NCLEX -- fundamentals, med surg, leadership/mgmt

diseases that must be reported to CDC

"charms mtvss" = 11 -C: chickenpox (varciella) -H: hep A, B, + C -A: AIDS/HIV -R: rubella -M: measles (rubeola) -S: salmonellosis -M: meningitis -T: TB -V: VRE -S: shigellosis -S: streptococcus pneumoniae invasive disease

edu for how to eat w/ CN IX damage

-1. inhale deeply -2. hold breath tightly to close the vocal cords -3. place food in mouth and swallow while continuing to hold breath -4. cough to dispel remaining food from vocal cords -5. swallow a second time before breathing

what is the best measure of renal function

-GFR -if that is not available than creatinine is better than BUN

what is included in postmortem care?

-allow family members to assist with care

meds that cause pupils to contract

-cholinergics = miotics (pilocarpine, carbachol) -adrenergic agonist = dipiverfrin, epi -b-block = timolol, betaxolol -carbonic anhydrase inhibitor = acetazolamide -prostaglandin analogues = lantanoprost, bimatoprost -alpha adrenergic agonist = apraclonidine, brimonidine

SSAs of trigeminal neuralgia

-chronic pain of trigeminal nerve (CN V) SSAs -electric shock-like pain in the lips and gums -severe pain along the cheekbone fxn of CN 5 = sensory for teeth, eyes, skin, and tongue; motor for chewing

MS (what? + labs/dx + SSAs + interventions + meds)

-chronic, progressive, immune-mediated disease of CNS -patches of demyelination in brain and spinal cord in which sx occur in relapse + remission type pattern -chronic disease of CNS associated with autoimmune response -manifestations may vary depending on area of nervous system affected -most common in women age 20-40 -development of plaque in white matter of CNS which blocks impulse transmission between CNS and body -initial onset may be followed by total remission -- is progressive with increasing loss of function -triggers can start the exacerbations - try to ID triggers to avoid them -may not have deficits early in the disease -normal life expectancy (difference between this and ALS) -triggers: virus or infection, living in cold climate, genetic, physical injury, emotional stress, pregnancy, fatigue, overexertion, temp extremes, hot shower/bath -relapsing-remitting -- most common sx last weeks or months and resolve and return labs + dx -CSF -- elevated PRO and WBC, increase in myelin basic protein and an increase in IgG (the gold standard) -MRI presence of plaques -CT scan increased density in white matter and plaques -EMG -- shows the electrical activity -no one single test to diagnose -usually have all of these procedures done because difficult to diagnose SSAs -muscle weakness and spasticity -fatigue -intention tremors -numbness and tingling -ataxia -dysarthria (slur speech) -dysphagia -diplopia -decreased hearing and tinnitus -bowel and bladder dysfxn -cognitive changes, memory, judgment, calculations -tx based on current sx priority interventions -Pain: assess and medicate for pain /order -Protect eyes, eye patch (alternating) for diplopia -Potty: provide assistance, bladder training, encourage fluids to prevent urinary tract infections (UTIs). -Prevent skin breakdown. Think skin integrity. Turn, ROM -Prevent aspiration, assess gag prior to eating -Provide rest, need energy conservation, teaching about activity intolerance due to fatigue, exercise & stretch -Falls Precautions, may need assistive devices -Provide alternative communication options, maintain orientation, place object used daily in same place -think: 8 P's for promotion of safety -interventions based on their current symptoms -PT, bedside commode, assistance with walking -meds cause immunosuppression so need to monitor for infection and take infection precautions meds -immunomodulators - have antiviral effect Interferon-beta-Ia Interferon-beta-1(injection) -immunosuppressant's: Azathioprine Cyclosporine; used during exacerbation periods; not selective = risk for infection -muscle relaxants: diazepam baclofen - do not stop abruptly dantrolene; used if patient having problem with muscle spasticity -corticoidsteroid therapy (ACTH, methylprednisolone, cyclophosphamide) do not stop abruptly; decreases BG; take during exacerbations

situations that allow for implied consent

-emergency -tx is required to protect the pt's health -it is impractical to obtain consent -it is believed that the client would want treatment if able to consent

emergent reasons to call HCP

-falls -deteriorates significantly or dies -has critical laboratory results -needs a prescription that requires clarification -leaves against medical advice or runs away -refuses key treatments in a relevant period

how to know when able to progress diet after abd surgery

-first consume ice chips after demonstrating adequate bowel function (return of bowel sounds and passing flatus) -after ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet

when needs gown, gloves, mask, and faceshield

-gown + gloves = touching blood, body fluids, non-intact skin, mm, contaminated materials -mask + face/eye protection = anticipating splash of body fluids

contraindications for IV placement site

-impaired lymphatic drainage (prior mastectomy) -arteriovenous fistula or graft (used for hemodialysis) -areas DISTAL to old puncture sites -avoidance of areas that have obstructed blood flow, bruised areas, painful areas, or areas with skin conditions or signs of infection

good signs of fluid overload

-increased wt -poor UO -presence of crackles (NOT presence of edema)

expected SSAs of cirrhosis

-jaundice w/ elevated bilirubin -spider angioma -gynecomastia -testicular atrophy -palmar erythema

meds used to tx hepatic encephalopathy

-lactulose -rifaximin

normal ALP

-liver enzyme -alkaline phosphate -women: 45-115 -men: 30-100

how to care for PD catheter

-mask yourself and the pt -wash hands -use sterile gloves to remove old dressing and then discard gloves -aseptic technique = sterile gloves -use cotton swabs soaked in povidone-iodine to clean around catheter site -- circular motion from in to out -cleans area w/ sterile gauze pads using soap and water and rinse thoroughly -apply pre-cut gauze pads over cath site and tape only the edges

interventions for blood transfusion + priority axn for transfusion rxn

-need to void b4 start transfusion bc if have rxn need a fresh urine sample to check for hemolyzed RBCs -prep w/ 0.9% NaCl only -nothing else in tubing with blood -RN needs to stay w/ patient for first 15 min -transfuse entirety of blood w/in 4hr

alzheimer's (what? + SSAs + interventions + meds)

-most common form of dementia -chronic, progressive, degenerative disease -loss of memory, judgment, visuospatial perception and change in personality -forget to eat and drink; hard for family to deal with -progresses over 8-10 years -vascular degeneration at an accelerated rate -marked atrophy of the brain and neurofibrillary tangles -age 65 and older, family history SSAs -ability to fulfill household commitments -changes in short term memory -- tell you the same thing a bunch of times in a row -altered sense of smell (early) -difficulty organizing speech -incontinent -wandering; trouble sleeping (sleep walking) meds -cholinesterase inhibitors = donepezil - take before bed bc can cause drowsiness, dizziness, depression, diarrhea, deep muscle cramps; rivastigmine - most commonly used and better choice, can cause dizziness or drowsiness; galantamine - extended release need to take in AM, regular release is given 2xday, take with food, risk for bradycardia -antidepressants = TCA, SSRI; help if patient has depression w/ alzheimers -memantine - do NOT take if have renal impairment -ginkgo biloba - herbal, helps w/ memory, do NOT give to heart patients bc not compatible with anticoagulants (can cause more bleeding) priority interventions -techniques to help with memory: written and verbal reminder (dates, events, etc) cues-alarm clocks; med box; Safety/Life line; visual cues-label drawer, rooms, pictures; call client by name; introduce self each time; provide consistent people, routines and schedules; speak calmly, do not argue with client or attempt to reorient if in mod stage or beyond; need consistency! -need routine - pill boxes, alarms, reminders; later stages - need to reorient them but do NOT argue with them -prevent injury = remove safety hazards-rugs, caustic agents, matches; BEDS RAILS UP! -decrease environmental stimuli -use night lights -limit question to yes/no when possible -provide boundaries with red or yellow tape -teach realistic expectations of meds to client and family -do NOT keep next to busy part of floor/hospital - need less stimulation -- so do NOT put next to nurse's station edu to promote safety at home -keyed deadbolts (with keys removed) and close supervision -medical ID/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area -decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns -household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury -grab bars installed in showers and tubs -all meds should be out of the client's reach or locked away

SSAs see w/ abnormal bilirubin level

-norm: 0.2-1.2 -elevated = itching, jaundice, slceral icterus

interventions for acute decomp HF

-oxygen therapy -vasodilators (eg, nitroglycerin, nesiritide) -positive inotropes (dopamine, dobutamine) -- improve contractility but are only recommended if other medications have failed or in the presence of hypotension

interventions for catheter occlusion w/ PICC line

-prevent kink -reposition arm -confirm blood return -flush catheter between meds -admin antithrombolytic

ALS (what? + labs/dx + SSAs + interventions + meds)

-progressive disease that attacks neurons that control voluntary mvmt -adult onset, more common in men aged 40-60 -the muscles connected to the affected neurons weaken, atrophy and die, results in progressive loss of muscle function -characterized by weakness and wasting of muscles control WITHOUT sensory or cognitive changes -NO cure -eventual death d/t respiratory muscle paralysis -usually live with this for 3-5 years before death SSAs -tongue atrophy -weakness of hands and arms -twitching of the face -dysarthria -dysphagia -hyperreflexia of DTRs -loss of reflexes labs + dx -↑ Creatine Kinase (CK-BB) due to break down of muscle -electromyogram (EMG) - twitching denervation -muscle biopsy -- atrophic muscle fibers PFT's -vital capacity < 2L (normal: 3-4 L); causes decreased ability to breathe priority interventions -maintain airway, suction, bag-valve-mask device (ambu) and/or intubate as needed -- oxygenation highest priority d/t decreased vital capacity -monitor ABG's, administer oxygen -monitor VS and EKG through telemetry - monitor O2 sat -assess lung sounds -keep HOB elevated to 45 -TCDB q2h, use incentive spirometry and chest physiotherapy -- done to decrease risk of pneumonia which is common in ALS patients; pneumonia commonly precedes death -initiate aspiration precautions, assess gag reflex prior to eating, thicken liquids -- need to increase intake - will probably need supplements (ex: boost - high in PRO) -facilitate effective communications - language board -monitor I/O -monitor dietary intake and complete nutrition consult PRN -teach energy conservation measures -keep emergency equipment available - in case of respiratory distress -important to do frequent respiratory assessments to look for changes medications -riluzole: only treatment shown to improve survival by slowing down progress; does NOT cure ALS but it does help to slow down the progression/deterioration; need to start early in the disease process; take on empty stomach; need to monitor liver enzymes (ALT/AST) -neuroleptics: chlorpromzaine -- used in palliation of terminal restlessness and confusion -antispasmodics: Valium, Dantrium, Zanaflex

what is thoracentesis?

-remove fluid from lungs

interventions for catheter embolism w/ PICC line

-secure catheter -avoid pulling

fxn of ANA code of ethics

-set guidelines for providing care -outlines nurse's responsibility to pt -outlines profession of nursing -assists nurse in making ethical decisions

exploratory laparotomy (indications + pre-op + during/post-op)

-tx of appendicitis pre-op -wt, abd girth -void/foley post-op -fowler/semi-fowler -NGT if needed (w/ open approach -- clamp for 1-2hrs after eat) -NPO until able to tolerate fluids -strict I/O q1hr -ambulate, CDB, IS -irrigate peritoneal catheter or drains w/ aseptic technique as-rx

what is bryant traction

-used for hip/femur; peds only -used intermittently - pulling force applied by weights attached by rope to client

pt edu for hydrogen breath test

-used to detect h.pylori -NO abx or bismuth subsalicylate 1 month b4 test -NO PPI or sucralfate 1 week b4 test -NO h2 blocker 24hr b4 test

interventions for trach dislodgement

-w/in 1st 72hr = ventilate w/ bag-valve mask -after 1st 72hr = insert new trach tube using bedside obturator

normal ESR

-women: 0-20 -men: 0-15

1 mL = ____ gram

1 gram

1 gram = ___ mL

1 mL

post-void residual

(intervention for lower UTI) -done 20 minutes after person has voided to see how much in bladder -report >100 mL -200-300 cc w/ suprapubic swelling = notify HCP

CNs (ID + motor vs. sensory + fxn + how assess)

(oh oh oh to touch and feel virgin girls vaginas, AH) (some say marry money but my brother says big brains matter more) -I: olfactory (smell); sensory -II: optic (2 eyes); sensory -- controls central and peripheral vision; assess by cover one eye at a time and look straight and move your finger to the pt's peripheral fields -III: oculomotor; motor -- controls pupillary constriction and eye mvmt; pen light to assess AND ask pt to look up and down w/o moving head -IV: trochlear; motor -- move eye downwards; assess by having pt follow your moving finger -V: trigeminal; both -- sensory for teeth, eyes, skin, and tongue; motor for chewing; LOOK UP HOW TO ASSESS -VI: abducens; motor -- move eye side to side; assess by having pt follow your moving finger -VII: facial; both -- controls facial muscles (expressions) = raise eyebrows, frown, close eyes tight, puff cheeks, smile; motor for salivary and tear glands; sensory for taste buds of anterior tongue -VIII: vestivulocochlear; sensory -- important for ear function; controls hearing; assess w/ whisper test or rubbing fingers together at each ear -IX: glossopharyngeal; both -- sensory of pharynx + posterior taste; motor for swallowing -X: vagus; both -- sensory: throat; motor: swallow + speech; cardiac innervation (slows down) -XI: accessory; motor -- muscles that move head, neck, + shoulder -XII: hypoglossal; motor -- tongue mvmts

order of interventions for pt in acute resp distress

1. place in high-fowler 2. suction 3. admin 100% o2 via non-rebreather 4. assess lung sounds 5. notify HCP

biliary colic (what? + SSAs + interventions)

(w/ cholecystitis) -medical emergency -severe pain d/t obstruction of the cystic duct of the gallbladder or mvmt of one or more stones -SSAs: tachycardia, pallor, diaphoresis, extreme fatigue -can possible lead to shock -report s/sx to HCP or RR team asap

general interventions for pts who have MSK problem or are immobile

"ACCTIIVE" -Alignment: position appropriately; reposition q2hrs minimal; teach to use assistive devices (i.e., cane, crutches, WC) -Coughing and deep breathing -Collaboration: dietary (↑PRO, cal, ca and vit d), OT/PT -Transfer out of bed; hot and cold therapy. teach to dress, start with affected then unaffected extremity. -Incentive spirometer every hr -Increase fluids and fiber -deVices for immobilization: know care of (i.e. casts, traction, etc; prevent DVT w/ sequential compression device, elastic stockings; encourage use of unaffected limb -Exercises in bed, passive and/or active ROM; promote wt bearing

locations for heart auscultation

"APTM = always palpate the mitral" -A: aortic = RSB 2nd ICS -P: pulmonic = LSB 2nd ICS -T: tricuspid LSB 5th ICS -M: mitral = left midclavicular line at 5th ICS; apex; PMI

general SSAs of cancer

"CAUTION" -C: changes in bowel or bladder habits -A: a sore that does not heal -U: unusual bleeding or d/c -T: thickening or lumps in breasts or elsewhere -I: indigestion or difficulty swallowing -O: obvious changes in wart or mole -N: nagging cough or hoarseness

causes of false o2 readings

"COLDS" -C: circulation poor -O: pOlish -L: low temp -D: decreased hgb (anemia) -S: swelling (edema)

things that CANNOT be delegated

"EAT" -E: education, evaluation -A: assessment (INITIAL) -- can delegate re-assessment -T: teaching, transfer

SSAs of uremia

"MAP HIMSELF" -buildup of nitrogenous waste products in the blood from inadequate elimination d/t kidney failure (high BUN/creatinine) -M: metallic taste -A: anorexia, N/V -P: paresthesia -H: hiccups -I: itching (pruritis) -M: muscle cramp -S: SOB -E: edema -L: lethargy, fatigue -F: frost

who needs droplet precautions? + when to add PPE

"MM Pretty SPIDERS" = 10 -M: meningitis -- HiB, neisseria (until therapy for 24hr) -M: mumps -P: pneumonia -- HiB, meningococcal (until therapy for 24hr), streptococcus aureus, mycoplasma (NOT pneumococcal - only needs standard precautions) -S: strep. pharyngitis (group a) -P: pertussis -I: influenza -D: diptheria -E: epiglottitis -R: rubella -- add contact; until 7 days after rash onset -S: scarlet fever -PPE = mask -just mask and gloves = med admin + assessment + VS -mask + gloves + face shield + gown = risk of splash or contact w/ body fluids (ex: dressing change, wound care, suctioning) -YES dedicated equipment -YES single room -YES pt wears mask when leaves room -yes gloves if doing procedure but no gloves needed if just going in to take VS -NO gown required

who needs spinal immobilization

"NSAIDS" -N - Neurological examination; focal deficits include numbness and decreased strength -S - Significant traumatic mechanism of injury -A - Alertness. The client may be disoriented or have an altered level of consciousness -I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain -D - Distracting injury. Another significant injury could distract the client from spinal pain. -S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

interventions for peritoneal dialysis

"PERITONEAL" -P: practice sterile technique for catheter insertion -- permanently placed in abd -E: eval VS q15-30min; evaluate VS, abd girth, and wt w/ baseline -R: rotate pt side to side if inflow or outflow is inadequate -I: I/O and color of dialysate needs to be recorded -T: the outflow bag is below the pt's abd -O: observe for complications = abd, resp, discolored or decreased outflow -N: note if dressing is wet; note serum glucose inflow -E: evaluate for fibrin clot = gently milk tubing -A: always warm solute to body temp b4 give but never use microwave -L: lateral supine position to help w/ draining

multiple casualty triage (prioritization + actions)

"RPM" -R: respirations -P: pulse (blood flow, perfusion) -- use cap refill -M: mental status "30-2-can do" -RR should be between 10-30 -cap refill should be <2 sec -victim should be able to do what you ask actions limited to -opening airway -stop bleeding -elevate extremities -- for shock control -resuscitation is NOT attempted

general SSAs of anemia

"TIRED" -T: tachycardia -I: irritable (anxious) -R: RR increased, SOB, dyspnea -E: eval for bleed -D: decreased BP, o2 sat, and color (pale) -cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of anemia -yellow conjunctiva + mm, jaundice -fatigue, tired

group of infections that cause fetal abnormalities

"TORCH infection" -T: toxoplasmosis -O: other [parvo-B19/varicella zoster] -R: rubella -C: cytomegalovirus -H: herpes simplex -do NOT let pregnant nurse interact w/ pts w/ these infections

nursing interventions for MSK traction device

"TRACTIONNN" -T: Try to do ROM, ROM Q shift minimally - maintain body alignment -R: Respiratory complications prevent -A: Assess neurovascular: early signs: increased pain, paresthesia (tingling/numb), pallor; late signs: pressure, paralysis, loss of pulses -C: Care of Pin Site (skeletal or external fixation methods) -1 cotton swab per pin q8hrs w/ peroxide and iodine (per protocol) -T: Trapeze to help move -- w/ halo need to move as a unit so as not to apply pressure to the rods to avoid loosening of pins -I: Infection prevent: monitor temperature, WBC, observe color, smell, amt drainage; I/O - watch for urinary retention, constipation -O: Ongoing assessment that traction weights to hang freely; Assure that the pulley ropes are free of knots, avoid lifting or removing weights -N: Need wrench to release rods from vest used with Halo traction (taped to front of vest for emergency); -N: Notify HCP: severe pain, muscle spasms, pain not relieved by meds and/or repositioning -N: Nutrition for healing - ↑PRO, calories, calcium, vit D

what does a neurologic assessment consist of

GCS, PERRLA, movement and strength of the extremities, and vital signs

what organs are in RUQ, LUQ, RLQ, LLQ

RUQ: "ADULT HGK" -A: ascending colon -D: duodenum -U: ureter -L: liver -T: transverse color -H: head of pancreas -G: gallbladder -K: kidney LUQ: "BK STUDS" -B: body and tail of pancreas -K: kidney -S: spleen -T: transverse colon -U: ureter -D: descending colon -S: stomach RLQ: "RA SCUBA" -R: rectum -A: appendix -S: SI -C: cecum -U: ureter -B: bladder -A: ascending colon LLQ: "BUDSS" -B: bladder -U: ureter -D: descending colon -S: SI -S: sigmoid colon

pulmonary edema (SSAs + interventions)

SSAs -hx orthopnea and/or paroxysmal nocturnal dyspnea -anxiety, restlessness -tachypnea (often >30/min), dyspnea, and use of accessory muscles -frothy, blood-tinged sputum -crackles on auscultation interventions -priority of care is to improve oxygenation by reducing pulmonary pressure and congestion -give diuretics (eg, furosemide) to remove excess fluid

UC vs. chron's (differences + similarities in SSAs + labs + axns)

UC -onset: females 15-25yo + males 55-65 yo -risk factor: low fiber diet, caucasian -edema and inflamed LI (continuous) -can form abscess -mucosal layer -can cause hemorrhage -LLQ abd pain + cramps -infrequent need for surgery -15-20 liquid stools/day -mucus, blood, or pus in stool -rectal bleed -vomiting, dehydration -different from chrons = YES BLEEDING -lab = ↑ pANCA (definitive dx) chrons -onset: 15-40 yo -inflamed and ulcers anywhere in GI tract -sporadic/patchy -involve all layers -often at distal ileum -can cause fistulas (abnorm tracts between bowel + skin/bladder or vagina) -frequent need for surgery -RLQ abd pain + cramp -5 loose stools/day -mucus or pus in stool -diarrhea + steatorrhea -difference from UC = NO BLEEDING (rare) -↓folic acid and B12 -WBCs in urine -↑anti-glycan antibodies (definitive dx) BOTH SSAs -anorexia, ↓wt -↑ temp -frequent stools -abd distended, tender, +/or firm -high pitched BS -joint pain -exacerbations and remissions -jewish ancestry is a risk factor BOTH labs -↓hgb/hct -↑ ESR -↑ WBCs (leukocytosis) -↑ CRP -↓albumin -stool for occult blood can be + -↓k, ↓mg, ↓ca, ↓na, ↓ cl -MRE, colonoscopy after acute flare, CT, abd x-ray BOTH meds -anti-inflammatory = sulfasalazine, mesalamine, basalazide, olsalazine -corticosteroid = prednisone, hydrocortisone, budesonide -immunosuppressant = cyclosporine, methotrexate, azathioprine, marcaptopurine -antidiarrheal = diphenoxylate + atropine, loperamide -immunomodulators = "-mab" BOTH axn (+ diverticulitis) -diet = high-calorie, high-PRO, low-fiber, no dairy, low-residue -low fiber during acute stage and acute exacerbations -high fiber when stable -frequent smaller meals -multivitamin -iron supplements -food diary -NPO and TPN to rest the bowel during acute exacerbation -teach s/sx of complication = pain, bleeding, infection, perforation (board rigid abd) -no NSAIDs, ETOH, smoking, or illicit drugs; no abx (unless rx) -exercise -NO MORPHINE -- bc can increase pressure in colon and exacerbate sx

how to ascent + descend stairs w/ cane

ascend = up w/ GOOD -1. step up with the stronger leg first -2. move the cane next, while bearing weight on the stronger leg -3. move the weaker leg descend = down w/ CANE + BAD -1. lead w/ the cane -2. bring the weaker leg down next -3. step down with the stronger leg

what is pancytopenia

deficiency of RBC, WBC, + platelets

early vs. late changes in neurovascular check

early Ps -pain -paresthesia (tingling, numbness) -pallor (pale color) late Ps -paralysis -pulselessness other P = pressure

priority intervention for bacterial meningitis w/ sepsis

fluid admin

what is grave's disease

hyperthyroidism

myasthenia crisis vs cholinergic crisis

myasthenia crisis (basically s/sx of MG) -respiratory distress/cyanosis -increased HR + HTN -poor cough -dysarthria = slur speech -dysphagia = decreased swallow/aspiration -bowel/bladder incontinence ↓UOP -ptosis (droopy eyelid) -strength improves with edrophonium (tensilon test) -usually d/t trigger/stress or not enough med cholinergic crisis -muscle fasciculations (twitch) --> resp distress, increased GI motility (abd cramps, N/V/D), hypersecretion, hypotension -meiosis (small pupil), blurred vision -weakness -strength worsened with edrophonium (tensilon test) -usually d/t too much med (too much pyridostigmine)

prevention + tx of blood infection w/ central venous catheter insertion

prevention -sterile technique tx -change entire infusion system -notify HCP -get cultures -admin abx

how to dress pt w/ MSK injury

start w/ BAD side then dress GOOD side

post-op + edu for bariatric surgery

-#1 priority = airway -diet of liquids + pureed food for 1st 6 weeks -semi-fowler w/ abd binder -ambulate ASAP -6 small feed per day -monitor for s/sx dumping syndrome

lab changes + SSAs see with liver dysfxn

-** elevated AST/ALT -low albumin = na and water retention = diluted blood = low-na

5 stages of CKD

-1 = at risk = GFR > 90 -- kidney damage w/ normal GFR, risk factors present for kidney disease -2 = mild = GFR 60-89 -- focus on reduction of risk factors -3 = moderate = GFR 30-59 -- azotemia (high BUN/creatinine), implement strategies to slow disease progression -4 = severe = GFR 15-29 -- manage complications, pt edu on options, prepare for RRT -5 = ESKD = GFR < 15 -- RRT or kidney transplant

emergency care for pt w/ extremity fracture

-1. Assess the patient's airway, breathing, and circulation and perform a quick head-to-toe assessment. -2. Remove the patient's clothing (cut if necessary) to inspect the affected area while supporting the area above and below the injury. Do not remove shoes because this can cause increased trauma unless the foot or ankle is injured. -3. Remove jewelry on the affected extremity in case of swelling. -4. Apply direct pressure on the area if there is bleeding and pressure over the proximal artery nearest the fracture. -5. Keep the patient warm and in a supine position. -6. Check the neurovascular status of the area distal to the fracture, including temperature, color, sensation, movement, and capillary refill. Compare affected and unaffected limbs. -7. Immobilize the extremity by splinting; include joints above and below the fracture site. Recheck circulation after splinting. -8. Cover any open areas with a dressing (preferably sterile).

priority of interventions for anaphylactic shock

-1. call for help -2. maintain airway and breathing - administer high-flow O2 via non-rebreather mask -3. IM epinephrine -- dose repeated q5-15 min if there is no response -4. elevate the legs -5. volume resuscitation with IVF -6. give bronchodilator like albuterol -7. give antihistamine (diphenhydramine) -8. give corticosteroids (methylprednisolone)

steps for obtaining a wound culture

-1. perform hand hygiene, and apply clean gloves. remove the old dressing. remove and discard gloves. -2. perform hand hygiene, and apply sterile gloves. assess the wound bed. cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris. remove and discard gloves -3. perform hand hygiene, and apply clean gloves. gently swab the wound bed with a sterile swab, from the wound center toward the outer margin. avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora -4. place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. -5. apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification. apply new dressing -6. remove and discard gloves, and perform hand hygiene. label the specimen, and document the procedure.

steps to measure pulsus paradoxis

-1. place client in semirecumbent position -2. have client breathe normally -3. determine the SBP using a manual BP cuff -4. inflate the BP cuff to at least 20 mm Hg above the previously measured SBP -5. deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure -6. continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure -7. determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox -8. the difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

what are the 4 phases of tonic-clonic seizure

-1. prodromal phase = period with warning signs that precede the seizure (before the aural phase) -2. aural phase = period before the seizure when the client may experience visual or other sensory changes; not all clients experience or can recognize a prodromal or aural phase before the seizure -3. ictal phase = period of active seizure activity -4. postictal phase = pt may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

1st, 2nd, and 3rd priority levels

-1st = ABCs plus V - airway, breathing, circulation, and vital signs -2nd = mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal laboratory values, and risk -3rd = longer-term issues such as health education, rest, and coping

pts who should receive flu vaccine (not live)

->/= 6 months old -have chronic conditions -immunocompromised -health care workers and caretakers -pregnant women

pre-op + post-op amputation

-A: assess neurovascular signs for potential complications; early signs = pain, paresthesia, pallor; late signs = paralysis, pulselessness -M: monitor for infection (record drainage from wound site, color, smell) note temp and WBC count -P: position stump ↑ on pillow during first 24 hrs to ↓edema; then position affected extremity in dependent position after first 24 hrs to promote blood flow -U: you need to implement shrinkage interventions (↓ edema and prepare for prosthesis; may use stump shrinker sock or air splint) -T: treat pain - phantom pain -- may treat with beta blockers or gabapentin (neurontin) -A: avoid prolonged sitting -T: try to prevent contractures: ROM, have client lie prone several times per day to avoid flexion contractures, discourage prolonged sitting, PT teach exercises to prevent, do NOT place pillow under knee -E: encourage and support grieving process, encourage rehabilitation; edu on how to transfer and use mobility devices and aids, how to manage phantom pain meds -opioids = residual limb pain -calcitonin = phantom pain -antispasmodic = muscle spasms -b-blocker = constant dull, burning pain -anti-epileptic = knife-life or sharp burning pain

ABCDE rule for moles

-A: asymmetry (eg, one half unlike the other) -B: border irregularity (eg, edges are notched or irregular) -C: color changes and variation (eg, different brown or black pigmentation) -D: diameter of 6 mm or larger (about the size of a pencil eraser) -E: evolving (eg, appearance is changing in shape, size, color)

priority interventions for acute appendicitis

-ABC** -- focus 1st on C = circulation -#1 = IVF w/ IV crystalloids (NS, LR) to prevent circulatory collapse d/t fluid loss from vomiting + diarrhea and NPO status -NPO -IV pain meds

prioritization principles

-ABCs -systemic before local = "life b4 limb" -acute before chronic -actual problem before potential future problem -recognize and respond to trends vs. transient findings -recognize signs of emergency complications vs. expected pt findings examples -prioritize admin of med to pt in acute pain over ambulating pt at risk of thrombophlebitis -recognize timing of admin of anti-DM and antimicrobial meds is more important than admin of some other meds

SSAs + interventions for hypo-na vs. hyper-na

-BOTH SSAs: lethargy, seizure, tachycardia -BOTH axn: seizure precautions, daily wt, I/O hypo-na -SSAs: weak, confused, HA, anorexia, N/V, muscle cramps, twitching, HYPOTENSION, WT GAIN, edema -axn: RESTRICT ORAL FLUID INTAKE, med: conivaptan hydrochloride hyper-na -SSAs: fever, swollen + dry tongue, sticky mm, hallucinations, restless, irritable, HTN, hyperreflexia, twitching, pulm edema -axn: IVF of hypotonic or isotonic fluids, INCREASE ORAL FLUID INTAKE

complications + interventions for peritoneal dialysis

-D: dialysate leakage = clear fluid from insertion site -B: bleeding/blood tinged fluid -- expected when first placed but normally clears up w/in 1-2 weeks -H: hyperglycemia, hyperlipidemia -- check blood sugar and may need to give insulin -I: infection; incomplete recovery of fluid; PRO loss -P: pain/discomfort -- warm dialysate to body temp b4 give (do NOT use microwave) -P: peritonitis -O: outflow/inflow of dialysis is poor -R: resp compromise = difficulty breathing, rapid RR, crackles

aneurysm (what? + SSAs + interventions + complications)

-EMERGENCY -type of hemorrhagic stroke and intracranial bleed -enlarged, weak area of artery; not actually bleeding until aneurysm bursts -lead to IICP -need to control BP to prevent it from bursting -abnorm ballooning or blister along a normal artery commonly developing in a weak spot on the artery wall -ID w/ CT scan (w/ contrast?) SSAs -N/V, photophobia, CN deficits, stiff neck, changes in mental status -rupture = sudden severe HA described as "worst HA of life" interventions -procedure to stop bleed complications -rebleed or rupture is common complication of aneurysm and AVM; may occur w/in 1st 24hr of initial bleed and up to 7-10 days later; SSAs: severe HA, N/V, decreased LOC, neuro deficits -monitor for s/sx of hydrocephalus or vasospasm after surgical repair

care for cervical traction

-Freely let weights hang (NEVER have weights sitting on floor) -Routinely monitor skin integrity. -Accidentally displace weights-call HCP -Cannot remove weights; clean pin sites per hospital protocol -The client's alignment should be maintained. -Unrelieved muscle spasms after medicating for pain should be reported to HCP. -Ropes are free of knots. -Eliminate lifting weights. Examine traction sites for redness, drainage, etc. -potential for skin breakdown for the occipital and coccygeal areas -promote strengthening exercises for uninjured areas -admin meds (opioids, NSAIDs, muscle relaxants)

possible complications of PEEP

-High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension. -high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema.

how to administer phenytoin

-IV slowly -no more than 50 mg/min -do NOT mix w/ glucose -admin in 0.9% NaCl -monitor for bradycardia + heart block -best to give med thru central line instead of peripheral line to prevent extravasation -if giving via NGT need to turn off feedings 1hr b4 and after admin -can be given IV or PO; NEVER GIVE IM -highly toxic effects = cardiac, resp, liver, and bone marrow suppression

live vaccines

-MMR -varicella -rotavirus -influenza nasal spray -yellow fever

reasons to use different o2 delivery devices

-NC: short-term use in responsive postoperative clients to treat hypoventilation and reverse hypoxemia effectively, able to eat and drink, comfortable, delivers o2 concentrations of up to 44% -non-rebreather: emergency use, delivers high concentrations of o2 (up to 90%-95%), requires a tight face seal, is restrictive and uncomfortable -simple face mask: used if hypoxemia does not resolve w/ other measures, delivers a higher concentration of oxygen (40%-60%), more uncomfortable and restrictive, must be removed to eat or drink -venturi mask: used to deliver a guaranteed o2 concentration to pt w/ unstable COPD, ID by green piece on mask

priority of interventions w/ cholecystitis

-NPO during N/V episodes -NGT to low suction for severe vomiting -semi-fowler -IVF w/ elect w/ N/V -meds: analgesic, antiemetic, antipyretic, abx priorities if actively vomiting -#1: institute strict NPO -#2: give antiemetic (can be suppository) -#3: fluid + elect replacement -#4: insert NGT w/ low suction

how long does it take for PEG tube tract to mature

-PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks -tube dislodgment <7 days from placement requires surgical or endoscopic replacement -attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis

SSAs of impending respiratory failure

-PaCO2 >/= 45 -PaO2 </= 60 -paradoxical breathing -mental status change -absence of wheezing and silent chest -single word dyspnea -respiratory acidosis

what is the BEST indicator that a malnutrition pt is responding well to nutritional therapy

-WEIGHT GAIN!!!!! -NOT ALBUMIN -pre-albumin is better indicator than albumin

edu for pt w/ meniere's disease

-abnormal inner ear fluid balance --> vertigo, tinnitus, pressure in ear pt edu -small, frequent meals low in sodium -fall precautions -quiet envi -drink plenty of fluids but avoid caffeine and alc -avoid MSG, ASA, and aspirin-containing meds which may increase sx

guillian-barre (what? + SSAs + dx + interventions/pt edu + tx/meds)

-acute and rapidly progressing but full recovery is expected but recurrence is common -damage to myelin sheath - causes demyelination --> problems with signal transmission --> muscle weakness, paresthesia, pain -ascending paralysis →totally paralysis (mechanical ventilation - paralysis of diaphragm and can't breathe w/o diaphragm -- at risk for respiratory depression) -basically same process as MS - difference is this is episodic (occurrence comes and goes - can't predict) SSAs -progressive motor weakness and abnormal sensory perception -sudden onset -muscle weakness - problems with movement -loss of reflexes arms and legs -decreased BP and poor BP control -uncoordinated mvmt, clumsiness/falls -blurred vision/double vision -difficulty moving facial muscles - may have facial paralysis similar to bells palsy -MOST IMPORTANT things to consider when assessing: weakness, potential for paralysis, potential for respiratory depression dx -lumbar puncture for CSF- ↑PRO levels -CBC- ↑leukocytes -electromyogram (EMG) - ordered after done other two dx and see SSAs; shows electrical activity in the muscles -MRI, CT, ABG nursing interventions/pt edu -do NOT give flu vaccine -- prevent flu w/ hand hygiene, avoid crowds, weak mask -early sx of impending resp failure that need to report = inability to cough, shallow resp, dyspnea, hypoxia, inability to lift the head or eye brows -manage airway to promote gas exchange = suction PRN -- monitor the color consistency and the amount of secretions -elevate HOB to 45 degrees or higher -CPT, TCDB, IS, O2 as-rx -monitor for dysrhythmias using cardiac monitor -work with speech regarding swallowing issues remember to check gag -- check gag to decrease risk of pneumonia -work with PT/OT on self care -perform passive and active ROM q2-4 hrs -antiembolism stocking and sequential compression devices Immobile = risk for DVTs -develop a plan for communication tx -plasmapheresis OR immunoglobulin therapy (IVIG) -meds: anticoagulants, gabapentin (for neuropathic pain), TCA -typically corticosteroids are not utilized unless medically necessary to treat other coinciding disorders

osteomyelitis (what? + SSAs + interventions)

-acute or chronic bone infection -long term chronic complication w/ long term abx SSAs -bone pain worse w/ mvmt and is constant, localized, and pulsating -erythema, edema, fever, tenderness -local swelling, redness, warmth -malaise -bone pain different from norm -chills, excessive sweating, low back pain, swelling of ankles/feet/legs interventions -IV abx asap -if have wound drainage then need contact precautions -implement wound irrigation

interventions to prevent recurrence of DVT

-adequate fluid intake and limit caffeine and alcohol to avoid dehydration -elevate the legs when sitting and dorsiflex the feet often -resume an exercise program (walking, swimming) and change positions frequently -stop smoking, avoid restrictive clothing -consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels -NO need to avoid traveling in a car or airplane but if travel >4hr must use preventive measures (compression stockings, exercise calf and foot muscles frequently, walk every hour) -avoid crossing the legs at the knees or ankles

how to prevent post-op pneumonia

-adequate pain control -ambulate w/in 4-8hr of surgery -cough w/ splint q1hr -deep breathe + IS q1hr -fowler position -hand hygiene -swab mouth w/ chlorhexidine q12hr

steps for performing wound irrigation

-administer the analgesic 30-60 minutes before the procedure -don a gown and mask with face shield to protect from splashing fluid -need surgical asepsis = sterile gloves -use a 30- to 60-mL sterile irrigation syringe -attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area -use continuous pressure to flush the wound, repeating until drainage is clear -dry the surrounding wound area to prevent skin breakdown and irritation -clean wound from the least to the most contaminated area

normal suction pressure

-adults = 100-120 -kids = 50-75

pt edu for barium swallow (+ when to call HCP)

-aka small-bowel follow through + takes x-rays -fast 8 hr b4 -test usually takes 60-120 min -drink plenty of fluids after the examination to facilitate barium removal -chalky stools may be present 24-72 hrs after exam -call HCP: if brown stools do not return after 72 hrs, abdominal pain or fullness is present, black/tarry stools

what to ask + tell pt b4 give contrast medium

-allergy to shellfish, iodine, seafood, eggs, milk, or chocolate -hx asthma -hx renal impairment -dehydration -currently taking nephrotoxic meds (aminoglycosides, NSAIDS) -metformin use (no 24hr b4 and 48hr after; do NOT resume metformin after procedure til assess kidney fxn) -hydration status -- BP, HR, RR, MM, skin turgor, urine concentration -last time ate or drank anything -increase fluids after -facial flushing, warmth feeling -can have metallic or salty taste in mouth

renal arteriogram/angiography (what? + pre-op + post-op)

-allows the radiopaque contrast medium to enter the renal blood vessels and generates images to determine blood vessel size and abnormalities -imaging w/ IV contrast dye to see vascular parts of kidney -IV dye so take into account all considerations w/ systemic contrast dye pre-op -use femoral or brachial artery -locate and mark peripheral pulses -void b4 -take into account edu for contrast media post-op -bed rest for 6-8hr -monitor VS til stable -observe for swelling + hematoma -palpate peripheral pulses and do vascular checks

who cannot leave against medical advice (AMA)

-altered consciousness -mental illness (danger to self or others) -being under chemical influence (drugs or alcohol) -parents may not refuse life-, limb-, or organ-saving treatment on behalf of their minor child for religious or personal reasons; they can make that decision only for themselves. If the parents deny critical treatments to the child, the hospital may seek protective custody.

care for halo fixation device

-always have wrench attached to vest -move pt as unit w/o applying pressure to fixation device -Skin integrity (monitor) -Alignment of body (maintain) -Freely let weights hang if in traction -Evaluate pin sites for infection. Equipment available to remove halo in case client was to experience a cardiac or respiratory arrest. -may be worn for 8-12 weeks -should be able to fit a finger between skin and device -special wrench to remove vest -PIN SITE care -NO driving -cleaning pin sites with sterile solution (eg, chlorhexidine, water) -keep the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin -place foam inserts under pressure points to prevent pressure injury -place a small pillow under the client's head when supine to reduce pressure on the device -keep the correct-sized wrench available at all times in case of emergency

myasthenia gravis (what? + SSAs + interventions + meds)

-an acquired autoimmune disease -antibodies produced by thymus gland --> damage of ach receptor sites --> impaired transmission at junction --> voluntary muscle weakness that increases w/ activity + improves w/ rest -periods of exacerbation and remission -often involves the ocular muscles -remissions and exacerbations -the thymus gland is often abnormal (hyperplasia) - overgrowth of thymus gland tissue -characterized by muscle weakness -triggers: infection, stress, fatigue, pregnancy, increased body temp, hyperthyroidism, bone marrow transplant SSAs -progressive muscle weakness that improves with rest -poor posture -early sx = ocular muscle dysfxn --> aspiration risk; s/sx: diplopia, ptosis, dysphagia, dysphonia, drooping of eyes; weakness will progress -weak or incomplete eye closure -loss of bowel and bladder control -- incontinence -fatigue -difficulty with swallowing or chewing -respiratory difficulty, difficulty managing secretions -decreased facial muscle strength -sensory manifestations: muscle achiness, paresthesia's, decreased sense of smell and taste labs + dx -thyroid function-thyrotoxicosis -serum PRO electrophoresis- RA lupus and other immune disorders -acetylcholine receptor antibodies- ↑MG -repetitive Nerve Stimulation (RNS) -electromyography (EMG) -single-fiber EMG -tensilon (edrophonium chloride) testing - DIAGNOSTIC TEST priority interventions -#1 = oxygenation/airway -keep at bedside = bag mask, intubation kit, suction equip -plan activities in early AM to avoid fatigue -give small, frequent high-calorie meals during peak time of meds (w/in 45min of admin) -give meals during peak time of med to decrease aspiration risk -assess swallow and gag reflex (cranial nerves 9,10) prior to eating -monitor lungs sounds for crackles, wheezes and rales -monitor ABGS -assisted cough techniques, RT for chest PT -promote mobility -during periods of weakness provide active and passive ROM -provide periods of rest and need to cluster care -administer medications on schedule -- PRIORITIZATION QUESTION - HIGH PRIORITY IF MEDS ARE DUE -teach energy conservation -protect eye lubricating eye drops, patch if can't close eyes all the way meds/tx -anticholinsterases - enhance neuromuscular impulse transmission -drug of choice: pyridostigmine -- plan meal times; do not admin to patients with urinary or intestinal obstruction; want to eat 45min-1hr AFTER taking med to avoid aspiration; do NOT take magnesium because may cause muscle weakness; careful use w/ opioids; overdose can cause cholinergic crisis -promptly respond to excessive stimulation symptoms: excess salivation, urinary urgency, bradycardia—atropine (antidote) -immunosuppressants: corticosteriods, IVIG if steroids don' work -plasmapheresis -thymectomy = possible tx but not always effective b/c may have hyperplasia of thymus

interventions for phlebitis w/ PICC line

-apply low degree heat -d/c if not resolved

interventions for infection w/ PICC line

-aseptic technique -keep dressing clean and dry

initial interventions in emergency mgmt of chest pain

-assess airway, breathing, and circulation (ABCs) -position client upright unless contraindicated -apply oxygen, if the client is hypoxic -obtain baseline vital signs, including oxygen saturation -auscultate heart and lung sounds -obtain a 12-lead electrocardiogram (ECG) -insert 2-3 large-bore intravenous catheters -assess pain using the PQRST method -medicate for pain as prescribed (eg, nitroglycerin) -initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor) -obtain baseline blood work (eg, cardiac markers, serum electrolytes) -obtain portable chest x-ray -assess for contraindications to antiplatelet and anticoagulant therapy -administer aspirin unless contraindicated

interventions for catheter dislodges w/ PICC line

-assess blood return, discomfort in jaw, chest, or eat -contact HCP

different types of pacing + how show up on EKG

-atrial pacing = spike before p wave -ventricular pacing = spike before qrs -atrioventricular (dual chamber) = spike before p wave AND qrs

edu for pt w/ lactose intolerance

-avoid lactose-containing dairy products (eg, milk, ice cream) -eat cheese or yogurt in moderation -take lactase enzyme w/ meal containing dairy -take calcium and vit D supplements -milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance -some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency

SSAs of basilar skull fracture

-bleed from nose + ears -raccoon eyes -otorrhea, rhinorrhea -- CSF from ears or nose -battle's sign = ecchymosis on mastoid bone -do NOT insert NGT to pt w/ basilar skull frature

priority axn for foreign body in eye

-both eyes should be shielded to prevent eye movement and additional injury -nurse should immediately refer the client to an ophthalmologist for further evaluation and tx

cushing's triad

-bradycardia -severe HTN (increased SBP) w/ wide pulse pressure (big difference between SBP + DBP) -irregular breathing (bradypnea, cheyne-strokes)

pleural effusion (what? + SSAs)

-buildup of fluid between the tissues that line the lungs and the chest -decreased tactile fremitus -diminished breath sounds

causes + SSAs + interventions for hypo-ca vs. hyper-ca

-calcium has inverse relationship with phsophorus -BOTH SSAs: -BOTH axn: hypo-ca -causes: celiac disease, lactose intolerance, chron's, alc use disorder, hypo-mg -SSAs: tetany, cramps, paresthesia, dysrhythm, trousseau sign, chvostek sign, seizure, hyperreflexia, impaired clotting time -axn: seizure precautions, IV calcium admin slowly and must be diluted in D5W (NEVER in NS) hyper-ca -SSAs: -axn:

key s/sx of cardiac tamponade

-can occur from obstruction of chest tube so if have quick decrease in chest tube output, monitor for s/sx of cardiac tamponade -sudden onset of pulsus paradoxus (systolic BP decreases >10 mmHg during inspiration) -hypotension w/ narrow pulse pressure -JVD w/ clear lung sounds -muffled or distant heart tones -pulsus paradoxus -dyspnea -tachypnea -tachycardia

hypertensive encephalopathy (what? + SSAs + interventions)

-can see in pt w/ CKD -emergency -type of HTN crisis characterized by N/V and HA -tx is urgent (ie, within 1 hour) to prevent damage to the heart, kidney, and brain -pt should check BP at home, if possible, and then proceed to the emergency department for further assessment and treatment (eg, titration of anti-HTN meds)

how to care for cast

-casts applied when swelling ↓ (usually 24-48hr after injury) -↑cast above level of heart during 1st 24-48 hrs (keep limb on pillow) -after 1st 24-48hrs keep cast in dependent position to improve circulation -apply ice during 1st 24-36hrs to reduce swelling -arm case = support arm w/ sling when walking or standing -leg cast = elevate on several pillows and apply ice for 1st 24hr or as-rx -handle cast w/ palm of hands before dry to prevent damage -should be able to insert a finger between cast and skin -reasons to call HCP: hot spots, malodor, unable to move fingers/toes, numbness, increased pain, change in any of the 6 Ps

types of pts who CANNOT use valsalva maneuver

-causes = temporarily slower HR, decreased CO, IICP, IIOP, increased intra-abd/thoracic pressure -IICP -stroke -head injury -heart disease -glaucoma -eye surgery -abd surgery -cirrhosis

virchow's triad

-causes/risks for thrombosis -venous stasis -endothelial injury -hypercoagulable state

reasons to go to ER in pt w/ concussion

-change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) -worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics -visual changes (eg, blurring) -motor problems (eg, difficulty walking, slurred speech) -sensory disturbances -seizures -N/V or bradycardia (indicates IICP)

fibromyalgia (what? + SSAs + mgmt)

-chronic MSK pain and not an inflammatory disease with unknown cause SSAs -pain, stiffness and tenderness in back of the neck, upper chest, trunk and lower back and extremities -- these areas are known as trigger points -pain and tenderness to the above areas come and go but can be exacerbated by stress, increase activities, sleep deprivation and weather -generalized fatigue mgmt -maximize mobility -control pain: NSAIDS, Tramadol -adequate sleep; manage stress and anxiety -anticonvulsant: Pregabalin (Lyrica) to help decrease nerve pain by increasing serotonin and norepinephrine in the brain -SSRI/SNRI (duloxetine) help decrease nerve pain by increasing serotonin and norepinephrine in the brain -TCA (amitriptyline and nortriptyline) help with sleep and muscle spasms -exercise regularly: Aerobic exercise, strengthening exercises, stretching, biking, swimming.

scleroderma (what + SSAs)

-chronic formation of scar tissue that hardens the skin -uncommon, chronic, inflammatory, autoimmune CTD -"hardening of the skin" -confused with lupus -renal impairment is the leading cause of death

parkinson's (what? + dx + tx + SSAs + interventions + meds)

-chronic, progressive neuro d/o caused by loss of pigmented cells of substantia nigra + depletion of dopamine needed for voluntary movement -have good cognitive fxn and can think clearly but cannot control their mvmts diagnostics = CSF -- decreased dopamine levels; MRI, PET treatments -medications -deep brain stimulation -- pacemaker-like device inserted into brain to help stop tremors -pallidotomy -- probe into globus palitius area of brain and destroy brain cells (heat) = help easy sx; higher risk SSAs -affects the motor ability with four cardinal symptoms: tremor, rigidity (stiff), bradykinesia (move slowly)/akinesia, postural instability -pill rolling -cogwheel -masklike facial expression (expression-less) -chewing and swallowing difficulties -uncontrolled drooling -- usually at more advanced stages; also have impaired swallowing -changes in speech pattern -resting tremors -- tremors get better w/ mvmt -dysfxn of bowel and bladder -- often see constipation -depression priority interventions -administer medications on time -- need to take on time on schedule for it to be most effective -assess safety related to eating and fall risk -- potential for aspiration d/t problem w/ drooling and impaired swallowing -assess lung sounds and respiratory effort -engage in exercise ROM, yoga, walking programs -- tremors improve with purposeful mvmt -work with rehab team OT, PT, speech to maximize function -work with dietitian and speech to meet increased metabolic needs -- have a higher caloric need d/t energy burned w/ tremors -use alternative methods of communications -provide family with community support and coping -electric razor -high-FAT diet -encourage clothing that fosters independence (NO buttons, zippers, or snaps) med: dopaminergics/dopamine agonist = carbidopa/levodopa -withhold levodopa for 8-12 hours before admin carbidopa/levodopa -may not take effect immediately -it is a dose depending period medication - make sure they keep taking it -need to keep on regular schedule for best results -- every day, same time, around food times -avoid foods high in pyroxidine (pork, beans, beef etc) -PRO should be divided in equal parts - need to have a little PRO w/ each meal -levodopa may cause dark urine and sweat (harmless) -may cause dry mouth - institute good mouth care -take meds with food, soon after eating -change position slowly (prone to orthostatic hypotension) -increase fluids and exercise to prevent constipation - increase fiber med: ropinirole -AEs: hallucinations, drowsiness, postural hypotension -educate on slow position changes -use caution in older adults because have greater risk for AEs meds: anticholinergics: trihexyphenidyl

RA (what? + early vs. late SSAs + complications + labs + pt edu/interventions + meds)

-chronic, progressive, autoimmune d/o impacting synovial joints -joint impacted BILATERALLY -onset: 35-45 yo early SSAs -morning stiffness -joint swelling and erythema -pain with rest AND mvmt -low grade fever -fatigue -weakness -anorexia -paresthesias -muscle weak and atrophy (d/t disuse) -usually starts in hands late SSAs -joint deformities -- swan neck, ulnar deviation, nodules of fingers -moderate to severe pain -morning stiffness -severe fatigue -osteoporosis (bones easily fractured) -anemia -wt loss -subq nodules -peripheral neuropathy -vasculitis -fibrotic lung disease -sjogren's, felty's, or caplan's syndrome -renal disease -lung nodules (can impair lung fxn) labs -serum positive anti-CCP = probably have very severe RA - +ANA -- if negative than r/o RA - +rheumatic factor - +ESR - + CRP -albumin - decreased w/ inflammation -WBC elevated interventions -warm/hot morning shower to help w/ stiffness -cool compress for edema -cluster care; rest periods -control pain -assistive devices; fall risk precautions -foods high in vitamins, PRO, and iron (need nutritionally dense foods); small, frequent meals -use moist heat for stiffness and cold packs for pain -sleep in a flat, neutral position -priority assessment = PAIN CONTROL priority meds -#1 methotrexate then give antimalarials (hydroxychloroquine); NSAIDs; COX-2 inhibitors; prednisone (steroids); DMARDs complications -sjogren's syndrome - obstruction of secretory ducts; sx: dry eye, dry mouth, dry vagina; tx sx: artificial tears, KY jelly, keep mouth moist -felty's syndrome - hepatosplenomegaly; r/t vasculitis -caplan's syndrome - RA nodules in the lungs; nodules damage the surrounding tissue = problem with perfusion -secondary osteoporosis - fractures -vaculitis - organ ischemia; autoimmune disorder; inflammation of arteries can disrupt blood flow and cause ischemia; RA most commonly affects smaller arteries in the skin, eyes, and brain; monitor for skin lesions, decrease in vision, and sx of cognitive dysfxn -cervical subluxation - risk quadriplegia and respiratory compromise; can compress the spinal cord and cause quadriplegia -coping - depression

types of bone fractures

-closed or simple - not break the skin; can usually be reduced w/ sedation or pain med -complex or open or compound - disrupts skin integrity and causes open wound; surgery is needed to repair; risk for infection and compromised circulation

complications of HD + interventions

-clotting/thrombosis -- give anticoagulant (heparin -- keep protamine sulfate nearby) -hypotension -- replace fluid with IV solution or blood; decrease the rate of dialysis; lower the HOB; d/c if pt unresponsive -anemia -- give erythropoietin, monitor hgb + RBC level, monitor for hypotension + tachycardia, give blood -air embolism -infection -- sterile technique -disequilibrium syndrome = rapid decrease in BUN and fluid volume (hypovolemia) -- assess for cerebral edema or increased ICP; report UO < 1mL/kg/hr; if BP decreases then position on back w/ legs up -steal syndrome = fistula decreases arterial blood flow to areas below fistula; sx = cold/numb fingers, gangrene -muscle cramps, HA -bleeding -dysrhythmia, angina -pseudo aneurysm = d/t repeated needle punctures at same site

pleurisy (what + SSAs)

-complication of pneumonia -caused by inflamed parietal and visceral pleurae rubbing together -characterized by stabbing pleuritic chest pain that increases on inspiration -will have pleural friction rub = squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers -need to be reported to HCP

what are rhonchi

-continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger airways -NOT a classic sx of HF

what to know for buddhism

-contraception is allowed -reincarnation -need a quiet, calm, and peaceful envi -chanting is common -no alc -many are vegetarians

retrograde pyelogram (what? + pre-op + post-op + complications)

-contrast dye injected into bladder/ureter to see urine flow; NOT a vascular image -retrograde = reverse -do not worry about contrast dye getting into vascular system unless IV pyelography is specified pre-op -bowel-prep to clean out colon -possible sedation -NPO after midnight -- may have fluids -pt in lithotomy position -have emergency equip available during post-op -pt goes to PACU -monitor airway, breathing, changes in VS, changes in UO -s/sx bladder puncture = severe pain including abd pain, N/V -urine may be pink or tea-colored but no gross bleeding expected -notify HCP of obvious clots and decreased/no UO or if pt has fever or elevated WBC (infection)

SSAs of bowel strangulation

-cut off blood supply to bowel -medical emergency -can result in ischemia + obstruction which can lead to necrosis + perforation SSAs -absent bowel sounds -abd distention -N/V -pain -fever -tachycardia

types of lower UTIs + SSAs + pt edu

-cystitis: most common UTI; bladder inflamed and infected -urethritis: urethral walls inflamed and infected -prostatitis: inflammation and infection of prostate; common problem w/ BPH SSAs -frequency, urgency, small amt urine voided, dysuria, hematuria, nocturia -fever, chills, malaise -lower back pain, abd discomfort -perineal itching; urethral discharge -U/A = increased PRO + WBC, presence of leukoesterase, casts, and bacteria, nitrates present w/ e.coli pt edu -increase fluids (up to 3L); increase calories -avoid caffeine, carbonated drinks, and tomatoes (increase bladder spasms) -drink cranberry juice -cotton underwear -urinate q3-4hrs instead of waiting for bladder to be full; empty bladder as soon as have urge to void

SSAs of absence seizure

-daydreaming episodes or brief (<10 seconds) staring spells -absence of warning and postictal phases -absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) -unresponsiveness during the seizure -no memory of the seizure

SSAs that indicate need for suctioning

-decreased o2 sat -altered mental status = irritability, lethargy -increased heart rate -increased respiratory rate -increased work of breathing = flared nostrils, use of accessory muscles -ABS =crackles, wheezes, rhonchi -pallor, mottled, or cyanotic skin coloring

what is cystic fibrosis

-defective protein responsible for transporting sodium and chloride causes the secretions from the exocrine glands to be thicker and stickier than normal -sticky respiratory secretions lead to the inability to clear the airway and a chronic cough -pt eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections. -also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax -- sx: sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in o2 sat -pt will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent intervention

info about DASH diet

-diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats -include fresh fruits and vegetables, and whole grains in the daily diet -choose fat-free or low-fat dairy products -choose meats lower in cholesterol (fish, poultry) and alternate protein sources (legumes) instead of red meats -limit intake of sweets, foods high in sodium (potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat -high in fruits + veg, moderate in low-fat dairy, low in animal PRO

expected SSAs of HF

-dilutional hyponatremia d/t excess fluid and can cause fatigue and HA

pt edu for chronic diverticulosis to prevent future episodes of diverticulitis

-diverticulosis linked to constipation so focus on avoiding constipation -high-fiber diet (whole-grains, fruit, veg) -good fluid intake -regular exercise -may need fiber supplement like psyllium -avoid high-FAT foods

how to apply condom catheter

-do NOT retract foreskin

movement + positioning of pt w/ stroke

-do NOT use weak arm to move up in bed -dress weak side first -when walking, assist pt by walking on the WEAK side -position wheelchair on STRONGER side -transfer the pt toward the stronger (not the weaker) side; if the client is weak on the left side, ask the client to pivot on the right side

labs + dx for CKD

-early UA = hematuria, proteinuria, changes in SG (decreased or fixed) -late UA = osmo increases -↓na (< 135) -↓ca (norm: 8.8 - 10.3; SSAs = TWITCH) -↓pH (< 7.35) -- metabolic acidosis -↑k (> 5) -↑phosphorus (norm: 2.5 - 4.5) -↑mg (norm: 1.6 - 2.4) -↓RBCs,↓hct/hgb (d/t anemia) -to determine stage of CKD, a urine collection of 3 hours to 24 hours is usually done to assess creatinine clearance -give mucomyst and lots of fluids after give contrast as long as have good kidney fxn -serum creatinine does not increase until at least 50% of kidney fxn is lost -decreased urea nitrogen levels w/ liver and kidney dysfxn -BUN is not always elevated w/ kidney disease and is not the best indicator of kidney fxn -creatinine clearance affected by age, gender, height, wt, diet, and activity level; race?

nursing interventions to control/decreased IICP

-elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion -administering stool softeners to reduce the risk of straining (eg, Valsalva maneuver) -managing pain well while monitoring sedation -managing fever (eg, cool sponges, ice, antipyretics) while preventing shivering -maintaining a calm environment with minimal noise (eg, alarms, television, hall noise) -ensuring adequate oxygenation -hyperventilating and preoxygenating the client before suctioning; reducing CO2 (a potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP -avoid performing interventions in clusters

autonomic dysreflexia (what + causes + prevention + SSAs + interventions + meds)

-emergency -SCI at T6 or higher triggered by noxious stimuli at T6 or below -neurologic emergency -- prompt tx or could have HTN stroke -can happen at any time -common causes: distended bladder -- or kink in catheter, constipation, fecal impaction, pressure ulcers, full bladder, UTI, infection, ingrown toenail, long bone fractures -prevention: bowel/bladder distention, manage room temp, monitor for early VS changes, no restrictive clothes, cath bag not too full SSAs -above level of injury (vasodilation) = sudden HTN, pounding HA, bradycardia, flushed face, JVD, diaphoresis, apprehension, blur vision, see spots, nasal congestion -below level of injury (vasoconstriction) = pallor, cool, no sweating, goosebumps interventions -#1 = SIT UP and lower legs -#2 = ID cause -- kinks in cath, cath ASAP if bladder distended, remove impaction (use anesthetic ointment), loosen constrictive clothes -train pt to have bowel mvmt at same time each day -- priority is diet -monitor BP q10-15min -call HCP or RR meds -vasodilators to lower BP = hydralazine, nitroprusside, nitrates (NTG), minoxidil -CCB (class 2) to help lower BP = nifedipine, amlodipine, felodipine, nicardipine (NOT verapamil or diltiazem bc will further lower HR) -prophylactic med if have AD frequently = alpha-blocker (prazosin, "-sin")

SSAs of acute close-angle glaucoma

-emergency -obstruction of outflow of aqueous --> IIOP SSAs -rapidly progressing visual impairment -severe pain in and around eye -blur vision w/ dilated pupils -N/V

BPH (what? + SSAs + labs/dx + interventions + therapeutic procedures)

-enlargement of prostate w/ age causing urinary dysfxn -impair outflow of urine --> susceptible to infection and retention --> kidney infections SSAs -urinary frequency, urgency, incomplete emptying of the bladder -nocturia -diminished force of urine stream -straining, hesitancy, dribbling -painless hematuria -urinary stasis and persistent urinary retention leads to frequent UTIs labs -prostate specific antigen > 4ng/ml monitor -U/A and culture -- elevated WBCs, bacteria if have UTI -CBC -- RBCs possibly decreased d/t hematuria -BUN/creatinine elevated d/t kidney damage dx procedures -digital rectal exam - will show enlarged smooth prostate -transrectal u/s - used to r/o prostate cancer interventions -frequent ejaculation to decrease size of prostate -avoid large amounts of fluid -urinate when feel urge -decrease caffeine and alcohol -avoid anticholinergics, decongestants, and antihistamines b/c decrease bladder tone -initially tx with meds and life style modifications -med: tamsulosin therapeutic procedures -transurethral needle ablation - low level radiation to shrink prostate -prostatic stent - placed to keep urethra patent -transurethral microwave therapy - heat applied to prostate to decrease size -transurethral incision of the prostate - incision to prostate to remove constriction of urethra -transurethral resection of the prostate (TURP)

NGT (equipment needed + insertion procedure + nurse mgmt + check for placement + "NGTUBE")

-equip: 60mL syringe, pH indicator strips -check placement q4hr -- XRAY, aspirate gastric contents (pH < 6), do NOT inject air bolus -measure output, empty container, or mark w/ time and date q8hr (record + note characteristics) -maintain slack in tubing for safe pt mvmt in bed -edu pt to call for assistance when getting out of bed -check suction machine q2hr -increase HOB w/ feed to avoid aspiration -be alert for fever, chest pain, tachypnea, labored breathing, diminished breath sounds over affected area -document: reason, type and size of NGT, describe and amt aspirated, how pt tolerated procedure -checking initial placement: XRAY -checking subsequent placement: aspirate and check pH (stomach pH = 1.5-4) "NGTUBE" -N: never give w/o checking XRAY/placement -G: give warm/room temp fluids and feeds -T: turn to right side -U: use gravity -B: be sure to aspirate gastric contents -E: end w/ water and chart

SSAs to report for pt w/ chest tube

-excessive drainage = > 100 mL/hr -excessive frank red drainage = hemorrhage -s/sx infection -air or fluid in chest = diminished breath sounds

risk factors for SLE

-female -age 15-40 -latino, AA, asian -long term use of chlorpromazine, hydralazine, isoniazid, procainamide -exposure to mercury and/or silica -exposure to sunlight

how to perform colostomy irrigation

-fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp -hang the container on a hook or intravenous pole -instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma -lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place -slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes -clamp the tubing if cramping occurs, until it subsides -once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet

family disaster kit should include...

-flashlight w/ extra batteries -battery-powered radio -nonperishable foods -1 gallon of water per person -basic first-aid supplies -matches in waterproof container -liquid bleach -emergency blanket and/or sleeping bag and pillow -rain gear -clothing and sturdy footwear -rx and OTC meds -toiletries -important documents and money

pericarditis (SSAs + interventions/tx)

-fluid accumulates within the pericardial sac and compresses the heart -can be a complication of an MI and respiratory infections SSAs -sharp pleuritic chest pain; substernal precordial pain that radiates to left side of neck, shoulder and back -pain worse w/ breathing (mainly inspiration), coughing, swallowing, and supine -pain relieved by sitting up and leaning forward -ST elevation is common and not worry-some -SOB -tachycardia, increased temperature -pericardial friction rub -- auscultated at left lower sternal border tx -YES = combo of NSAIDs or aspirin plus colchicine (anti-inflammatory), + give abx -NO = ASA or anticoagulants bc may increase possibility of tamponade -keep the HOB elevated -apply heat to the area -eval CO

interventions for SIADH

-fluid restriction to <1000 mL/day -oral salt tablets to increase serum sodium -hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations -vasopressin receptor antagonists (eg, conivaptan) -maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration

interventions for pt w/ AKI

-fluids + electrolytes depend on phase -want pt on bed rest bc creatinine is the biproduct of muscle use and want to reduce muscle use to decrease creatinine production -give mucomyst and lots of fluids after give contrast to protect kidneys -daily wt; accurate I/O -cardiac monitoring for possible arrhythmias due to hyperkalemia -assess for s/sx FVE -report UO < 0.5mL/kg/hr for 2hrs -decrease PRO intake

foods that help w/ teeth integrity

-fresh fruit + veg -nuts -cheese -plain yogurt

best and quickest way to decrease potassium level

-give IV 50% dextrose and regular insulin -if pt has ECG changes from hyperkalemia then need to give IV calcium gluconate first to stabilize cardiac muscle -furosemide takes time to be effective so would not be best intervention

risk factors for pressure injuries

-greatest risk factors = older, limited mvmt, long bone (femur) or hip fractures, quadriplegia, critically ill -impaired cognitive fxn (ex: dementia) -incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, infection -positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients

muscular dystrophy (what? + mgmt)

-group of genetic disorders caused by protein deficiency in the muscle membranes -progressive muscle weakness with eventual inability to control voluntary movement -major cause of death = respiratory failure r/t respiratory muscle weakness mgmt -respiratory therapist: respiratory dysfunction related to respiratory muscle weakness -PT/OT -multi-focal care: Involves the entire health care team -relief from chronic pain -protection from injury -financial and home care -bowel and bladder control -goal: provide supportive care to make patient comfortable -no drugs except for steroids have been found to slow the disease progression

heparin induced thrombocytopenia (HIT)

-heparin causes a decrease in platelet count because of the formation of a complex with platelet factor 4, IgG antibodies against platelet-heparin complex that the spleen proceeds to destroy 2 forms -first form (platelets >100,000) normalizes within a few days -second form (platelets <40,000) is a life-threatening autoimmune process that requires immediate heparin discontinuation

diet for pt w/ CKD

-high BUN = need to decrease PRO intake -can increase PRO intake once start dialysis -increased CHO for energy -low-na, low-k, low-p, low-mg -increased iron and folic acid foods (d/t anemia) -moderate fat -increase calcium intake -increase vitamin d rich foods -increase bran and fiber -dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges, coconuts, watermelons, and avocados) contain high potassium levels -dairy products are also high in phosphorus

TPN (what? + contains + how give + care/maintenance)

-hypertonic solution -contains: dextrose, PRO, elect, minerals, trace elements, insulin -admin via central venous device -- PICC, subclavian, internal jugular vein care/maintenance -verify w/ other nurse b4 give -give via infusion pump -monitor: daily wt, I/O, sx infection, glucose q4-6hr -change dressing q48-72hr -change IV tubing and fluids q24hr -if unavailable, admin dextrose 10% in water to prevent hypoglycemia

how to care for burns

-if dry chemicals are present on skin or clothing do NOT wet them -brush off any dry chemicals present on skin or clothing -liquid chemical burn -- need to wash off -cover the pt and maintain NPO status

what is dunlap traction

-immobilize the upper arm in the treatment of contracture or supracondylar fracture of the elbow -mechanism uses a system of traction weights, pulleys, and ropes and may be accompanied by skin traction

pt edu for extracorporeal shock wave lithotripsy (ESWL)

-increase fluid intake to help flush out the kidney stone fragments -expect some bruising and pain of the back and/or flank of the affected side -analgesics may be required -expect to see blood in the urine (hematuria) -urine color should progress from bright red to pink-tinged during the first several hours -hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) -report any symptoms of infection (eg, fever, chills) to HCP

what is polycythemia

-increase of RBCs, WBCs, + platelets -SSAs = HTN, thrombosis and possible necrosis -- bc blood thick and sluggish -elevated blood count and serum osmo on labs -elevated hct/hgb -risk for developing blood clots d/t increased blood volume and viscosity -tx = phlebotomy (take away blood bc pt has too much) -Itching is a common and frustrating symptom of PV. Reducing water temperature, using starch baths, and patting the skin dry rather than rubbing vigorously are beneficial. -preventive measures (eg, elevating the legs when sitting) and symptoms to report. They should take measures to prevent dehydration, and avoid iron-rich foods and hot showers/baths.

cholecystitis (patho + labs + risk factors + SSAs + pt edu + call HCP)

-inflammation of gallbladder -risk factors = 4Fs -- female, fat, fertile, forty; low-cal, low-PRO diet, high cholesterol/triglycerides, rapid wt loss, genetics, aging -labs = increased WBC, bilirubin, AST, LDH, serum cholesterol, and amylase/lipase SSAs -sharp RUQ pain radiating to right shoulder -pain after eat high-fat or high-volume meal -pain causes tachycardia, pallor, diaphoresis -murphy sx -- pain w/ deep insp w/ palpitation under right ribcage -rebound tenderness -- pain once relieve pressure -N/V, anorexia -dyspepsia, belching (eructation), flatulence -fever -jaundice/clay-colored stools, dark urine, steatorrhea (most common w/ chronic) -feel abs fullness -older adults: confused, localized tenderness, no pain or fever -biliary colic -- tachycardia, pallor, diaphoresis, extreme exhaustion = HCP -wt loss d/t extreme pain when eat lifestyle changes/ pt edu -low-fat diet (KNOW FOODS HIGH IN FAT TO AVOID) -wt reduction -- daily wt -avoid of gas-forming foods (beans, cabbage, cauliflower, broccoli) -small frequent meals -admin fat-soluble vitamins (A, D, E, K) and bile salts (help break down bilirubin and dissolve gallstones) -diet should be high fiber and low fat, avoid gas forming foods -morphine for severe pain relief but may cause sphincter of oddi spasms

peritonitis (SSAs + interventions)

-inflammation of peritoneum + lining of abd cavity SSAs = "PERITONITIS" -P: pain that decreases with flexion of the right hip or increases with coughing or mvmt; pain in abd is sharp and constant; pain that has progressed to LUQ -E: eval for hiccups; emergency -- HCP -R: rigid, board-like, and distended abd w/ rebound tenderness -I: implement NPO; insert NGT to decompress -T: tachycardia -O: observe for absent/decreased bowel sounds -N: N/V, anorexia, diarrhea -I: increased WBC >/= 20,000 -T: tense, guarding abd, rigid muscles -I: increased temp -S: s/sx FVD interventions -emergency = HCP -NPO -NGT to decompress -IVF and abx as-rx -strict I/O and daily wt -fowler or semi-fowler; fetal position -HH and strict asepsis interventions (THORNS) -T: TCDB -H: heavy life no for 6 weeks -O: O2 -R: rest, resume home activities slowly as tolerated -N: NG suction, NPO -S: semi-fowler

ankylosing spondylitis (what + pt edu)

-inflammatory disease affecting the spine, has no known cause or cure -characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility -low back pain and morning stiffness that improve with activity are the classic findings -involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation pt edu -promote extension of the spine with proper posture, daily stretching, and spine-stretching exercises (eg, swimming, racquet sports) -stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications -manage pain with moist heat and NSAIDs -take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility -rest during flare-ups -sleep on back on firm mattress

HTN crisis (interventions + goal + SSAs + possible complications)

-initial goal: decrease the MAP by no more than 25% or to maintain MAP at 110-115 -- pressure can then be lowered further over a period of 24 hrs -important to lower BP slowly bc too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys which may result in stroke, renal failure, or MI tx/interventions -IV vasodilators (ex: nitroprusside sodium) -IV nitrates or anti-HTN (ex: nitroprusside, labetalol, nicardipine) -prioritize neuro assessment as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention -continuous monitoring of BP, telemetry, UO -assess for vision changes (eg, blurred vision, blind spot) or papilledema, as these are signs of progressing HTN crisis SSAs -BP >/= 180/ >/= 120 -hypertensive encephalopathy = severe HA, confusion, N/V, seizure possible complications -high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, HF, papilledema)

steps for abd exam

-inspect -auscultate -percuss -palpate

cystoscopy (what? + pre-op + post-op)

-invasive procedure -scope to view bladder + ureter -used to remove calculi from urethra, bladder, and ureter and to tx lesions of the bladder, urethra, or prostate pre-op -NPO if given general anesthesia -give cathartics/enemas as-rx -deep breathe to relieve bladder spasms -monitor for postural hypotension -lithotomy position post-op -urine may be pink or tea-colored but no gross bleeding expected -look for leg cramps d/t lithotomy position -assess for back pain or abd pain -expect pink-tinged urine, frequency, dysuria, and abd discomfort for up to 48 hrs -increase fluid intake, avoid alcohol and caffeine -take a mild analgesic and tub/sitz bath to relieve discomfort -notify HCP = inability to void, gross hematuria, blood clots, fever, chills, severe pain

compartment syndrome (SSAs + interventions)

-irreversible if persists beyond 4-6hr -occurs when pressure w/in one or more of the muscle compartments of extremity compromises circulation resulting in an ischemia - edema cycle -increased pressure within one or more compartments reduces circulation to the area. -tx = fasciotomy SSAs -- *CHANGE IN 6Ps** -pain - unrelieved w/ elevation or meds or intense pain w/ passive stretch -pallor, cyanosis -paresthesia -- tingle/numb = indicates early nerve ischemia -paralysis/immobility of digits -late: neuromuscular damage in 4- 6 hr w/o tx -compartment pressure >8 mmHg -edema -unequal pulses, flexed posture -tense muscle swelling -tissue necrosis = paresis/paralysis -pulses weaken but rarely disappear -affected area is usually palpably tense interventions -HCP ASAP -loosen constrictive dressings -cut cast on one side -may have to do fasciotomy - surgical incision through subcutaneous tissue and fascia to relieve pressure and circulations -post Fasciotomy: sterile packing for open wounds -prevent complications: observe for infection, renal failure, shock - hemorrhage

meds to tx hyper-K

-kayexalate -50% dextrose w/ insulin -calcium gluconate -bicarb -loop diuretic

pt edu w/ IBS

-keep a daily record of symptoms, dietary intake, and stress level to help identify IBS triggers -limit intake of gas-producing foods: legumes (beans), cruciferous vegetables (cabbage, broccoli), and foods containing fructose (eg, honey, apples) -practice stress reduction techniques (meditation, yoga) -perform regular exercise -reduce daily caffeine intake -do NOT fast or otherwise drastically reduce oral intake (ex: clear liquid diet) even during periods of moderate or severe sx

pancreatitis (labs/dx + risk factors + SSAs + interventions + diet + call HCP)

-labs: decreased ca (norm: 8.5-10.2), decreased mg (norm: 1.5-2.5), increased amylase/lipase, AST/ALT, bilirubin, WBCs -triggers: high fat intake, alcohol, gallstones SSAs -sudden severe epigastric pain that radiates to back, left flank, or left shoulder -pain worse after meal and when lying down -no pain relief w/ vomiting -small decrease in pain w/ fetal position -N/V, wt loss -hyperglycemia -steatorrhea (fatty, yellow, foul-smelling stools) -turner sx (left flank) and cullen sx (periumbilical) -- usually only in severe cases -sx inflammation and peritonitis -trousseau sx (inflate BP cuff = flex fingers/wrist) -chvosteck sx (CN7--tickle side of face = twitch) -serious complications: hyperglycemia, hypovolemia, latent hypoxia, ARDS, hypocalcemia interventions -NPO!!! til pain free + NGT!!! -give IVF to combat FVD -give IV opioids for pain (do NOT give meperidine) -watch for sx of abscess formation = high fever, leukocytosis, increasing abd pain = call HCP ASAP + start abx -monitor INR/PTT, glucose, ca/mg, albumin -monitor resp status q4-8hrs -HCP -- pt beginning to resume oral food intake has N/V/D -limit stress/stimuli (quiet, dark, comfy envi) -sitting or fetal position -bed rest -close door during meals -meds: opioids, h2 block, PPI, abx, pancrealipase (viokase), anticholinergics diet -NPO til pain gone and bowel sounds are present = need TPN/banana bag -small frequent meals -bland, low-FAT, high-PRO, mod-CHO -avoid caffeine, chocolate, and alc -begin w/ clear liquids after pain relief -avoid gastric stimulants (ex: spices) -NGT (assess pt frequently for return of peristalsis by asking pt if have passed flatus or had a stool -- return of BS not reliable indicator)

how to prevent contractures after amputation?

-lie prone several times each day -avoid sitting in a chair for ≥1 hr -ROM -PT teach exercises to prevent -do NOT place pillow under knee -do NOT elevate the limb -use figure 8 compression bandage -bandage should be worn at all times until the residual limb is healed -prone position with hip in extension for 30 min 3-4x/day

toxic megacolon (what? + SSAs)

-life-threatening complication of IBD -- most frequently w/ UC SSAs -abd pain/distension -bloody diarrhea -fever -s/sx shock = hypotension, tachycardia -REPORT TO HCP ASAP

thing that could cause BUN to increase

-liver or kidney disease -dehydration, decreased renal perfusion -high PRO diet -infection -stress -steroid use -GI bleed

things increase risk for hepatic encephalopathy + need to be reported to HCP

-low serum potassium -high PRO intake -GI bleeding -constipation -hypovolemia -infection

pt edu w/ ulcerative colitis

-low-residue, high-protein, high-calorie diet -supplemental vitamins and minerals -small, frequent meals -at least 2000-3000 mL/day of fluids -avoid caffeine, alcohol, and tobacco

how to calculate glasgow coma scale

-lowest = 3 -highest = 15 -8 = intubate

what to know for judiasm

-males not allowed in delivery room -yes circumcised -someone stays w/ body at all times after death -food needs to be kosher -milk and meat cannot be served at same meal or prepared on same dishes -no pork or shellfish -do not use electrical appliances during the sabbath

what to know for hinduism

-males not circumcised -thread placed around wrist/neck -vegetarian encouraged -- usually no beef or pork -right hand used for eating and left hand used for toileting and hygiene -personal hygiene very important

central venous pressure (what? + norm + meaning of abnorm levels)

-measurement of right ventricular preload (volume within the ventricle at the end of diastole) -reflects fluid volume problems -norm = 2-8 mm Hg -elevated = right ventricular failure or fluid volume overload

rhabdomyolysis (what? + SSAs + interventions)

-medical emergency -caused by muscle injury that releases myoglobin into the bloodstream -occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma -acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability SSAs -dark, oftentimes bloody urine, oliguria, and fatigue interventions -#1 priority = admin large IV bolus to preserve kidney fxn -pain and sx mgmt -get cardiac monitoring

complications after endovascular abd aortic aneurysm repair

-minimally invasive procedure where aortic graft is placed tru femoral artery -no adb incision required -renal artery occlusion can occur due to graft migration or thrombosis so need careful monitoring of UO and kidney fxn -monitor the puncture sites in the groin area for bleeding or hematoma -palpate and monitor peripheral pulses -report sx of graft leakage or separation = ecchymosis of groin/penis/scrotum/perineum, increased abd girth, tachycardia, weak/absent peripheral pulses, decreasing hct/hgb; increased pain in the pelvis/back/groin, decreased UO

anastomotic leak (what + SSAs)

-most common complication w/ bariatric surgery + can be life threatening SSAs -- need to report to HCP ASAP -increasing back, shoulder, and/or abd pain -restlessness -tachycardia -oliguria -s/sx of severe abd pain w/ s/sx sepsis

fat emboli (SSAs + interventions)

-most common complication w/ long-bone fracture SSAs -earliest sx = altered mental status -high RR, dyspnea -high HR, chest pain -high temp -hemoptysis (blood in vomit) -confusion, anxiety -hypoxia -late sx = petechiae over neck, upper arms, chest, abd -respiratory distress syndrome (eg, dyspnea, tachycardia, sudden and worsening chest pain, hypoxemia, restlessness, anxiety) interventions -report ASAP -bedrest -hydration w/ IVF -prevent hypovolemic shock -analgesia -O2 -blood transfusions if needed -minimizing mvmt of a fractured long bone and early stabilization of the injury with surgery reduces the risk for fat embolipain exacerbated by weight-bearing, crepitus, morning stiffness subsiding within 30 minutes, decreased joint mobility and range of motion, and atrophy of supporting muscles

pre-op + post-op paracentesis

-needle aspiration of ascitic fluid from abdominal cavity; relieves abd pressure from fluid build-up pre-op -assess albumin, PRO, glucose, amylase, BUN/creat -void b4 -assess wt + abd girth and compare to post-op -***POSITION SITTING UP DURING -- high-fowler or as upright as possible post-op -maintain pressure after --> dry sterile gauze -lay on UNAFFECTED side for 1-2hrs -monitor elect, wt, abd girth (1L fluid removed = 1 kg or 2.2 lbs) -temp q4hr x 48hrs -I/O q4hrs -give albumin, IVs, diuretics -- per order -monitor for s/sx hypovolemia, infection, change LOC -maintain bed rest per protocol -sx bladder perforation = decreased/no UO, pain -equip: tray and vacuum bottle (maintain sterility) -may need to give albumin after bc removed w/ fluid so check labs

location of pain for nephrolithiasis, ureterolithiasis, and urolithiasis

-nephrolithiasis = stones in kidney; flank pain -ureterolithiasis = stones in ureter; flank pain that radiates to abd, scrotum, testes, or uvula = calculi in ureter or bladder -urolithiasis = stones in urinary tract; severe colicky pain (10/10) -flank pain = stone in kidney or ureter -flank pain that radiates to and, scrotum, testes, or vulva = stone in ureter or bladder

care for nephrostomy tube

-never clamp -irrigate only w/ rx for 10mL of 0.9% NaCl if there is little to no output

admin of K (how + rate)

-never via IV push, bolus, or IM -need to always dilute -more diluted for peripheral lines then central lines -no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line -no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line -use pump for IV admin -admin through large bore needle -d/c asap if infiltration occurs

d/c edu for pt w/ pneumonia

-no OTC cough suppressants -cool mist humidifier at night -do CDB + IS at home -drink 1-2 L/day -notify HCP of any increase in sx (ex: SOB, cough, sputum production, chest pain, fever, confusion) -eat a balanced diet -increase activity slowly over about 2 weeks + take rest periods PRN

what to know for mormon

-no alc, coffee, or tea -fasting required 1x/month

pt edu post-op pacemaker + ICD implant

-no lift affected arm above shoulder until approved to by HCP to prevent dislodgement of lead wires on the endocardium -ICD firing may be painful -no long-term restrictions on traveling or driving -if pt experiences repeated ICD shocks w/o dysrhythmia resolution, the nurse should promptly obtain a manual external defibrillator and initiate measures to prevent hemodynamic instability and cardiac arrest

what would cause albumin levels to change

-norm: 3.5-5.0 -decreased w/ malnutrition, alcoholics -low = FVE, ascites, edema, wt gain

best indicator of successful interventions

-objective criteria -an objective measurable result that can be correlated with the intervention

functions of lobes of brain

-occipital lobe = receives visual images -frontal lobe = controls executive function and personality -temporal lobe = receives auditory input -parietal lobe = receives sensory input

neurogenic shock (SSAs + interventions)

-occurs from vasodilation soon after spinal injury SSAs -hypotension -bradycardia -pink and dry skin intervention -give isotonic fluids to tx hypotension to maintain vital organ perfusion

pt edu for small bowel capsule endoscopy

-only water 8-10hr b4 -NPO 2hr b4 -abd marked for placement for sensors -admin capsule w/ full glass of water -resume normal diet 4hr after swallow pill

risk factors for pelvic inflammatory disease (PID)

-oral contraceptive use and age at menarche are not associated with an increased risk of PID -most common causes are gonorrhea + chlamydia

contact precautions (which infections/organisms? + nursing axn)

-organisms spread by direct or indirect contact w/ pt or envi/contaminated equip infections/organisms -c.diff -MSRA (and MSSA) -vancomycin-resistant enterococcus (VRE) -herpes zoster (shingles) and varicella zoster (chickenpox, smallpox) -- add airborne; until visible lesions are gone -hep A if have fecal incontinence -- until 7 days after onset of jaundice -rubella -- add droplet -herpes simplex -- until lesions crusted over -salmonella -shigellosis -staph. aureus -peds: RSV, rotavirus, head lice (pediculosis) -viral meningitis -- for infants and young children -HPV, candidiasis. gonorrhea -major abscesses of cellulitis, decubitus -PPE = N95 mask nursing axn = "PRIVATE" -P: private room or cohort w/ same organism -R: remove gown, gloves, and perform HH between patients; don upon entering room and discard b4 leave room; NO mask required -I: immediately after pt care need to perform HH w/ soap and water -V: visibly soiled contaminants (ex: stool, blood) = change gloves immediately -A: alcohol is not effective -- must do HH w/ c.diff -T: the pts w/ VRE/MRSA -- not in room w/ c.diff -E: equipment is dedicated = do NOT share *****HH w/ alcohol-based hand rubs is appropriate unless visible soiling or exposure to c.diff***** -******use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for c.diff and scabies**********

bell's palsy (what? + SSAs + interventions + meds)

-paralysis of cranial nerve VII (but may affect V and VIII) -symptoms go into remission within 3 months for most -cause is believed to be related to dormant herpes simplex 1 virus -infection or cold can trigger -once have it once at a higher risk for having it again -SSAs: cannot wrinkle brow, drooping eyelid and cannot close eye, cannot puff cheeks, drooping mouth, cannot smile or pucker priority interventions -protect the clients eye from dryness and ulceration -- may need eye patch (need to protect their eye) or eye drops; close the eye and lubricate with artificial tears and ointment -risk for aspiration: eat and drink on unaffected side; if mouth is affected it may affect eating and chewing putting that client at risk for aspiration -keep a distraction free environment during meals -facial exercises and massage -use caution when administering medication meds -corticosteroids to control inflammation -mild analgesics if pain present -nerve blocks may be used for chronic pain -gabapentin (neurontin) may be used for neuropathic pain is significant

who needs airborne precautions?

-pathogens remain infectious over long distances when suspended in air "My Chicken Has TB" -M: measles (rubeola) -- contagious 4 days b4 + after rash appears; no school or daycare until 21 days after onset of rash -C: chickenpox, smallpox = varicella -- add contact; until lesions crust over -H: herpes zoster (shingles) -- add contact; until lesions crust over -T: TB -- until 3 neg sputum cultures; only if active (not for latent TB) -SARS -- + eye protection -PPE = gown + gloves nursing axn = "AIR" -A: airborne infection isolation room -- single pt room, keep door closed, neg pressure room -I: insist that pt wears surgical mask when leave room (try and limit pt leaving room) -R: respiratory protection w/ N95 mask -NO gown -yes gloves if doing procedure but no gloves if doing something simple like VS -yes dedicated equipment

who can give consent

-patient -- competent adult -legal guardian -designated power of attorney (DPOA) -emancipated or married minor -parent of a minor -court order

modifications for CPR in pregnant women

-performing chest compressions slightly higher on the sternum -displacing the uterus to the client's left side

tumor lysis syndrome (what + SSAs + tx)

-potential complication of chemo -SSAs: hyper-K, hyper-P, hypo-Ca, severely elevated uric acid (hyperuricemia) -ca phosphate and uric acid deposits in kidney and cause renal injury tx -allopurinol can be given to decrease uric acid levels but has no impact on ca, k, or p levels -aggressive hydration, correction of electrolyte abnormalities (eg, loop diuretics, phosphate binders), and hypouricemic agents (eg, allopurinol)

refeeding syndrome (what + SSAs + prevention)

-potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism) -hypophosphatemia causes muscle weakness and respiratory failure -deficiencies in potassium and magnesium potentiate cardiac arrhythmias -aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure SSAs -rapid decline in phosphorous, potassium, and/or magnesium (PPM) -FVE -high-Na, hyperglycemia -thiamine deficiency prevention -obtain baseline electrolytes -initiate nutrition support cautiously with low-calorie feedings -closely monitor electrolytes -increase caloric intake gradually

hepatic encephalopathy (precipitating factors + SSAs)

-precipitating factors = hypokalemia, constipation, GI hemorrhage, infection SSAs -early: sleep disturbances -late: lethargy, coma -altered mental status (ask A&O questions) -presence of asterixis = flapping tremors of the hands -- assessed by having the client extend the arms and dorsiflex the wrists -fetor hepaticus = musty, sweet odor of the breath -elevated blood ammonia level

edu + meds for pt w/ gout

-primary: result from imbalance in purine metabolism; most common -secondary: can be d/t overuse of diuretics, renal insufficiency, "crash" diets, and chemotherapeutic agents -SSAs: tenderness, inflammation, erythema, warmth; severe pain pt edu -increased risk for uric acid kidney stone -maintain bed rest during acute attack -use bed cradle to keep linen elevated above affected joint -good fluid intake >/= 3L/day -limit foods high in purines (organ meats, yeast, sardines, spinach) -keep diary of triggers -NO alc -lose wt SLOWLY (rapid wt loss may trigger flare-up or increase incidence of uric acid kidney stones) meds -acute phase = NSAIDs/tylenol + colchicine -chronic tx = allopurinol, febuxostat tophi -rarely seen -can appear on outer ear, arms, fingers, and toes near the joints -can occur w/ chronic gout -hard to palpation with an irregular shape -risk for infection -skin that covers the tophi can become irritated and break the skin and drain yellow, gritty substance

SSAs + axn for fat overload syndrome

-pt receiving fat emulsion type of nutrition SSAs -fever -increased TGL -clotting problems -multi-system organ failure axn -d/c infusion -notify HCP ASAP

instructions for pt w/ scabies

-pt with scabies and all persons in close contact should receive tx with a scabicide cream applied to all skin surfaces -potentially infested belongings should be washed and dried on the hottest settings or sealed in plastic bags for ≥3 days -fumigation of living areas is not necessary

what is arthrocentesis (+ results)

-pull fluid out of synovial joint -used to dx RA + gouty arthritis -RA = fluid cloudy with a lot of PRO, increased WBC and rheumatic factor -if synovial fluid has crystals = RULE OUT RA -can take tylenol for pain -gout = will show uric acid crystals

intervention for poor dialysate flow w/ peritoneal dialysis

-r/t constipation -bowel prep b4 place PD -eat high-fiber diet and use stool softeners -make sure drainage bag is lower than pt's abd -make sure no kinks or twisting -ensure that clamps are open -turn pt to other side (reposition pt) -YES = supine or low-fowler = reduced abd pressure -NO = sit, stand, or coughing = increased abd pressure and possible leak from cath spot

disequilibrium syndrome + hypotension w/ HD (what? + SSAs + interventions)

-rapid decrease in BUN and fluid volume (hypovolemia) d/t too rapid exchange of fluid -can result in cerebral edema and IICP -most common w/ older adults and new HD pts SSAs -significant hypotension, dizzy -N/V -significant changes in LOC -seizure -agitation -anemia -severe sx = mental status change, seizure, coma -mild sx = N/V, HA, fatigue, restlessness interventions -#1 = contact HCP -#2 = decrease rate or stop dialysis -report UO < 1mL/kg/hr -position on back w/ legs up; lower HOB -notify HCP -give anticonvulsants, barbiturates, and erythropoietin PRN -give o2 -maintain patent airway -monitor VS -admin NS bolus if needed -give IVF for hypotension -- d/c dialysis if IVF does not correct low BP

malignant hypothermia (what? + SSAs)

-rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia -key s/sx = hypercapnia, muscle rigidity, hyperthermia

peak levels and when to draw

-reflect the highest concentration -oral = measure 1-2 hr after admin -IM = measure 1hr after admin -IV = measure 30min after admin

trough levels and when to draw

-reflect the lowest concentration -obtained w/in 15min b4 next dose

treatment of frost bite

-remove clothing and jewelry to prevent constriction -do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged -immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool -higher temperatures do not significantly decrease rewarming time but can intensify pain -avoid heavy blankets or clothing to prevent tissue sloughing -provide analgesia as the rewarming procedure is extremely painful -as thawing occurs, the injured area will become edematous and may blister -elevate the injured area after rewarming to reduce edema -keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings -monitor for signs of compartment syndrome

SSAs of PE

-restlessness -one-word dyspnea -SOB w/ activity -tachycardia -pleuritic chest pain -severe anxiety -ABG = respiratory alkalosis + hypoxemia

mitral valve regurg (what? + mgmt)

-result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from LV through the mitral valve into LA --> dilation of LA + reduced CO + pulmonary edema -pts are often asymptomatic but are instructed to report any new symptoms indicative of HF (dyspnea, orthopnea, wt gain, cough, fatigue) which require immediate intervention -LA enlargement can also result in afib (sx: palpitations)

osteomalacia (what? + pt edu)

-reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed pt edu -increase intake of ca, phosphorus, and vit d

what is ventricular bigeminy

-rhythm in which every other beat is a PVC

how to collect sputum culture

-rinse the mouth with water before collecting sample -avoid touching the inside of the sterile container or lid -inhale deeply several times and then cough forcefully -assume a sitting or upright position -collect sample early in AM after wake-up

PAD vs. PVD (risk factors + SSAs + interventions

-risk factors: smoking, obese/sedentary, DM, hyperlipidemia, alcohol/illicit drug use PAD SSAs -intermittent claudication -diminished pulses -non-healing ulcers on toes -shiny, hairless extremities -thick brittle nails -gangrene interventions -lower extremities below the heart when sitting and lying down - improves arterial blood flow -engage in moderate exercise (30- to 45-min walk, 2x day) -daily skin care = application of lotion - prevents skin breakdown from dry skin -maintain mild warmth (eg, lightweight blankets, socks -stop smoking, avoid tight clothing and stress -take prescribed medications (vasodilators, antiplatelets) -no heating pad PVD SSAs -brown, hard extremities -ulcers on inside of ankle

PICC line (what? + nursing care)

-same as central catheter -inserted via the cephalic or basilic vein and terminates in the SVC -indicated for admin of noxious medications (parenteral nutrition, chemotherapy), for long-term IV therapy, or in pt w/ poor venous access nursing care -aseptic technique and routine care -sterile dressing changes q48hr + immediately if dressing is loose/torn, soiled, or damp w/ gauze dressing or 7 days w/ transparent semi-permeable dressing (biopatch) -flushing the line b4 and after med admin -blood pressures/venipunctures on unaffected arm -inspect the insertion site for sx infection and dressing integrity -all infusing meds (except vasopressors) must be paused BEFORE drawing blood from the PICC to prevent false interpretation of the pts serum levels -do NOT delegate PICC line dressing change to LPN

vit b12 deficiency (who seen w/ + SSAs + how prevent)

-seen w/ vegans -b12 foods = animal products -chronic deficiency may cause megaloblastic anemia and neurological sx SSAs of chronic deficiency include -peripheral neuropathy (eg, tingling, numbness) -neuromuscular impairment (eg, gait problems, poor balance) -memory loss/dementia (in cases of severe/prolonged deficiencies)

peritonsilar abscess (what + SSAs +axn)

-serious complication that can result from tonsillitis or pharyngitis SSAs -fever -"hot potato" (muffled) voice -trismus (inability to open the mouth) -pooling of saliva (drooling) -deviation of the uvula to one side -can progress to life-threatening airway obstruction (dysphagia, stridor, restlessness) -need to assess pt ASAP bc life-threatening

myxedema coma (what? + SSAs + interventions)

-severe hypothyroidism causing decreased LOC SSAs -key sx: hypothermia, bradycardia, hypotension, hypoventilation -hyper- or hypotension with narrow pulse pressure -decreased mental status, psychosis, seizure, coma -nonpitting edema of hands, face, tongue -pericardial effusion -hyponatremia + hypoglycemia -possible concurrent adrenal insufficiency or hypothalamic/pituitary dysfunction interventions -#1 priority = oxygenation + airway = emergency trach intubation and mechanical vent if pt showing sx of resp failure = slow or shallow breathing, low o2 sat -IV levothyroxine

YES + NO delegate to LPN/PN

-should delegate care of stable clients with expected outcomes YES -monitor findings (as input to the RN's ongoing assessment) -reinforce pt teaching/edu from a standard care plan -trach care + suctioning -NGT: insertion, check patency, admin enteral feed -insert urinary catheter -calculate and monitor IV flow rate -admin IVPB meds -sterile = specimen collection + dressing change -meds: subq, oral, IM, inhaled -perform ostomy care -collect data + determine normal vs. abnormal finding (ex: auscultating breath sounds, observing for accessory muscle use) BUT evaluation of the collected data (ex: determining the pt's response to a bronchodilator medication) is the responsibility of the RN, as it requires use of the nursing process -can delegate most med admin, pt monitoring, edu reinforcement, and routine procedures -specific assessments = lung sounds, bowel sounds, neurovascular checks -document observations + interventions -ex: LPN may determine that a client's colostomy stoma is an abnormal color whereas the RN synthesizes assessment findings (eg, color, temperature, capillary refill) to determine the quality of tissue perfusion -"monitor" NO -unstable or acute care pt -initial teaching -nursing process = ADPIE -IV meds; continuous IV drug infusions -alert or call another department -- RN needs to do this -*evaluation*

osteoporosis (what? + interventions + meds)

-skeletal disease characterized by low bone mass (osteopenia) and deterioration of bone tissue -clients prone to fractures -osteoclastic > osteoblastic (bone resorption > bone building activity) interventions/meds -exercise - key in prevention of osteoporosis; also for management of osteoporosis -physical therapy -meds: calcium and vitamin D supplements, bisphosphonates, or estrogen agonist/antagonist

pt edu post-CABG

-smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise -encourage a daily shower as a bath could introduce microorganisms into the surgical incision sites -surgical incisions are washed gently with mild soap and water and patted dry -incisions should not be soaked or have lotions or creams applied as this could introduce pathogens -light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP -lifting, carrying, and pushing heavy objects are isometric activities -- HR + BP increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge -gradually resume activity and possibly participate in a cardiac rehabilitation program -no driving for 4-6 weeks or until the HCP approves -if able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity -call HCP = chest pain or shortness of breath that does not subside with rest, fever >101 F (38.3 C), redness, drainage, or swelling at the incision sites

axn for wound dehis + evisceration

-stay with the client and have someone bring sterile supplies -notify the HCP -make the client NPO in preparation for emergency surgery -place the client in low fowler's position with knees slightly flexed -cover viscera with sterile dressings saturated in NS solution -assess vital signs and monitor for signs of shock

laparoscopic nissan fundoplication (LNF) (what? + post-op/edu)

-stomach wrapped around esophagus to reinforce the fxn of the LES -commonly used in hiatal hernia repair -standard surgical tx for severe GERD -post-op complications: temporary dysphagia (watch for aspiration), gas bloat syndrome (difficult belching to relieve distention), atelectasis/pneumonia (watch resp. fxn) post-op/pt edu -avoid offending foods, large meals, eating before bed, tight clothing -upright after eat -4-6 small meals/day -lose wt -elevate HOB 15.2-20.3 cm (6-8in) w/ blocks -soft diet for 1 week and no tough foods, soda, raw veg -anti-reflux meds as-rx for at least 1 month -no drive for 1 week -walk daily but no heavy lifting -wash incision with soap and water, rinse well, and pat dry -small dressing = remove 2 days after; steri-strips = remove 10 days after -support incision during mvmt and coughing to avoid strain on sutures

thyroid storm (what + cause + SSAs)

-sudden severe increase in thyroid hormone -occurs when pt w/ hyperthyroidism (grave's disease) experiences a stressful event (trauma) SSAs -rapid onset of fever, tachycardia, and elevated BP -anxious, tremulous, restless -confusion, psychosis, seizures, coma -cardiac arrhythmias (a.fib) -severe N/V -altered mentation

circumstances where the nurse is legally required to report to appropriate civil authorities

-suspected elder abuse must be reported to the appropriate authorities for investigation -deaths that meet medical examiner reporting guidelines (eg, suspected to be the result of a crime, trauma, or suicide) to the authorities for investigation; local medical examiner has the legal authority and obligation to perform an autopsy independent of the family's wishes -impaired or intoxicated health care workers, regardless of their position -do NOT report reason for an emergency department visit cannot be communicated to employers without the client's permission -health authorities must be notified of a reportable sexually transmitted disease regardless of client wishes. -depending on the condition, authorities may report findings to sexual contacts, but it is a violation of client privacy for the nurse to share this information with the client's family or spouse

circumstances where personal health info can be disclosed w/o obtaining consent from pt or pt's family

-suspicion of child or elder abuse -required by law -- suspicion of criminal activity -need to report to state agency or health department -- report communicable disease

SSAs to report to HCP after insertion of IVC filter

-sx PE = chest pain, shortness of breath -sx vascular injury = bleeding causing back pain

SSAs of SLE

-sx may vary widely w/ the individual -insidious onset = comes on slowly and may not have obvious sx at first -exacerbations + remissions -joints = polyarthralgia, arthritis, joint swelling -skin = butterfly rash, coin-like lesions (w/ discoid type), photosensitivity (need sun-screen); clean skin w/ mild soap, pat dry, + apply moisturizer; use steroid cream -kidney = glomerulonephritis, kidney failure (increased BUN/creat); can have PRO + blood in urine, edema (limit na intake); if see HTN + edema then know kidneys are involved -blood = anemia, raynaud's disease, pancytopenia (low WBC, RBC, + platelets) -heart = pericarditis (sx: tachycardia, low BP, wide pulse pressure), myocarditis (sx: chest pain, fatigue, arrhythmia, fever) -- need to report sx -lungs = pleural effusion, pneumonia -neuro = psychosis, paresis, migraines, seizures, depression -fever, malaise, wt loss, abd pain, anorexia (need small frequent meals) -alopecia -lymphadenopathy -blur vision - +ANA (antinuclear antibodies)

how to care for salem sump tube that is attached to continuous suction

-taking care of NGT attached to continuous suction is different from caring for an NGT for EN -type of NGT but not used for feeding; used to decompress the stomach -larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere -if gastric content refluxes, 10-20 mL of air can be injected into the air vent -maintain pt in semi-fowler's position -turn off suction briefly during auscultation of bowel sounds -keep the air vent (blue pigtail) open and above the level of the pt's stomach -provide mouth care q4 hrs to maintain moisture of oral mucosa and promote comfort -inspect the drainage system for patency -do NOT pull back to see gastric residual (only for pt on feeding)

SSAs of sepsis + SIRS

-temp > 38.3 C or < 36 C -↑ HR > 90 -↑RR > 20 or ↓PaCO2 < 32 -WBC >12,000 or <4,000 -↑immature neutrophils (bands) > 10% of WBCs -↑lactate level (generally > 2 mmol/L) -2 markers for early ID of sepsis/SIRS = ↑lactic acid + ↑procalcitonin

SSAs showing pt going into septic shock

-temp > 38.3 C or < 36 C -↑ HR > 90 -↑RR > 20 or ↓PaCO2 < 32 mmHg -WBC >12,000 or <4,000 -SBP < 90 or MAP < 65 -↑immature neutrophils (bands) > 10% of WBCs -↑lactate level (generally > 2 mmol/L) -prolonged cap refil (> 3-4 sec)

spinal shock (SSAs + interventions)

-temporary loss of motor, sensory, reflex, and autonomic function below level of injury -immediate response of cord to the injury -return of bladder function, reflexes and muscle spasticity indicates resolution of spinal shock -usually resolves in 48hrs but may last for weeks -more w/in 1t 24hr -- d/t direct injury to spinal cord SSAs -loss of sensation -flaccid paralysis -absence of all voluntary and reflex neurologic activity below level of injury -decreased peristalsis, loss of bowel sounds and abd distention = paralytic ileus can occur quickly w/in 72 hrs interventions -may give steroids initially to help with swelling to prevent secondary damage

paralytic ileus (what? + SSAs + interventions)

-temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility who at risk? -abd surgery, pt taking analgesic or anesthetic, immobility (ex: stroke) SSAs -absent bowel sounds -abd discomfort + distension -N/V interventions -NGT -NPO -IVF -NON-OPIOID pain meds -antiemetic

occult blood test (what + mgmt + results)

-test to see if blood in stool -annual test to detect colon cancer -NO red meat, ASA, turnips, and horseradish for at least 72hr b4 to avoid false positive -vitamin C rich foods or supplements may cause false negative -NSAIDs + ASA d/c 7 days b4 -use wooden applicator and apply to test card as directed with label -apply couple of drops of processor on opposite side of card or send to lab per protocol -BLUE = positive for blood in stool

TURP (what? + pre-op + post-op + complications + how to calculate UO)

-transurethral resection of the prostate -most common surgical procedure for BPH -retroscope inserted into urethra and enlarges passageway of urethra -epidural and spinal anesthesia typically used pre-op -d/c anticoagulants -usually use epidural or spinal anesthesia -edu pt on post-op indwelling cath -- will feel urge to void while in place but pt should not try to void -give IVF and abx post-op -monitor for bleeding -small amt of blood in urine and small clots is normal -OOB, ambulate w/ supervision -strict I/O -indwelling 3 way catheter -reorient pt frequently -continuous bladder irrigation to prevent obstruction and increase rate to keep output pink; use isotonic NS -analgesic for pain -even after d/c of CBI, pt should still continue increased PO fluid intake for several days so urine is pale yellow -monitor UO, VS, pain q2-4hr -monitor hgb/hct for anemia d/t blood loss -avoid heavy lift, prolong sit, constipation or straining -encourage fluid intake -keep catheter taped tightly to pt leg -edu on kegal exercises complications -catheter obstruction = severe bladder spasm w/ decreased UO; input is equal to or greater than the output; should 1st attempt to dislodge clot w/ direct injection of irrigation solution into cath w/ syringe -- if cannot clear, call HCP -significant bleed = ongoing bright red, ketchup-like blood in the outflow after 1st 24hr OR large clots OR regression back to bloody once urine has become pretty normal; need to call HCP -bleeding is most likely w/in 1st 24hr; inform surgeon of any bleed -VS changes w/ bleed = tachycardia, hypotension, increased RR, LOC, increased temp -HCP = fever, drop in BP, low UO (<30cc/hr), intake > output, obstruction not able to be cleared, bleed -infection -incontinence -retrograde ejaculation -TURP syndrome = hypo-na, confusion, bradycardia, hypo/HTN, N/V, visual changes how to calculate pt's actual UO -fluid in urinary drainage bag - amt of irrigating solution that was used = actual UO -divide by the excess amt by the number of hrs you have been measuring to calculate the hourly UO and make sure it is adequate -outflow should be > inflow -LOOK AT EXAMPLE IN IGGY ON P. 1479

risk factors for DVT

-trauma (endothelial injury and venous stasis from immobility) -major surgery (endothelial injury and venous stasis from immobility) -prolonged immobilization (eg, stroke, long travel) causing venous stasis -pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) -oral contraceptives (estrogen is thrombotic) -underlying malignancy (cancer cells release procoagulants) -smoking (produces endothelial damage by inflammation) -old age -obesity and varicose veins (venous stasis) -myeloproliferative disorders (increase blood viscosity)

addison crisis (trigger + SSAs)

-triggered by stress SSAs -hypotension -tachycardia -dehydration -hyperkalemia -hyponatremia -hypoglycemia -fever -weakness -confusion

urosepsis (what? + SSAs)

-type of sepsis from urinary tract -late s/sx of UTI; what happens if UTI progresses upwards to kidney -if not tx, can lead to pyelonephritis and urosepsis, which can lead to septic shock and death -SSAs = fever, N/V, tachycardia, hypotension, tachypnea -earliest sx = confusion, decreased LOC (may be only sx in elderly)

how to position patients with one-sided pneumonia who are hypoxic

-unaffected (GOOD) side DOWN -helps to increase perfusion to the healthy lung and improve oxygenation -ex: pt w/ left-lobe pneumonia should be positioned lying on right side

pyelonephritis (what? + risk factors + SSAs/labs + interventions)

-upper UTI where one or both kidneys becomes infected -see acute confusion w/ older adults risk factors -pregnancy -obstruction - stones ureter or kidney -reflux - structural deformities -SCI -chronic illness -- DM, HTN, chronic cystitis -bladder tumor; prostate enlargement -analgesic use -antibody reactions; cell mediated immunity; autoimmune reactions acute SSAs -fever, chills -N/V -tachycardia, tachypnea -flank pain, CVA tenderness -often colicky abd discomfort -general malaise or fatigue -burning, urgency, or frequency of urination -nocturia -U/A same as w/ lower UTI chronic SSAs -HTN; CKD -unable to conserve na -decreased urine concentration (serum osmo < 275), resulting in nocturia -hyperkalemia and metabolic acidosis labs (different from lower UTI) -elevated BUN/creatinine -elevated CRP/ESR interventions -#1 = pain -- analgesics, acetaminophen preferred over NSAIDs -#2 = potential for CKD -abx to tx infection -monitor for s/sx of urospesis and shock (hypotension, tachycardia, fever, tachypnea) -perineal care; hand hygiene -BP control slows the progression of kidney dysfxn -rest periods

what is bucks traction + proper interventions

-used for hip/knee; for adults -used intermittently - pulling force applied by weights attached by rope to client interventions -HOB flat or semi-fowler (max 20-30 degrees) -pt supine -leg elevated w/ flat pillow underneath -reg neurovasc checks and skin integrity -loosen velcro straps if the boot is too tight and tighten the straps if the boot is too loose -provide a fracture pan -weights freely hanging at all time EXCEPT when pt is repositioning (staff member should support the wt)

rule of 9s (adult vs. peds)

-used to calculate amt of IVF needed in 1st 24hr for burn pt -formula = 4mL/kg/%TBSA -half given in 1st 8hrs after burn -second half given in remaining 16hrs -if pt is burned at 1000 and does not arrive to the ED until 1100 you will need to give the first 8 hrs of fluid in 7 hrs -difference for child = front and back of head is 18%; each leg is 13.5% total

raynaud's disease (what + SSAs + prevent)

-vasospastic disorder resulting in an episodic vascular response r/t cold temperatures or emotional stress -most commonly affects women age 15-40 SSAs -white --> blue/purple color of fingers, toes, ears, nose) w/ numbness and coldness -when blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling tx -acute vasospasms are treated by immersing the hands in warm water -if conservative mgmt unsuccessful pt may be rx CCB to relax arteriole smooth muscle and prevent recurrent episodes pt edu for prevention -wear gloves when handling cold objects -dress in warm layers -avoid extremes and abrupt changes in temperature. -avoid vasoconstricting drugs = cocaine, amphetamines, ergotamine, pseudoephedrine -avoid excessive caffeine intake -refrain from use of tobacco products -implement stress management strategies like yoga, tai chi

d/c edu for pt w/ burns

-wear pressure garment 23.5 hr/day -regular exercise -elevate extremity as much as possible -keep skin moisturized -control itching w/ cool baths + loose cotton fabric -avoid sun -consume extra calories and PRO to help w/ healing

enteral nutrition (who for? + route of admin + how admin + mgmt/care)

-who? = pts who can not take oral intake, but have a functioning gut = intubated head/neck surgery, anorexia, dysphagia, at risk for aspiration -risk of sepsis is reduced compared to TPN rout of admin -oral -nasogastric tube -nasoduodenal or nasojejunal (small bore feeding tube) -- may need to go lower for absorption reasons -gastrostomy, jejunostomy tubes -- possible to have both (one for meds and one for feed) -**may be administered via bolus, intermittent, or continuous feedings how admin -gravity = do not push the medication in, manual feed, flow rate is controlled by gravity, hold bag or syringe at least 18 inches above pt head -pump = flow rate is controlled by pump, rate per MD order, rates are gradually increased goal per MD order, dietitian recommendation, or protocols mgmt/care -check gastric residual q4hr -hold if gastric residual > 500 -semi-fowler -verify acidic pH ≤5 -return aspirated GRV to the stomach -flush the tube before and after feedings -standard hygiene precautions: clean technique -change disposable feeding bags q24 hours -- even if not empty -check tubes for residual prior to feeding -- pull back on syringe to see if any residual -hold feeding for residual ≥ 150 mL -- if less than this just push back into the gut -insert 10-20mL of air into feeding tube and listen w/ stethoscope -- not really recommended for checking placement anymore bc may compromise integrity of tubing (need to do XRAY) -flush tubing w/ 30-50 mL water b4 and after meds and feedings -admin water as prescribed between feedings -check placement: aspirate 10mL of gastric contents to check pH (gastric pH is very acidic = 1.5-3.5) -XRAY is most precise method of checking placement -**for continuous feeds, flush tubing and check placement q4 hours! -potential complications: aspiration (keep HOB elevated, stop feeding if have to put pt supine for any reason), diarrhea, skin breakdown -give meds one at a time

what to know for islam (muslim)

-yes circumcised -dying pt faced towards Mecca (east) -halal (permitted) meats are from animals slaughtered during payer ritual -haram (prohibited) foods are pork, gelatin, alc, and animal w/ fangs -pt may pray 5x/day, facing Mecca (east), and have prayer rug -give pt privacy during prayers -women cover entire body w/ clothing -women may refuse/avoid male workers -for women = modesty is highly valued and most body parts are covered, give female workers,

normal CRP

0-0.8

broca vs. wernicke aphasia

ALPHABETICAL -B = E -W = R

criteria for metabolic syndrome

1. abd obesity: waist circumference (men: ≥40 inch, women = ≥35 inch 2. high serum TGL >150 or hypertriglyceridemia drug treatment 3. low HDL (men: <40, women: <50 mg/dL 4. HTN ≥130/85 or HTN drug tx 5. fasting blood glucose ≥100 or hyperglycemia drug treatment

procedure for measuring for orthostatic hypotension + dx

1. have pt lie down for at least 5 min 2. measure BP + HR 3. have pt stand 4. repeat BP + HR measurements after standing at 1- and 3-minute intervals -dx: drop in SBP of ≥20 or DBP of ≥10, or experiencing lightheadedness or dizziness

process for budgeting

1. planning -- assess needs 2. set goals -- determine what should be accomplished 3. prepare -- develop plan (time frame) 4. monitoring and approval -- implement plan 5. modification -- eval outcome and revise and modify PRN

normal aldolase

1.0-7.5 units/L (0.02-0.13 microkat/L)

recommended target serum glucose range for clients receiving nutritional support

140-180

b12 anemia vs. folic acid anemia

b12 anemia -YES has nervous system problems = paresthesia + poor balance -SSAs: glossitis (red, beefy smooth tongue) -will have macrolytic RBCs (high MCV) -shilling test to ID -give cyanocobalamin (1,000mcg IM daily for 2 weeks --> q1 week til hct levels normal --> qmonth for life) folic acid anemia -does NOT have nervous system problems -SSAs: glossitis (red, beefy smooth tongue)

what is a severely reduced peak flow rate

< 50% of personal best

gastric residual that indicates EN needs to be held

> 500 mL

amount of chest tube drainage right after surgery that should be reported to HCP

>100mL/hr

erythropoietin (AEs + interventions)

AEs/outcomes -- "DIARRHEAS" -D: DVT -I: IV or subq -A: aches in joints -R: risk for MI/stroke -R: report UO < 50mL/hr -H: HTN, HA -E: enhanced sense of well-being -A: appetite increases -S: seizure -avoid driving or hazardous activity during beginning of tx -take iron supplements, b12, and folic acid -will have increased reticulocyte count in 1-6 weeks -requires frequent hct testing for dosage adjustments -give 3x/week -expected outcomes: O2 increases; decreases fatigue, weakness, SOB -not typically prescribed unless the client has symptomatic anemia with hemoglobin of <10 g/dL -do NOT give if have low platelet level!!!!!!

indications for dialysis w/ AKI vs. CDK

AKI -symptomatic uremia -- changes in LOC, N/V/D, pericarditis, neuropathy, decline in cognition -hyperkalemia > 6.5 mEq/l -hypervolemia -- depends on the patient's underlying health -metabolic acidosis pH < 7.1 -fluid overload -- that inhibits tissue perfusion -creatinine > 4 mg/dl -AKI = done if creatinine 3-4 -CKI = not done if creatinine 5-6 bc pt is used to it (that's their normal) -BUN > 50 mg/dl (ARF as high as 200) - only if in combo w/ elevated creatinine CKD -NOT creatinine -BUN > 120 -uremia -- sx = intractable N/V, confusion, seizures, or severe bleed from platelet dysfunction -uncontrolled HTN -metabolic acidosis (pH < 7.2) -GFR < 15ml/min -K > 6 -- symptomatic w/ ECG changes -fluid volume overload -- does not respond to diuretics

agents of bioterrorism: category A, B, C

category A -highest priority -threat to national security -easily transmitted and high mortality rate -smallpox, botulism, anthrax, tularemia, ebola, plague category B -2nd-highest priority -moderate morbidity rates and low mortality rates -typhus fever, ricin toxin, diarrheagenic e. coli, west nile category C -3rd-highest priority -emerging pathogens that could be engineered for mass dissemination -easy to produce and have potential for high morbidity and mortality rates -hantavirus, flu, TB, rabies

anticipatory guidance educational goals should be...

client-oriented, realistic, objective, measurable, and focused on preparing for future needs specific to the client

reason for decorticate + decerebrate posturing

decorticate -flexion of arms into chest, clenched fists, extended legs w/ pointed toes -damage to tract between brain and spinal cord decerebrate -extension of arms + legs, pointed toes, backward arching of head -deterioration of upper brain stem

SSAs of colorectal cancer

Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option 2) Abdominal discomfort and/or mass (not common) (Option 1) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option 4) Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option 3) Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option 5)

what is DIC

Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death.

SSAs of ruptured cerebral aneurysm

EMERGENCY -worst HA of life -stiff neck -neurologic deficits -diplopia -seizure -vomiting

SSAs of IICP (early vs. late + other)

early SSAs -adult: HA, LOC changes, restless, irritable, lethargic, changes in speech, ataxia -infant/child: "PIES" -- projectile vomit, poor feed; increased high-pitch cry, HA; enlarged (bulging) fontanels; separation of suture lines (enlarged head circumference); irritable, lethargic late SSAs -cushing's triad -- bradycardia, severe HTN w/ wide pulse pressure, irregular breathing (bradypnea, cheyne-strokes) -pupillary changes other SSAs -decreased LOC -- lethargy --> coma -decreased motor response to command -decreased sensory response to painful stimuli -alterations in pupil size and rxn -- dilated pupils -papilledema -- optic swelling w/ sluggish disc --> HA and seizures -motor loss or dysfxn -- usually appears contralateral (opposite side) to the site of the injury -decorticate or decerebrate posture -contralateral hemiparesis or hemiplegia may develop -spinal fluid leak -diplopia -poor thermoregulation -***constant HA, decreased mental status, sudden onset of emesis "HEEADS" -H: HA; severe HTN w/ wide pulse pressure, bradycardia (VS changes occur late) -E: eye (pupil changes) -- CN: II, III, IV, and/or VI -E: emesis (projective vomit not preceded w/ nausea) -A: airway status = PRIORITY -- o2 sat, swallow/gag reflex, cheyne-strokes (late) -D: disc (optic) swelling = papiledema; drug use -S: seizure, spinal fluid leak, speech changes, sensory and motor fxn impaired

peritonitis w/ peritoneal dialysis (SSAs + interventions)

early SSAs -cloudy, opaque, or bloody outflow -poor dialysis inflow or outflow SSAs = "PERITONITIS" -P: pain that decreases with flexion of the right hip or increases with coughing or mvmt; pain in abd is sharp and constant; pain that has progressed to LUQ -E: eval for hiccups; emergency -- HCP -R: rigid, board-like, distended abd w/ rebound tenderness -I: implement NPO; insert NGT to decompress -T: tachycardia, fever -O: observe for absent/decreased bowel sounds -N: N/V, anorexia, diarrhea -I: increased WBC >/= 20,000 -T: tense, guarding abd, rigid muscles -I: increased temp -S: s/sx FVD -cloudy outflow w/ PD interventions -notify HCP -prepare for possible surgery -monitor site for drainage -rotate catheter -milk tubing to break fibrin clot -check tubing for kinks or closed clamps -teach pt to consume foods that help to avoid constipation prevention -use meticulous sterile technique when caring for the PD catheter and when connecting and disconnecting dialysate bags

major AE of endocarditis

emboli resulting in... -stroke - paralysis on one side -spinal cord ischemia - paralysis of both legs -ischemia to the extremities - pain, pallor, and cold foot or arm -intestinal infarction - abdominal pain -splenic infarction - left upper-quadrant pain

impact of albumin on VS

IV albumin increases intravascular fluid volume and may be used to prevent hypotension + tachycardia a/w paracentesis

SSAs of gastric vs. duodenal ulcers

gastric ulcer = occurs in stomach -pain occurs 30-60min after meal -pain WORSE w/ food -hematemesis (bloody vomit) more common than melena (dark stool) -pain at left of midline (LUQ) or upper epigastrium -pain rarely worse at PM -malnourished duodenal ulcer = occurs in duodenum (just after pyloric sphincter) -pain occurs 1.5-3hrs after meal -pain RELIEVED by food or antacid -melena (dark stool) more common -pain often awakens pt during the night between 1-2 am -pain to the right or below epigastrium -well-nourished BOTH -dyspepsia, nausea, bloating -sharp burning or gnawing pain -uncomfortable feeling of fullness or hunger -wt loss -anemia

general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem

general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem

JP drain (+ hemovac, wound vac dressing, collection container) vs. T-tube (+ penrose drain)

JP drain = active drain (+ hemovac, wound vac dressing, collection container) -low neg pressure to remove fluids -maintain compressed reservoir -empty q4-12 hrs or when 1/2-2/3 full -unclog w/ gentle strip or milk -while totally compressed, clean spout w/ alc and replace plug T-tube = passive drain (+ penrose drain) -drain by gravity -- keep bag below level of gallbladder -never irrigate, aspirate or clamp without order -initially drains > 400 mL/day, gradually decreases -report sudden ↑ in drainage > 1000 mL/day -inspect surrounding skin for breakdown/infection (protect with barriers) -clamp 1-2 hours before and after meals -monitor PO tolerance -barrier creams with zinc are good protectants -can milk or strip but NO irrigate (do NOT add anything to drain) -take showers, not baths BOTH -HH and aseptic technique when clean and dressing change -no kinks -can gently milk or strip

YES vs. NO meds to give b4 HD

NO give b4 HD -anti-HTN -BP lowering meds (ex: furosemide) -abx -digoxin -water-soluble vitamins (B, C, folic acid) -SUBQ heparin (bc heparin is given w/ dialysis) YES give b4 HD -insulin lispro -fat soluble vitamins (A, D, E, K) -phosphate binders (calcium containing [calcium carbonate and calcium acetate]) and non-calcium containing [sevelamer and lanthanum])

what at bedside for seizure

O2, artificial oral airway (oropharyngeal airway), suction, IV, side rails up, bed in lowest position

OA vs. RA (SSAs + labs + meds)

OA -maybe unilateral, affects only a single joint -affects wt bearing joints, hands and spine -non-systemic -pain exacerbated by weight-bearing -morning stiffness that subsides w/in 30 min decreased joint mobility and range of motion -atrophy of supporting muscles -crepitus - felt when moving the affected joint -heberden's nodes (bony nodules at the distal interphalangeal joints) -bouchard's nodes (bony nodules at the proximal interphalangeal joint) -may experience pain to palpation -joint may be enlarged d/t bony hypertrophy -may have inflammation at the joint d/t secondary synovitis -labs: normal or slightly elevated ESR -meds: NSAIDS and acetaminophen RA -joints impacted bilaterally -morning stiffness that lasts at least 1 hr -bilateral, symmetric, affects multiple joints -usually effects upper extremities first -swan neck or ulnar deformity -see other systemic sx as well -paresthesia = numbness, tingling, or burning in hands and feet -often experience red, warm, stiff, swollen pain with palpation to the affected joint -labs: elevated rheumatoid factor, ESR, and ANA -meds: NSAIDS, Methotrexate, leflunomide, corticosteroids, biological response modifiers, immunosuppressive agents -should take supplements: glucosamine + chondroitin sulfate

OT vs. PT

OT -emphasizes the skills necessary for activities of daily living like dressing, bathing, cognitive or perception issues) -is for "above the waist" PT -focuses on mobility, ambulation, ability to transfer, and use of related equipment -is for "below the waist"

appendicitis (SSAs + pre-op + post-op)

SSAs -WBC increased = 10,000-18,000 -initial = mild cramping pain in epigastric or periumbilical area -late = constant intense RLQ pain -N/V (usually abd pain comes first) -decreased appetite (anorexia) -rebound tenderness over mcburney's point (RLQ, between snterior iliac creas and umbilicus) -normal to low-grade temperature -decreased UO pre-op -NPO -IVF -semi-fowler -NO laxatives, enema, or heat to site post-op -morphine for pain -IV abx -NGT for peritonitis -maintain drains -risk for infection = BS q2-4hrs; oral care q2hrs; diet: increased cal, PRO, vit C; sterile, aseptic technique w/ dressing change; TCDB/IS q1-2hrs

acute diverticulitis (SSAs + axn/care)

SSAs -alternating diarrhea + constipation -painful cramps + tender in LLQ -chills or fever -tachycardia -N/V axn/care -focuses on allowing the colon to rest and the inflammation to resolve -NPO -- more acute cases require complete rest of the bowel; less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet -bed rest -IVF -IV meds = abx + pain meds (opioids given in moderate to severe cases that require hospitalization) -prevent increased intra-abd pressure = NO straining, coughing, lifting -NO laxatives or enemas -low-residue diet (low-fiber) -NGT for N/V or abd distention -avoid/eliminate: ETOH, nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries -begin w/ clear liquids then advance to low-fiber then eventually long term have high-fiber diet -NO MORPHINE -- bc can increase pressure in colon and exacerbate sx

SSAs + axn/edu for GERD

SSAs -cough at night (worse when lay down) -hoarseness (acid = dryness), wheeze at night (GERD can trigger asthma attack) -eructation = burping -flatulence -odynophagia = painful swallow -pain relieved almost ASAP by drinking water, sitting up, taking antacids -occur 20min-2hr after eat meal axn/edu -limit foods = chocolate, caffeine, fried, fatty, alc, carbonated drinks, spicy, acidic, peppermint -yes chew gum -no eat 3hr b4 bed -small frequent meals -sleep on RIGHT side -elevate HOB 6-12 inches -avoid heavy lifting, strain and working in a bent over position -avoid drugs that lower LES pressure and cause reflux = oral contraceptives, anti-cholinergic, sedatives, NSAIDs, nitrates, CCB, theophylline -exercise regularly to decrease wt

PUD (SSAs + axn/edu)

SSAs -dull, gnawing, burning mid-epigastric and/or back pain w/ localized tenderness -sx worse w/ empty stomach -anemia = decreased hct/hgb -dyspepsia, nausea, bloating -sharp burning or gnawing pain -uncomfortable feeling of fullness or hunger -wt loss axn/edu -limit/avoid bedtime snacks, tobacco, ETOH, caffeine, caf and decaf coffee, tea, carbonation -limit/avoid NSAIDs, corticosteroids, ASA -complementary and alternative therapy (hypnosis and imagery): decrease stress -monitor for orthostatic changes in VS and HR - suggest GI bleed or perforation -need adequate rest -monitor for hematemesis (bloody vomit) or melena (bloody stool) -regular exercise -balanced diet -avoid very cold + very hot foods

dumping syndrome (SSAs + initial mgmt + prevent)

SSAs -early = vertigo, diaphoresis, hypotension, tachycardia, palpitation, abd cramp, N/V, diarrhea - sx occur 15-30 min after meals -late = cramp, dizzy, diaphoresis, confusion - occur 90min-3hr after eat - d/t rapid release of blood glucose -> increased insulin release -> hypoglycemia initial mgmt -small frequent meals -replace simple sugars with complex CHO -incorporate high-fiber and PRO-rich foods prevent -eat multiple small meals -diet: high-PRO, high-FAT, low-CHO, avoid sugars, low-fiber, avoid milk -separate consumption of food and fluids by at least 30min -give dicyclomine for pain -monitor AEs of anti-cholinergic (dry mouth, constipation, urinary retention, can't see/pee/spit) -small frequent meals, eat slow -low-roughage foods -lie down flat for 30-60 min after meal to slow mvmt of food -monitor for hypoglycemia and give hyperglycemia oral agent

SSAs + prevention + tx of extravasation w/ IV infusion

SSAs -pain, blanching, swelling, redness prevent -know vesicant potential b4 give med tx -stop infusion -d/c administration set -aspirate drug if possible -cool compress -document condition of site

air embolism w/ CVC (SSAs + prevent + tx)

SSAs -rapidly developed respiratory distress -hypoxemia -dyspnea -sense of impending doom prevention -pt lay flat when changing admin set or needles -have pt perform valsalva (bear down) or exhale during removal -apply an air-occlusive dressing (usually gauze with a tegaderm dressing) tx -#1 = clamp tubing -#2 = place pt in left lateral trendelenburg -#3 = admin 100% o2 via non-rebreather -#4 = call HCP -#5 = stay w/ pt and provide reassurance -apply occlusive dressing -continuously monitor VS + resp effort

cardiogenic shock (SSAs + interventions)

SSAs -reduced CO (hypotension, narrow pulse pressure), which can lead to pulmonary edema (tachypnea, bibasilar crackles, decreased o2 sat) -early = restless, anxious, ↑RR, ↑HR, normal BP -late = BP< 90 or 30mm<systolic baseline, changes in LOC, crackles, cool clammy skin, pulses decreased + thready interventions -meds: inotropic agent (norepinephrine), NTG, vasopressor -give o2; may need intubation -if have chest pain -- get cardiac enzymes + EKG -do NOT give fluids, monitor fluids + strict I/O -notify HCP

perforation (SSAs + interventions)

SSAs + interventions = "PERFORATION" -P: pain in chest or abd; sudden onset of epigastric pain that radiates to back and right shoulder -E: emergency surgery needed, prepare pt -R: record I/O; eval drainage amt, color, and odor -F: fluid replacement as rx -O: obtain and insert NGT -R: rebound tenderness; N/V, guarding -A: abd distended, rigid, and board-like -T: tell HCP asap -I: increased VS -- ↑HR, ↑RR, ↑temp ↑pain, ↑abd girth, ↑WBC -O: observe for possible subq air in neck -N: need abd xray STAT but do NOT give contrast media -tenesmus = cramping rectal pain, feel like need to have bowel mvmt

what is a phlebostatic axis arterial line

The phlebostatic axis (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest) is an external reference point on the thorax used to determine proper placement of the pressure monitoring system transducer when measuring direct BP, CVP, and/or cardiopulmonary pressures invasively. It is also used as a reference point for the upper arm when measuring BP indirectly.

diet for pt w/ ostomy

YES -decrease odor: buttermilk, cranberry juice, parsley, yogurt -decrease gas: yogurt, crackers, toast NO -high fiber: popcorn, coconut, brown rice, multigrain bread -stringy vegetables: celery, broccoli, asparagus -seeds or pits: strawberries, raspberries, olives -edible peels: apple slices, cucumber, dried fruit -odor forming: fish, eggs, asparagus, garlic, beans, dark green leafy -gas forming: dark green leafy, beer, carbonated, dairy, corn, gum, skip meal, smoke

indications + contraindications for receiving live flu vaccine

YES -healthy individual age 2-49 NO -age </= 2yo or >/= 50yo -immunosuppressed = HIV (+ close contact) -chronic CV, pulm, neuro, neuromusc, metabolic disease -hx guillian-barre -pregnant -child/adolescent on long-term aspirin -severe allergy to vaccine

YES + NO delegate to AP/UAP

YES = 5 Rs -R: report change; recognize situations to report to superior -R: remind -R: routine tasks -R: range-of-motion (passive) -R: reinforce procedures and principles -basic hygiene and grooming -assistance w/ ADL -- nutrition, elimination, mobility -ambulating -feeding -- w/o swallow precautions -specimen collection -- NOT sterile -I&O -VS -- stable pt only -non-invasive skills -maintain safe envi -apply protective ointment -obtain objective data for stable pts -check blood glucose level + report -perform oral (nonsterile) suctioning for pt during oral care -dressing changes only for chronic wounds using clean technique -bring blood products to and from the blood bank -collect a clean-catch or midstream urine specimen NO -sterile technique -unstable or acute care pt -monitoring -alert or call another department -- RN needs to do this -offer OJ if a pt's BG < 70 -collect urine specimen from foley cath -- NO bc sterile

criteria for contacting rapid response

acute change in any of the following... -HR <40 or >130/min -SBP <90 mm Hg -RR <8 or >28/min -o2 sat <90 despite oxygen -UO <50 mL/4 hr -level of consciousness

leadership styles: authoritative, democratic, laissez-faire

authoritative -makes decisions for group -motivate w/ coercion -communication w/ chain of command -effective w/ employees w/ little or no formal edu democratic -includes group to make decisions -motivates by supporting achievements -communication up and down chain of command laissez-faire -makes few decisions and does little planning -motivation responsibility or individual staff members -communication up and down chain of command -effective w/ professional employees

diet for pt w/ IBS-D

avoiding gas-producing foods (eg, broccoli), caffeine, alcohol, and gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and increase fiber

glomerulonephritis vs. nephrotic syndrome

glomerulonephritis -d/t recent strep infection -key = tea-colored urine -edema: face, eyelids, hands, abd; JVD; pitting edema of LE nephrotic syndrome -key = massive proteinuria (> 3.5g in 24-hr urine sample) -edema -- periorbital (face) -- worse in AM and subsides during day; BLE edema may increase during day -lipiduria -- fats/lipids in urine -low serum albumin/PRO (< 3g) -- pt is immunocompromised -hyperlipidemia (worry about stroke) -give ACEIs bc decrease PRO loss in urine SSAs of BOTH -FVE + pulm edema d/t retention of fluids + na -- dyspnea, SOB, crackles, s3, wt gain, HTN (w/ HA), tachypnea, tachycardia -uremia: fatigue, lack of energy, anorexia, N/V -dysuria (painful pee), oliguria (little/no UO) -changes in LOC -change in UO pattern, urine color, volume, clarity, or color -fever, back pain -anorexia U/A for BOTH -hematuria (blood/RBC in urine); RBC casts -proteinuria (PRO in urine; foamy urine) -- need 24-hr urine collection; causes low serum albumin levels -get urine sample w/ 1st void in AM -reddish-brown or cola/tea-colored urine -high specific gravity (>1.030) labs for BOTH -high-k, high-p, high-mg, low-na, low-ca -diluted blood d/t fluid retention -increased WBC -low serum albumin -delayed clotting or increased bleeding w/ high aPTT, INR, PT; decreased clotting proteins, anemia -decreased immunity d/t decreased antibodies -elevated BUN/serum creatinine + decreased GFR = reduced kidney fxn interventions/edu for BOTH -bed rest -fluid allowance = output + 500cc/24hr -PRO may be decreased if azotemia is present (high BUN) -avoid vitamin C -restrict k, na, and fluids (output + 500cc/24hrs) -small frequent meals -cluster care/conserve energy -relaxation techniques and diversion activities -measure BP and wt at same time each day -daily wt, abd girth, I/O -edu pt to notify HCP of sudden increase in wt or BP -seizure precautions d/t low-na -increase calories

triage: green, yellow, red, black

green (class 3) -- nonurgent -minor injuries not needing immediate tx -can delay tx for 2-4hrs -d/c pts -pt usually ambulatory -ex: closed fracture, contusion yellow (class 2) -- delayed/urgent -major injuries that require tx -can delay tx to 30min-2hr -RPM w/in desired values -pt has significant injuries -ex: open fracture w/ distal pulse red (class 1) -- immediate/emergent -immediate threat to life -cannot delay tx -RPM falls outside desired values -critical pt black (class 4) -expected and allowed to die -prepare for morgue -pt cannot breathe after opening the airway or mortally wounded -ex: cardiac arrest

causes of high vs. low-pressure ventilator alarms

high = dry -copious secretions -cough, wheeze, bronchospasm -displaced or extubated tube -blocked w/ water -kinked -pt fighting or biting tube -pneumothorax low = leak -tube disconnected, dislodged -pt stops spontaneously breathing -pt is able to speak -cuff leak

humidifier vs. dehumidifier

humidifier -keep the mucosa moist, reducing the risk of nosebleeds -adds moisture to air when it's too dry dehumidifier -takes moisture out of air when it's too humid

hyper-acute vs acute vs chronic renal transplant rejection (SSAs + tx)

hyper-acute = 1st 48hrs -SSAs: fever, HTN, pain at transplant site, tenderness over graft site -tx: remove vessels to kidney or asap remove kidney acute = 1 week - 2 years -most common -SSAs: oliguria/anuria, low-grade fever, lethargy, HTN, azotemia (↑BUN/creat), FVE,↑K, enlarged tender kidney, edema, fluid + elect imbalance, elevated WBC -tx: increase doses of immunosuppressive drugs chronic -gradual occurrence -months to years -SSAs: gradual increase in BUN/creat, fluid retention, changes in serum elect levels, fatigue, return to baseline; NO fever or local tenderness/swelling -tx: conservative mgmt until dialysis required

SSAs of hyperglycemia + hypoglycemia

hyperglycemia = "FLUSHED" -F: find ketones in urine and blood -L: lethargic, LOC variable -- from stuporous, obtunded, or coma -U: unusual thirst, UO increased, hunger = EARLY -S: skin warm, dry, and flushed, ↑temp -H: hyperventilation w/ fruity breath -E: elevated HR, low BP, poor skin turgor -- d/t FVD (pt is dehydrated d/t polyuria) -D: drowsy, decreased appetite, N/V, abd pain, cramping -BG > 250 or > 126 -metabolic acidosis -hypercapnia hypoglycemia: mild = "TIRED", severe = "COMAS" -BG < 50mg/dL or < 70 -T: tremor, tachycardia, palpitations, tingling of mouth or extremities -I: irritable, impaired vision (blur or double) -R: restless, anxious, HA -E: excessive hunger -D: diaphoresis -C: confusion, concentration poor --> coma -O: orientation decreased, difficulty thinking -M: mental status decreased, LOC changes, behavior changes -A: apathy, lethargy -- severe -S: seizure -paralysis -nervous, anxiety, irritability, emotionally unstable -general weakness, fatigue -pt is NOT dehydrated -no change in RR -NEGATIVE ketones in blood or urine -cold and clammy = give them candy -tingling sensation -abrupt onset = SNS sx = ↑HR, palpitations, diaphoresis, shaky -gradual onset = PNS sx = HA, tremor, weak, lethargic, disoriented

SSAs hypoglycemia vs. hyperglycemia

hypoglycemia -diaphoresis -pallor, cool -epinephrine is released during hypoglycemia and causes trembling, palpitations, anxiety/arousal, restless, shaky hyperglycemia -polyuria -wt loss

ileostomy vs. colostomy (about + axn/edu)

ileostomy -surgical opening into ileum to drain stool; bypasses LI -done when entire colon removed d/t disease (ex: UC, crohn's) -stools more liquid/loose -expected outcomes = bile-colored, liquid, > 1,000L/day, decreases to 500L/day after 7 days to weeks, output is continuous -avoid high fiber foods for 1st 2 months, chew food well, ↑fluids, slowly add fiber back into diet colostomy -surgical opening into LI to drain stool -stools more formed -done when bowel needs rest for healing (ex: diverticulitis) -expected outcomes = small to moderate amt of mucus w/ semi-formed stool 4-5 days after surgery, output pattern similar to the pre-op pattern nursing axn/edu -stoma should be pink and moist -apply skin barrier and creams to peristomal skin -monitor output (look at trends) - more liquid and acidic if closer to SI -empty bag when ¼-1/2 full -watch for skin breakdown -keep diary of intake and food habits

timeline of fluid shifts + labs seen w/ burns

initial fluid shift (1st 24hr) -HYPOVOLEMIA - note concept slide elevated hbg/hct d/t loss of fluid volume (early) -CBC -- ↑ hct/hgb first but may fall as start to rehydrate -fluid shifts into interstitial spaces -↓Na level d/t third spacing -↑K d/t cell destruction -- higher K w/ more extensive cell damage -- will have low K when start to rehydrate -don't be surprised if have wide swings in elects -need to rehydrate w/ LR fluid mobilization (48-72 hrs after injury) -give dextrose and water + K, albumin -↓hbg/hct d/t fluid shift from interstitial into vascular -↓Na d/t renal and wound losses -↑K d/t renal loss and mvmt back into cells -↓albumin +↓protein d/t fluid loss -WBC initial ↑ and then ↓ w/ left shift -↑glucose d/t stress response -hypoxemia -metabolic acidosis (↑K)-- not much perfusion to cells -- H goes into cells and pushes K out of cell -- cells die and have hyper-K

ischemic vs. hemorrhagic stroke

ischemic -occurs as a result of an obstruction within a blood vessel supplying blood to the brain -SSAs = typically during sleep or w/I 1 hr of wake; signs develop slowly or abruptly; slurred speech; facial droop; TIA's -intervention = fibrinolytic therapy and/or blood thinners (w/in 4.5hr); get therapy ASAP hemorrhagic -occurs when a weakened blood vessel ruptures -2 types: of aneurysms and arteriovenous malformations -SSAs = typically during active hours; rapid onset; severe HA; nuchal rigidity; IICP -intervention = do NOT use blood thinners; focus on stabilizing client vs., stopping bleeding; high risk for rebleed and angiospasm; no stimulation; seizure precautions, NPO, assess swallow fxn, prevent further raise in ICP or BP = reduce stimuli (quiet and dimly lit envi + limit visitors); give stool softener, reduce exertion, strict bed rest, assist w/ ADLs, maintain head in midline position

laparoscopic vs open approach cholecystectomy (nurse axn + possible complications)

laparoscopic -common to have right shoulder pain from free air -- relieve w/ ambulation and application of heat and place pt in sims position -give food and water when fully awake -activities resumed in about 1 week -sx bile leak or hemorrhage = RUQ pain, vomit, abd distend -- HCP asap open approach -activity precautions for 4-6 wks -T-tube or JP drain left in 1-2 wks -report sudden increases in drainage, foul odor, pain, fever, or jaundice -take showers instead of baths until T-tube removed -clamp T-tube 1-2hrs b4 and after meals to prepare for removal -- train bile to empty into the gut -stools should return to brown within about 1 week -diarrhea is common -normal for output to not equal input for 1st several hrs -ability to void should return w/in 6hrs -sx blocked bile duct = large increase in t-tube drainage -normal for output to be greenish brown for 1st 24hrs -being w/ clear liquids and progress to solid foods as peristalsis returns -sx obstructed t-tube = no drainage, nausea, pain

interventions for medical vs. surgical asepsis

medical asepsis (clean) -HH -do not place items on floor of pt room -do not shake linens -clean LEAST soiled area first -place moist items in plastic bags surgical asepsis (sterile) -no cough, sneeze, or talk directly over field -only DRY sterile items touch the field -1 inch border is non-sterile -keep all objects above waist and w/in vision -do not turn back to field -HH + sterile gloves

how to dislodge an obstruction in a urinary catheter

milk the tubing = squeeze and release the full length of the tubing, starting from a point close to the client and ending at the drainage bag

myopia vs. hyperopia vs. presbyopia

myopia -nearsightedness -distant objects appear blurry -can see NEAR objects hyperopia -farsightedness -close objects appear blurry -can see FAR away objects presbyopia -farsightedness a/w aging -close objects appear blurry -can see FAR away objects -progressive condition where lens of eye loses its ability to focus

phases of AKI

onset -onset of event and lasts hrs to days oliguric (1-7 days) -sudden onset -UO < 400mL in 24hr -edema -elevated BUN/creat, elevated SG -metabolic acidosis w/ elevated K -- causes pt to be drowsy, stupor, seizure/coma -HF, dysrhythmias -hypervolemia (FVE -- holding onto urine) -hypo-na; hyper-k; hyper-phos; hypo-ca; hyper-mag -neurologic sx = may escalate to stupor, seizures, and coma -limit fluids based on the pt's output on the previous day -if pt has rising BUN need to restrict PRO intake because BUN is a product of PRO metabolism -the longer the duration of oliguria/anuria = less likely for pt to return to full/baseline kidney fxn diuretic (1-3 weeks) -UO of 1-5 L/day -osmotic diuresis d/t high levels of urea -kidneys have recovered ability to excrete waste but not to concentrate urine -hypovolemia; hypotension -hypo-na; hypo-k -elevated BUN/creatinine -decreased SG -watch for dehydration; need to give pt lots of fluids -care needs to be focused on fluid and electrolyte replacement recovery (lasts up to 12 months) -BUN/creatinine will plateau then decrease + return to baseline -normal kidney fxn, minor loss of fxn, or none at all -improved renal fxn and energy -UO >0.5mL/kg/hr -VS stable; no temp -electrolytes at baseline -no arrhythmias -neuro status intact -fluid balance -labs may return to baseline starting at end of diuretic phase -goal: maintain hydration, prevent electrolyte depletion, continue to support renal fxn

how to reduce risk of aspiration in pt w/ trach

partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs

nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings

partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs

antidote for norepi and dopamine

phentolamine

pre-op + during/post-op conscious sedation

pre-op -Educate about procedure and meds to be used. -Dentures, jewelry, and hearing aids removed -Use of any medications? Last dose of diuretic, anti-HTN, narcotic! preexisting med hx -Consent needs to be signed -Assess allergies: anesthetic agents/any prior experience with sedation or anesthesia/allergic reaction? do full assessment: baseline VS, cardiac rhythm, and LOC -Time client last ate or drank (usually NPO for 4 hr. prior) -Establish IV access and keep vein -open fluids, equip for monitoring attached during/post-op -Assess contin LOC, VS, SaO2 cardiac rhythm, lips, mucous membrane color airway obst - insert airway; arrhythmias/do 12 lead ECG; admin antidysrhythmics and fluids; anaphylaxis: give epinephrine. -IV fluids and vasopress for ↓B/P. -Respiratory depression: Have emergency equip available. Give O2, reversal agents: naloxone; review discharge criteria -Deep breathe/cough. -Reg/stable VS for 30-90 min. -Intake of fluids with no problem. -No nausea, vomiting, SOB -K (C)onsciousness/same as before procedure.

renal biopsy (pre-op + intra-op + post-op + complications)

pre-op -NPO 4-6hr but give IVF -blood labs -- platelet, aPTT, PT -HTN managed aggressively to prevent bleed -XRAY of kidney -d/c all anticoagulants, antiplatelet, NSAIDs for at least one week -type and crossmatch blood intra-op -sedation -prone position w/ pillow under abd + shoulders on bed -pt holds breath + remains still post-op -pt positioned on the affected side for 30-60 min and on bed rest for 24 hours -major risk for bleeding -- look at hgb/hct -monitor the dressing site, VS (esp changes in BP), UO, hgb/hct for 1st 24hr -s/sx internal bleed = flank pain, low BP, low UO, sx of hypovolemia or shock, tachycardia, tachypnea -severe bleed = bruising along flank and back w/ pain -strict bedrest in supine position w/ back roll for support for 2-6hrs; HOB may be elevated; bed rest for 24hr -monitor VS q15min for first hr -pressure at puncture site for 20 min -pt may resume oral intake of foods and fluids -limited bathroom privileges after bedrest if no evidence of bleeding -most common complication is hematuria -if bleeding occurs, need IVF, PRBC or both to prevent shock -if no bleed, pt can resume general activities after 24hr -avoid lifting heavy objects, exercising, or strenuous activities for 1-2 weeks

pre-op + post-op joint arthroplasty (replacement)

pre-op -assess risk -procedure is contraindicated if: recent infection, arterial impairment to affected extremity, non-compliance, unstable co-morbidities (cardiac/resp); hx that increases risk for DVT's post-op -J: joints need exercise; early ambulation, get out of bed on unaffected side; ambulate day of surgery -O: observe and monitor for bleeding, hypovolemia, prevent and monitor for DVT; exercises to reduce risk of DVT = ankle dorsiflexion, circles w/ feet, push feet into bed while tightening quads, straight leg raises -I: infection -- record drainage, color, WBC, temp; use aseptic technique for wound care and emptying drains -N: need correct positioning = hip replacement: avoid internal rotation, avoid flexion of hip > 90 degrees, keep abductor pillow in place while in bed, do not position on operative side, position supine w/ HOB </= 60 degrees; knee replacement: avoid flexion of the knee for knee replacement; maintain continuous passive motion (CPM) machine to promote joint mobility -T: treat pain -wt bearing is delayed for several weeks after knee and only a few weeks w/ hip -life span of joint = 10-20yrs -neurovasc assess q2-4hr -- mvmt, sensation, color, pulse -use elevated seating or raised toilet -use straight chairs w/ arms -use abduction pillow while in bed and when turning but do NOT cross legs -externally rotate pt's toes (NOT internally) -need homecare for 4-6 weeks -care for incision daily w/ soap and water -monitor for s/sx of DVT, PE, and bleed if on anti-coag -meds: NSAIDs, opioids, abx, anticoags

pre-op + post-op liver biopsy

pre-op -assess wt and abd girth, and ID of -NPO ≥ 6 hours -avoid medications as ordered (aspirin, warfarin, NSAIDS) -assess coag labs (PT, aPTT, INR, platelet) post-op -lay on RIGHT side for few hrs -monitor for BLEEDING!! -- look at hct/hgb -monitor abd girth, VS, RR

pre-op + intra-op + post-op endoscopy

pre-op -conscious sedation -atropine may be given to dry secretions -avoid anticoag, ASA, + NSAIDs for several days -local anesthetic spray may be given to inactivate gag intra-op -left side-lying and HOB elevated during procedure post-op -sitting or supine with elevated HOB -NPO until gag returns (usually 30-60 min), then can drink or eat as tolerated -monitor VS and respiratory status -comfort measures for expected hoarseness + sore throat for several days = cough drops -explain to client may have ↑flatulence due to air being instilled during procedure -resume normal activities the next day or when fully awake -VS q15-30min until sedation wears off -d/c IVF if pt tolerates PO fluids (no N/V) -no drive for 12-18hrs -safety = bed rails, assist w/ walk -need to be d/c w/ someone

pre-op + intra-op + post-op lumbar puncture

pre-op -empty bladder -informed consent intra-op -position: side w/ knees pulled toward chest and chin tucked down -pain may be felt radiating down the leg, but it should be temporary -remove needle and apply pressure over site w/ sterile dressing post-op -flat for 4-8 hrs -look at site for hematoma/infection or spinal fluid leak -encourage fluids

craniotomy (pre-op + post-op + what report)

pre-op -no alc, smoke, NSAIDs, anticoag for >/= 5 days b4 -NPO >/= 8hr post-op -neuro check (GCS, LOC, pupil rxn) and VS q15-30min for 1st 4-6hrs --> q1hr (monitor O2 + CO2) -position: do NOT lay on operated side, head in neutral position, avoid hip and knee flexion -do NOT give opioids -avoid coughing, sneezing, or straining (may need stool softeners) -monitor I/O for DI or SIADH -- also to prevent constipation -compression devices to prevent DVT -DB and reposition q2hr -- NO COUGH -monitor ICP (goal: < 15) -- report sx of IICP -- may give antiemetic for vomiting bc vomiting can contribute to IICP -edema/ecchymosis around eye is common = give cold compress -routine cardiac monitoring d/t possible dysrhythmias -check dressing for drainage q1-2 hrs -- mark each shift -if have drains measure output q8hr (norm: 30-50 mL/8hrs) -irrigate eyes w/ warm saline or artificial tears to avoid irritation -HCP: new neuro deficits, decreased LOC, motor weak/paralysis, aphasia, decreased sensation, sluggish pupil rxn, personality changes, sx IICP, saturated head dressing or drainage > 50mL/8hr

pre-op + intra-op + post-op colonoscopy

pre-op -uses conscious sedation -avoid medications as ordered (aspirin, warfarin, NSAIDS) -NPO ≥ 6 hours, or after midnight (except water) -preparation: bowel prep 24-48 hrs prior: laxatives, GoLytely, clear liq diet 24 hrs prior, nothing red, no pulp, stop iron 5 days before. Note: contraindications to bowel prep: peritonitis/perforation, inflammatory bowel disease, obstruction -drink prep quickly to prevent nausea intra-op -left side-lying (w/ knees to chest) -continuous pulse ox post-op -NPO til fully awake and passes flatus -VS q15-30min til pt alert -keep pt left side-lying to promote passing flatus -keep top side rails up til pt alert -assess for rectal bleed and severe pain -fullness and mild abd cramp expected for several hrs -fluids available after pass flatus -fullness, cramp, flatus expected for several hrs -report excessive bleed or severe pain to HCP ASAP -s/sx bowel perforation: severe abd pain and guarding, possible fever later -s/sx hypovolemic shock: dizzy, light-headed, decreased BP, increased HR, pallor, altered LOC (1st sx w/ geriatric) -s/sx hemorrhage: rapid drop in BP

prevention + tx of hematoma w/ IV infusion

prevent -avoid veins not easily seen or palpated -obtain hemostasis after insertion tx -remove IV device and apply light pressure -monitor for s/sx of phlebitis and tx

prevention + tx of catheter embolus w/ IV infusion

prevent -do not reinsert stylet needle into catheter tx -immediately apply tourniquet high on extremity to limit venous flow -prepare for removal under XRAY

prevention + tx of phlebitis w/ IV infusion

prevent -rotate site q72-96hrs -aseptic technique for PICCs -avoid excessive activity w/ extremity tx -stop infusion -remove peripheral catheters -warm compress -insert new catheter in opposite extremity

prevention + tx of infiltration w/ IV infusion

prevent -use smallest catheter -assess blood return tx -stop infusion -remove peripheral catheters -cool compress and elevate extremity -insert new catheter in opposite extremity

prevention + tx of lumen occlusion w/ central venous catheter insertion

prevention -flush w/ NS b4, between, and after meds tx -use 10mL syringe w/ pulsing motion

prevention + tx of pneumothorax w/ central venous catheter insertion

prevention -use U/S -avoid subclavian tx -admin o2

primary + secondary + tertiary health promotion + disease preventions

primary prevention -focus on promoting health + preventing disease -immunization programs -education -nutrition and fitness activities secondary prevention -focus on early ID of illness, providing tx, and conducting activities geared to prevent a worsening health status -communicable disease screening and case finding -early detection and tx of HTN -exercise programs for older adults who are frail tertiary prevention -focus on preventing long-term consequences of chronic illness or disability and supporting optimal fxn -prevention of pressure ulcers as a complication of SCI -promoting independence for a pt following stroke

what is macular degeneration

progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field.

what does RICE stand for?

rest, ice, compression, elevate

SSAs of right vs left-side stroke/brain injury

right-sided brain injury -paralyzed left side: hemiplegia (partially paralyzed) on the left side -left sided neglect (poor left-sided vision) -spatial-perceptual deficits: steps; problems with perception (depth) - can't tell how deep or how far away things are Safety - risk for falling down steps -tend to deny/minimize problems -- "its not that bad", "I'm alright I can still walk"; unaware of deficits -rapid performance short attention span; do not try and teach them for a long period of time d/t impaired attention span - very hard time focusing -impulsive, impaired judgment -- can cause friction in relationships with family -impaired sense of humor -disoriented to time, place, and person -unable to recognize faces -cortical blindness -confabulation; euphoria; constant smiling -overestimates own abilities (risk for injury) -loss of ability to hear tonal variations left-sided brain injury -paralyzed right side: hemiplegia (partially paralyzed) on right size -impaired speech/language -- aphasias, agraphia, alexia -impaired right/left discrimination -slow performance -- do things slower (move, process), cautious -aware of deficits -- depression, anxiety, guilt, worthlessness, worry about future, quick anger and frustration, intellectual impairment -impaired comprehension related to language, math -possible memory deficit -vision: inability to discriminate words and letters; reading issues; poor right-sided vision, cortical blindness -no deficits w/ hearing

hiatal hernia (risk factors + SSAs + axn/edu)

risk factors -high-fat diet; caffeine; smoke; CCB, anticholinergic, nitrates; obesity SSAs -regurg, belch, heartburn, dysphagia -epigastric pain -breathlessness or feeling of suffocation after eat -chest pain that mimics angina -sx worse after a meal or when supine axn -barium swallow w/ fluoroscopy -no strain or vigorous exercise -monitor for bleed

VS for shock vs. IICP

shock -hypotension -tachycardia -tachypnea -hypothermia -weak pulse pressure -decreased LOC IICP -HTN -bradycardia -bradypnea -hyperthermia -high pulse pressure -decreased LOC

SSAs of small bowel vs. large bowel obstruction (+ interventions)

small bowel obstruction -abrupt/rapid onset of sx -pain = sporadic + colicky -severe fluid and elect imbalances -metabolic alkalosis (r/t N/V) -visible peristalsis in upper and middle abd -upper or epigastric abd distension -profuse, projectile vomiting w/ fecal odor -- vomiting relieves pain -does NOT have absolute constipation large bowel obstruction -gradual onset of sx -pain = diffuse + constant -minimal fluid and elect imbalances -metabolic acidosis (not always present) -minimal/no vomiting -lower abd distention -YES has absolute constipation + lack of flatus -obstipation or ribbon-like stools for partial obstruction BOTH SSAs -obstipation (can't pass stool and/or flatus for >/= 8hrs) -abd distention -hyperactive high-pitched bowel sounds above site of obstruction -hypo-active bowel sounds below site of obstruction BOTH interventions -NPO -NGT to decompress -IVF -pain control measures

sterile vs. non-sterile dressing changes + procedures

sterile -TPN -PICC line -thoracentesis + paracentesis -accessing or connecting dialysis catheter -post-op cholecystectomy dressing changes -post-op appendectomy dressing changes -spina bifida dressing -chest tube dressing -suctioning past oral cavity -urine sample from foley cath -ICP monitor -lumbar puncture -PAD ulcer dressings non-sterile -oral suctioning -clean catch or mid-stream urine sample

pt edu w/ PUD

stop smoking; avoid chronic NSAID use; avoid meals or snacks before sleeping; avoid multiple small meals; limit alcohol and caffeine

subdural vs. epidural hematoma (SSAs + interventions)

subdural hematoma -type of brain bleed -blood accumulation in the subdural space (between the dura mater and the arachnoid matter) -venous bleed = slow bleeding -acute = sx develop over 24-48hr; rapid deterioration/critical; changes in LOC, pupillary changes; hemiparesis -subacute = s/sx 48hr-14 days; no acute s/sx at onset, hematoma enlarges and produces progressive sx (hemiparesis, obtundation, aphasia) -chronic = weeks to months - often geriatrics, forgotten history of head injury, usually progressive mental or personality changes; sx may mimic CVA -intervention = surgical eval and/or burr holes w/ drain placement epidural hematoma -type of brain bleed -blood accumulation in the space between the dura and skull -usually arterial from middle meningeal artery (MMA) due to temporal bone fracture (hit side of head) -arterial bleed = rapid bleeding -can occur w/in minutes of injury -monitor pt suspected or dx w/ this LOC + GCS q5-10min -SSA = injury --> brief loss of consciousness --> lucid (awake + talking) --> rapid deterioration -intervention = burr holes + placement of drain to relieve increasing ICP

interventions for urine sample, clean-catch sample, catheter sample, and 24-hr urine collection

urine sample -collect 1st specimen voided in AM -send to lab ASAP or put on ice -make sure sample is covered clean-catch sample -self-clean before voiding -pee little in toilet then start collecting into container -at no time should any part of the pt's anatomy touch the lip or inner aspect of the container catheter sample -clamp distal to injection port -clean port cap and allow to dry -attach sterile 5 mL syringe into port and get desired amount of urine -inject sample into sterile container 24-hr urine -place signs -initial collection: void, discard urine, and note time; if using foley -- empty bag, discard urine, and note start time -collect all urine for next 24hr -at end: ask pt to empty bladder and add that urine to the container

when do advanced directives go into effect

when the client is unable to speak for him/herself due to such conditions as mental incapacity

incident report (when to file + what included + actions)

when to file -error = med, procedure, tx, equipment-related -injury = equipment-related, needlestick, pt fall, visitor or volunteer -threat made to pt or staff -loss of property (dentures, jewelry, personal wheelchair) -diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) -treatment (error in performance of procedure, treatment, dose; avoidable delay) -preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) -other (failure of communication, equipment failure, system failure) actions -complete ASAP and w/in 24hr -confidential and not shared w/ pt -not placed in health care record/chart BUT description of incident should be documented factually in pt record -forward to risk mgmt department or officer what included -objective description of incident and actions taken to safeguard pt -assessment and tx of any injuries sustained

TPN (who needs it + what's in it + nursing care)

who? -pt not eaten for 5 days and can't for next 5 days -inadequate nutrition for 7-10 days -wt loss of 7% body weight -altered ability to absorb nutrition -prolonged recovery -hypermetabolic state -chronic malnutrition what's in it? -standard IV therapy: </= 700 cal/day -lipids/essential fatty acids in separate bag -can contain calories, dextrose (20-50%), PRO, elect, vitamins, trace elements, lipids, essential fatty acids interventions -admin via central line ONLY -gradually increase rate (</= 10% hourly) -check glucose q4-6hrs for at least 24hrs then per protocol -- give insulin as rx -keep dextrose 10% at bedside -monitor fluid balance, daily wt, I/O, daily CBC, electrolytes -prepare solution under sterile conditions -hang new solution q24hrs -change IV tubing and finter q24hrs w/ each new bag to prevent air embolism -always use filter on infusion line -have 2 RNs sign off -do NOT place any other fluids or meds in same line -change dressing around IV site q48-72hrs