, tremors, hyperactive with an increased Moro reflex, increased deep-tendon reflexes, increased muscle tone, abrasions and/or excoriations on the face and knees, and convulsions. ☐Metabolic, vasomotor, and respiratory findings - nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min, sweating, and a temperature greater than 37.2° C (99° F). ☐Gastrointestinal - poor feeding, regurgitation (projectile vomiting), diarrhea, and excessive, uncoordinated, and constant sucking. ■Opiate withdrawal ☐Can last for 2 to 3 weeks ☐Manifestations of neonatal abstinence syndrome - rapid changes in mood, hypersensitivity to noise and external stimuli, dehydration, and poor weight gain ■Heroin withdrawal ☐Manifestations of neonatal abstinence syndrome - low birth weight and SGA, decreased Moro reflexes (rather than increased), and hypothermia or hyperthermia. ■Methadone withdrawal ☐Manifestations of neonatal abstinence syndrome - an increased incidence of seizures, sleep pattern disturbances, higher birth weights, and higher risk of sudden infant death syndrome (SIDS) ■Marijuana withdrawal ☐Preterm birth and meconium staining. ■Amphetamine withdrawal ☐Clinical findings - Preterm or SGA, drowsiness, jitteriness, sleep pattern disturbances, respiratory distress, frequent infections, poor weight gain, emotional disturbances, and delayed growth and development ■Fetal alcohol syndrome ☐Clinical findings X-Facial anomalies include eyes with epicanthal folds, strabismus, and ptosis; mouth with a poor suck, small teeth, and cleft lip or palate X-Deafness X-Abnormal palmar creases and irregular hair X-Many vital organ anomalies, such as heart defects, including atrial and ventricular septal defects, tetralogy of Fallot, and patent-ductus arteriosus X-Developmental delays and neurologic abnormalities X-Prenatal and postnatal growth retardation X-Sleep disturbances ■Tobacco ☐Clinical findings - prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, and developmental delays

pressure ulcer prevention

Prevention -Keep skin clean, dry, and intact. Provide a firm, wrinkle-free foundation with wrinkle-free linens. -Use pressure-reducing surfaces and devices. -Inspect the client's skin frequently and document the client's risk using a tool such as the Braden scale. -Clean the skin with a mild cleansing agent and pat it dry immediately following urine or stool incontinence. -Bathe with tepid water (not hot) and minimal scrubbing. -Apply dimethicone-based moisture barrier creams or alcohol-free barrier films to the skin of clients who are incontinent. -Do not use powder or cornstarch to prevent friction or repel moisture due to their abrasive grit and aspiration potential. -Reposition the client in bed at least every 2 hr and every 1 hr in a chair. Document position changes. -Keep the head of the bed at or below a 30° angle (or flat), unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels. -Use pressure-reducing devices (overlays; replacement mattresses; specialty beds; kinetic therapy; foam, gel, or air cushions). -Keep clients from sliding down in bed, as this increases shearing forces that pull tissue layers apart and cause damage. -Lift, rather than pull, clients up in bed or in a chair, because pulling creates friction that can damage the outer layer of skin (epidermis). -Raise heels off of the bed to prevent pressure. -Ambulate clients as soon as possible and as often as possible. -Instruct clients who are mobile to shift their weight every 15 min when sitting. -Implement active and passive exercises for clients who are immobile. -Do not massage bony prominences. -Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and calorie needs. -Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts the client at greater risk for skin breakdown, slowed healing, and infection. -Provide nutritional support as indicated, such as vitamin and mineral supplements (especially A, C, zinc, copper), nutritional supplements, and enteral and parenteral nutrition

falls

Prevention of Falls ◯Complete a fall-risk assessment upon admission and at regular intervals on the client. ◯The plan for each client is individualized based on the fall-risk assessment. ■For example, if the client has orthostatic hypotension, instruct the client to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing, and to stand at the side of the bed for a few seconds prior to walking. ■General measures to prevent falls include the following: ☐Be sure the client knows how to use the call light, that it is in reach, and encourage its use. ☐Respond to call lights in a timely manner. ☐Use fall-risk alerts, such as ID wristbands per facility protocol. ☐Provide regular toileting and orientation of confused clients as needed. ☐Ensure adequate lighting. ☐Orient the client to the setting (grab bars, call light) to ensure he knows how to use all assistive devices and can locate necessary items. ☐Place clients at risk for falls near the nursing station. ☐Ensure that bedside tables and overbed tables and frequently used items (telephone, water, tissues) are within the client's reach. ☐Maintain the bed in the low position. ☐For clients who are sedated, unconscious, or otherwise compromised, the bed rails are kept up, and the bed is kept in the low position. ☐Avoid the use of full side bed rails for clients who get out of bed or attempt to get out of bed without assistance. ☐Provide the client with nonskid footwear and nonskid bath mats for use in tubs and showers. ☐Use gait belts and additional safety equipment, as needed, when moving clients. ☐Keep the floor free from clutter with a clear path to the bathroom (no scatter rugs, cords, furniture). ☐Keep assistive devices nearby after validation of safe use by the client and family (glasses, walkers, transfer devices). ☐Educate the client and family/caregivers on identified risks and the plan of care. Clients and family who are aware of risks are more likely to call for assistance. ☐Lock wheels on beds, wheelchairs, and carts to prevent the device from rolling during transfers or stops. ☐Use chair or bed sensors for clients at risk for getting up unattended to alert staff of independent ambulation.

Erythromycin (Romycin)

Prophylactic eye care is the mandatory instillation of antibiotic ointment into the eyes to prevent ophthalmia neonatorum. Infections can be transmitted during descent through the birth canal. Ophthalmia neonatorum is caused by Neisseria gonorrhoeae or Chlamydia trachomatis and can cause blindness.

wound care

Provide adequate hydration and meet protein and calorie needs. -Encourage an intake of 2,000 to 3,000 mL of fluid/day, from food and beverage sources if not contraindicated (heart and renal failure). -Provide education about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains). -Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein increases the risk for a delay in wound healing and infection. -Provide nutritional support (vitamin and mineral supplements, nutritional supplements, and enteral and parenteral nutrition). Most adult clients need at least 1,500 kcal/day for nutritional support. Perform wound cleansing. -For clean wounds, such as a surgical incision, cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin). -Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. -Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents Never use the same gauze to cleanse across an incision or wound more than once. -Do not use cotton balls and other products that shed fibers. -If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30- to 60-mL syringe with a 19-gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer's, or an antibiotic solution. For wound dressings -Woven gauze (sponges) - Absorbs exudate from the wound -Nonadherent material - Does not stick to the wound bed -Self-adhesive, transparent film - A temporary "second skin" ideal for small, superficial wounds -Hydrocolloid - An occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wound's surface to prevent evaporation of moisture from the skin -------Maintains a granulating wound bed -------May stay in place up to 7 days -Hydrogel (Aquasorb) - Composition is mostly water; gels after contact with exudate, promoting autolytic debridement and cooling ------For infected, deep wounds, or necrotic tissue ------Not for moderately to heavily exudating wounds ------Provides a moist wound bed ------May stay in place for 3 days

Breast care

Provide breast care for clients who are lactating. ☐Wear a well-fitting, supportive bra continuously for the duration of lactation. ☐Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. ☐To relieve breast engorgement, have the client completely empty her breasts at each feeding. Allow the infant to nurse on demand, which would be about 8 to 12 times in 24-hr period. Massaging the breasts during feeding can help with emptying. Allow the infant to feed until the breast softens. If the second breast does not soften after the infant's feeding, the breast may be emptied with a breast pump. Alternate breasts with each feeding. ☐For breast engorgement, apply cool compresses between feedings and apply warm compresses, or take a warm shower prior to breastfeeding. These actions will increase milk flow and promote the letdown reflex. ☐For flat or inverted nipples, suggest that the client roll the nipples between her fingers just before breastfeeding to help them become more erect and make it easier for the infant to latch on. Use a breast shield between feedings. ☐For sore nipples, the client should apply a small amount of breast milk to her nipple and allow it to air dry after breastfeeding. ☐Have the client apply breast creams as prescribed and wear breast shields in her bra to soften her nipples if they are irritated and cracked. ☐Promote adequate fluid intake to replace fluid lost from breastfeeding as well as to provide an adequate amount of milk for the infant. ■Breast care for nonlactating clients ☐Wear a well-fitting, supportive bra continuously for the first 72 hr. ☐Suppression of lactation is necessary for clients who are not breastfeeding. Avoid breast stimulation and running warm water over the breasts for prolonged periods until no longer lactating. ☐For breast engorgement, which may occur on the third or fifth postpartum day, apply cold compresses 15 min on and 45 min off. Fresh, cold cabbage leaves can be placed inside the bra. Mild analgesics may be taken for pain and discomfort of breast engorgement.

● First-generation NSAIDs (COX-1 and COX-2 inhibitors) ◯Aspirin ◯Ibuprofen (Motrin, Advil; IV preparations include Caldolor, NeoProfen) ◯Naproxen (Naprosyn); naproxen sodium (Aleve) ◯Indomethacin (Indocin) ◯Diclofenac (oral forms - Voltaren, Cataflam, Cambia, Zipsor; intradermal forms - Flector patch, Pennsaid, Voltaren gel) ◯Ketorolac (generic; Sprix, an intranasal form) ◯Meloxicam (Mobic) ●Second-generation NSAIDs (selective COX-2 inhibitor) ◯Celecoxib (Celebrex)

Purpose ●Expected Pharmacological Action ◯Inhibition of cyclooxygenase - Inhibition of COX-1 can result in decreased platelet aggregation and kidney damage. Inhibition of COX-2 results in decreased inflammation, fever, and pain. ●Therapeutic Uses ◯Inflammation suppression ◯Analgesia for mild to moderate pain, such as with osteoarthritis and rheumatoid arthritis ◯Fever reduction ◯Dysmenorrhea ◯Inhibition of platelet aggregation, which protects against ischemic stroke and myocardial infarction (aspirin) contraindications/Precautions ●Contraindications for aspirin and other first-generation NSAIDs ◯Pregnancy (Pregnancy Risk Category D) ◯Peptic ulcer disease ◯Bleeding disorders, such as hemophilia and vitamin K deficiency ◯Hypersensitivity to aspirin and other NSAIDs ◯Children and adolescents who have chickenpox or influenza (aspirin) ●Use NSAIDs cautiously in older adults, clients who smoke cigarettes, and in clients who have Helicobacter pylori infection, hypovolemia, asthma, chronic urticaria, and/or a history of alcoholism. ●Celecoxib is contraindicated in clients who have an allergy to sulfonamides. ●Ketorolac is contraindicated in clients who have advanced renal dysfunction. Use should be no longer than 5 days because of the risk for kidney damage. ●Second-generation NSAIDs should be used cautiously in clients who have known cardiovascular disease.

med error report

Report all errors, and implement corrective measures immediately. ☐Complete an unusual occurrence report within the specified time frame, usually 24 hr. This report should include: *The client's identification *The name and dose of the medication *An accurate and objective account of the event *The time and place of the incident *Who was notified *What actions were taken *The signature of the person completing the report ☐This report does not become a part of the client's permanent record, and the report should not be referenced in another part of the record.

Hypomagnesemia Hypomagnesemia is a serum magnesium level less than 1.3 mEq/L.

Risk Factors Increased magnesium output -GI losses (diarrhea, nasogastric suction) -Thiazide or loop diuretics Inadequate magnesium intake or absorption: -Malnutrition -Alcohol use disorder -Laxative use *Subjective and Objective Data -Neuromuscular - increased nerve impulse transmission (hyperactive DTRs, paresthesias, muscle tetany), positive Chvostek's and Trousseau's sign -GI - hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus -Cardiovascular - dysrhythmias, tachycardia, hypertension *Nursing Care -Discontinue magnesium-losing medications. -Administer oral or IV magnesium sulfate following safety protocols. IV route is used because IM can cause pain and tissue damage. Oral magnesium can cause diarrhea and increase magnesium depletion. Monitor closely. -Encourage foods high in magnesium, including whole grains and dark green vegetables. -Implement seizure precautions.

staff witness inappropriate behaviors

Staff members who witness an inappropriate action by a coworker should report the infraction up the chain of command. At the time of the infraction, this may be the charge nurse. The unit manager should also be notified, and written documentation by the manager may be placed in the staff member's permanent file.

pressure ulcer STAGES AND INTERVENTIONS

Stage I - Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage II - Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III - Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV - Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). Unstageable - No determination of stage because eschar or slough obscures the wound.

six major types of urinary incontinence

Stress - The loss of small amounts of urine when laughing, sneezing, or lifting primarily due to weak pelvic muscles, urethra, or surrounding tissues. Urge - The inability to stop urine flow long enough to reach the bathroom due to an overactive detrusor muscle with increased bladder pressure. Overflow - Urinary retention from bladder overdistention and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle. Reflex - The involuntary loss of a moderate amount of urine usually without warning due to hyperreflexia of the detrusor muscle, usually from altered spinal cord activity. Functional - The inability to get to the bathroom to urinate due to physical, cognitive, or social impairment. Total - The unpredictable, involuntary loss of urine that does not generally respond to treatment.

RuptuRe oF the uteRus

Subjective Data ◯Client reports sensation of "ripping," "tearing," or sharp pain. ◯Client reports abdominal pain, uterine tenderness. Objective Data ◯Physical assessment findings ■Nonreassuring FHR with signs of distress, bradycardia, variable and late decelerations, and absent or minimal variability ■Change in uterine shape and fetal parts palpable ■Cessation of contractions and loss of fetal station ■Manifestations of hypovolemic shock: tachypnea, hypotension, pallor, and cool, clammy skin Patient-Centered Care ●Nursing Care ◯Administer IV fluids. ◯Administer blood product transfusions if prescribed. ◯Prepare the client for an immediate cesarean birth, which may involve a laparotomy and/or hysterectomy. ◯Inform the client and her partner about the treatment

Peptic Ulcer Disease

Subjective Data ◯Dyspepsia - heartburn, bloating, nausea, and vomiting (may be perceived as uncomfortable fullness or hunger) ◯Pain *GaStric Ulcer=30 to 60 min after a meal, Rarely occurs at night, Pain exacerbated by ingestion of food *DUoDenal Ulcer=1.5 to 3 hr after a meal. Often occurs at night. Pain may be relieved by ingestion of food or antacid. Objective Data ◯Physical Assessment Findings ■Epigastric pain upon palpation. Pain that radiates to the back may indicate perforation is imminent. May be left upper epigastrium (gastric) or right epigastrium (duodenal). ■Bloody emesis (hematemesis) or stools (melena). ■Weight loss.

uRiNaRy tRaCt iNfeCtioN

Subjective Data ◯Reports of urgency, frequency, dysuria, and discomfort in the pelvic area ◯Fever ◯Chills ◯Malaise ●Objective Data ◯Physical assessment findings ■Change in vital signs, elevated temperature ■Urine (cloudy, blood‑tinged, malodorous, sediment visible) ■Urinary retention ■Pain in the suprapubic area ■Pain at the costovertebral angle (pyelonephritis) ◯Diagnostic procedures ■Urinalysis for WBCs, RBCs, protein, bacteria Nursing Care ◯Obtain either a random or clean‑catch urine sample. ◯Administer antibiotics and teach the client the importance of completing the entire course of antibiotics as prescribed. ◯Teach the client proper perineal hygiene, such as wiping from front to back. ◯Encourage the client to increase her fluid intake to 3,000 mL/day to dilute the bacteria and flush her bladder. ◯Recommend that the client drink cranberry and prune juice to promote urine acidification, which inhibits bacterial multiplication.

Provide tracheostomy care every 8 hr to reduce the risk of infection and skin breakdown

Suction the tracheostomy tube, if necessary, using sterile suctioning supplies. ■Remove soiled dressings and excess secretions. ■Apply the oxygen source loosely if the client's SpO2 decreases during the procedure. ■Use cotton-tipped applicators and gauze pads to clean exposed outer cannula surfaces. Use the facility-approved solution. Clean in a circular motion from the stoma site outward. ■Use surgical asepsis to remove and clean the inner cannula (with the facility-approved solution). Use a new inner cannula if it is disposable. ■Clean the stoma site and then the tracheostomy plate. ■Place a fresh dressing under and around the tracheostomy holder and plate. ■Replace tracheostomy ties if they are wet or soiled. Secure the new ties before removing the soiled ones to prevent accidental decannulation. ■If a knot is needed, tie a square knot that is visible on the side of the neck. Check that one or two fingers fit between the tie and the neck.

Infiltration and Extravasation

Swelling around the site and proximal or distal to the IV Edema "puffiness" in the dependent area of the extremity Skin taut or rigid with blanching Sensation of coolness treatment: Remove using direct pressure with gauze sponge until bleeding stops. Apply cool compresses. Elevation is optional. Avoid starting a new IV site in the same extremity.

Symptoms of carbon monoxide poisoning

Symptoms of carbon monoxide poisoning include nausea, vomiting, headache, weakness, and unconsciousness. *Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body. ◯Carbon monoxide cannot be seen, smelled, or tasted.

TPN

TPN administration is usually through a central line, such as a tunneled triple lumen catheter or a single- or double-lumen peripherally inserted central (PICC) line. -Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. Interventions -Check capillary glucose every 4 to 6 hr for at least the first 24 hr. -Clients receiving TPN frequently need supplemental regular insulin until the pancreas can increase its endogenous production of insulin. -Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations. -Older adult clients have an increased incidence of glucose intolerance

Stress Testing

The cardiac muscle is exercised by the client walking on a treadmill. This provides information regarding the workload of the heart. Once the client's heart rate reaches a certain rate, the test is discontinued. Clients can become too tired, may be disabled or physically challenged, and be unable to finish the test. The provider can prescribe the test to be done as a pharmacological stress test. *Indications Angina Heart Failure Myocardial Infarction Dysrhythmia *Preprocedure Nursing Actions -Ensure that a signed informed consent form is obtained. -Explain to the client that he will be walking on a treadmill, and comfortable shoes and clothing are recommended. -If a pharmacological stress test is prescribed, a medication such as adenosine (Adenocard) or dobutamine (Dobutrex) is given to stress the heart instead of walking on the treadmill. -Instruct the client to fast 2 to 4 hr before the procedure according to facility policy and to avoid tobacco, alcohol, and caffeine before the test. *Intraprocedure Nursing Actions -Apply a 12-lead ECG to monitor the client's heart rate during the test. *Postprocedure Nursing Actions -The client is monitored by 12-lead ECG and his blood pressure is checked frequently until he is stable. -The provider reviews findings with client.

Hyperthyroidism

The thyroid gland produces three hormones: thyroxine (T 4), triiodothyronine (T3), and thyrocalcitonin (calcitonin). Secretion of T3 and T4 is regulated by the anterior pituitary gland through a negative feedback mechanism. Clinical Manifestations -Nervousness, irritability, hyperactivity, emotional lability, decreased attention span -Weakness, easy fatigability, exercise intolerance -Heat intolerance -Weight change (usually loss) and increased appetite -Insomnia and interrupted sleep -Frequent stools and diarrhea -Menstrual irregularities (amenorrhea/decreased menstrual flow) -Libido initially increased in both men and women, followed by a decrease in libido as the condition progresses -Warm, sweaty, flushed skin with velvety-smooth texture -Tremor, hyperkinesia, hyperreflexia -Exophthalmos (Graves' disease only) -Vision changes, retracted eyelids, global lag -Hair loss -Goiter -Bruit over the thyroid gland -Elevated systolic blood pressure and widened pulse pressure -Tachycardia and dysrhythmias -Findings in older adult clients are often more subtle than those in younger clients. -Occasionally an older adult client who has hyperthyroidism will demonstrate apathy or withdrawal instead of the more typical hypermetabolic state. -Older adult clients who have hyperthyroidism often present with heart failure and atrial fibrillation. Laboratory Tests -Serum TSH test - Decreased in the presence of Graves' disease (may be elevated in secondary or tertiary hyperthyroidism) Free thyroxine index (FTI) and T3 - Elevated in the presence of disease -Thyrotropin-releasing hormone (TRH) stimulation test - Failure of expected rise in TSH Nursing Care -Minimize the client's energy expenditure by assisting with activities as necessary and by encouraging the client to alternate periods of activity with rest. -Promote a calm environment. -Assess the client's mental status and decision-making ability. Intervene as needed to ensure safety. -Monitor the client's nutritional status. Provide increased calories, protein, and other nutritional support as necessary. -Monitor intake and output, and the client's weight. -Provide eye protection (patches, eye lubricant, tape to close eyelids) for a client who has exophthalmos. -Monitor vital signs and hemodynamic parameters (for a client who is actually ill) for findings of heart failure. -Report a temperature increase of 1 degree or more to the provider immediately. -Monitor ECG for dysrhythmias. -Assure the family that any abrupt changes in the client's behavior are likely disease related and should subside with antithyroid therapy. -Avoid excessive palpation of the thyroid gland. -Administer antithyroid medications. -Prepare the client for a total/subtotal thyroidectomy if the client is unresponsive to antithyroid medications or has an airway-obstructing goiter.

chest tube

The water seal chamber allows air to pass through a narrow channel and bubble out through the bottom of the water seal. It is also used to determine intrathoracic pressure. The water seal chamber fluctuates with the pressure and can be seen by the fluctuation of the water level. Should be filled to the 2 cm line The suction control chamber is atmospherically vented section containing water and is connected with the water seal chamber. By adding or removing water in the suction control chamber the chest drain controls the amount of suction imposed on the patient. More water more suction. A patient air leak is confirmed when air bubbles are observed going from right to left in the air leak monitor.

chest tube

The water seal chamber allows air to pass through a narrow channel and bubble out through the bottom of the water seal. It is also used to determine intrathoracic pressure. The water seal chamber fluctuates with the pressure and can be seen by the fluctuation of the water level. Should be filled to the 2 cm line The suction control chamber is atmospherically vented section containing water and is connected with the water seal chamber. By adding or removing water in the suction control chamber the chest drain controls the amount of suction imposed on the patient. More water more suction. A patient air leak is confirmed when air bubbles are observed going from right to left in the air leak monitor. Continuous bubbling in the water seal air leak monitor will confirm a persistent air leak. Intermittent bubbling with float ball oscillation will confirm the presence of an intermittent air leak. No bubbling with minimal float ball oscillation at the bottom of water seal will indicate no air leak is present.

lochia

Three stages of lochia ■Lochia rubra - bright red color, bloody consistency, fleshy odor, may contain small clots, transient flow increases during breastfeeding and upon rising. Lasts 1 to 3 days after delivery. ■Lochia serosa - pinkish brown color and serosanguineous consistency. Lasts from approximately day 4 to day 10 after delivery. ■Lochia alba - yellowish, white creamy color, fleshy odor. Lasts from approximately day 11 up to and beyond 6 weeks postpartum. ◯Lochia amount is assessed by the quantity of saturation on the perineal pad as being either: ■Scant (less than 2.5 cm) ■Light (less than 10 cm) ■Moderate (more than 10 cm) ■Heavy (one pad saturated within 2 hr) ■Excessive blood loss (one pad saturated in 15 min or less, or pooling of blood under buttocks) *Assess for pooled lochia on the pad under the client, which may not be felt by the client. Massaging the uterus or ambulation may result in a gush of lochia with the expression of clots and dark blood that has pooled in the vagina, but should soon decrease back to a trickle of bright red lochia when in the early puerperium.

A nurse is reviewing the health care record of a client who has a prescription for conjugated equine estrogens (Premarin). In which of the following conditions is the use of estrogens contraindicated A nurse is explaining the mechanism of action of combination oral contraceptives to a group of clients. The nurse should tell the clients that which of the following actions occur with the use of combination oral contraceptives? A nurse is providing teaching to a female client who is taking testosterone (Andronaq-50) to treat advanced breast cancer . The nurse should tell the client that which of the following are adverse effects of this medication? (Select all that apply.) A nurse is providing teaching to a client who is to start alfuzosin (Uroxatral) for treatment of benign prostatic hyperplasia. Which of the following is an adverse effect of this medication? A nurse is caring for a client who has angina and asks about obtaining a prescription for sildenafil (Viagra) to treat erectile dysfunction. Which of the following medications should not be taken concurrently with sildenafil? Expected Pharmacology ●Finasteride slows the production of testosterone, which reduces the size of the prostate and subsequently promotes urinary elimination.

Thrombophlebitis- Estrogen increases the risk of thrombolytic events. Estrogen used is contraindicated for a client who has a history of thrombophlebitis -Oral contraceptives cause thickening of the cervical mucus, which slows sperm passage. - Oral contraceptives alter the lining of the endometrium, which inhibits implantation of the fertilized egg. -Oral contraceptives prevent pregnancy by inhibiting ovulation. Deepening voice Male pattern baldness Facial hair hypotension Isosorbide (Isordil) Adverse Effects ●Decreased libido ●Decreased ejaculate volume ●Gynecomastia ●Orthostatic hypotension

chest tube

Water seals are created by adding sterile fluid to a chamber up to the 2 cm line. The water seal allows air to exit from the pleural space on exhalation and stops air from entering with inhalation. ◯To maintain the water seal, the chamber must be kept upright and below the chest tube insertion site at all times. The nurse should routinely monitor the water level due to the possibility of evaporation. The nurse should add fluid as needed to maintain the 2 cm water seal level. ◯The height of the water in the suction control chamber determines the amount of suction transmitted to the pleural space. A suction pressure of -20 cm H2O is common. The application of suction results in continuous bubbling in the suction chamber. The nurse should monitor the fluid level and add fluid as needed to maintain the prescribed level of suctioning. ◯Tidaling (movement of the water level with respiration) is expected in the water seal chamber. With spontaneous respirations, the water level will rise with inspiration (increase in negative pressure in lung) and will fall with expiration. With positive-pressure mechanical ventilation, the water level will rise with expiration and fall with inspiration. ◯Cessation of tidaling in the water seal chamber signals lung reexpansion or an obstruction within the system.

Cystocele

a protrusion of the posterior bladder through the anterior vaginal wall. It is caused by weakened pelvic muscles and/or structures. subjective *Urinary frequency and/or urgency ■Stress incontinence ■History of frequent urinary tract infections ■Sense of vaginal fullness ■Dyspareunia ■Fatigue ■Back and pelvic pain objective ☐A pelvic examination reveals a bulging of the anterior vaginal wall when the client is instructed to bear down. ☐Bladder ultrasound measures residual voiding. ☐Urine culture and sensitivity is used to diagnosis urinary tract infection associated with urinary stasis. ☐A voiding cystourethrography is performed to identify the degree of bladder protrusion and the amount of urine residual.

Methicillin-resistant Staphylococcus aureus (MRSA)

a strain of Staphylococcus aureus that is resistant to all antibiotics, except vancomycin. Vancomycin-resistant Staphylococcus aureus (VRSA) is a strain of Staphylococcus aureus that is resistant to vancomycin, but so far is sensitive to other antibiotics specific to a client's strain. ◯Nursing Actions ■Obtain specimens for culture and sensitivity prior to initiation of antimicrobial therapy. ■Monitor antimicrobial levels and ensure that therapeutic levels are maintained. ◯Client Education ■Complete the full course of antimicrobial therapy. ■Avoid overuse of antimicrobials. ●Transporting a Client ◯If movement of the client to another area of the facility is unavoidable, the nurse takes precautions to ensure that the environment is not contaminated. For example, a surgical mask is placed on the client with an airborne or droplet infection, and a draining wound is well covered.

acute glomerulonephritis

a streptococcal infection precedes the majority of cases of acute glomerulonephritis. Other infections that can cause glomerulonephritis include pneumococcal infections and viral infections. pallor, reports of anorexia, and lethargy. Distended neck veins and increased blood pressure are expected findings.

Hallucinations

are sensory perceptions that do not have any apparent external stimulus. Examples include the following: ☐Auditory - hearing voices or sounds. X-Command - the voice instructs the client to perform an action, such as to hurt self or others. ☐Visual - seeing persons or things. ☐Olfactory - smelling odors. ☐Gustatory - experiencing tastes. ☐Tactile - feeling bodily sensations. Nursing Care ◯Milieu therapy is used for clients who have a psychotic disorder both in acute mental health facilities and in community facilities, such as residential crisis centers, halfway houses, and day treatment programs. ■Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations. ■Assertive community treatment (ACT) - intensive case management and interprofessional team approach to assist clients with community-living needs. ◯Promote therapeutic communication to lower anxiety, decrease defensive patterns, and encourage participation in the milieu. ◯Establish a trusting relationship with the client. ◯Encourage the development of social skills and friendships. ◯Encourage participation in group work and psychoeducation. ◯Use appropriate communication to address hallucinations and delusions. ■Ask the client directly about hallucinations. The nurse should not argue or agree with the client's view of the situation, but may offer a comment, such as, "I don't hear anything, but you seem to be feeling frightened." ■Do not argue with a client's delusions, but focus on the client's feelings and possibly offer reasonable explanations, such as, "I can't imagine that the president of the United States would have a reason to kill a citizen, but it must be frightening for you to believe that." ■Assess the client for paranoid delusions, which can increase the risk for violence against others. ■Provide for safety if the client is experiencing command hallucinations due to the increased risk for harm to self or others. ■attempt to focus conversations on reality-based subjects. ■Identify symptom triggers, such as loud noises (may trigger auditory hallucinations in certain clients) and situations that seem to trigger conversations about the client's delusions. ■Be genuine and empathetic in all dealings with the client. ◯Assess discharge needs, such as ability to perform activities of daily living. ◯Promote self-care by modeling and teaching self-care activities within the mental health facility. ◯Relate wellness to the elements of symptom management. ◯Collaborate with the client to use symptom management techniques to cope with depressive symptoms and anxiety. Symptom management techniques include such strategies as using music to distract from "voices," attending activities, walking, talking to a trusted person when hallucinations are most bothersome, and interacting with an auditory or visual hallucination by telling it to stop or go away. ◯Encourage medication compliance. ◯Provide teaching regarding medications. ◯Whenever possible, incorporate family in all aspects of care.

leukopoietic growth factors ●Select Prototype Medication: filgrastim (Neupogen) ●Other Medication: pegfilgrastim (Neulasta)

adverse effects -bone pain -luekocytosis -splenomegaly and risk of splenic rupture with long-term use Nursing administration ●Administer filgrastim by intermittent IV bolus, continuous IV, subcutaneous infusion, or subcutaneous injection. ●Do not agitate the vial of medication. Use each vial for one dose, and do not combine with other medications. Do not put the needle back into the vial when withdrawing the medication. ●Monitor CBC two times per week. ●If client will be administering subcutaneous filgrastim at home, provide thorough instruction on self-administration procedures.

cardiac glycosides ●Select Prototype Medication: digoxin (Lanoxin, Lanoxicaps, Digitek)

adverse effects ›Dysrhythmias (caused by interfering with the electrical conduction in the myocardium) ›Cardiotoxicity leading to bradycardia interventions ›Conditions that increase the risk of developing digoxin-induced dysrhythmias include hypokalemia, increased serum digoxin levels, and heart disease. Older adult clients are particularly at risk. ›Monitor serum levels of K+ to maintain a level between 3.5 to 5.0 mEq/L. ›Instruct clients to report signs of hypokalemia (nausea/vomiting, general weakness). Potassium supplements may be prescribed if clients are concurrently taking a diuretic. ›Teach clients to consume high-potassium foods (green leafy vegetables, bananas, potatoes). ›Monitor the client's digoxin level. »Therapeutic serum levels may vary, but usually range from 0.5 to 2.0 ng/mL. »Signs of toxicity may appear at levels less than 1.75 ng/mL. »Clients who have heart failure respond best with serum medication levels between 0.5 to 0.8 ng/mL. »Dosages should be based on serum levels and client response to medication. ›Teach clients to monitor pulse rate, and recognize and report changes. The rate may be irregular with early or extra beats noted. GI effects include anorexia (usually the first sign), nausea, vomiting, and abdominal pain. ›CNS effects include fatigue, weakness, vision changes (diplopia, blurred vision, yellow-green or white halos around objects). interactions medication/food ●Management of digoxin toxicity ◯Digoxin and potassium-sparing medication should be stopped immediately. ◯Monitor K+ levels. For levels less than 3.5 mEq/L, administer potassium IV or by mouth. Do not give any further K+ if the level is greater than 5.0 mEq/L. ◯Treat dysrhythmias with phenytoin (Dilantin) or lidocaine. ◯Treat bradycardia with atropine. ◯For excessive overdose, activated charcoal, cholestyramine, or Digibind can be used to bind digoxin and prevent absorption.

Home safety infants and toddlers

aspiration ›Keep all small objects out of reach. ›Check toys and objects for loose or small parts and sharp edges. ›Do not feed the infant hard candy, peanuts, popcorn, or whole or sliced pieces of hot dog. ›Do not place the infant in the supine position while feeding or prop the infant's bottle. ›A pacifier (if used) should be constructed of one piece and never placed on string or ribbon around the neck. suffocation ›Teach "back to sleep" mnemonic and always place infants on back to rest. ›Keep plastic bags out of reach. ›Make sure crib mattress fits snugly and that crib slats are no more than 2 3/8inches apart. ›Never leave an infant or toddler alone in the bathtub. ›Do not place anything in crib with infant. ›Remove crib toys, such as mobiles, from over the bed as soon as the infant begins to push up. ›Keep latex balloons away from infants and toddlers. ›Fence swimming pools and use a locked gate. ›Begin swimming lessons when the child's developmental status allows for protective responses such as closing her mouth under water. ›Teach caregivers CPR and Heimlich maneuver. ›Keep toilet lids down and bathroom doors closed. Falls ›Keep crib and playpen rails up. ›Never leave the infant unattended on a changing table or other high surface. ›Use gates on stairs, and ensure windows have screens. ›Restrain according to manufacturer's recommendations and supervise when in high chair, swing, stroller, etc. ›Place in a low bed when toddler starts to climb. burns ›Reduce setting on water heater to no higher than 120° F ›Teach dangers of playing with matches, fireworks, and firearms. ›Teach school-age child how to properly use microwave and other cooking instruments.

Chorionic villus sampling (CVS)

assessment of a portion of the developing placenta (chorionic villi), which is aspirated through a thin sterile catheter or syringe inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance and analyzed. ◯CVS is a first-trimester alternative to amniocentesis with one of its advantages being an earlier diagnosis of any abnormalities. CVS can be performed at 10 to 12 weeks of gestation. ●Indications for the use of CVS during pregnancy ◯Potential diagnoses ■Women at risk for giving birth to a neonate who has a genetic chromosomal abnormality (cannot determine spina bifida or anencephaly) ◯Client education ■Instruct the client to drink plenty of fluid to fill the bladder prior to the procedure to assist in positioning the uterus for catheter insertion. ■Provide ongoing education and support.

Blood loss during childbirth

average blood loss is 500 mL in an uncomplicated vaginal delivery and 1,000 mL for a cesarean birth

dysrythmias

bradycardia - pacemaker afib, svt, vtach with pulse- synchronized cardioversion vtach without pulse or vfib- dfib

malignant hyperthermia

clinical Manifestations ›Acute life-threatening medical emergency. ›Inherited muscle disorder, chemically induced by anesthetic agents. ›Triggering agents include inhalation anesthetic agents, and the muscle relaxant succinylcholine ›Hyper metabolic condition causing an alteration in calcium activity in muscle cells (muscle rigidity, hyperthermia, and damage to the central nervous system). ›Tachycardia is a first manifestation, dysrhythmias, muscle rigidity, hypotension, tachypnea, skin mottling, cyanosis and protein in urine (myoglobinuria). ›Elevated temperature is a late manifestation - rising 1° to 2° C (2° to 4° F) every 5 min. treatment ›Terminate surgery ›Dantrolene (Dantrium) is a muscle relaxant to treat the condition ›100% oxygen, arterial blood gases ›Infuse iced IV 0.9% sodium chloride ›Apply a cooling blanket, ice to axillae, groin, neck and head, iced lavage

Hypoglycemia

frequently occurs in the first few hours of life secondary to the use of energy to establish respirations and maintain body heat. Newborns of mothers who have diabetes mellitus, are small or large for gestational age, are less than 37 weeks of gestation, or are greater than 42 weeks of gestation, are at risk for hypoglycemia and should have blood glucose monitored within the first 2 hr of life. Follow facility protocols regarding frequency of assessing blood glucose levels. ◯Nursing Actions ■Monitor for jitteriness; twitching; a weak, high-pitched cry; irregular respiratory effort; cyanosis; lethargy; eye rolling; seizures; and a blood glucose level less than 40 mg/dL by heel stick. ■Give formula immediately or have the mother breastfeed to elevate blood glucose. Brain damage can result if brain cells are depleted of glucose.

Group B streptococcus ß-hemolytic (GBS)

is a bacterial infection that can be passed to a fetus during labor and delivery. Physical Assessment Findings ■Positive GBS may have maternal and fetal effects, including premature rupture of membranes, preterm labor and delivery, chorioamnionitis, infections of the urinary tract, and maternal sepsis. ◯Laboratory Tests ■Vaginal and rectal cultures are performed at 36 to 37 weeks of gestation. Medications ◯Penicillin G or ampicillin (Principen) is most commonly prescribed for GBS. ■Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hr. The client may be prescribed ampicillin 2 grams IV initially, followed by 1 g every 4 hr. ■Bactericidal antibiotic is used to destroy the GBS.

Cephalohematoma

is a collection of blood between the periosteum and the skull bone that it covers. It does not cross the suture line. It results from trauma during birth such as pressure of the fetal head against the maternal pelvis in a prolonged difficult labor or forceps delivery. It appears in the first 1 to 2 days after birth and resolves in 2 to 3 weeks.

HELLP syndrome

is a variant of GH in which hematologic conditions coexist with severe preeclampsia involving hepatic dysfunction. HELLP syndrome is diagnosed by laboratory tests, not clinically. ◯H - hemolysis resulting in anemia and jaundice ◯EL - elevated liver enzymes resulting in elevated alanine aminotransferase (ALT) or aspartate transaminase (AST), epigastric pain, and nausea and vomiting ◯LP - low platelets (less than 100,000/mm3), resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possibly disseminated intravascular coagulopathy (DIC)

Caput succedaneum

localized swelling of the soft tissues of the scalp caused by pressure on the head during labor) is an expected finding that may be palpated as a soft edematous mass and may cross over the suture line. Caput succedaneum usually resolves in 3 to 4 days and does not require treatment.

potassium supplements

nursing administration ●Oral formulations ◯Mix powdered formulations in at least 4 oz of liquid. ◯Advise clients to take potassium chloride with a glass of water or with a meal to reduce the risk of adverse GI effects. ◯Instruct clients not to crush extended-release tablets. ◯Instruct clients to notify the provider if they have difficulty swallowing the pills. Medication may be supplied as a powder or a sustained-release tablet that is easier to tolerate. ●IV administration ◯Never administer IV bolus. Rapid IV infusion can result in fatal hyperkalemia. ◯Use an IV infusion pump to control the infusion rate. ◯Dilute potassium and give no more than 40 mEq/L of IV solution to prevent vein irritation. ◯Give no faster than 10 mEq/hr. ◯Cardiac monitoring is indicated for serum potassium levels outside of normal parameters. ◯Assess the IV site for local irritation, phlebitis, and infiltration. Discontinue IV immediately if infiltration occurs. ◯Monitor the client's I&O to ensure an adequate urine output of at least 30 mL/hr.nursing evaluation of Medication effectiveness ●Depending on therapeutic intent, effectiveness may be evidenced by serum potassium level within expected reference range (3.5 to 5.0 mEq/L).

episiotomy care

promote measures for the client to help soften her stools. ◯Educate the client about proper cleansing to prevent infection. ■The client should wash her hands thoroughly before and after voiding. ■The client should use a squeeze bottle filled with warm water or antiseptic solution after each voiding to cleanse the perineal area. ■The client should clean her perineal area from front to back (urethra to anus). ■The client should blot dry, not wipe. ■The client should sparingly use a topical application of antiseptic cream or spray. ■The client's perineal pad should be changed from front to back after voiding or defecating. ◯Promote comfort measures. ■Apply ice packs to the client's perineum for the first 24 to 48 hr to reduce edema and provide anesthetic effect. ■Encourage sitz baths at a temperature of 38° to 40° C (100° to 104° F)or cooler at least twice a day. ■Administer analgesia, such as nonopioids (acetaminophen [Tylenol]), nonsteroidal anti-inflammatories (ibuprofen [Advil]), and opioids (codeine, hydrocodone), as prescribed for pain and discomfort. ■Opioid analgesia may be administered via a PCA (patient-controlled analgesia) pump after cesarean birth. Continuous epidural infusions may also be used for pain control after cesarean birth. ■Apply topical anesthetics (Americaine spray or Dermoplast) to the client's perineal area as needed or witch hazel compresses (Tuck's Pads) to the rectal area for hemorrhoids.

Air Embolism

sudden onset of dyspnea, chest pain, anxiety, hypoxia nursing Actions -Leave central lines clamped when not in use. -Have the client hold breath while the tubing is changed. -If the client has sudden shortness of breath, place in Trendelenburg on left side, give oxygen, and notify the provider (to trap and aspirate air)

Amniocentesis

the aspiration of amniotic fluid for analysis by insertion of a needle transabdominally into a client's uterus and amniotic sac under direct ultrasound guidance locating the placenta and determining the position of the fetus. It may be performed after 14 weeks of gestation. ●Interpretation of findings ◯Alpha-fetoprotein (AFP) can be measured from the amniotic fluid between 16 and 18 weeks of gestation and may be used to assess for neural tube defects in the fetus or chromosomal disorders. May be evaluated to follow up a high level of AFP in maternal serum. ■High levels of AFP are associated with neural tube defects, such as anencephaly (incomplete development of fetal skull and brain), spina bifida (open spine), or omphalocele (abdominal wall defect). High AFP levels also may be present with normal multifetal pregnancies. ■Low levels of AFP are associated with chromosomal disorders (Down syndrome) or gestational trophoblastic disease (hydatidiform mole).

beta2 adrenergic agonists Select Prototype Medication: albuterol (Proventil, Ventolin) Other Medications: ◯Formoterol (Foradil Aerolizer) ◯Salmeterol (Serevent) ◯Terbutaline (Brethine)

therapeutic uses adverse effects complications interactions Nursing Administration ●Instruct clients to follow manufacturer's instructions for use of metered-dose inhaler(MDI), dry-powder inhaler (DPI), and nebulizer. ●When a client is prescribed an inhaled beta2-agonist and an inhaled glucocorticoid, advisethe client to inhale the beta2-agonist before inhaling the glucocorticoid. The beta2-agonist promotes bronchodilation and enhances absorption of the glucocorticoid. ●Advise clients not to exceed prescribed dosages. ●Ensure that clients know the appropriate dosage schedule (if the medication is to be taken on a fixed or a as-needed schedule). ●Formoterol and salmeterol are both long acting beta2-agonist inhalers. These inhalers are used every 12 hr for long-term control and are not used to abort an asthma attack, or exacerbation. These long-acting agents are not used alone but are prescribed in combination with an inhaled corticosteroid. ●A short-acting beta 2-agonist is used to treat an acute episode. ●Advise clients to observe for indications of an impending asthma episode and to keep a log of the frequency and intensity of exacerbations. ●Instruct clients to notify the provider if there is an increase in the frequency and intensity of asthma exacerbations.

intraUtErinE dEviCE (iUd)

›A chemically active T-shaped device that is inserted through a woman's cervix and placed in the uterus by the provider. Releases a chemical substance that damages sperm in transit to the uterine tubes and prevents fertilization. ›The device must be monitored monthly by clients after menstruation to ensure the presence of the small string that hangs from the device into the upper part of the vagina to rule out migration or expulsion of the device.

diaphragm and spErmiCidE

›A female client should be fitted with a diaphragm properly by a provider. ›A client must be refitted by the provider every 2 years, if there is a 7 kg (15 lb) weight change, full-term pregnancy, or second-term abortion. ›Requires proper insertion and removal. Prior to coitus, the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. The diaphragm must remain in place for at least 6 hr after coitus. ›Spermicide must be reapplied with each act of coitus. ›A client should empty her bladder prior to insertion of the diaphragm

injECtabLE progEstins (dEpo-provEra)

›An intramuscular injection given to a female client every 11 to 13 weeks. ›Start of injections should be during the first 5 days of a client's menstrual cycle and every 11 to 13 weeks thereafter. Injections in postpartum nonbreastfeeding women should begin within 5 days following delivery. For breastfeeding women, injections should start in the sixth week postpartum. ›Advise clients to keep follow-up appointments. ›A client should maintain an adequate intake of calcium and vitamin D.

transdErmaL ContraCEptivE patCh

›Contains norelgestromin (progesterone) and ethinyl estradiol, which is delivered at continuous levels through the skin into subcutaneous tissue. ›A client applies the patch to dry skin overlying subcutaneous tissue of the buttock, abdomen, upper arm, or torso, excluding breast area. ›Requires patch replacement once a week. ›Patch is applied the same day of the week for 3 weeks with no application of the patch on the fourth week.

OSTOMY CARE

›If a wound ostomy continence nurse is not available, educate the client about stoma care. ›Perform hand hygiene. ›Put on gloves. ›Remove the pouch from the stoma. ›Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. ›Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. ›Apply paste if necessary. ›Measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening. ›Cut the opening in the skin barrier. ›If necessary, apply barrier pastes to creases. ›Apply the skin barrier and pouch. ›Fold the bottom of the pouch and place the closure clamp on the pouch. ›Dispose of the used pouch. Remove the gloves and perform hand hygiene.

Bone marrow suppression (low WBC count or neutropenia, bleeding caused by thrombocytopenia or low platelet count, and anemia or low RBCs

›Monitor WBC, absolute neutrophil count, platelet count, Hgb, and Hct. ›Assess clients for bruising and bleeding gums. ›Instruct clients to avoid crowds and contact with infectious individuals.

basaL body tEmpEratUrE (bbt)

›Temperature can drop slightly at the time of ovulation. This can be used to facilitate conception, or be used as a natural contraceptive. ›A woman is instructed to measure oral temperature prior to getting out of bed each morning to monitor ovulation.

Z-track

›Type of IM injection that prevents medication from leaking back into subcutaneous tissue. ›It is often used for medications that cause visible and/or permanent skin stains, such as certain iron preparations.

bladder retraining

›Use timed voidings to increase intervals between voidings/decrease voiding frequency. ›Perform pelvic floor (Kegel) exercises. ›Perform relaxation techniques. ›Offer undergarments while the client is retraining. ›Teach the client not to ignore the urge to void. ›Provide positive reinforcement as the client maintains continence. ›Eliminate or decrease caffeine drinks. ›Take diuretics in the morning.

inhalation - administered through metered dose inhalers (mdi) or dry powder inhalers (dPi)

›for an MDI, instruct the client to: »Remove the cap from the inhaler mouthpiece. »Shake the inhaler five or six times. »Hold the inhaler with the mouthpiece at the bottom. »Hold the inhaler with the thumb near the mouthpiece and the index and middle fingers at the top. »Hold the inhaler about 2 to 4 cm (0.8 to 1.6 in) away from the front of the mouth or close the mouth around the mouthpiece of the inhaler with the opening pointing towards the back of the throat. »Take a deep breath and then exhale. »Tilt the head back slightly, press the inhaler, and, at the same time, begin a slow, deep breath. Continue to breathe slowly and deeply for 3 to 5 seconds to facilitate delivery to the air passages. »Hold the breath for 10 seconds to allow the medication to deposit in the airways. »Take the inhaler out of the mouth and slowly exhale through pursed lips. »Resume normal breathing. ›A spacer may be used to keep the medication in the device longer thereby increasing the amount of medication delivered to the lungs and decreasing the amount of the medication in the oropharynx. ›If a spacer is used: »Remove the covers from the mouthpieces of the inhaler and of the spacer. »Insert the MDI into the end of the spacer. »Shake the inhaler five or six times. »Exhale completely, then close the mouth around the spacer mouthpiece. Continue as with an MDI. ›For a DPI: »Do not shake the device. »Take the cover off the mouthpiece. »Follow the directions of the manufacturer for preparing the medication, such as turning the wheel of the inhaler. »Exhale completely. »Place the mouthpiece between lips and take a deep breath through the mouth. »Hold the breath for 5 to 10 seconds »Take the inhaler out of the mouth and slowly exhale through pursed lips. »Resume normal breathing. ›If more than one puff is prescribed, instruct the client to wait the length of time directed before administering the second puff. ›Instruct the client to remove the canister and rinse the inhaler, cap, and spacer once a day with warm running water and dry it completely before using it again.

Immunizations (1-3yr)

■12 to 15 months - Inactivated poliovirus (IPV) (third dose between 6 to 18 months); Haemophilus influenzae type B (Hib); pneumococcal vaccine (PCV); measles, mumps, and rubella (MMR); and varicella ■12 to 23 months - Hepatitis A (Hep A), given in two doses at least 6 months apart ■15 to 18 months - Diphtheria and tetanus toxoids and pertussis (DTaP) ■12 to 36 months - Yearly seasonal trivalent inactivated influenza vaccine (TIV); live, attenuated influenza vaccine (LAIV) by nasal spray (at 2 years of age)

Assess for behaviors that impair and indicate a lack of mother-infant bonding

■Apathy when the infant cries. ■Disgust when the infant voids, stools, or spits up. ■Expresses disappointment in the infant. ■Turns away from the infant. ■Does not seek close physical proximity to the infant. ■Does not talk about the infant's unique features. ■Handles the infant roughly. ■Ignores the infant entirely. ◯Assess for signs of mood swings, conflict about maternal role, and/or personal insecurity. ■Feelings of being "down." ■Feelings of inadequacy. ■Feelings of anxiety related to ineffective breastfeeding. ■Emotional lability with frequent crying. ■Flat affect and being withdrawn. ■Feeling unable to care for the infant.

contact precautions

■Contact precautions protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms). Contact precautions require: ☐A private room or a room with other clients with the same infection. ☐Gloves and gowns worn by the caregivers and visitors. ☐Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag.

droplet precautions

■Droplet precautions protect against droplets larger than 5 mcg and travel 3 to 6 ft from the client (streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). Droplet precautions require: ☐A private room or a room with other clients with the same infectious disease, ensuring that each client have their own equipment. ☐Masks for providers and visitors.

Taking a telephone prescription

■If possible, have a second nurse listen on an extension. ■Ensure that the prescription is complete and correct by reading back to the provider: the client's name, the name of the medication, the dosage, the time of administration, frequency, and route. ■Remind the provider that the prescription must be signed within the specified amount of time. ■Enter the prescription in the client's health record.

Manifestations of heart failure (HF)

■Impaired myocardial function ☐Sweating, tachycardia, fatigue, pallor, cool extremities with weak pulses, hypotension, gallop rhythm, cardiomegaly ■Pulmonary congestion ☐Tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough, orthopnea, exercise intolerance ■Systemic venous congestion ☐Hepatomegaly, peripheral edema, ascites, neck vein distention, periorbital edema, weight gain ◯Manifestations of hypoxemia ■Cyanosis, poor weight gain, tachypnea, dyspnea, clubbing, polycythemia *Hypercyanotic spells (blue, or "Tet," spells) manifest as acute cyanosis and hyperpnea

findings of chronic kidney disease

■Neurologic - lethargy, decreased attention span, slurred speech, tremors or jerky movements, ataxia, seizures, coma ■Cardiovascular - fluid overload (jugular distention; sacrum, ocular or peripheral edema), hypertension, dysrhythmias, heart failure, orthostatic hypotension ■Respiratory - uremic halitosis with deep sighing, yawning, shortness of breath, tachypnea, hyperpnea, Kussmaul respirations, crackles, pleural friction rub, frothy pink sputum ■Hematologic - anemia (pallor, weakness, dizziness), ecchymoses, petechiae, melena ■Gastrointestinal - ulcers in mouth and throat, foul breath, blood in stools, nausea, vomiting ■Musculoskeletal - osteodystrophy (thin fragile bones) ■Renal - urine contains protein, blood, particles; change in the amount, color, concentration ■Skin - decreased skin turgor, yellow cast to skin, dry, pruritus, urea crystal on skin (uremic frost) ■Reproductive - erectile dysfunction Laboratory Tests ■Urinalysis ☐Hematuria, proteinuria, and decrease in specific gravity. ■Serum creatinine ☐Gradual increase over months to years for CKD exceeding 4 mg/dL. May be as high as 15 to 30 mg/dL. ■BUN ☐Gradual increase with elevated serum creatinine over months to years for CKD. May be as high as 180 to 200 mg/dL. ■Serum electrolytes ☐Decreased sodium (dilutional) and calcium; increased potassium, phosphorus, and magnesium. ■CBC ☐Decreased hemoglobin and hematocrit from anemia secondary to the loss of erythropoietin in CKD.

traction care

■Nursing Actions ☐Assess neurovascular status of the affected body part every hour for 24 hr and every 4 hr after that. ☐Maintain body alignment and realign if the client seems uncomfortable or reports pain. ☐Avoid lifting or removing weights. ☐Ensure that weights hang freely and are not resting on the floor. ☐If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider. ☐Ensure that pulley ropes are free of knots, fraying, loosening, and improper positioning at least every 8 to 12 hr. ☐Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications and/or repositioning. Move the client in halo traction as a unit, without applying pressure to the rods. This will prevent loosening of the pins and pain. ☐Routinely monitor skin integrity and document. ☐Use heat/massage, as prescribed, to treat muscle spasms. ☐Use therapeutic touch and relaxation techniques.

Open Reduction and Internal Fixation (ORIF)

■Nursing Actions ☐Prevent dislocation, especially of hip. ☐Monitor skin integrity. ☐Ensure heels are off bed at all times and inspect bony prominence every shift. ☐Perform a neurovascular assessment. ☐Observe the cast or dressing for postoperative drainage. The cast may have a window cut in it through which the incision can be viewed. An elastic wrap is used to keep the window block cover in place to decrease localized edema. ☐Observe for signs of fat and pulmonary embolism. ☐Provide antiembolism stockings and a sequential compression device to prevent DVT and administer prescribed anticoagulants. ☐Monitor the client's pain level. -Administer analgesics, antispasmodics, and/or anti-inflammatory medication (NSAIDS) and assess relief. -Position for comfort and with ice on the surgical site. ☐Monitor for signs of infection. -Monitor the client's vital signs, observing for fever, tachycardia, incisional drainage, redness, and odor. -Monitor laboratory values (WBC, ESR). -Provide surgical aseptic wound care. *Increase physical mobility as appropriate. -Consult physical and occupational therapy for ambulation and activities of daily living (ADLs). -Monitor orthostatic blood pressure when the client gets out of bed for the first time. Turn and reposition the client every 2 hr. -Have the client get out of bed from the unaffected side. -Position the client for comfort (within restrictions). ☐Support nutrition. -Encourage increased calorie intake. -Ensure use of calcium supplements. -Encourage small, frequent meals with snacks. -Monitor for constipation.

mastitis

■Painful or tender, localized hard mass, and reddened area usually on one breast ■Chills ■Fatigue Nursing interventions for mastitis ■Provide the client with education regarding breast hygiene to prevent and manage mastitis. ☐Instruct to thoroughly wash hands prior to breastfeeding. ☐Instruct to maintain cleanliness of breasts with frequent changes of breast pads. ☐Encourage allowing nipples to air‑dry. ☐Teach proper infant positioning and latching‑on techniques, including both the nipple and the areola. The client should release the infant's grasp on the nipple prior to removing the infant from the breast. ☐Instruct the client about completely emptying her breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth. ☐Encourage using ice packs or warm packs on affected breasts for discomfort. Instruct the client to continue breastfeeding frequently (at least every 2 to 4 hr), especially on the affected side. Instruct the client to manually express breast milk or use a breast pump if breastfeeding is too painful. ☐Instruct the client to begin breastfeeding from the unaffected breast first to initiate the letdown reflex in the affected breast that is distended or tender. ☐Encourage rest, analgesics, and fluid intake of at least 3,000 mL per day. ☐Encourage the client to wear a well‑fitting bra for support. ☐Tell the client to report redness and fever. ☐Administer antibiotics, and teach the client the importance of completing the entire course of antibiotics as prescribed.

Manifestations of increased intracranial pressure include:

■Severe headache. ■Deteriorating level of consciousness, restlessness, irritability. ■Dilated, pinpoint, or asymmetric pupils, slow to react or nonreactive. ■Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea). ■Deterioration in motor function, abnormal posturing (decerebrate, decorticate, or flaccidity). ■Cushing reflex, which is a late finding characterized by severe hypertension with a widening pulse pressure (systolic - diastolic) and bradycardia. ■Cerebrospinal fluid leakage from the nose and ears ("halo" sign - yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose). ■Seizures.

airborne precautions

■Use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require: ☐A private room. ☐Masks and respiratory protection devices for caregivers and visitors. *Use an N95 or high-efficiency particulate air (HEPA) respirator if the client is known or suspected to have tuberculosis. ☐Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age of the structure. *If splashing or spraying is a possibility, wear full face (eyes, nose, mouth) protection.

Survival Potential

■Use this framework for situations in which health resources are extremely limited (mass casualty, disaster triage). ■Give priority to clients who have a reasonable chance of survival with prompt intervention. Clients who have a limited likelihood of survival even with intense intervention are assigned the lowest priority.

basic First-aid

●Complete the primary survey before performing first aid. ●Bleeding - Identify any sources of external bleeding and apply direct pressure to the wound site. ◯DO NOT remove impaled objects. ■Internal bleeding may require intravascular volume replacement with fluids and/or blood products or surgical intervention. ●Fractures and splinting ◯Assess the site for swelling, deformity, and skin integrity. ◯Assess temperature, distal pulses, and mobility. ◯Apply a splint to immobilize the fracture. Cover any open areas with a sterile cloth if available. ◯Reassess neurovascular status after splinting. ●Sprains ◯Refrain from weight-bearing. ◯Apply ice to decrease inflammation. ◯Apply a compression dressing to minimize swelling. ◯Elevate the affected limb. ●Heat stroke ◯Heat stroke must be identified quickly and treated aggressively. ◯Manifestations of a heat stroke include hot, dry skin, hypotension, tachypnea, tachycardia, anxiety, confusion, unusual behavior, seizures, and coma. ■Rapid cooling must be achieved. ☐Remove the client's clothing. ☐Place ice packs over the major arteries (axillae, chest, groin, neck). ☐Immerse the client in a cold-water bath. ☐Wet the client's body, then fan with rapid movement of air. ●Frostnip and frostbite ◯Frostnip does not lead to tissue injury and may be treated by warming. ◯Frostbite presents as white, waxy areas on exposed skin, and tissue injury occurs. ◯Frostbite may be full- or partial-thickness. ◯Warm the affected area in a 38° to 41° C (100.4° to 105.8° F) water bath. ◯Provide pain medication. ◯Administer a tetanus vaccination. ●Burns ◯Burns may result from an electrical current, chemicals, radiation, and/or flames. ■Remove the agent (electrical current, radiation source, chemical). ■Smother any flames that are present. Perform a primary survey. ■Cover the client and maintain NPO status. ■Elevate the client's extremities if not contraindicated (presence of a fracture). ■Perform a head-to-toe assessment and estimate the surface area and thickness of burns. ■Administer fluids and a tetanus toxoid.

alcohol withdrawal

●Effects of withdrawal usually start within 4 to 12 hr of the last intake of alcohol, peak after 24 to 48 hr, and subside within 5 to 7 days, unless alcohol withdrawal delirium occurs. ●Manifestations include nausea; vomiting; tremors; restlessness and inability to sleep; depressed mood or irritability; increased heart rate, blood pressure, respiratory rate, and temperature; and tonic-clonic seizures. Illusions are also common. ●Alcohol withdrawal delirium may occur 2 to 3 days after cessation of alcohol, may last 2 to 3 days, and is considered a medical emergency. Findings include severe disorientation, psychotic manifestations (hallucinations), severe hypertension, and cardiac dysrhythmias that may progress to death

fire Safety

●Fires in health care facilities are usually due to problems related to electrical or anesthetic equipment. Unauthorized smoking also may be the cause of a fire. ●All staff must be instructed in fire response procedures, which includes the following: ◯Knowing the location of exits, alarms, fire extinguishers, and oxygen turn-off valves ◯Ensuring fire doors are not blocked with equipment ◯Knowing the evacuation plan for the unit and facility ●The fire response in the health care setting always follows this sequence (RACE): ◯R - Rescue: Rescue and protect clients in close proximity to the fire by evacuating them to a safer location. Ambulatory clients can walk unattended to a safe location. ◯A - Alarm: Activate the facility alarm system, and then report fire details and location per facility protocol. ◯C - Contain: Contain the fire by closing doors and windows as well as turning off any sources of oxygen and electrical devices. Clients who are on life support are ventilated with a bag-valve mask. ◯E - Extinguish: Extinguish the fire if possible using an appropriate fire extinguisher. ■There are three classes of fire extinguisher: ☐Class A is for paper, wood, upholstery, rags, or other types of trash fires. ☐Class B is for flammable liquids and gas fires. ☐Class C is for electrical fires. ■To use a fire extinguisher, use the PASS sequence: ☐P - Pull the pin. ☐A - Aim at the base of the fire. ☐S - Squeeze the levers. ☐S - Sweep the extinguisher from side to side, covering the area of the fire.

Herpes Zoster (Shingles)

●Herpes zoster is a viral infection. It initially produces chickenpox, after which the virus lies dormant in the dorsal root ganglia of the sensory cranial and spinal nerves. It is then reactivated as shingles later in life. ◯Shingles is usually preceded by a prodromal period of several days, during which pain, tingling, or burning may occur along the involved dermatome. ◯Shingles can be very painful and debilitating. Assessment ◯Risk Factors ■Concurrent illness ■Stress ■Compromise to the immune system ■Fatigue ■Poor nutritional status ■Older adult clients are more susceptible to herpes zoster infection. The immune function of older adults may also be compromised, so assess them carefully for local or systemic signs of infection. ◯Subjective Data ■Paresthesia ■Pain that is unilateral and extends horizontally along a dermatome ◯Objective Data ■Physical Assessment Findings ☐Vesicular, unilateral rash (the rash and lesions occur on the skin area innervated by the infected nerve) ☐Rash that is erythematous, vesicular, pustular, or crusting (depending on the stage) ☐Rash that usually resolves in 14 to 21 days ☐Low-grade fever ■Laboratory Tests ☐Cultures provide a definitive diagnosis. But, the virus grows so slowly that cultures are often of minimal diagnostic use. ☐Occasionally, an immunofluorescence assay can be done. Patient-Centered Care ◯Nursing Care ■Assess/Monitor: ☐Pain. ☐Condition of the lesions. ☐Presence of fever. ☐Neurologic complications. ☐Signs of infection. ■Use an air mattress or bed cradle for pain prevention and control of affected areas. ■Isolate the client until the vesicles have crusted over. ■Maintain strict wound care precautions. ■Avoid exposing the client to infants, pregnant women who have not had chickenpox, and clients who are immunocompromised, although anyone who has not had chickenpox and has not been vaccinated is at risk. ■Moisten dressings with cool tap water or 5% aluminum acetate (Burow's solution) and apply to the affected skin for 30 to 60 min, four to six times per day as prescribed. ■Use lotions to help relieve itching and discomfort. ■Administer medications as prescribed. ◯Medications ■Analgesics (NSAIDs, narcotics) enhance client comfort. ■Antiviral agents, such as acyclovir (Zovirax), may shorten the clinical course. ●Complications ◯Postherpetic neuralgia ■Characterized by pain that persists for longer than 1 month following resolution of the vesicular rash ■Tricyclic antidepressants may be prescribed ■Postherpetic neuralgia is common in adults older than 60 years of age

impaired Coworkers

●Impaired health care providers pose a significant risk to client safety. ●A nurse who suspects a coworker of any behavior that jeopardizes client care or could indicate a substance use disorder has a duty to report the coworker to the appropriate manager. ●Many facilities' policies provide access to assistance programs that facilitate entry into a treatment program. ●Each state has laws and regulations that govern the disposition of nurses who have substance use disorders. Criminal charges could apply

Immune Defenses

●Nonspecific innate - Native immunity restricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs with all micro-organisms, regardless of previous exposure. ◯Temporary immunity that does not have memory of past exposures ◯Intact skin, the body's first line of defense ◯Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins ◯Inflammatory response with phagocytic cells, the complement system, and interferons localize the invasion and prevent its spread ●Specific adaptive immunity allows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro-organism. ◯Requires time to react to antigens ◯Provides permanent immunity ◯Involves B- and T-lymphocytes ◯Produces specific antibodies against specific antigens (immunoglobulins [IgA, IgD, IgE, IgG, IgM])

Nursing and CAM

●Nurses should do the following: ◯Understand the varieties of therapies available. ◯Be receptive to learning about clients' alternative health beliefs and practices (home remedies, cultural practices, vitamin use, modification of prescriptions). ◯Identify clients' needs for complementary or alternative therapies. ◯Incorporate complementary or alternative therapies into clients' care plans. ●Specialized licensed or certified practitioners may provide complementary or alternative therapies. These include:

Types of Pathogen

●Pathogens are the micro-organisms or microbes that cause infections. ◯Bacteria (Staphylococcus aureus, Escherichia coli, Mycobacterium tuberculosis) ◯Viruses - Organisms that use the host's genetic machinery to reproduce (HIV, hepatitis, herpes zoster, herpes simplex) ◯Fungi - Molds and yeasts (Candida albicans, Aspergillus) ◯Prions - Protein particles (new variant Creutzfeldt-Jakob disease) ◯Parasites - Protozoa (malaria, toxoplasmosis) and helminths (worms [flatworms, roundworms], flukes [Schistosoma]) ●Virulence is the ability of a pathogen to invade and injure a host. ●Herpes zoster (shingles) is a common viral infection that erupts years after exposure to chickenpox and invades a specific nerve tract.

6 rights of safe medication administration

●Right Client ◯Verify the client's identification each time a medication is given. The Joint Commission requires that two client identifiers be used when administering medications. ■Acceptable identifiers include the client's name, an assigned identification number, telephone number, birth date, or another person-specific identifier. ■Check identification bands for name, identification number, and/or photograph. ■Check for allergies by asking the client, looking for an allergy bracelet, and reviewing the medication administration record. ■Bar code scanners may be used to identify clients. ●Right Medication ◯Correctly interpret the medication prescription (verify completeness and clarity). ■Read the label three times: when the container is selected, when removing the dose from container, and when the container is replaced. ■Leave unit-dose medication in its package until administration. ■When using automated medication dispensing systems, the same checks are required and can be adapted. ●Right Dose ◯Calculate the correct medication dose. ◯Check a drug reference to ensure the dose is within the usual range. ●Right Time ◯Administer medication on time to maintain a consistent therapeutic blood level. ■It is generally acceptable to administer the medication 30 min before or after the scheduled time. However, refer to the drug reference or institution policy for exceptions. ●Right Route ◯The most common routes of administration are oral, topical, subcutaneous, IM, and IV. ◯Select the correct preparation for the ordered route (for example, otic versus ophthalmic topical ointment or drops). ◯Know how to administer medication safely and correctly. ●Right Documentation ◯Immediately record medication, dose, route, time, and any pertinent information, including the client's response to the medication. ◯For some medications, in particular those to alleviate pain, the client response will be evaluated and documented later, perhaps after 30 min.

Seizure Precautions

●Seizure precautions (measures to protect the client from injury should a seizure occur) are taken for clients who have a history of seizures that involve the entire body and/or result in unconsciousness. ◯Ensure rescue equipment is at the bedside, including oxygen, an oral airway, and suction equipment and padding for the side rails of the bed. A saline lock may be inserted for intravenous access if the client is at high risk for experiencing a generalized seizure. ◯Inspect the client's environment for items that may cause injury in the event of a seizure, and remove items that are not necessary for current treatment. ◯Assist the client at risk for a seizure with ambulation and transferring to reduce the risk of injury. ◯Advise all caregivers and family not to put anything in the client's mouth (except in status epilepticus, where an airway is needed) in the event of a seizure. ◯Advise all caregivers and family not to restrain the client in the event of a seizure, ensure the client's safety by lowering him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put the client on his side with his head flexed slightly forward if possible, and loosen clothing to prevent injury. ●In the event of a seizure ◯Stay with the client, and call for help. ◯Administer medications as prescribed. ◯Note the duration of the seizure and the sequence and type of movement. ◯After a seizure, assess mental status, oxygenation saturation, and vital signs of the client. Explain what happened to the client, and provide comfort, understanding, and a quiet environment for the client to recover. ◯Document the seizure in the client's record with any precipitating behaviors and a description of the event (movements, any injuries, length of seizure, aura, postictal state), and report it to the provider

Categories of CAM include the following

◯Alternative medical philosophy (traditional Chinese medicine, acupuncture, homeopathy) ◯Biological and botanical therapies (diets, vitamins, minerals, herbal preparations) ◯Body manipulation (massage, touch, chiropractic therapy) ◯Mind-body therapies (biofeedback, art therapy, meditation, yoga, psychotherapy, tai chi) ◯Energy therapies (Reiki, therapeutic touch acupuncture/pressure ›Needles or pressure along meridians to alter body function or produce analgesia homeopathic medicine ›Administering doses of substances (remedies) that would produce symptoms of the disease state in a well person to ill clients to bring about healing naturopathic medicine ›Diet, exercise, environment, and herbal remedies to promote natural healing chiropractic medicine ›Spinal manipulation for healing massage therapy ›Stretching and loosening muscles and connective tissue for relaxation and circulation Biofeedback ›Using technology to increase awareness of various neurological body responses to minimize extremes therapeutic touch ›Using hands to help bring energy fields into balance guided imagery/visualization therapy ›Encourages healing and relaxation of the body by having the mind focus on images healing intention ›Techniques that use caring, compassion, and empathy in the context of prayer to facilitate healing Breath work ›Various breathing patterns to reduce stress and increase relaxation humor ›A coping mechanism to reduce tension and improve mood meditation ›A technique to calm the mind and body simple touch ›Communicates presence, appreciation, and acceptance music therapy ›Type of relaxation therapy that provides distraction from pain; earphones improve concentration therapeutic communication ›Allows clients to verbalize and become aware of emotions and fears in a safe, nonjudgmental environment

Guidelines for Cleaning Contaminated Equipment

◯Always wear gloves and protective eyewear. ◯Rinse first in running cold water. Hot water coagulates proteins, making them adhere. ◯Wash the article in warm water with soap. ◯Use a brush or abrasive to clean corners or hard-to-reach areas. ◯Rinse well in warm water. ◯Dry the article - It is considered clean at this point. ◯Clean the equipment used in cleaning and the sink (still dirty unless a disinfectant is used). ◯If indicated, follow facility policy for recommended disinfection or sterilization. ◯Remove gloves and perform hand hygiene.

physical development Toddlers (1 to 3 Years)

◯Anterior fontanels close by 18 months of age. ◯Weight - At 30 months of age, toddlers should weigh four times their birth weights. ◯Height - Toddlers grow about 7.5 cm (3 in) per year. ◯Head circumference and chest circumference are usually equal by 1 to 2 years of age. Language ■Language increases to about 300 words by the age of 2 years. ■1 year - use one-word sentences, or holophrases ■2 years - use multiword sentences by combining two to three words ■3 years - combine several words to create simple sentences using grammatical rules

Bioterrorism

◯Bioterrorism is the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death. ◯Anthrax, variola, Clostridium botulism, and Yersinia pestisare examples of agents used by terrorists. ◯Nurses and other health professionals must be prepared to respond to an attack by being proficient in early detection, recognizing the causative agent, identifying the affected community, and providing early treatment to affected persons.

Infection Process

◯Causative agent (bacteria, virus, fungus, prion, parasite) ◯Reservoir (human, animal, water, soil, insects) ◯Portal of exit from (means for leaving) the host ■Respiratory tract (droplet, airborne) ☐Mycobacterium tuberculosis and Streptococcus pneumoniae ■Gastrointestinal tract ☐Shigella, Salmonella enteritidis, Salmonella typhi, hepatitis A ■Genitourinary tract ☐Escherichia coli, hepatitis A, herpes simplex virus (type 1), HIV ■Skin/mucous membranes ☐Herpes simplex virus and varicella ■Blood/body fluids ☐HIV and hepatitis B and C ◯Mode of transmission ■Contact ☐Direct physical contact - Person to person ☐Indirect contact with an inanimate object - Object to person ☐Fecal-oral transmission - Handling food after using a restroom and failing to wash hands ■Droplet ☐Sneezing, coughing, and talking ■Airborne ☐Sneezing and coughing ■Vector borne ☐Animals or insects as intermediaries (ticks transmit Lyme disease; mosquitoes transmit West Nile and malaria) ◯Portal of entry to the host ■May be the same as the portal of exit ●Stages of an infection ◯Incubation - interval between the pathogen entering the body and the presentation of the first symptom. ◯Prodromal stage - interval from onset of general symptoms to more distinct symptoms. During this time, the pathogen is multiplying. ◯Illness stage - interval when symptoms specific to the infection occur. ◯Convalescence - interval when acute symptoms disappear. Total recovery could take days to months.

Type 1 diabetes mellitus

◯Cause - lack or absence of insulin (due to destruction of pancreatic beta cells) ◯Nursing Actions ■Monitor blood glucose. ■Administer insulin as prescribed. ◯Client Education - Inform the client about long-term diabetes management.

Celiac disease

◯Celiac disease is also known as gluten-sensitive enteropathy (GSE), celiac sprue, and gluten intolerance. ◯It is a chronic, inherited, genetic disorder with autoimmune characteristics. Clients who have celiac disease are unable to digest the protein gluten. They lack the digestive enzyme DPP-IV, which is required to break down the gluten into molecules small enough to be used by the body. In celiac disease, gluten is broken down into peptide strands instead molecules. The body is not able to metabolize the peptides. If untreated, the client will suffer destruction of the villa and the walls of the small intestine. Celiac disease may go undiagnosed in both children and adults. ◯Clinical manifestations vary widely. Children who have celiac disease have diarrhea, steatorrhea, anemia, abdominal distention, impaired growth, lack of appetite, and fatigue. Typical manifestations in adults include diarrhea, abdominal pain, bloating, anemia, steatorrhea, and osteomalacia. ◯Treatment for celiac disease is limited to avoiding gluten. However, eliminating gluten, which is found in wheat, rye and barley, is difficult because it is found in many prepared foods. Clients must read food labels carefully in order to adhere to a gluten-free diet. Some gluten-free products are unappealing to clients, and many are more expensive that other products. Prognosis is good for clients who adhere to a gluten-free diet. ◯Nursing Interventions ■Encourage clients to eat foods that are gluten-free: milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats and fish, dried beans. ■Remind clients to read labels on processed products. Gravy mixes, sauces, cold cuts, soups, and many other products have gluten as an ingredient. Advise clients to read labels on nonfood products, which also may have gluten as an ingredient.

Diverticulosis and diverticulitis

◯Diverticula are pouches protruding through the muscle of the intestinal wall, usually from increased intraluminal pressure. They occur anywhere in the colon, but usually in the sigmoid colon. Unless infection occurs, diverticula cause no problems. ◯Clinical manifestations of diverticulitis include abdominal pain, nausea, vomiting, constipation or diarrhea, and fever, accompanied by chills and tachycardia ◯A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are easily passed, thus decreasing pressure within the colon. ◯During acute diverticulitis, a clear liquid diet is prescribed until inflammation decreases, then a high-fiber, low-fat diet is indicated. ◯Instruct the client to avoid foods with seeds or husks (corn, popcorn, berries, tomatoes). ◯Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventive approach.

The signs and symptoms, identifiable in the nursing assessment, of generalized or systemic infection

◯Fever ◯Presence of chills, which occur when temperature is rising, and diaphoresis, which occurs when temperature is decreasing ◯Increased pulse and respiratory rate (in response to the high fever) ◯Malaise ◯Fatigue ◯Anorexia, nausea, and vomiting ◯Abdominal cramping and diarrhea ◯Enlarged lymph nodes (repositories for "waste") laboratory and diagnostic results indicating infection include: ◯Leukocytosis (WBCs greater than 10,000/μL). ◯Increases in the specific types of WBCs on differential (left shift = an increase in neutrophils). ◯Elevated erythrocyte sedimentation rate (ESR) over 20 mm/hr. An increase indicates an active inflammatory process or infection. ◯Presence of micro-organisms on culture of the specific fluid/area. Diagnostic Procedures ◯Gallium scan - Nuclear scan that uses a radioactive substance to identify hot spots of WBCs ◯Radioactive gallium citrate - Injected by IV and accumulates in area of inflammation ◯X-rays, CT scan, magnetic resonance imaging (MRI), and biopsies to determine the presence of infection, abscesses, and lesions

Food poisoning .

◯Food poisoning is a major cause of illness in the United States. ◯Most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes,and Salmonella. ◯Healthy individuals usually recover from the illness in a few days. ◯Very young, very old, and immunocompromised individuals, as well as pregnant women, are at risk for complications. ◯Clients who are especially at risk are instructed to follow a low-microbial diet. ◯Most food poisoning occurs because of unsanitary food practice. ◯Performing proper hand hygiene, ensuring that meat and fish are cooked to the correct temperature, handling raw and fresh food separately to avoid cross contamination, and refrigerating perishable items are measures that may prevent food poisoning. ◯Check expiration dates, and clean fresh fruit and vegetables

Gastroesophageal reflux disease (GERD)

◯GERD occurs as the result of the abnormal reflux of gastric secretions up the esophagus. This leads to indigestion and heartburn. ◯Long-term GERD can cause serious complications including adenocarcinoma of the esophagus and Barrett's esophagus. ◯Clinical manifestations include heartburn, retrosternal burning, painful swallowing, dyspepsia, regurgitation, coughing, hoarseness, and epigastric pain. Pain may be mistaken for a myocardial infarction. ◯Nursing Interventions ■Instruct the client to avoid situations that lead to increased abdominal pressure, such as wearing tight-fitting clothing. ■Advise the client to avoid eating 2 hr or less before lying down. ■Advise the client to elevate the body on pillows instead of lying flat and to avoid large meals and bedtime snacks. ■Encourage weight loss for overweight clients ■Suggest that the client avoid trigger foods (citrus fruits and juices, spicy foods, carbonated beverages). ■Instruct the client to avoid items that reduce lower esophageal sphincter (LES) pressure, including fatty foods, caffeine, chocolate, alcohol, cigarette smoke and all nicotine products, and peppermint and spearmint flavors

Hematoma and intracranial hemorrhage

◯Monitor for severe headache, rapid decline in level of consciousness, worsening neurological function and herniation, and changes in ICP. ◯Surgery is required to remove subdural and epidural hematoma. ◯Intracranial hemorrhage is treated with osmotic diuretics.

Pancreatitis

◯Pancreatitis is an inflammation of the pancreas. ◯The pancreas is responsible for secreting enzymes needed to digest fats, carbohydrates, and proteins. ◯Nutritional therapy for acute pancreatitis involves reducing pancreatic stimulation. The client is prescribed nothing by mouth (NPO), and a nasogastric tube is inserted to suction gastric contents. ◯TPN may be used until oral intake is resumed. ◯Nutritional therapy for chronic pancreatitis usually includes a low-fat, high-protein, and high-carbohydrate diet. It may include providing supplements of vitamin C and B-complex vitamins.

pin site care

◯Pin Site Care ■Pin care is done frequently throughout immobilization (skeletal traction and external fixation methods) to prevent and to monitor for signs of infection including: ☐Drainage and redness (color, amount, odor). ☐Loosening of pins. ☐Tenting of skin at pin site (skin rising up pin). ■Pin care protocols (chlorhexidine) are based on provider preference and facility policy. A primary concept of pin care is that one cotton-tip swab is designated for each pin to avoid cross-contamination. ■Pin care is provided usually once a shift, 1 to 2 times a day, or per facility protocol. ■Crusting at the pin site should not be removed as this provides a natural barrier to bacteria.

standard precautions

◯Standard Precautions (Tier One) ■This tier of standard precautions applies to all body fluids (except sweat), nonintact skin, and mucous membranes. A nurse should implement for all clients. ■Hand hygiene using an alcohol-based waterless product is recommended after contact with the client, body fluids, and contaminated equipment and articles, and after removal of gloves. ■Alcohol-based waterless antiseptic is preferred unless the hands are visibly dirty, because the alcohol-based product is more effective in removing micro-organisms. ■Clean gloves are worn when touching all body fluids, nonintact skin, mucous membranes, and contaminated equipment and articles. ■Remove gloves and complete hand hygiene between each client. ■Masks, eye protection, and face shields are required when care may cause splashing or spraying of body fluids. ■Gloves are worn when touching anything that has the potential to contaminate the hands of the nurse. This includes body secretions, excretions, blood and body fluids, nonintact, skin mucous membranes, and contaminated items. ■Hand hygiene is required after removal of the gown. Use a sturdy moisture-resistant bag should for soiled items, and tie the bag securely in a knot at the top. ■Properly clean all equipment for client care; dispose of one-time use items according to facility policy. ■Bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin. ■Enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture-resistant container. ■A client does not need a private room unless he is is unable to maintain appropriate hygienic practices.

Nursing interventions to facilitate sibling acceptance of the infant

◯Take the sibling on a tour of the obstetric unit. ◯Encourage the parents to: ■Let the sibling be one of the first to see the infant. ■Provide a gift from the infant to give the sibling. ■Arrange for one parent to spend time with the sibling while the other parent is caring for the infant. ■Allow older siblings to help in providing care for the infant. ■Provide the preschooler with a doll to care for.

Liver disease

◯The liver is involved in the metabolism of almost all nutrients. ◯Disorders affecting the liver include cirrhosis, hepatitis, and cancer. ◯Malnutrition is common with liver disease. ◯Protein needs are increased to promote a positive nitrogen balance and to prevent a breakdown of the body's protein stores. ◯Carbohydrates are generally not restricted, as they are an important source of calories. ◯Caloric requirements may need to be increased based upon an evaluation of the client's stage of disease, weight, and general health status. ◯Multivitamins (especially vitamins B, C, and K) and mineral supplements may be necessary. ◯Alcohol, nicotine, and caffeine should be eliminated

Wood's light examination

◯Ultraviolet light is used to produce specific colors to reveal a skin infection. ◯Examination is performed in a dark room to evaluate pigment changes in a light-skinned client

Normal lochial flow patterns

☐Bright red vaginal drainage for 2 to 3 days. ☐Blood-tinged serous vaginal drainage from days 4 to 10. ☐White vaginal discharge from day 11 to 6 weeks.

Discontinue oxytocin if uterine hyperstimulation occurs.

☐Contraction frequency more often than every 2 min. ☐Contraction duration longer than 90 seconds. ☐Contraction intensity that results in pressures greater than 90 mm Hg as shown by IUPC. ☐Uterine resting tone greater than 20 mm Hg between contractions. ☐No relaxation of uterus between contractions

Types of Traction

☐Manual: A pulling force is applied by the hands of the provider for temporary immobilization, usually with sedation or anesthesia, in conjunction with the application of an immobilizing device. ☐Skin: Primary purpose is to decrease muscle spasms and immobilize the extremity prior to surgery. The pulling force is applied by weights that are attached by rope to the client's skin with tape, straps, boots, or cuffs. Examples include Bryant's traction (used for congenital hip dislocation in children) and Buck's traction (used preoperatively for hip fractures for immobilization in adult clients). ☐Skeletal: The pulling force is applied directly to the bone by weights attached by rope directly to a rod/screw placed through the bone to promote bone alignment. Examples include skeletal tongs (Gardner-Wells) and femoral or tibial pins (Steinmann pin). Weights 15 to 30 lb can be applied as needed. ☐Halo: Screws are placed through a halo-type bar that encircles the head into the outer table of the bone of the skull. This halo is attached to rods that are secured to a vest worn by the client. Ensure that the wrench to release the rods is attached to the vest when using halo traction in the event CPR is necessary.

Leadership

is the ability to inspire others to achieve a desired outcome.

electRocoNvulsive tHeRapy (ect)

nursing actions ●Preparation of the Client ◯The typical course of ECT treatment is three times a week for a total of six to 12 treatments. ◯The provider obtains informed consent. ■If ECT is involuntary, consent may be obtained from next of kin or a court order. ◯Medication management ■Any medications that affect the client's seizure threshold must be decreased or discontinued several days before the ECT procedure. ■MAOIs and lithium should be discontinued 2 weeks before the ECT procedure. ◯Severe hypertension should be controlled because a short period of hypertension occurs immediately after the ECT procedure. ◯Any cardiac conditions, such as dysrhythmias, should be monitored and treated before the procedure. ◯The nurse monitors the client's vital signs and mental status before and after the ECT procedure. ◯The nurse also assesses the client's and family's understanding and knowledge of the procedure and provides teaching as necessary. ◯thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate or glycopyrrolate (Robinul) is given to decrease secretions and counteract any vagal stimulation. ◯An IV line is inserted and maintained until full recovery Ongoing Care ◯ECT is administered early in the morning after the client has fasted for a prescribed period of time. ◯A bite guard should be used to prevent trauma to the oral cavity. ◯Electrodes are applied to the scalp, either unilaterally or bilaterally for encephalogram (EEG) monitoring. ◯The client is mechanically ventilated during the procedure and receives 100% oxygen. ◯Ongoing cardiac monitoring is provided, including blood pressure, electrocardiogram (ECG), and oxygen saturation. ◯An anesthesia provider administers a short-acting anesthetic, such as methohexital (Brevital), via IV bolus. ◯A muscle relaxant, such as succinylcholine (Anectine), is then administered. ◯A cuff is placed on one leg or arm to block the muscle relaxant so that seizure activity can be monitored in the limb distal to the cuff. ◯The electrical stimulus is typically applied for 0.2 to 0.8 seconds. Seizure activity is monitored, and the duration of the seizure, which is usually 25 to 60 seconds, is documented. ◯After seizure activity has ceased, the anesthetic is discontinued. ◯The client is extubated and assisted to breathe voluntarily. ●Postprocedure Care ◯When stable, the client is transferred to a recovery area where level of consciousness, cardiac status, vital signs, and oxygen saturation continue to be monitored. ◯The client is positioned on his side to facilitate drainage and prevent aspiration. ◯The client is monitored for ability to swallow and return of the gag reflex. ◯The client is usually awake and ready for transfer back to the mental health unit or other facility within 30 to 60 min after the procedure.

Syndrome of inappropriate antidiuretic hormone (SIADH)

◯This is a condition where fluid is retained as a result of an overproduction of vasopressin or antidiuretic hormone (ADH) from the posterior pituitary gland. ◯The condition occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH. ◯Treatment of SIADH consists of fluid restriction, administration of oral demeclocycline, and treatment of hyponatremia. ◯If SIADH is present, the client may be disorientated, report a headache, and/or vomit. ◯If severe or untreated, this condition may cause seizures and/or a coma.

prioritization principles in client care

*Prioritize systemic before local ("life before limb"). ›Prioritizing interventions for a client in shock over interventions for a client with a localized limb injury *Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation). ›Prioritizing the care of a client with a new injury/illness (e.g., mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client with a long-term chronic illness *Prioritize actual problems before potential future problems. ›Prioritizing administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis *Listen carefully to clients and don't assume. ›Recognizing that a postoperative client's report of pain could be due to pain in another location rather than expected surgical pain *Recognize and respond to trends versus transient findings. ›Recognizing a gradual deterioration in a client's level of consciousness and/or Glasgow Coma Scale score *Recognize signs of medical emergencies and complications versus "expected client findings." ›Recognizing signs of increasing intracranial pressure in a client newly diagnosed with a stroke versus the clinical findings expected following a stroke *Apply clinical knowledge to procedural standards to determine the priority action. ›Recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications

chemotherapy Side effectS

Mucosal ulceration skin breakdown Neuropathy loss of appetite hemorrhage cystitis alopecia

repiratory infections toddler

Nursing Care ◯Closely monitor progression of illness and ensuing respiratory distress. Observe for increased heart and respiratory rate, retractions, nasal flaring, and restlessness. ◯Make emergency equipment for intubation readily accessible. ◯Position the child to have optimal ventilation without increasing distress that would contribute to increasing respiratory distress. ◯Implement isolation precautions if indicated. ●Nasopharyngitis - Instruct parents about home management. ◯Give antipyretic for fever. ◯Rest. ◯Provide vaporized air (cool mist). ◯Give decongestants for children older than 1 year. ◯Give cough suppressants with caution (avoid oversedation). ◯Antihistamines are not recommended. ◯Antibiotics are not indicated. ●Bacterial tracheitis ◯Administer oxygen as prescribed. ◯Monitor continuous oximetry. ◯Administer antipyretics for fever. ◯Administer IV antibiotics as prescribed. ●Bronchitis - Instruct parents about home management. ◯Give antipyretics for fever. ◯Give a cough suppressant. ◯Provide increased humidity (cool mist vaporizer). ●Bronchiolitis ◯Provide humidified oxygen as prescribed. ◯Monitor continuous oximetry. ◯Encourage fluid intake if tolerated. ◯Administer IV fluids if oral intake not tolerated. ◯Suction nasopharynx as needed. ◯Administer nebulized bronchodilator. ◯Corticosteroids and antihistamines are not recommended. ◯Antibiotics are not recommended for RSV. ◯Chest percussion and postural drainage is not recommended. ◯Ribavirin administration is controversial. ●Allergic rhinitis - Instruct parents about home management. ◯Avoid allergens. ◯Give antihistamines. ◯Give nasal corticosteroids. ●Pneumonia ◯Viral (symptom management) ■Administer oxygen with cool mist as prescribed. ■Monitor continuous oximetry. ■Administer antipyretics for fever. ■Monitor intake and output. ◯Bacterial ■Encourage rest. ■Promote increased oral intake. ■Monitor I&O. ■Administer antipyretics for fever. ■Chest percussion and postural drainage is controversial. ■Administer IV fluids as prescribed. ■Administer oxygen as prescribed. ■Monitor continuous oximetry. ■Administer IV antibiotics as prescribed. ●Bacterial epiglottitis ◯Protect airway. ■Avoid throat culture or using a tongue blade. ◯prepare for intubation. ◯Provide humidified oxygen. ◯Monitor continuous oximetry. ◯Administer racemic epinephrine, corticosteroids, and IV fluids as prescribed. ◯Administer antibiotic therapy (ceftriaxone sodium or cephalosporin), starting with IV, then transition to oral to complete a 10-day course, as prescribed. ●Acute laryngotracheobronchitis and acute spasmodic laryngitis ◯Provide humidity with cool mist. ◯administer oxygen if needed. ◯Monitor continuous oximetry. ◯Administer nebulized racemic epinephrine as prescribed. ◯Administer corticosteroids: oral (prednisone), IM (dexamethasone), or nebulized (budesonide). ◯Encourage oral intake if tolerated. ◯Administer IV fluids as prescribed. ●Influenza - Instruct parents about home management. ◯Promote increased fluid intake. ◯Rest. ◯Give medications, as prescribed. ■Amantadine (Symmetrel) - for type A ☐Shortens the length of the illness. ☐Administer within 24 to 48 hr of onset of symptoms. ■Rimantadine (Flumadine) - for type A ☐Treats manifestations. ☐Give orally two times per day for 7 days for children older than 1 year. ■Zanamivir (Relenza) - for type A and B ☐treatment of influenza for children 7 and older or for prophylaxis for children 5 and older. ☐Start within 48 hr of manifestations. ☐Inhaled two times per day for 5 days. Oseltamivir (Tamiflu) - for type A and B ☐Decreases manifestations. ☐Give orally for 5 days for children older than 1 year. ☐Start within 48 hr of manifestations. ■Influenza vaccine - prevention ☐Recommended for children 6 months and older. ☐Live vaccination should not be used in children who are immunocompromised, have respiratory conditions, are pregnant, or have a history of Guillain-Barre syndrome. ■Antipyretic (pain or fever)

Solids are introduced around 4 to 6 months of age.

New foods should be introduced one at a time, over a 4- to 7-day period, to observe for signs of allergy or intolerance, which may include fussiness, rash, vomiting, diarrhea, and constipation. Vegetables or fruits are started first between 6 and 8 months of age. After both have been introduced, meats may be added. ■Citrus fruits, meat, and eggs are not started until after 6 months of age

Diabetes insipidus (DI)

◯This is a condition where large amounts of urine are excreted as a result of a deficiency of ADH from the posterior pituitary gland. ◯The condition occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH. ◯Treatment of DI consists of massive fluid replacement, careful attention to laboratory values, and replacement of essential nutrients as indicated

Alterations in behavior

☐Extreme agitation, including pacing and rocking ☐Stereotyped behaviors - motor patterns that had meaning to client (sweeping the floor) but now are mechanical and lack purpose ☐Automatic obedience - responding in a robotlike manner ☐Wavy flexibility - excessive maintenance of position ☐Stupor - motionless for long periods of time, comalike ☐Negativism - doing the opposite of what is requested ☐Echopraxia - purposeful imitation of movements made by others

Magnetic Resonance Imaging (MRI) Scan

An MRI scan provides cross-sectional images of the cranial cavity. A contrast media may be used to enhance the images. Unlike CT scans, MRI images are obtained using magnets, thus the consequences associated with radiation are avoided. This makes this procedure safer for women who are pregnant. The use of magnets precludes the ability to scan a client who has an artificial device (pacemakers, surgical clips, intravenous access port). If these are present, shielding may be done to prevent injury. MRI-approved equipment must be used to monitor vital signs and provide ventilator/oxygen assistance to clients undergoing MRI scans. Nursing Actions -Assess for allergy to shellfish or iodine, which would require the use of a different contrast media. -Ensure that the client's jewelry is removed prior to this procedure. The client should wear a hospital gown to prevent any metals from interfering with the magnet. -If sedation is expected, the client should refrain from food or fluids for 4 to 8 hr prior to the procedure.

Radiography (X-Ray)

An x-ray uses electromagnetic radiation to capture images of the internal structures of an individual. A structure's image is light or dark relative to the amount of radiation the tissue absorbs. The image is recorded on a radiograph, which is a black and white image that is held up to light for visualization. Some are recorded digitally and are available immediately. X-rays must be interpreted by a radiologist, who documents the findings.

alterations in speeCh

Flight of ideas ›Associative looseness ›The client may say sentence after sentence, but each sentence may relate to another topic, and the listener is unable to follow the client's thoughts. Neologisms ›Made-up words that have meaning only to the client, such as, "I tranged and flittled."echolalia ›The client repeats the words spoken to him. clang association ›Meaningless rhyming of words, often forceful, such as, "Oh fox, box, and lox." Word salad ›Words jumbled together with little meaning or significance to the listener, such as, "Hip hooray, the flip is cast and wide-sprinting in the forest."

med administrations for children

Oral Medication Hold the infant in a semireclining position similar to a feeding position. ◯Hold the small child in an upright position to prevent aspiration. ◯Administer the medication in the side of the mouth in small amounts. This allows the infant or child to swallow. *Only use the droppers that come with the medication for measurement. *Use a nipple to allow the infant to suck the medication. Optic Medication ◯Place the child in a supine or sitting position Administer ointments before nap or bedtime. ◯Provide atraumatic care. ■If infants clinch their eyes closed, place the drops in the nasal corner. When the infant opens his eyes, the medication will enter the eye. ■Apply light pressure to the lacrimal punctum for 1 minute to prevent unpleasant taste. Otic Medication ◯Place the child in a prone or supine position with the affected ear upward. ◯Children younger than 3 years: pull the pinna downward and straight back. ◯Children older than 3 years: pull the pinna upward and back. ◯Provide atraumatic care. ■Allow refrigerated medications to warm to room temperature prior to administration. ■Massage the outer area for a few minutes following administration. ■Play games with younger children. Nasal Medication ◯Position the child with the head extended. ◯Use a football hold for infants. ◯Provide atraumatic care. ■Insert the tip into the naris vertically, then angle it prior to administration. ■Play games with younger children Rectal Medication ◯Insert beyond both rectal sphincters. ◯Hold the buttocks gently together for 5 to 10 minutes. ◯Halve the medication lengthwise, if necessary. ◯Provide atraumatic care. ■Perform the procedure quickly. ■Use distraction. Injection Medications ◯Change needle if it pierced a rubber stopper on a vial. ◯Secure the infant and child prior to injections. ◯Assess the need for assistance. ◯Avoid tracking of medication. ◯When selecting sites, consider: ■Medication amount, viscosity, and type. ■Muscle mass, condition, access of site, and potential for contamination. ■Treatment course and number of injections. ■Age and size of child. Intradermal ◯Administer on the inside surface of the forearm. ◯Use a TB syringe with a 26- to 30-gauge needle with an intradermal bevel. ◯Insert needle at a 15° angle. ◯Do not aspirate. Subcutaneous (SQ) ◯Give anywhere there is SQ tissue. Common sites are the lateral aspect of the upper arm, abdomen, and anterior thigh. ◯Inject volumes of less than 0.5 mL. ◯Use a 1 mL syringe with a 26- to 30-gauge needle. ◯Insert at a 90° angle. Use a 45° angle for children who are thin. ◯Check policy for aspiration practices Intravenous (IV) Medications ◯Peripheral venous access devices ■Use a 24- to 20-gauge catheter. ■Use for continuous and intermittent IV medication administration. ■A child who requires short-term IV therapy may complete it at home with the assistance of a home health nurse. ◯Central venous access devices ■Short term: nontunneled catheter or peripherally inserted central catheters (PICC) ■Long term: tunneled catheter or implanted infusion ports ◯Provide atraumatic care ■Decide to insert a PICC before multiple peripheral attempts. ■Use a transilluminator to assist in vein location. ■Attach an extension tubing to decrease movement of the catheter. ■Avoid terminology such as a "bee sting" or "stick." Use play therapy. ■Apply EMLA to the site for 60 minutes prior to attempt. ■Keep equipment out of site until procedure begins. ■Perform procedure in a treatment room. ■Use nonpharmacologic therapies. ■Allow parents to stay if they prefer. ■Use therapeutic holding. ■Avoid using the dominant or sucking hand. ■Cover site with a colorful wrap. ■Swaddle infants. ■Offer nonnutritive sucking to infants before, during, and after the procedure.

Electroencephalography (EEG)

This noninvasive procedure assesses the electrical activity of the brain and is used to determine if there are abnormalities in brain wave patterns. Indications *EEGs are most commonly performed to identify and determine seizure activity, but they are also useful for detecting sleep disorders and behavioral changes. Preprocedure *Nursing Actions Review medications with the provider to determine if they should be continued prior to this procedure. Client Education -Instruct the client to wash his hair prior to the procedure and eliminate all oils, gels, and sprays. -If indicated, instruct the client to be sleep-deprived because this provides cranial stress, -increasing the possibility of abnormal electrical activity, such as seizure potentials, occurring during the procedure. -Increased electrical activity may be stimulated with exposure to bright flashing lights, or by requesting the client to hyperventilate for 3 to 4 minutes. *Intraprocedure -The procedure generally takes 1 hr. -There are no risks associated with this procedure. -With the client resting in a chair or lying in bed, small electrodes are placed on the scalp and connected to a brain wave machine or computer. -Electrical signals produced by the brain are recorded by the machine or computer in the form of wavy lines. This documents brain activity. -Notations are made when stimuli are presented or when sleep occurs. (Flashes of light or pictures may be used during the procedure to assess the client's response to stimuli.) -An EEG provides information about the ability of the brain to function and highlights areas of abnormality. *Postprocedure Client Education Instruct the client that normal activities may be resumed.

Personal boundary difficulties

disenfranchisement with one's own body, identity, and perceptions. This includes the following: ☐ Depersonalization - nonspecific feeling that a person has lost her identity; self is different or unreal. ☐ Derealization - perception that environment has changed.