NCLEX - PN MERCY REVIEW

Ace your homework & exams now with Quizwiz!

what is pain?

"Pain is whatever the experiencing person says it is, and exists whenever he/she says it does" (McCaffery). An unpleasant sensory (physical) and emotional (psychological) experience associated with actual or potential tissue damage Meaning that pain usually indicates a problem

know appropriate questions to ask in regards to patients chief complaints

'what is troubling you?"" "what has brought you to the [doctor/hospital/clinic]?" should be recorded in pts own words, encourage pts to elaborate by discussing specific symptoms. i.e: when the s/s started, if they are gradual or abrupt. how often does the problem occur. exact location of the distress. character of the complaint. activity engaged in when problem occured. factors that aggravate or alleviate

Care of patient post TAH (Total Abdominal Hysterectomy):

(Transcervial intrauterine endoscopy) allows direct visualization of all parts of the uterine cavity by means of lighted optical instrument.

Care of a Patient Post Cystectomy:

(removal of bladder) -urinary diversions -skin care -risk for bleeding -if new bladder from other tissue dont forget to train -MOSTLY MADE THIS UP, I HAVE NO IDEA WHERE TO FIND THIS. I KINDA DO BUT IM TOO LAZY TO LOOK FOR IT. I DONT TRUST GOOGLE. AND IM TOO LAZY TO OPEN THE MED-SURG BOOK. GOOD LUCK THO -Prez_Jmoney

Care of Patient Post Prostatectomy

(removal of the prostate)

Care of a Patient with Post TURP

(transurethral surgical resection of the prostate - surgical instrument is introduced into the urethra and the area of obstruction are cut away) take vital signs every 2 hours initially, monitor for pallor and rising pulse, monitor for potential for bleeding, urethral stricture, fistula, urinary incontinence, bladder neck constriction, administer stool softeners to prevent straining

rationalization

* Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. John tells the rehab nurse, "I drink because it's the only way I can deal with my bad marriage and my worse job."

projection

* Attributing feelings or impulses unacceptable to one's self to another problem. Sue feels a strong sexual attraction to her track coach, and tells her friend, "He's coming on to me!" Patient dislikes the nurse, will state, "She hates me!"

legal rights of mental health patients

* Patients with a psychiatric diagnosis are guaranteed the same civil rights as any other citizen. * The right to human tx and care (medical and dental) * The right to vote in national, state and local government elections. * The right to refuse medication * The right to the least restrictive alternative * Confidentiality and right to privacy * A written plan of care/tx that includes discharge follow up, as well as participation in the care plan and review of that plan * Care with respect, dignity, and without discrimination * Adequate supervision.

nursing interventions associated with suicide

* Provide a safe environment. Constant supervision, 1:1. Never leave them alone without relief from staff. Conduct regular body searches. Remove belts, shoe laces, sheets, shaving supplies, hangers, cosmetics, mirrors. On admission: paper dishes and plastic spoons only and inspect all items from home.

39. Know the clinical manifestations of Meniere's disease

** A CHRONIC DISEASE OF THE INNER EAR CHARACTERIZED BY RECURENT EPISODES OF VERTIGO, PROGRESSIVE UNILATERAL NERVE DEAFNESS AND TINNITUS** • Vertigo • Unilateral/bilateral hearing loss • Nausea • Vomiting • Diaphoresis • Nystagmus (condition of involuntary eye movements) • Tinnitus • Fullness in the ear

Osteomyelitis

** A musculoskeletal chronic or acute Infection Causes: Soft tissue infection - Pressure Ulcers - vascular ulcers - incision - direct bone contamination from: - surgery - open fracture - traumatic injury - gunshot wound - Hematogenous: staphylococcus aureus (most common pathogen) - difficult to treat because bone is less vascular and infected S/S - severe pain in the infected area - swelling & redness - Fever 103-104 - general malaise Treatment: - Bedrest - immobilization (use splint) - drain may be placed surgically into the bone - surgical debridment (antibiotic impregnated beads) Nursing Intervention: - ** avoid pathological fracture: * Immobilization w/splint * Assisted devices to avoid weight bearing * handle with care painful - keep extremity in good alignment - contact precautions - handle secretions carefully - infectious - pain management High Risk: - elderly - malnourished - corticosteroid therapy & immunosuppressants - obese - impaired immune system - chronic illnesses (DM, Rheumatoid Arthritis)

41. Know the nursing intervetions associated with Meniere's disease especially diet

** Goal is to eliminate the attacks ** • Absolute bed rest • Quiet dark room • IV Valium and/or Dramamine • Avoid anything that vasoconstricts: caffeine, nicotine, and decongestants • Limit sodium intake to 2000mg daily

Cast Care Complications Compartment Syndrome

** Increased tissue pressure within a limited space; cast muscle, compartment leading to anoxia and necrosis. - Permanent lost of function > 6 hrs. - CMS checks S/S - exposed extremity is dusky, pale - cool skin temp. - delayed capillary refill - Not relieved by opiods - Passive stretching causes pain. - Nerve Ischemia & swelling continues - Paresthesia (numbness or tingling of skin) or paralysis - Hypoesthesia Management: 1. **Elevate extremity to heart level 2. **Notify MD 3. **Bi Valve Cast with MD order a. loosen or remove and bivalve cast (cut in half longitudinally) to reduce constriction and allow for inspection of skin. 2. Maintain limb alignment 3. Fasciotomy if pressured is not relieved or restored to relieve pressure within muscle compartment. 4. Debridement/grafting may be needed Post-Op 1. Sterile dressing: keep clean and free from infection 2. Limb splint 3. ROM 4. Elevate limb

Parkinson's Disease Medication

** Medications are given together for combined effect. **Rebound symptoms if medications are given late. Levodopa (Larodopa) therapy- most effective, esp. first few years then wanes - Adverse Effects- Confusion, hallucinations, depression, sleep alterations with prolonged use - Nursing considerations- Not with Vit.B6 or with narrow angle glaucoma, postural hypotension, take with meals Anticholinergic agents- To control tremor & rigidity- Benztropine mesylate- Cogentin Antivirals- Symmetrel- To reduce rigidity, tremor, & bradykinesia Dopamine agonists- Permax, Parlodel used to postpone the initiation of Cardopa & Levodopa therapy ** PET in determining the amount of levodopa uptake in the brain

42. Know how to instill ear drops in a child and a adult

**SIT LIE WITH HEAD TURNED TO UNAFFECTED SIDE ** • ADULTS: hold the auricle up & back • CHILDREN: hold auricle down & back

State the purpose of the Denver Developmental Screening Test.

*Denver Developmental Screening Test* DDST test for assessing a young childs in order to detect delays;

describe nursing interventions to support clients spiritual beliefs and religious practices

*Recognition and encouragement of the body/body/sprit in promotion of health* • Identifying and validating client's inner resources: − Coping methods − Humor − Motivations/Attitude/Optimism − Self-determination • Providing Presence • Support religious practices • Assist in prayer/meditation • Converse about spirituality • Refer client for spiritual counseling if needed or requested Examples of encouragement for clients' healthy spiritual : - Needing to leave behind a legacy (storytelling, recording life stories) - Encouraging creative expression (writing, art, and/or music) - Fostering need for client to be in touch with nature/maintain a sense of wonder BEING PRESENCE: Definition: • Being present • Being there • Being with the client FEATURES OF PRESENCING: • Giving of self in the moment • Being available with one's whole self • Active listening with full awareness • Being present in a meaningful way to the other Four Levels of Presencing: • Presence: − Physically present but not focused on client. • Partial presence: - Nurse present, doing a task on client, superficial relation with client. • Full presence: - Nurse is physically, mentally, and emotionally present - Intentionally focusing on client • Transcendent presence: - Nurse is physically, mentally, emotionally, and spiritually focused on client - A transpersonal/transforming experience REMEMBER: • Assist with prayer - Ask client: • What do you want to say in your prayer? - Participate if appropriate, provide privacy, quiet environment •Refer patients for spirituality counseling as needed - Community/clergy

Identify the normal growth & development patterns and ages and stages of maturation for children in all age groups.

*Milestones* *Infancy 0-1* mth- toys= black and white mobiles; Infancy 1-3 mths- posterior fontanel closes (back of the head); Infancy 3-4 mths- may start to roll over(at will 5-6 mths); Infancy 4mths- rooting reflex gone; Infancy 5 mths- sits alone briefly, cradle gym/infant swing; Infant 6 mths- eruption of first deciduous teeth occurs; Infancy 8mths- pulls to standing position ; can use pincer grasp (use thumb and finger to hold); has full trunk support; pincer grasp; Infancy 9mths- creeps and crawls; Infancy 10 mths- walks when led; holds own bottle/drinks from a cup; Infancy 11mths-12mths- begins to walk alone with wide stance, likes push/pull toys, says bye-bye, ma ma, da da and a few similar words *The Toddler* bowel and bladder control is achieved by 2 ½ -3years, primary dentition complete by 2 ½ yrs; Autonomy vs shame and doubt, Ritualism (keep routine); Toilet Independence- myelination of spinal cord complete by age 2: voluntary control of sphincters; willing to sit for at least 5-10 minutes; Toddler 15-18mths: anterior fontanel CLOSES, builds a tower of 2 soft block at 15 mths; builds 4 blocks at 18 mths, likes riding toys; vocabulary of 5-10 words; At 18 ths- begins to feed self, Toilet training may begin because voluntary anal sphincter control ability begins.; Toddler 24 mths- vocabulary of 300 words, suses plural words, builds a tower of 7 blocks, opens doors, climbs on furniture; Toddler 30 mths- all primary deciduous teeth, says full name, builds a tower of 9 blocks. *The Preschool child 3-5 yrs* Egocentrism; cooperative play; acceptance of separation; Preschool language development- in the preschool period, the number of words in the child's sentence should be equivalent to the child's age; 3yrs old rides tricycle, imaginary playmate, builds tower of 10 blocks, bladder control achieved, likes climbing activities/wagons/little cars; 4 yrs- counts four pennies accurately, buttons and unbuttons clothes, Vocabulary of 1500 words; 5 yrs - counts 10 pennies accurately, vocabulary is 2000 words. *The school age child* concrete operations- thinking is logical; 6yrs - loses primary teeth; 7 yrs- writes; 8 yrs- less picky eaters; 9 yrs- interest in competitive sports; 10 yrs- vocabulary increases; 11-12 yrs: puberty may begin *Adolescents 13-18 yrs* peer group is extremely important and very influential ; acceptance; independence; adolescents seek autonomy from their parents; according to erickson, the major developmental task of adolescence is to establish a sense of identity (mirror is their best friend); Remember the 5 "I"- image of self; identity; independence; interpersonal relationships; intellectual maturity; Young adolescents are still in concrete operations stage; by middle adolescence formal operations stage is reached; characterized by abstract reasoning and logic; Safety issues- automobile accidents, depression and suicides.

Normal weight gain on infant

- 1 to 2 lbs a month - double by 6 months - triple by 10 mth to 1 yr - increases hight 9-10 inches

Toddlers

- 13 months to 3 yrs - can learn to feed themselves - hot dogs are dangerous - avoid stews and casseroles

Patient w/Traction Nursing Interventions Priorities

- 1st assess body alignment & anatomical position - pull up if at foot of bed - administer pain meds

Calorie requirement for lactation

- 500 plus per day

Best describe a mentally healthy person

- A state of emotional, psychological, and social wellness. - Evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability. - Autonomy and independence: the individual looks within for guiding values and rules. The individual considers the opinions and wishes of other but does not allow them to dictate their lives. - Maximization of potential: the individual is oriented to continuous growth. - Tolerance of life's uncertainty: the individual faces day-to-day challenges with hope and a positive outlook. - Self-esteem: the individual has a realistic awareness of abilities and limitations. - Mastery of environment: the individual can deal with and influence the environment in a capable, competent, and creative manner. - Reality orientation: the individual can distinguish reality from a dream, fact from fantasy, and act accordingly. - Stress management: the individual tolerates life's stresses, appropriately handles anxiety, grief, and the experience of failure without devastation. The individual uses support from significant others to cope with crises.

Therapeutic communications Questions and Answers

- Active listening: being attentive to what they patient is saying - both verbally and nonverbally. This communicates acceptance, respect, and trust. Ex. Physical posture that communicates the patient has your attention. Watching for non-verbal cues as the patient speaks. *excellent for a new admit - Using silence: accepting pauses or silences - several seconds or minutes. Give the patient the opportunity to collect and organize their thoughts, to think through a point, or to introduce a topic of greater concern. Ex. Sitting quietly or walking with the pt. - Giving broad openings: allows the patient to take the initiative in introducing the topic; emphasizes the importance of the client's role in the interaction. Ex. "What would you like to talk about today?" "Tell me what you are thinking." "Describe your feelings." - Reflecting: questions and feelings are reflected back to the patient so they may be recognized and accepted - good to use when the patient asks for advice. Adding what you heard about the patient's feelings. Ex - PT: What do you think I should do about my wife's drinking problem? PN: What do you think you should do? PT: My brother spends all my money and has the nerve to ask for more. PN: this makes you feel angry? - Restating: actively listening for the patient's basic message and then repeating the main idea of what the patient says; repeating their thoughts and feelings in similar words. Ex - PT: I can't study, my mind keeps wandering. PN: you have trouble concentrating? - Touch: providing appropriate forms of touch to reinforce caring feelings. Touch varies across individuals, and cultures - the nurse must be sensitive to the patient's response/comfort. Ex. Arm of the patient shoulder, handshake. - Seeking clarification: a method of making the patient's broad overall meaning of the message more understandable. To clarify, the nurse can reinstate the basic message or confess confusion, and ask the patient to repeat the message. Ex. I'm not sure I understand that, would you please say that again. I'm not sure I follow, tell me more about that. - Offering self: suggesting ones presence, interest, or wish to understand the patient without making any demands or attaching conditions to receive the nurse's attention. Ex. "We can sit here for a while; we don't need to talk unless you would like to" "I'll stay with you until your daughter arrives" - Giving information: providing in a simple direct manner, specific factual information the patient may or may not have requested. Ex. "Your surgery is scheduled for 11am tomorrow." - Reflecting: directing ideas, feelings, questions, or content back to the patient to enable them to explore their own ideas and feelings about a situation. Example: PT: What can I do? PN: what do you think would be helpful? PT: Do you think I should tell my husband? PN: You seem unsure about telling your husband.

Rules for PPN and TPN

- Always run through control pump if TPN runs out hang an IV of D10W until the pharmacy delivers the next bag - Non IV certified LPN's cannot hang by Florida Law - Never run anything together in the same IV line gradually discontinue - Assess for fluid overload (SOB, wet respirations, chest pain, disorientation or confusion) - Report wet, soiled or non-occlusive dressings

ABCD nutritional assessment

- Anthropometic measures - Biochemical data - serum protein, serum albumin, tranferrin, TIBC: total protein intake & use. - Clinal signs - Dietary history- allergies, chewing, swallowing See page 29 through 31

Nursing Intervention Hemorrhagic Stroke

- Assess respiratory status - Assess neurological status - Monitor vital signs - Elevate HOB to 30-45 degrees (Semi-Fowlers) - Optimal tissue perfusion Aneurysm Precautions - Decrease sensory stimuli - Bed rest with sedation - Analgesics for headache - AE hose Management: - Manage hypertension especially >55 - Decrease smoking & alcohol intake - Manage high cholesterol - Recover brain from the insult (bleeding) - Prevent risk of rebleeding

Know the most important nursing diagnosis for MS

- CSF electrophoresis will show IgG reflecting immunoglobin abnormality - MRI -Primary diagnostic tool - Evoked Potential Studies - CT Scan

Ergotamine tartrate (Cafergot)

- Can arrest or reduce severity of headache if taken at first sign of attack - Acts on smooth muscle, causing prolonged constriction of the cranial blood vessels - Side effects include aching muscles, numbness and tingling, nausea, and vomiting * Do not take ergotamines with triptans because of potential for prolonged vasoactive reaction (Vasoconstriction)

What to check on on a regular bases and offer a patient in the Seclusion Room.

- Check restraints - offer food and water - offer to go to the bathroom

Differrence between a Complete & Incomplete Protein

- Complete Proteins has a High biological value. It closely resembles amount & combination of amino acids in the human body. Animal sources are most often a complete protein. i.e., meat, fish, poultry, milk, cheese - Incomplete Proteins - Plant Sources, have a lower biological value (can be made complete in the right combo of food at the same meal)

Proper Application/Use of Traction

- Continuous - Never interrupted - good body alignment - ropes not obstructed - weights hang freely - knots must not touch pulley or foot of bed

Patient w/Traction Complications/Preventions

- DVT, PE, Venous stasis: SCD, isometric exercises, ankle pumps, AE hose, Antiplatelets (lovanox), anticoagulants, hydration, ROM - Pressure Ulcers - assess skin 3x/day - Drop Foot - Pneumonia: use incentive spirometer, hydrate - Constipation: Fluid, fiber, stool softner - Urinary Stasis & Infection: TOWREEDA - Anorexia: supplements, high caloric foods - Atelectasis - nerve pressure - Circulatory Impairment: assess CMS q1 for 1st 24 hrs - Pin care as prescribed q8hrs

Bone Tumor Pathologic Fracture Intervention

- Fall prevention - Assistive devices - Physical Therapy

Enteral feeding

- Feeding through the GI tract for patients with swallowing difficulties or at risk of aspiration, unable to ingest foods, impaired upper GI tract - Suction stomach contents: gastric decompression to prevent gastric distention, nausea & vomiting

Foods to Avoid in Migraines

- Foods containing tyramine, monosodium, glutamine, nitrates, wine, chocolate & milk products

Nursing Intervention for a patient that is really depressed? Not eating, showering, doesn't want to get out of bed.

- Frequent small meals with high caloric value - be calm & soothing - encourage talking - do not offer false reassurance For Mileu - start with simple activities; getting up, showering, eating - involve in group activities as much as possible - assign duties that includes a talent they might have or something they can handle or be good at

S/S Alcohol withdraw syndrome

- Hand tremors - Sweating - N&V - Anxiety - Agitation - Hallucinations - Seizures

s/s of Parkinson disease

- Head bent forward - Fine tremors of hand /head - Pill rolling of the hands - Shuffling propulsive gait - Rigid stance - Loss of postural reflexes - Masklike expression - Stooped posture - Weight loss - Drooling - Poor articulation (Dysarthria) - Dysphagia - Constipation - Difficulty in writing - Difficulty in pivoting - Dementia - Confusion - Difficulty from rising from a sitting position - Loss of balance - Difficulty in turning from side to side - Three cardinal signs : Tremors, bradykinesia (abnormally slow movement propulsive gait, stooped posture) - Head bent forward - Fine tremors of hand /head - Pill rolling of the hands - Shuffling propulsive gait - Rigid stance - Loss of postural reflexes - Masklike expression - Stooped posture - Weight loss - Drooling - Poor articulation (Dysarthria) - Dysphagia - Constipation - Difficulty in writing - Difficulty in pivoting - Dementia - Confusion - Difficulty from rising from a sitting position - Loss of balance - Difficulty in turning from side to side - Three cardinal signs : Tremors, bradykinesia (abnormally slow movement propulsive gait, stooped posture)

Parkinson's Disease Clinical Manifestations

Inserting a Nasogastric tube

- High, Fowlers position - measure from tip of nose to the tip of the earlobe to the tip of the sternum (xiphoid process) - Check for correct placement by stomach aspiration for nasogastric larger gauge as well as ausculate air by insufflation ( instill 30-50cc bolus of air)

Parkinson's Disease Nursing interventions

- Improve mobility (Explain to patient that tremors at rest can be stopped by holding onto an object or grasping items) - Improve nutrition - Improve communication - Supporting coping abilities - Patient/family education - Home care considerations - Assess for dyskinesias

Nursing interventions patient with a MS

- Improve self care - Support adaptation to sexual dysfunction - Promote spiritual health - Patient education - Home care considerations - Remove exacerbating factors that may trigger an adverse relapse

Anhedonia

- Inability to feel pleasure - Loss of pleasure in something once enjoyed.

Iron Deficiency Anemia

- Inadequate absorption or excessive loss of iron - A chronic microcytic, hypochromic anemia Causes: 1. Most common cause in adult men and postmenopausal women is bleeding; ulcers 2. Low intake of Iron 3. Problem with absorption of Iron 4. RBC may be normal or low Clinical Manifestations: 1. Fatigue/weakness- due to poor cellular metabolism secondary to the lack of oxygen. Severe cases: - Palpitations - Pallor - Dyspnea - GI complications - Stomatitis (ulcers/inflammation of mouth) - Dysphagia (difficulty swallowing) - Pica (clay, laundry starch) Nursing Interventions: 1. Oral ferrous sulfate or ferrous gluconate, usually 300 mg tid 2. Patient instructed to take oral supplements 1 hour before meals or 2 hours after meals 3. Teach pt/family to observe for nausea, constipation, abdominal distress and diarrhea 4. Can be taken with food to avoid gastritis 5. Enteric coated is poorly absorbed (should be avoided) 6. Don't give with dairy products or antacids, it decreases absorption 7. Parenteral iron dextran (Imferon®) Given IM (Z tract)- 50-250 mg 8. Folic acid and/or vitamin B12 Teaching: 1. Preventive education (pregnant women or menstruating) 2. Diet high in iron - Organ meats, red meats, beans, (black, pinto, garbanzo), leafy green vegetables, raisins, molasses, egg yolks, shellfish, prunes, peaches and grapes 3. Take on empty stomach with Vit. C for best absorption 4. Educate the patient about changes in stool with iron therapy 5. Liquid iron supplements stains teeth so administer with straw 6. Frequent oral care (ferrous sulfate deposits on teeth)

care of pt with iron deficient anemia

Cardinal S/S of ADHD Select all that apply

- Inattentiveness - Overactivity - Impulsiveness

Leukemia

- Increased levels of Leukocytes in the circulation. - Overcrowding of cells Clinical Manifestations: 1. Prolonged bleeding 2. Bleeding gums, bleeding from the nose 3. Menstrual periods, abnormal 3. Patechiae, ecchymosis, skin rash or lesion 4. Fever, lymphadenopathy 5. Splenomegaly 6. Bone pain or tenderness 7. Weight loss 8. Shortness of breath aggravated by exercise, 9. Fatigue, Pale Nursing Interventions: 1. Assess for s\s of infection 2. Watch for bleeding 3. Make sure that the patient is not on ASA Patient education: 1. Discuss treatment modalities 2. Discuss advance directives with the patient 3. Ensure adequate rest

ECT - Safety Outpatient setting

- Informed Consent - NPO - have pt. void - dentures out - metals out - Crash Cart present MD/anesthesiologist/psychiatrist present - Must take VS & verify gag reflex - Outpatient: tx. up to 3x/week for 6-15 treatments or up to 5 weeks ** No Driving

care of a pt pre and post ECT

Conduct Disorder Behaviors (select all that applies) S/S

- Little Empathy for others - low self esteem - poor frustration tolerance - Temper outburst - 3:1 boys to girl - up to 50% develop antisocial personality disorder Mild Disorder - lying - truancy - staying out late Severe disorder - causing harm to others - forced sex - cruelty to animals - burglary & robbery Clusters: - aggression toward people & animals - destruction of property - deceitfulness & theft - serious violations of rules

Signs of Autism

- Little eye contact or facial expressions - Limited gestures to communicate - Limited capacity to relate to or express emotion with others (social interactions) - Lack spontaneous enjoyment - Little expression of moods/affect - Limited ability to play with toys - May see hand flapping, body twisting, and head banging

Describe fecal incontinence

- Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter - At specific times (after meals), or irregularly - Two types--- Partial (cannot control flatus or minor soiling) or Major (cannot control feces of normal consistency) - Causes Emotional distress and/ or social isolation -Dysfunction of anal sphincters .Vaginal delivery, surgical procedures ( repair or colostomy), trauma, tumors .Decreased Rectal Compliance .Impaired rectal sensation -Diabetes mellitus, multiple sclerosis, dementia, meningomyelocele, spinal cord injuries -Fecal Impaction .Impaired mental function, immobility, rectal hyposensitivity, inadequate intake of fluids and dietary fiber -Idiopathic

Osteoporosis

- Metabolic disease, bone absorption high; Loss of bone mass; Fragile bones, fracture prone ** Clinical Manifestations: - ** Kyphosis, loss in height - ** Vertebral collapse (ribs) - ** Fractures (hip, wrist) - **Constipation, abdominal distention - Pathological fractures - Chronic pain - Impairment of balance and respiratory function Risk Factors: - ** elderly - ** Caucasian and asian females - postmenopausal, hyperthyroidism, anorexia nervosa, malabsorption syndrome, renal failure - ETOH, caffeine, smoking, lack of sunlight - ** small frame - family history - Hormones (estrogen, calcitonin, testosterone) - lack of weight bearing exercise - ** low weight and BMI - ** low calcium, Vit D., high phosphate, carbonated drinks - corticosteroids, anti-seizure, heparin, thyroid medications Prevention: - Early identification - prevent fractures - ** weight bearing exercises - reduction of caffeine, cigarettes, alcohol Nursing Interventions: - Pt education - ** safety precautions, fall prevention - handle pt's gently - pain management - improving bowel functions

Nursing care of a patient with pneumonia

- Monitor C&S results antibiotic peak and through - Analgesics non-narcotic, antipyretics Hydration (force fluids if not contraindicated CHF, CRF) - Antitussive agents - Antihistamines - CPT (before meal and position for postural drainage base on lung area to be drained - IV fluids to res from eating

Levodopa

- Most effective, esp. first few years then wanes - Adverse Effects- Confusion, hallucinations, depression, sleep alterations with prolonged use - Nursing considerations- Not with Vit.B6 or with narrow angle glaucoma, postural hypotension, take with meals

Clinical Manifestation of a Stroke

- Numbness or weakness - Face, arm, or leg (Esp. on one side of body) - Change in mental status, confusion - Trouble speaking /understanding the language - Visual disturbances - Problems walking, dizziness, - Loss of balance, coordination - Severe, sudden headache (Throbbing) - motor loss - perceptual disturbance - sensory loss

2. Review the nursing interventions associated with amblyopia

- One eye does not function to the part of the other by large degree for no known reason - Usually see in children - One eye tends to be smaller than the next Correction : Patching the good eye

Nursing Intervention Seizure Drug Therapy

- Patients receiving phenytoin (Dilantin) have to have thorough oral hygiene after each meal (Gum massage, daily flossing, and regular dental care) - All important to prevent or control gingival hyperplasia - Normal Dilantin level is 10-20 mcg/mL (Monitor through regular blood draws)

stroke treatment including t-PA

- Place objects within intact field of vision (unaffected side) - Approach patient from side of intact field of vision - Encourage use of eyeglasses if available - When teaching the patient, do so within patient's intact visual field - Encourage use of cane or other object to identify objects in periphery of visual field - Explain to patient location of object when placing it near patient - Consistently place patient care items in same location - Do not tell patient to ignore affected side - Driving ability will need to be evaluated - HMG-CoA Reductase inhibitors (statins) for stroke patients Tissue Plasminogen Activator - Dissolves blood clot but, needs to be given within 3 hours, contraindicated in certain patients (Low platelet level, uncontrolled high blood pressure, etc.) - Contraindicated: symptoms greater than 3 hr before to admit, anticoagulated with INR greater than 1.7, or a patient who has recently had any type of intracranial pathology (previous stroke, head injury, and stroke).

Seizure Nursing Interventions

- Prevent injury - Reduce fears - Improve coping skills - Patient education (Do not drink anything with alcohol in it, do not stop taking anti-seizure meds, wear medical alert bracelet, follow-up with care) - Mental outlook - Oral Hygiene - Vocational rehabilitation - Pad side rails - Airway/suction at bedside - Vocational rehab - Ongoing evaluation - Genetic counseling - Managing patient complications - Financial considerations

Clinical Manifestation of Migraine Headaches

- Recurrent headaches that last 4-72hrs - Has 4 parts 1. Prodrome (pre-headache) - depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea or constipation 2. Aura - Unilateral with moderate pain; may cause photophobia, phonophobia & nausea - last less than 1 hour - visual disturbance, numbness, tingling of lips, face, hands, mild confusion, slight weakness of extremity, drowsiness & dizziness 3. Headache - throbbing, intensifies over several hours. - severe & incapacitating - photophobia, nausea & vomiting - last 4 to 72 hours 4. Postdrome - pain subsides - muscle contraction in neck & scalp, with muscle ache & localized tenderness, exhaustion & mood changes - physical exertion exacerbates the headache pain.

Role of the Nurse in TPN/PPN Nursing Interventions

- Report sudden fevers immediately - assess for phlebitis (inflammation of leg or arms) - sterile dressing changes every 3 days - I&O, weight every day - Check Labs, especially blood sugars as ordered or q6h - * change bag and tubing q24h - Non IV certified LPN's cannot hang by Florida Law

Nursing Diagnoses electrolyte imbalance

- Risk of fluid volume imbalance - Fluid volume deficit related to poor intake/vomiting/diarrhea - High Risk for fluid deficit related to diuretic therapy/poor intake - Fluid volume excess related to sodium & water retention - Impaired gas exchange related to hypoventilation

What are the positive effects for a person on antipsychotic medication? What behavior do you want to see improved?

- To improve overall quality of life - Encourage health lifestyle changes & monitoring personal mental health - Maximize ADL functions - Balance Mood - Improve interpersonal relationships - Improve though process Antipsychotics Haldol, Geodon - To calm, reduce impulsive (bizarre behavior) - Reduce hallucinations, illusions, delusions - Improve Train of thought

purpose of assessment

- To supplement, confirm, or refute data obtained in the nursing history (patients may at times underreport their symptoms) - To obtain data that will help establish nursing diagnoses and plans of care - To evaluate the physiological outcomes of health care/nursing - To identify areas for health promotion and disease prevention - To clarify information: patients may be in denial about their illness - For patients who have altered levels of consciousness/mental status, be sure to obtain the observations of relatives and friends - Surveillance of health status - Identification of latent or occult disease (concealed) - Screening for a specific type of disease (case finding) - Follow-up care. - To obtain information that will help the nurse establish - To establish a patient/nurse relationship - To obtain data about the patient - To identify patient strengths - To identify actual and potential problems - Sequential development of the chief complaint

how is HIV transmitted

- Unprotected sex with an infected partner - Contact with body fluids (blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk) From mother to child - Trans placental - Breast milk - At time of delivery - 20-40% chance of transmission - Babies born to HIV + mothers will be positive at birth due to maternal antibodies passed to infant - test in 3-6 months to determine for certain - Medication therapy reduces the chances

Why are nurses prone to addiction

- Work Stress - Accecibility

Define TPN

- a tailored solution that includes the use of dextrose, fats, proteins, electrolytes, vitamins, minerals & trace elements - it's a hypertonic solution - usually infused through a Central Venous access device (CVAD)

Characteristics of NREM Sleep

- activity is RAS is inhibited -slow-wave sleep: on deg waves maybe long continuous -deep/restful: most of sleep during night (nrem)

How the DRI is Calculated

- age - sex - height & weight - for calories: energy expenditure

Total vegan diet

- all animal food sources are excluded including dairy and eggs - this diet is low/inadequate in vit. B12, FE, Ca, and vit. D

What does Full Liquid Diet mean

- all clear liquids plus Milk, ice cream, strained soups, fruit & vegetable juices, custard, pudding, creamed cereals, yogurt, food liquid at room temperature

Soft liquids/- pureed

- all liquids - used for patients with difficulty swallowing thin fluids - usually low on residue (fiber)

a nurse is reinforcing instructions for a client who is scheduled for a cervical biopsy. which of the following should the nurse include in the instruction?

- avoid heavy lifting approximately 2 weeks after procedure = until cervix is healed -avoid the use of tampons for 2 weeks after procedure = until cervix has heeled

a nurse is reviewing information with a female client who has frequent urinary tract infections. which of the following information should the nurse include?

- avoid sitting in a wet bathing suit = may increase the risk for a UTI by colonization of bacteria in a moist and warm environment. -empty the bladder when there is an urge to void = rather than retaining because of the increase risk for UTI. -take a tub bath daily = or a shower to promote good hygiene and decrease colonization in the perineal area that can cause a UTI.

Primary regulator of Fluid Intake

- body's thirst mechanism-(hypothalamus) - changes is osmotic pressure, vascular volume and angiotensin (hormone released in response to decreased blood flow to the kidneys)

Identify normal characteristics of feces

- brown/yellow - formed, soft, semisolid, moist - cylindrical - 100-400 g/day - aromatic - small amounts of undigested roughage

Water loss

- can not be stored - sensible water loss; measurable loss, urine output, emesis - insensible water loss; not measurable, respiration, perspiration, feces, diarrhea

Age affecting fluid & electrolytes

- children have greater needs than adults because of immature kidneys, greater surface area & higher metabolic rate, higher respiratory rate, rapid turnover of fluids - elderlies thirst response blunted, nephrons are less able to preserve water in response to ADH, heart disease, increased levels of atrial natriuretic factor, impaired renal failure, multiple drugs - higher risk of dehydration

Factors affecting nutritional status of the elderly

- chronic illness; 85 % of elders have one or more diseases, osteoporosis, DM, atherosclerosis, HTN, cancer - elderly patients alter their diets to prevent complications, due to chronic disease - poor dentition - diminished capability to shop and prepare meals

Identify abnormal characteristics of feces

- clay/white, black/tarry, red, pale, orange/green - hard/dry, diarrhea - narrow, pencil-shaped, string like stool - pungent (sharp) - pus, mucus, parasites, blood, fat, foreign objects

Clinical measurements used in patients with fluid & electrolyte imbalance

- daily weight (1 kg = 1 Liter of fluid) take before breakfast & after 1st void, similar clothing, same scale - vital signs - intake & output

Nursing interventions for heartburn (2nd & 3rd trimester)

- decrease fats, spices, caffeine - small frequent meals - drink fluid between meals

Bottle feeding teaching

- do not feed propped up with a pillow or towel; risk of aspiration, gas or colic - do not leave milk out over 2 hrs - do not store milk in fridge more than 48 hrs - do not reuse formula not completely consumed (bacterial growth from babies saliva) - do not put older babies to bed with a bottle other than water

Strategies on how to improve weight loss

- don't skip meals to avoid becoming ravenous - eat breakfast - eat 3 meals, slowly - set realistic goals (1 to 2 lbs wk) - eat a variety in moderation - exercise & sleep

Electrolyte

- electrically charged particles that are part of the body's fluids and play an important role in cell function - measured in miliequivalent (mEq/L), chemical combining power of an Ion - milligrams per 100 milliliters (mg/mL), referes to weight of an Ion - Calcium levels usually reported in milligrams per deciliter (1dL=100mL)

Temperature Affecting Fluid & Electrolytes

- excessive heat causes sweat production, which in turn causes an increase in the demands for fluids - water and salts lost through sweating, salt depletion causes fatigue, weakness, headache, GI symptoms (anorexia or heatstroke) - risk of heat exhaustion or heatstroke

Gender & Body Size Affecting Fluid & Electrolytes

- fat cells have little or no water - muscle/lean tissue has more water concentration Male - 60% of weight is water Female - 52% of weight is water

How to improve eating habits in child

- finger foods - avoid mixtures of food; stews & casseroles - switch to 2% milk - have them eat breakfast - become a role model since parents and peers eating habits are an influence - never force them to eat - do not use foods as a reward - do not routinely offer sweets

Filtration

- fluid & solutes move together across a membrane from one compartment to another - movement is from an area of higher pressure to one of lower pressure i.e., fluid & nutrients move from capillary membranes to the surrounding tissues

dietary patterns

- habits begin in infancy - child should be allowed to eat based on his own hunger and satiety

What can premature intro of food lead to

- inadequate enzymes to digest complex CHO: fill up before getting adequate milk to meet nutritional needs. - immature GI tract can result in food allergies - inadequately anatomic readiness: tongue thrust - inadequately sociological readiness; open mouth

Nursing interventions electrolyte imbalance

- increase fluids - decrease fluids - Dietary changes to prevent further imbalances - oral electrolyte supplements - Administer electrolytes as ordered - Parenteral Fluid & Electrolyte replacement (IV)

What are the types of coping strategies depending on duration?

- long-term coping strategies: .is constructive .helps with more permanent coping .example: change in lifestyle -short-term coping strategies: .temporary .ineffective to deal with reality on a permanent basis

What leads to Anorexia

- loss of appetite due to the decreased metabolic rate and the increased catabolism that accompany immobility - Nitrogen Imbalance - refusal to eat, rapid weight loss, and emaciation of person who believes they are fat, may induce vomiting and use laxatives to stay thin

Carbohydrates

- macronutrient: needed in large amounts - Composed of carbon, hydrogen, oxygen: CHO - easily digested - all digestible CHO is broken down into glucose; normal serum glucose level is 70-100mg/dL

Carbohydrates

- macronutrient: needed in large amounts - Simple sugars, to complex CHO (starches & Fiber_ - Composed of carbon, hydrogen, oxygen: CHO - easily digested - all digestible CHO is broken down into glucose; normal serum glucose level is 70-100mg/dL

Care for patients with Iron Deficiency Anemia

- most commonly seen in preschoolers 3- 5 yrs old. If the have problems chewing meats --> - have them eat non-meat sources of iron with vit. C rich foods to enhance absorption i.e., raisins, spinach, beets, beans, peanut butter, whole grains, iron fortified cereals, eggs

Snacks

- most snacks are empty & high in fat & sugar - if well planned they can add to the nutrient value of growing child or active adult as well as add to the reducing diet

When should you not breast feed

- mothers who use street drugs - prescribed drugs for some chronic illness - mother becomes pregnant - mother has HIV or other infectious disease communicable through breast milk - vegan may produce milk deficient in vit. D and B12

What is a certification of death?

- only done by physician, coroner or nurse if authority is granted -certificate is signed by attending physician

Describe diarrhea

- passage of liquid feces - increased frequency of defecation - caused by rapid peristalsis - ingested irritants cause diarrhea (defensive mechanism) - loss of electrolytes SYMPTOMS - spasmodic cramps - increased bowel sounds - irritation of anal region - fatigue - weakness - malaise - emaciation CAUSES - psychological stress - medications - antibiotics - iron - cathartics - food allergies - food intolerance - diseases of the colon (mal absorption of syndromes; Crohn's disease)

Diet for pregnant women

- protein - Folic Acid 122% - decrease risk of neural tube - Vit. D - Iron - Calcium - calories increase by 300/day in the 2nd and 3rd trimester (1 glass of milk per meal) - prenatal vitamins - 6-8 glasses of fluids

Nitrogen Balance

- protein metabolism - the status of protein nutrition in the body. It is the measure of degree of protein anabolism and catabolism. - When Nitrogen intake = Nitrogen output, a state of Nitrogen balance exist. - A negative Nitrogen Balance is using more than you have.

Advantages of breast feeding

- provides antibodies - protectant against developing food allergies - decrease incidence of some chronic diseases later in life, NIDDM, chrohn's disease, obesity - infants feed on demand

Soft liquids

- pureed - all liquids - used for patients with difficulty swallowing thin fluids rather than thick liquids and semi solids - usually low on residue (fiber)

Diet in elderly

- reduce caloric needs yet keep nutrition needs and nutrition value unchanged - lean meats, bake or broil, use low fat milk , cheese, ect. - increased Ca to 1200mg & vit. D for risk of osteoporosis - Mg for cardiac rhythm - B12 supplement because as people age diminished intrinsic factor reduces the ability to absorb

What is loss of muscle tone?

- relaxation of facial muscles -difficulty speaking -difficulty swallowing and gradual loss of gag reflex -decreased activity of the GI tract -possible urinary and rectal incontinence -diminished body movement

Medical management for a patient with TB

- relieve symptoms - kill all viable tubercle bacilli - return to optimum health, work, family - prevent transmission - Every active case must be reported to health department - Every active case is treated simultaneously with a combination of drugs - Multiple drug regimens are used to destroy as many viable organisms - Quickly and to minimize emergence of resistant organisms ( a variety of drugs enables one agent to destroy mutants that are resistant to 1st drug) - Close contacts examined and followed; - placed on preventive treatment: a. isoniazid (INH) for approximately 6 - 12 months to prevent active disease b. Chemotherapeutic Agents (antitubercular agents) for 6 - 12 months c. Prolonged treatment necessary to eradicate and prevent relapse Five first-line medications are used 1. isoniazid (INH) 2. rifampin (Rifadin) 3. pyrazinamide 4. streptomycin 5. ethambutol (Myambutol) - Noninfectious after 2 to 3 weeks of continuous medication therapy - vitamin B is usually administered with INH (prevent peripheral neuropathy) - Patients not infected with HIV 9 months of daily INH is preferred treatment 4 months of RIF is acceptable alternative - Sputum culture results are monitored for effectiveness of treatment and compliance

What is Goal of taking care of a patient with Anorexia Nervosa

- restore a healthy weight & healthy eating habits - Small, frequent, high caloric foods. - Family therapy; refrain from arguing; simple, clear instructions, record I&O, monitor & limit activity; assess risk for suicide

changing habits

- slow step by step process - education - motivation - desire, willingness, conviction

Nursing interventions for morning sickness (1st trimester)

- smaller more frequent meals, don't leave stomach empty - decrease fat, increase complex CHO - low fat protein snack before bed i.e., cheese or yogurt - dry toast, crackers before arising

What should vegans add to their diet

- soy products fortified with B12 & Iron (Fe) - soy milk is fortified with Ca

Types & Sources of CHO

- starches are insoluble ( can not dissolve in water) - their main function is satiety (fullness) and assist in assisting the digestive tract eliminate waste products.

Signs of a well nourished infant

- steady weight gain (1-2lbs/month) - 8 to 12 feedings per/24hrs - 6 or more wet diapers/24 hrs - 1 BM/day (more but not less) - moist mucous membrane - happy & vigorous - sleeps well * breast fed babies have more BM's

Normal changes that occur in pre-schoolers

- strong preference of certain food types - general disinterest in foods - finger foods are most enjoyable

Nursing assessment of a patient with fluid & electrolyte

- take a good nursing history - obtain clinical measurements - assess skin turgor - perform physical exam - review lab tests

What does Clear Liquid Diet mean

- temporary - 400-500 k cal i.e., ginger ale, gelatin without fruit, ices, hard candy, anything you can see through

characteristics of NI

-1st site is UTI, respiratory tract -1st cause iss lak of hand washing

what is the amount of fluid administered for a cleansing enema?

-500 - 1000 mL [adult] hypotonic, isotonic, soap 70-130mL [if Hypertonic] 150-200mL prepackaged [fleet enema] oil

analyze key factors in painmanagement

-Acknowledge and Accept Client's Pain Are you in pain? What does it feel like? Where is the pain? -Listen Attentively: Restate what the patient tells you, and add "how can I help you?" Explain the importance of asking questions to define the pain as unique and ask if they have any other feelings of discomfort - Encouragement of Pain Diary for clients with chronic pain: Records pain, its characteristics, and associated situation/factors which assist improve pain management. Attend to the client promptly and keep them informed. 84 -Assist support persons: Provide accurate information Teach about the disease, medications, and non-drug relieving techniques Provide emotional support Give opportunities for them to discuss their emotional reactions. 85 - Reduce Misconceptions: Pain is an individual experience Address patients fear of addiction - Reduce fear and anxiety: Allow the client to talk about pain and verbalize feelings Provide accurate information -Prevention of pain: Preventative pain management Before/after surgery Before/after procedures

nursing care of a pt who received a bone marrow transplant

-Administer immunosuppressants initiation of corticosteroid therapy - for Phlebitis, monitor for jaundice, abdominal pain, liver enlargement. Check daily weight & abdominal girth to monitor fluid retention. - vital signs and blood oxygen saturation; assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste changes; and providing ongoing support and patient teaching. - Psychosocial assessments

Characteristics of REM Sleep

-Around 20% of sleep is REM in an adult -recurs about every 90 minutes and lasts 5-30 minutes -not as restful as NREM -difficult to arouse -most dreams occur in REM (thats why you can remember some if you awaken at the end of REM) -brain highly active (its metabolism increases 20%) -acetylcholine & dopamine increase. acetylcholine highest levels in REM -Eye movement occur -tone of voluntary muscles decreases -deep tendon reflexes are absent -may arouse spontaneously -gastric secretions increase -HR & RR are irregular -areas of learning, thinking, organizing info is stimulated

seven warning signs of cancer CAUTION

-Change in bowel habits - colorectal cancer -Asore that does not heal on the skin or mouth that can be malignant -Unusual bleeding/discharge from rectum, bladder or vagina -Thickening of breast tissue or a new lump in breast -Indigestion or trouble swallowing -Obvious changes to moles or warts -Nagging cough or hoarseness that persists for 4-6 weeks

Cultural accommodation and negotiation

-Considered clients viewpoint on health care and negotiates the plan of care(nurse-client negotiation) as a collaborative process. -Shows differences between nurse and client on health, illness and treatment -Negotiation considers harm or benefit that clients cultural health practices may bring into health care. If danger or harm, nurse must educate client on scientific view

Discuss nursing interventions to assist clients who have difficulty with fecal elimination

-Constipation: .increase fluid intake .drink hot liquids .fruit juices (prune juice) .fiver (raw fruit, bran products, whole grain cereals, and bread) -Diarrhea: .increase fluids and bland foods .small amounts (easier absorption) .avoid excessively hot or cold fluids (increase peristalsis) .spiced foods and high fiber foods can aggravate diarrhea -Flatulence: .limit carbonated beverages, drinking straws, chewing gum .gas forming foods: cabbage, beans, onions, cauliflower .exercise, moving in bed, ambulation .rectal tube

surgeries

-DIAGNOSIS: staging and treatment -PROPHYLAXIS: the removal of a risk tissue or organ -palliative: to improve quality of life

What is depression?

-Grief over what happened and what cannot be. -May talk freely

types of exercise

-Isotonic (dynamic) -Isometric (static or setting) -Isokinetic -Resistance -Aerobic -Anaerobic

8. Know what to teach for a patient with impaired vision

-Low Vision & Blindness - Visual impairment that requires devices and strategies plus corrective lenses to perform tasks - Nurses need to include safety as the priority intervention in their teaching plans for patients with impaired vision - Defined as best corrected visual acuity (BCVA) of 20/70 to 20/200 - Blindness 20/400 to no light perception - Absolute blindness absence of light perception - Nursing Management for the hospitalized blind patient - Emotional support, physical independence and safety - Introduce oneself before entering room - Orient patient to surroundings - Communicate with other personnel ¡VPlace sign - Keep phone, call bell within reach at all times - Assist with meals

Diagnostic aids

-MAMMOGRAPHY: uses xrays images of the breast -MRI: used of magnetic fields and radiofrequency signals to create sectional images of diverse body parts -ENDOSCOPY: direct visualization of the body cavity -NUCLEAR MEDICINE IMAGING: use IV injection or ingesting of radioisotope substance -PET SCAN: through the use of tracer that provided black and white color images

Identify essential aspects involved in assessing a patient's stress and coping patterns.

-Nursing history: .ask about perceived stressors/duration .past/present coping strategies .explore with patient .data collected from client communication would be subjective date. -physical examination (objective data): verbal, motor, cognitive signs .examples: nervousness, biting nails, changes in blood pressure, increase work of breathing (dyspnea) .remember if coping is effective, the nurse may not observe signs and symptoms

nursing interventions with chemotherapy

-PPE -handwashing before and after -instruct family memebers on necessary precautions -monitor pt for dehydration fluid and electrolytes imbalances and need for IV fluid -observe s/s of infection -report unusual bleeding, bruising, or visual disturbances -gentle and systematic oral hygiene

apical pulse

-Prepare the patient Locate the apical impulse - PMI - point of maximal intensity (fifth intercostal space, mid-clavicular line) Auscultate and count the heart beats Assess the rhythm and strength of the heart beat Document and report Normally the apical pulse and the radial pulse are identical When the heart or vasculature is diseased, a difference between apical and radial pulse may occur - known as a Pulse Deficit Apical and radial pulse taken simultaneously A full 60 second count In no instance is the radial pulse greater than the apical pulse Pulse deficit can the result of CHF where the heart is weak and does not pump enough blood Or tachycardia where not enough time to fill the heart with blood

Patient education about the following drugs: INFORMATION FROM DRUGGUIDE.COM

-Pyridium: Instruct patient to take medication exactly as directed. If a dose is missed, take as soon as remembered unless almost time for next dose. Advise patient that while phenazopyridine administration is stopped once pain or discomfort is relieved, concurrent antibiotic therapy must be continued for full duration of therapy. Do not save unused portion of phenazopyridine without consulting health care professional. Inform patient that drug causes reddish-orange discoloration of urine that may stain clothing or bedding. Sanitary napkin may be worn to avoid clothing stains. May also cause staining of soft contact lenses. Instruct patient to notify health care professional if rash, skin discoloration, or unusual tiredness occurs. -Flomax: Emphasize the importance of continuing to take this medication, even if feeling well. Instruct patient to take medication at the same time each day. If a dose is missed, take as soon as remembered unless almost time for next dose. Do not double doses. May cause dizziness. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Caution patient to change positions slowly to minimize orthostatic hypotension. Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications, especially cough, cold, or allergy remedies. Emphasize the importance of follow-up visits to determine effectiveness of therapy. -Bactrim: for tract infection -Cipro: Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. Instruct patient to notify health care professional immediately if signs and symptoms of hepatotoxicity (anorexia, jaundice, dark urine, pruritus, or tender abdomen), rash, signs of hypersensitivity, or tendon (shoulder, hand, Achilles, and other) pain, swelling, or inflammation occur. If tendon symptoms occur, avoid exercise and use of the affected area. Increased risk in >65 yrs old, kidney, heart and lung transplant recipients, and patients taking corticosteroids concurrently. Therapy should be discontinued.

Develop nursing diagnoses related to fecal elimination

-Risk for deficient fluid volume r/t .prolonged diarrhea .abnormal fluid loss through ostomy -Risk for impaired skin integrity r/t .prolonged diarrhea .bowel incontinence .bowel diversion ostomy -Low self esteem r/t .ostomy .fecal incontinence .need for assistance -Deficient knowledge(bowel training, ostomy management) .r/t lack of previous experience -Anxiety r/t .lack of control of fecal elimination secondary to ostomy .response of others to ostomy

how to administer insulin

-SQ -rotate sites : may lead to trophy or hypertrophy of local tissue and leads to decrease of insulin absorption

Clinical manifestations of the following STD or STI:

-Syphilis: Primary: painless lesion called a chancre. Secondary: generalized infection with a rash. Tertiary: Final stage- progressive inflammatory dx with potential to affect multiple organs. -Gonorrhea: Local inflammation. Men- urethritis, edididymitis. Women- frequently asymptomatic uterine cervix is primary site S/S- UTI, vaginal discharge and itching. If left untreated can lead to an increase risk of PID -Herpes: Itching, pain, swelling, begins with macule to papule to vesicle to blister and ulcer. Women- labia is the primary site. Men- glans penis, foreskin, penile shaft affected. Flu like symptoms, swollen lymph nodes in groin, fever, malaise, headache, myalgia, dysuria, lesions subside in 2 weeks. -Chlamydia: PID, chronic pain, infertility in women. Men- urethritis, asymptomatic, but can transmit to women. -Trachomatis: inflammation of the vaginal epithelium, burning and itching (STD vaginitis) Vaginal discharge- thin vaginal discharge (sometimes frothy), yellow, yellow-green, foul smelling, irritating, vulvitis with itching and burning.

Cultural models of nursing care

-Transcultural nursing(madeleine leininger): focuses on providing care within differences and similarities of beliefs, values and cultural patterns -health traditions model(rachel e. spector): based on concept of holistic health and explains what people do from a traditional perspective.

Describe sleep and biorhythms:

-Two types of sleep: 1 REM Sleep 2 NREM Sleep -Circadian Rhythms: 1)another name for biorhythm: .the biologic clock that exists in all living things .rhythms are controlled from within the body .synchronized with: .the environment .gravity .light/darkness .electromagnetic forces .circadian: from Latin circa dies meaning "about the day" .The cyclic nature of sleep: . controlled by the reticular formation in the brain stem .integrates sensory information from the peripheral nervous system (PNS) and relays it to the cerebral cortex .cerebral cortex and reticular formation must be intact for regulation of sleep and wake .Circadian regularity: .begins by the 6th week of life .by the age of 3-6 months, most infants have a regular sleep/wake cycle .Circadian Synchronization: .when a persons biological clock coincides with the sleep/wake cycle .awake when body temp is highest .asleep when body temp is lowest ( sleep neurotransmitters) .Serotonin: thought to lessen the response to sensory stimulation .Gamma-aminobutyric acid (GABBA): .Shuts off activity of the reticular activating system (RAS) .Darkness and sleep preparation causes a decrease in stimulation of RAS .Pineal Gland: .Begins secreting melatonin (decreases alertness) -During sleep: .growth hormone is secreted .cortisol is inhibited -With daylight: .melatonin is at its lowest .cortisol is at its highest -Wakefulness is also associated with high levels of : .acetylcholine .dopamine .noradrenaline

a nurse on a medical unit is caring for several clients. which of the following clients are at risk for developing pyelonephritis?

-a client who is 32 weeks of gestation = is at risk for developin pyelonephritis because of increased pressure on the urinary system during preganncy causing reflux or retention of urine. -a client who has kidney calculi = is at risk for pyelonephritis because stones harbor bacteria -a client who has a neurogenic bladder = can retain urine, promoting bacterial growth and causing pyelonephritis -a client who has diabetes mellitus = at risk for pyelonephritis because glucose that can be in the urine promotes bacterial growth

Grief

-a complete response to the emotional experience due to loss and may be exhibited by behaviors, thoughts, and/or feelings associated with sorrow or having overwhelming distress. -bereavement: loved ones subjective responses to experience of loss or death -Mourning: behavioral process in which the grief is revolved or changed. Influenced by spiritual beliefs, cultures and customs -Grieving assists the individuals to cope with the loss slowly and to accept the loss as part of reality

characteristics of angina

-a syndrome of paroxysms of pain or pressure -insufficient coronary blood flow and inadequate O2 to myocardium [demand exceeds supply] -sudden onset, short duration, precipitated by exertion or stress; relieved by rest and/or NTG -blockage in coronary artery -ischemia causes pain -stable angina is relieved with NTG and rest -unstable angina progressively increases, not precipitated by activity, not relieved by rest or NTG, impending MI -silent ischemia: EKG changes during stress test or telemetry with no pain, esp. with hx of DM or due to age [related to decreased sensitivity of pain receptors]

Identify the cultural concepts

-acculturation: involuntary process through which people incorporate behaviors/ideas traits from another culture -assimilation: when a person develops a new/different cultural identity -race:classification of people according to shared biologic characteristics, genetic markers, features. (white, black, asian indian) -discrimination -culture shock: disorder that occurs from one cultural setting to another -heritage: things passed down from previous generations -heritage consistency: clients identify with their traditional cultural system -heritage inconsistency: clients have acculturated into the new dominant culture of the modern society in which they now reside

What are the types of coping depending on appropriateness?

-adaptive/effective coping: .effective to deal with stressful events .minimizes stressful events -maladaptive/ineffective coping: .leads to unnecessary distress for the person and others around

identify major factors contributing to Health Disparities

-age -poverty -access to care -poor health literacy -provider biases/prejudices -poor provider-client communication -some minority groups

Factors affecting the grief process: (8)

-age -significance of loss -culture -spiritual beliefs -gender -socioeconomic status -support system -cause of loss

factors increasing susceptibility to infection

-age: infants and elderly -medical therapies

list 2 things that the nurse may be worried about post thyroidectomy surgery

-airway status [resp., cough, swallowing] -> blood. -difficulty breathing [airway] -tetany caused by inadvertent removal of the parathyroid glands during surgery NOTE: calcium gluconate and trach kit at bedside, monitor Ca levels q8h

list four nursing interventions associated with hypothyroidism

-alternate activity with rest periods -provide extra blankets or clothing to the pts to prevent chilling -teach importance of follow up. testing and follow up care -encourage pt to verbalize feelings of concern, possible depression. reassure symptoms will disappear with treatment

What is autopsy?

-an examination of body after death -sudden death or occurring within 48 hours of admission to determine cause of death - learn more about disease and collecting statistics

passive immunity

-antibodies are produced by another source, animal or human [are required]. -natural: antibodies transferred from immune mother to her baby through placenta or breast milk; lasts months to 1 yr

s/s of grieving (9)

-anxiety/depression -lack of concentration/communication -weight loss or gain/difficulty swallowing/vomiting -fatigue/sleep disturbances - blurred vision/ dizziness/ fainting/headaches -excessive sweating -palpitations/chest pain/ dyspnea -crying/sobbing -menstrual disturbance/ alteration in libido

blood pressure sites

-arm: most common -thigh: auscultate over the popliteal surface -leg: auscultate over posterior tibial/dorsalis pedis -forearm: auscultate over brachial artery

Describe the physiology of sleep

-arterial blood pressure falls -pulse rate decreases -peripheral blood vessels dilate -cardiac output decreases -skeletal muscles relax -basal metabolic rate decreases 10% - 30% -growth hormone levels peak -intracranial pressure decreases

care of a patient post valve replacement

-asses for pts risk of emboli -follow up care for anticoagulant therapy

Post cardiac cath care

-assess femoral/distal sites -assess BP and pulse -NPO until gag -BR for 2-6hrs post based on the size of the catheter used -angio seals may be used (provide mechanical compression at site) [cork at site where tubes are inserted so pt does not bleed]

neutropenic diet

-avoid all fresh fruits and veggies -avoid raw/raw-cooked meat, fish and eggs -avoid raw nuts -make sure all dairy products are pasteurized -avoid yogurts with live and active cultures

properties of antiseptic and disinfectives

-bactericidal: destroys bacteria -bacteriostatic: reduces the growth and reproduction of some organisms

factors affecting heat production

-basal metabolic rate [BMR] -muscle activity increase BMR -thyroxin output: increase BMR -epinephnrine, norepinephrine = sympathetic nervous system -fever

How do family patterns affect cultural care?

-basic unit of society -important role in cultural influences on health -cultural values determine: .communication within the family group .norm for family size .role of specific family members .value placed on a ember of family (elder) -family values: .older relatives living with other family members .nursing home or not .family visiting patient -cultural gender-role behavior: .taking instruction from male nurse rather than female nurse or vice versa -naming systems: .Japanese and Vietnamese family name first and ends in -san which means Mr. Mrs. Miss. -Decision making (matriarchal or patriarchal society) -disclosing information

What actions do you take for a patient with a sleep problem?

-bed-linen clean and dry -clean/dry gown -encourage own/thicker clothes -provide sufficient blankets -relaxation -administering sleep meds -tach about side effects of meds and caution with ETOH -assess need for and the use of meds with elderly

a nurse is reviewing discharge instructions with a client who has spontaneously passed a calcium oxolate stone. which of the following foods should the nurse instruct the client to avoid?

-black tea and spinach = both contain calcium oxolate

Ways to manage urinary incontinence

-bladder training: involves resisting the urge to void and patient voids on timetable; the goal is to gradually lenghten the intervals between voids, stabilize bladder, drecrease urgency. -habit training: a imed but not to avoid the urge to voidor delay voiding -pelvic muscle exercises (kegel) -maintain skin integrity (meticulous skin care) -external catheters(condom catheter):better than foley catheter because prevents UTI

What is sensory impairment?

-blurred vision -impaired senses of taste and smell -research found hearing is the last to go

How do you asses a patient with a sleep problem?

-brief sleep history .use of medications .sleep environment .recent changes in sleep patterns and/or difficulty in sleeping .sleep diary -physical exam .facial appearance .behavior .energy level .diagnostic tests .polysomnography (sleep study)

What are physiological indicators of stress?

-caused by stimulations of sympathetic sf neuroendocrine systems -depends on personal perception of events -clinical manifestations: .pupils dilate to increase vision .diaphoresis (increased sweat production) .tachycardia and increased cardiac output .increased production of mineralocorticoids (retention of Na+ and H2O which leads to increased blood volume) .rate/depth in respiration increased .mouth may be dry .urinary output decreased

Common sleep Disorders:

-chronic insomnia -insomnia -acute insomnia -hypersomnia -parasomnias -narcolepsy -sleep deprivation (result, not disorder)

Common type of urine specimens collected by the nurse

-clean voided specimen (routine analysis) -timed speciment (1,2,12,24hrs): if collecting for 24 hrs, first have them void and dispose that void; and after that you will start collecting and documenting -straight catheter

Describe the care involved in a supra pubic catheter

-clean/wash around catheter daily -assess

types of enemas

-cleansing enemas: intended to remove feces -soapsuds: irritates mucosa, distends colon -oil: mineral,olive,cotton seed oils, lubricates feces and mucosa -carminative enemas: given to expelflatus, solution release gas, ditention of colon and rectum, stimulates paristalsis -retention enema [oil or med]: retained 1-3 hrs, oil softens feces, antibiotics enema, nutritive enemas -return flow enemas: expelflatus, alternating flow 100- 200 ml of fluid in and out of rectum stimulates paristalsis, repeat 5 to 6 times until flatus expelled and abdominal distension is relieved.

What is acceptance?

-comes to terms with death/loss of loved one -may have decreased concern in surroundings and support people -may desire to begin making plans

What is feces?

-composition: normally 75% water, 25% solid materials -consistency: soft but formed -color: normally brown (stercobilin and urobilin, which derive from bilirubin) -odor: affected by bacteria, type of diet .Escherichia coli and staphylococci affect odor and color

How do you implement for a patient with a sleep problem?

-create a restful environment .reduce environment distractions/noises -support bedtime rituals -promote comfort/relaxation -schedule medications to prevent nocturnal awakeness

Identify the characteristics need to provide culturally responsible care

-culturally sensitive: possess some basic knowledge of an constructive attitudes toward health traditions observed among culturally diverse groups in the clinical setting -culturally appropriate: application of the background knowledge to provide a client with the best possible health care -culturally competent: being capable of understanding, respecting, and attending to the total context of the clients situation and use a complex combination of knowledge, attitudes and skills to deliver effective care

What is algol mortis?

-decrease in body temperature

Diagnostic tests for MI

-decreased BP increase pulse: shock -cold, clammy, ashen or severe pallor [diaphoresis=bad sign] -ECG changes: ST elevation, ST depression -CK-MB most specific: begins to elevate after 2-4 hrs, peak at 12-24hrs. [results from MI, if it keeps rising it is showing signs of ischemia!] -troponin: time frame similar to CK-MB but remains fo up to 2 weeks and unstable angina [ischemia] can also cause elevation [good to assess silent MI]

contact precautions

-dedicate use of non critical patient care equipment to a single room -private rooms are used for isolation because they maintain a negative pressure and have special vents to the outside -avoid transporting patients outside of isolation room if possible

What is the information needed for the nurse to complete a history dealing with fecal elimination?

-defecation pattern -description of feces and any changes -fecal elimination problems -factors influencing elimination -presence and management of ostomy

Nursing dx associated with urinary and reproductive disorders:

-deficient knowledge -acute pain -fear -infection RT: urinary tract obstruction -altered urinary elimination: incontinence RT: -anxiety with anticipated loss pre op -imbalanced nutrition, less than body requirements -risk for impaired skin integrity -risk for fluid volume deficit or excess -bleeding risk -non-compliance

guidelines for standard precautions

-designated for all patients in the hospital -apply to blood, all bodily fluids, excretions and secretions except sweat non intact skin and mucous membranes -handle, transport and process soiled linen in manner to prevent contamination of clothing and transfer of microorganisms

Identify factors affecting voiding

-developmental factors -psychosocial factors -fluid and food intake -medications -muscle tone -pathological conditions -surgical and diagnostic procedures

nursing diagnosis associated with cancer

-diagnosis is based on assessment of physiological and functional changes -determine the extent of cancer -identify possible spread -evaluate the function of involved and un involved body systems -obtain tissue and cells for analysis

Management of atrial fibrillation

-digoxin as an antiarrhythmic serum range 0.9-2.1 -quinidine serum range also monitored -anticoagulants: prevent clot formation in pooled atrial blood. given forever. coumadin-PO-PT&INR-Vitamin K [to ensure levels frequent levels of PT&INR are drawn to ensure therapeutic blood levels]

Teaching about nitroglycerine

-dilates veins causing the blood to pool in body, reducing preload -increases coronary blood flow by causing coronary vasolidation -replace q6mnths because of short life span -do not swallow. NPO for 15 minutes -if it is not expire NTG will burn sublingually -may take up to 3 tabs 5 minutes apart if not relieved. the best thing to do is to take 2 and call 911 before taking the third one -make position changes slowly because of hypotension -always carry with you -always keep away from heat and light should be in a brown bottle for protection PATCH: -lasts up to 6 hrs -rotate sites -remove old patch first -time and date on paper -removed at night to prevent tolerance

s/s of SIADH

-dilutional hyponatremia - high urine sodium lvls and low serum sodium levels -fluid retention - decreased urine output -weight gain -others: AMS / delayed deep tendon reflexes

What is the slowing of the circulation?

-diminished sensation -mottling and cyanosis of the extremities -cold skin, first feet then hands, ears and nose -decelerated and weaker pulse -decreased blood pressure

What is liver mortis?

-discoloration from breakdown of RBC in tissue -located in dependent areas of body

care of patient with radiation implant

-distance: the greater the distance from the radiation source, the less the exposure -time: limited to 30 minutes of direct care per 8 hrs -shielding: the dose of rays is reduced as the thickness of lead shielding is increased. [dosimeter badges are required]

nursing care involved with radiation implants

Ways to prevent urinary tract infections

-drink eight 8-ounch glasses of water daily -frequent voiding (every 2-4hrs) -void immediately after sex -avoide bubble bath, harsh soaps, powderor sprays to the perineal area -avoid tight fitting pants -wear cotton clothes for ventilation of perineal area -women wipe from front to back -increase acidity of urine by taking vitamin C daily

What is chronic insomnia?

-duration greater than one month -main causes: .Women: hormonal changes .Most common in America

Clinical manifestations of heart failure

-dyspnea -orthopnea -easy fatigability -JVD -pitting edema -decreaseUO

Past

-emphases on tradition -things are done the way they have always been done -historical power plays a part

Present

-emphasis on here and now -future arrives on its own

Future

-emphasis on progress and change -whats new - technology, breakthroughs

a nurse is assisting with the plan of care for a client who has chronic pyelonephritis. which of the following are appropriate actions by the nurse?

-encourage daily inatake of 3L = to mantain dilute urine during the day and night -palpate the costovertebral angle = for flank tenderness, which can indicate inflammation and infection -monitor urinary output = to determine that 1-3L of urine is excreted daily. -administer anti-infective medication = to treat the bacteriuria and decrease progressive damage to the kidney

What is hypersomnia?

-enough sleep at night but cannot stay awake during the day -causes: usually organic/functional problems, metabolic disorders

bathing

-excellent opportunity for nurses to assess psychological and learning needs, orientation to time/place/person -its the best time to do a head to toe assessment

What are the interventions to help patient's minimize and manage stress?

-exercise -nutrition -sleep/rest -time management -have patient breath before injection -explain procedures -massage to help patient relax -offer support -listen attentively -educate client -convey atmosphere of trust, empathy and caring -eliminate environmental/situational stressors (noise, many visitors) -use short/clear sentences

what are clinical manifestations associated with thyroid storm

-extreme tachycardia -elevated temperature above 101.3F hyperpyrexia exaggerated symptoms of hyperthyroidism

s/s of DM

-fasting plasma glucose [FPG] greater than or equal to 126mg/dL -3P's: polyuria, polydipsia, poluphagia -fatigue: cells are starving, no energy -weight loss: [type 1 N/V / abdominal pain if DKA]

signs of DM

-fasting plasma glucose [FPG] greater than or equal to 126mg/dL -3P's: polyuria, polydipsia, poluphagia -fatigue: cells are starving, no energy -weight loss: [type 1 N/V / abdominal pain if DKA]

s/s of systemic function

-fever -increased pulse and respiratory rate -enlargement / tenderness of lymph nodes

Nursing interventions associated with retention cath.

-fluid intake : 3,000mL/day if not contraindicated -dietary : acidify the urine(helps reduce UTI) foods thatll increase the acidity are eggs, cheese, meat and poultry, whole grains, cranberries, plums, drunes and tomatoes -routine changing of cathether not recommended, only if there is an obstruction -when removing assess for voiding. they may need bladder re-training. if voiding after removal is less than 100mL per void, then considered dysfunctional

a nurse is reviewing the medical record of a client who has premenstrual syndrome [PMS]. which of the following medications are used to treat PMS?

-fluoxetine: [prozac] = an SSRI is used to treat emotional symptoms of PMS, such as irritability and mood swings, has an added effect to treat physical symptoms. -spinorolactone: [aldactne] = diuretic and can reduce bloating and weight gain associated with PMS -ethinyl estradiol/ drospirenon [yasmin] = oral contraceptions that contain drospirenone reduce the symptoms of PMS

What is an organ donation?

-for medical/dental education, research or transplantation -donor can be a living person or a cadaver

What is a DNR order?

-for terminally ill -signed when no resuscitation wanted in the event of a respiratory or cardiac arrest -patient or health care surrogate/proxy make this decision -must be signed by physician

a nurse in a providers office is obtaining a history for a client who is being evaluated for benign prostatic hyperplasia [BPH]. which of the following findings are indicative of this condition?

-frequent UTIs = in the presence of BPH, pressure on the urinary structure leads to urinary stasis, which in turn promotes the occurrence of urinary tract infections. -hemturia = painless in presence of BPH -urinary incontinence = occurs in presence of BPH due to increased volume of residual urine

Care of a patient post CABG

-head to toe assessment -LOC -changes may signal impending shock from poor cerebral perfusion -often nurses 1st clue - restlessness, slight confusion -check for arrhythmias or disrrhythmias -MONA -IV NTG -ace inhibitors decrease BP and increase UO which decreases the O2 demand on the heart. -administer O2 -VF -rehab

active immunity

-host produces its own antibodies - artificial antigen [vaccine]blasts many years but may need reinforcement by boosters

a nurse is reinforcing discharge instructions with a client who is post op from a TURP. what indications should the nurse include?

-if urine appears bloody, stop activity and rest = activity might be the cause, rest to promote reclotting of the incision site -avoid drinking caffeinated beverages = it is a bladder stimulant and should be avoided -take a stool softener once a day = to keep stool soft and prevent bleeding during BM

Factors affecting normal sleep:

-illness .sleep/awake cycles disturbed .people need more sleep .dyspnea, peptic ulcers -Lifestyle .irregular schedules .exercise late in day .doing activities before bedtime -environment .noise .temperature .light/darkness .presence of unusual stimuli .absence of usual stimuli -Nocturia .excessive urination at night -doing activities before bedtime -exercise late in day -stress -alcohol and stimulants

What is insomnia?

-inability to fall asleep/remain asleep -people awaken tired -most common in america

nursing interventions for pts c sepsis

-infection control -using aseptic technique -proper hand hygiene -appropriate urinary cath care -appropriate central line care -assess pt with skin breakdown

body defenses against infection

-intact skin and mucous membranes are first line of defense unless broken -normal secretions of skin - acidic -nasal passages - cilia -GI tract

How can a nurse convey cultural sensitivity?

-introduce yourself and explain your role -address clients by the last name until they give permission to use other names -respect and support the clients culture, wishes, requests -be authentic and acknowledge your lack on knowledge about their culture -use language that is culturally sensitive -assist with language limitations -find out clients thoughts/concerns about illness or condition -try to develop nurse-client trust if possible -do not make assumptions about clients. ask when in doubt -show respect for clients support people

specific [immune] defenses

-involves the immune system response to foreign proteins from bacteria or other transplanted tissues [antigens]

inflammatory response

-it is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of injury and promotes repair of damaged tissue -characteristics: impaired function of the part (if severe)

care of skin for pt c radiotherapy

-kKEEP SKIN DRY: do not wash skin until Dr. orders -wash c mild soap, rinse, pat dry c warm or cool water. no hot water! -do not remove lines or ink marks, no tape on skin -avoid powders, lotions, creams, alcohol or deodorants -wear loose-fitting clothing -use and electric razor, no pre or after shave -protect skin from sun, chlorinated pools

3 nursing interventions associated with hyperthyroidism

-keep pt in AC because of poor heat tolerance -set pt apart because of body image disturbances -keep medication in check because when stopped symptoms come back and with them physical changes as well

Nursing interventions associated with collecting urine specimens

-label date, time and how obtained -place in biohazard bag and in bag of transport -take to the lab: must transport to lab ASAP or store specimen in a regrigerator. if left out for more than 1 hour, itll break down and test is innefective. **clean voided sample should be collected in the morning (it's more uniform and higher pH, 10mL)

What are advanced directives?

-legal documents to make medical decision for patients when they are unable -all hospitals must provide patients with information about this right to declare their personal wishes about treatment and give them opportunity to make a decision. (living will, health care proxy or power of attorney, health care surrogate)

assessment findings of cardiovascular disorders

-level of consciousness: lethargy or agitation. both s/s of hypoxia -look for signs of distress. color of skin [pale] use of accessory muscles -weight/height: could be a sign of fluid retention -color: make sure its not pale or blue -temperature: clammy, cold and wet are not good signs, bad signs of poor tissue perfussion -hypertension: >140/90. postural hypo-tension. drops with position changing. -pulse pressure: 180/20 is too wide, 140/100 is too close, signs of cardiac disease. [40-50 is a good range] -rhythm: reg. vs. irreg. sign of abnormality -quality: strong or weak pulse? -JVD : bad sign when pulsating. fluid overload. looks like tubes sticking out [distress] -apical pulse -heart auscultation: s1 and s2 are normal sounds, s3 usually involves overload, s4 sounds like a gallop and is related to resistant of blood in the ventricle -murmurs -inspection of the extremities: capillary refill, >3 seconds is bad. changes in pulse, pain, loss of movement, numbness, color [specifically to extremities] -edema -clubbing

Discuss ways to reduce flatulence

-limit carbonated beverages, drinking straws, chewing gum -gas forming foods -- cabbage, beans, onions, cauliflower -exercise, moving in bed, ambulation -rectal tube

a nurse is reviewing discharge instruction with a client who had a spontaneous passage of a calcium phosphate kidney stone. which of the following should the nurse include in the instructions?

-limit intake of food high in animal protein = it contains calcium phosphate -reduce sodium intake = affects the precipitation of calcium phosphate in the urine -report burning with urination to the provider = this can indicate an infection -increase fluid intake to 3L a day = a decrease in fluid intake can cause dehydration, which increases the risk of stone formation

nursing care for pt receiving radiation

-limit time spent in room to number of minutes -assess pt brief once per shift -communicate with pt via telephone -all personnel providing care to pt must wear film badge -NO VISITORS are permitted

list diagnostic test utilized to asses for hyperthyroidism

-low levels of TSH -T3 an T4 increased [high levels] -vital signs -physical exam [large thyroid or goiter or palpation] .soft, may pulsate [thrill] .bruit heard over thyroid artery

How do you plan for a patient with a sleep problem?

-maintain/develop a sleep pattern that provides sufficient energy for daily activities -create short patient goals related to main long term goal

foot/nail care

-make sure to wash and dry feet well, especially between the toes for pts with diabtes, and peripheral vascular disease -file nails, DO NOT CUT NAILS

Care of a patient post pacemaker including teaching

-minimize pt activity initially since activity may dislodge the pacemaker [2weeks] -make sure pt receives all identification information about the pacemaker -teach the pt signs of pacemaker dislodgement -be careful with anything magnetic -maybe set off during airport screening -after surgery be careful with raising arm above head -assess insertion site for infection -CXR after to assess placement of device and leads -avoid friction over the insertion site -wear a medic alert band -initially no soaking in the tub

how to mix insulin

-mix insulin: clear to cloudy R to NPH = withdrawal NPH to R = put in Air

Nursing intervention associated with and IVP:

-monitor allergic reactions -always have emergency equipment in case of allergies .oxygen .epinephrine .vasopressors .airway and suction equipment -monitor urine output -teach patient that he.she may experience: .temporary feeling of warmth .facial flushing .unusual oral flavor

Nutritional Value

-most cultures have staple foods that are plentiful and accessible in the environment .rice, wheat, corn, pineapple, etc -cultural practices related to food .food preparation and serving .steam vs. fried .kosher; dairy and meat separate meals .food related: breast feed vs. bottle-feed .remedy or treatment for illness - hold/cold .religious practices .roman catholics - no meat on Fridays during lent .orthodox jews and islams, no pork

a nurse in a providers office is reviewing information with a client who has dysfunctional uterine bleeding [DUB ]. which of the following statements by the client indicate understanding of the information?

-my heavy bleeding may be due to a hormonal imbalance = DUB can be caused by progesterone deficiency -my doctor may perform a D&C to find out whats causing my abnormal bleeding = when the provider performs a dilation and curretage , endometrium scraped from the uterine wall is sent to the laboratory for evaluation

side effects of chemo

-neutropenia -N/V -diarrhea -constipation -weightloss -fatigue -anemia -stomatitis -leukopenia -renal failure

nursing interventions for thrombocytopenia

-normal platelet counts is 150,000 -400,000 -thrombocytopenia is when the blood count is below 100,000 -these pts are a high risk for bleeding when count is below 20,000 -nurse must report if count is less than 50,00 to primary care provider and prevent risk for bleeding

Identify ways in which to assess urine

-normal urine : 96% water and 4% solutes -color : straw(yellow), amber, transparent -odor : faint/mildly aromatic -sterility : no microorganisms -pH : 4.5-8.0 (average 6) -normal output : 1,200-1,500mL in 24 hrs -glucose : absent -ketone bodies (acetone) : absent -blood : absent

apical radial pulse

-normally apical and radial are identical -when the heart or vasculature is diseased, a difference between the 2 may occur: pulse deficit [CHF] -taken simultaneously -full 60 sec count -radial is NEVER greater than apical pulse

What is acute insomnia?

-not longer than one month -caused by personal stressors

Discuss the functions of sleep

-not totally understood -physiological effects on nervous systems and body -restores normal activity and balance in nervous system -necessary for protein syntheses (repair process) -important for psychological well-being -sleep deprivation causes deterioration in mental functioning -poor sleep causes: .emotional irritability .poor concentration .difficulty making decisions

What are nursing measure to care for the body after death?

-notify family asap -prepare body to look as natural as possible -close eyes -put denture in mouth -clean environment (Especially after a code) -hygiene/clothing change/clean linen -positioning: supine/pillow behind head and shoulders ; arms to the side or across abdomen ; remove jewelry -allow family to view body -allow to visit up to 2 hours -identification and wrapping: ID band behind wrist; labels on toe and outside of shroud; muslims place the body facing their special temple Mecca -Body taken to morgue to be picked up by funeral home. Storing body in cool temperature to prevent fast tissue softening and liquefying -embalming: injection of chemical to kill bacteria and prevent fast decomposition. not all religious practices embalm

What is labeling of the deceased?

-nurses complete the labeling of body -legally important for as go on the body and on the shroud -name, hospital number and physician name

list different treatment modalities for DM

-nutrition - diet and weight control foundation of diabetes management -excercise -monitoring -pharmacologic therapy -education

What evaluation do you do for a patient with a sleep problem?

-observe for s/s of REM/NREM deprivation -observe duration of sleep -ask how they feel when waking -effectiveness of interventions including goals set: .ex. relaxation, med, ingesting milk products, rituals

assessing body temperature

-oral: adv: most accessible & convenient Disad: mercury in glass thermometers can break.could injure mouth following oral surgery, inaccurate [did pt. drink?] -rectal: adv: most reliable measurement, disad: could injure rectum, presence of stool could interfere, could result in ulcerations and rectal perforations in infants and newborns -AXILLARY: underarm, -adv: safest and most noninvasive -disad: thermometer must be left in position for a long time to obtain a more accurate reading TYMPANIC: ear, adv: readily accessible, reflects core temp, very fast, place in ear and click button. disadv: can be uncomfortable and risk of damaging membrane, right and left measurements can differ, cerumen cam affect reading

Nursing diagnoses appropriate for MI

-pain [chest] -ineffective breathing -altered tissue perfussion -anxiety

types of surgery to treat cancer [palliative, prophylactic,diagnostic]

-pallaitive surgery is to improve quality of life -prophylactic surgery is to prevent [at risk tissue] -diagnostic to diagnose like biopsy for a tissue sample

nursing interventions for a pt receiving a PET scan

-patient preparation, which involves explaining the test and teaching the patient about inhalation techniques and the sensations (eg, dizziness, light headedness, and headache) that may occur. The IV injection of the radioactive substance produces similar side effects. -Relaxation exercises may reduce anxiety during the test. -The patient should also be reassured that radiation exposure is at safe and acceptable levels, similar to those of other diagnostic x-ray studies. -Check Glucose

a nurse is instructing a client how to perform kegel exercises. which of the following instructions should the nurse include?

-perform sets of exercises four times a day -contract the circumvaginal and/or perirectal muscles = as if trying to stop the flow of urine or passing flatus -gradually increase the contraction period to 10 seconds = she might need to slowly reach this goal -follow each contraction with at least 10 seconds of rest period. = 10 - 15 seconds -perform while sitting, lying, and standing = should be performed in all three positions

korotkoffs sounds

-phase 1: first faint, clear tapping or thumping sounds (systolic pressure) -phase 2: muffled, whooshing or swishing sound -phase 3: blood flows freely; crisper/ more intense -phase 4: muffled and have a soft, blowing sound -phase 5: period of silence (diastolic pressure)

two ways to measure pain intensity

-physical: pain receptors and nerves -emotional: feelings and beliefs

list of clinical manifestations associated with hyperthyroidism

-poor tolerance to heat they stay in AC most of the time -exophthalmos = big eyes, bulge out, body image disturbance -increased appetite -progressive loss of weight -tachycardia

diastolic

-pressure of blood when the ventricles are at rest -difference between the two is pulse pressure (40mmHg)

cancer prevention

-primary: complete prevention of disease, often through methods that inhibit exposure to risk factors -secondary: activities detect disease early [self breast and testicular exams] and limit disease before and after diagnosis -teritiary: involves preventing further disability and restoring a higher level of functioning in someone with a disease

Discuss nursing interventions used to maintain normal fecal elimination patterns

-privacy -timing urge -nutrition and fluids -exercise .in supine, tighten abdominal muscles (pull in), gold for 10 seconds, repeat 5-10 min x4/day .in supine, contract the thigh muscles and hold for 10 seconds repeat x4/day -positioning .squatting; leaning forward .elevated toilet sit, bed side commode, bed pants (fracture, regular) . regular bedpan (high back) regular bedbound clients .slipper or fracture bedpan- for clients unable to raise buttocks (fracture)

What are the types of coping strategies depending on focus?

-problem-focuses coping: .seeks improvement by making changes or taking actions -emotional-focused coping: .thoughts and actions to relieve emotional distress .does not improve situation, but person feels better

3. Review the correct way to instill ophthalmic eye drops

-proper hand washing before and after instilling drops - Evert lower lid and instill eye drop/s onto conjunctival sac - Maximize therapeutic effects - Minimize systemic effects -Wait 5-10 minutes before instilling another eye medication - Warn patient before of blurred vision, stinging, burning ¡V normal and temporary - Never touch eye with tip of bottle or tube - Recap bottle immediately after use - If patient cannot feel the drop ¡V refrigeration is encouraged Apply eye drops before ointments

an older adult client is having a annual physical exam at a providers office. which of the following client findings indicates additional follow-ups is needed in regard to the prostate gland?

-prostate specific antigen PSA is 7.1ng/mL = although the PSA level is typically elevated in an older adult male, a PSA level of greater tha 4ng/mL warrants additional follow up. -the client reports a weak urine stream = a clinical manifestation of benign prostatic hyperplasia and warrants follow up

Signs of worsening left sided heart failure

-pulmonary congestion/due to increase in pulmonary pressure that causes DYSPNEA, COUGH, CRACKLES AND LOW OXYGEN SATURATION -orthopnea -frothy pink tinged sputum

4 phases of respiration

-pulmonary ventilation: ventilation or breathing [the movement of air in and out of the lungs while we inhale and exhale -alveolar gas exchange: capillary exchange which involves the diffusion of CO2 between the alveoli and the pulmonary capillaries -transport of CO2: transport of CO2 between the tissues and the lungs -systemic diffusion: movement of CO2 and O2 between systemic capillaries and the tissues

risk for factors that increase risk of cancer development

-radiation -chemical carcinogens -viruses -inherited factors

characteristics included when assessing pulses

-rapid [tachy] slow [brady] cardia -volume: weak or strong -rhythm: regular or irregular

What is changed in respiration?

-rapid, shallow, irregular or abnormally slow: cheyne-strokes respirations -noisy breathing, referred to a death rattle due to collection of mucous in throat

5. Know clinical manifestations of bacterial conjunctivitis

-redness -itchiness -tearing -scratching -pain is usually not present -purulent discharge = [bacterial]

What is denial?

-refuses to believe that the loss is happening -not ready to deal with practical problems -may assume artificial joyfulness to prolong denial -behaves inappropriately

Space orientation

-relative concept involving relationships between the individual, body and objects and persons within that space -intimate zone, personal zone, and social/public zone -nurse moves through all 3 zones and needs to be aware of the differences and respecting the culture -nurses must ask permission and explain procedure/reasos before entering client's spouse

Care of CBI Post Surgery

-risk for fluid volume excess -acute pain -deficient knowledge -bleeding, risk for -infection, risk for -urinary elimination, risk for obstructed catheter -monitor strict I&O -frequent VS -monitor drainage tubing and irriagte for obstruction [blood clots] -monitor ability to void -abdominel distention -sitz bath encouraged assistant to walk as well -dressing change as ordered -wound care stool softeners -s/s of infection and skin integrity

Discuss the process of digital removal of a fecal impaction

-risk of vagal response sometimes, cardiac arrhythmia -oil retention enema suggested 30 min before -after procedure - cleansing enema or suppository -lidocaine (xlocaine) gel 5 minutes before (if permitted in institution) .obtain assistance from second person if needed .right or left lying position, knees flexed, back toward nurse .absorbent pad' bed pan under client; bedpan nearby .avoid unnecessary exposure .clean gloves, lubricate index finger .remove stools in small pieces/help clean .assess patient (HR, facial pallor, diaphoresis) .assist pt to commode/bedpan/toilet

types of exudates

-serous: serum, watery with few cells -purulent: thicker with presence of pus that contains leukocytes, dead tissue debris and bacteria [pus=bad] -sanguineous: large amount or RBC -serous sanguineous: clear and blood tinged *course of drainage : sanguineous -> serous sanguineous -> serous

How do you diagnose a patient with a sleep problem?

-sleep pattern disturbance -others .high risk for injury .self-esteem disturbance .ineffective individual coping .fatigue .impaired social interaction .high risk for impaired gas exchange .altered thought processes .anxiety .activity tolerance

staging

-stage 0: cancer in situ -stage i: tumor limited to the tissue origin -stage ii: limited local spread -stage iii: extensive local and regional spread -stage iv: metastasis

What is rigor mortis?

-stiffing occurs 2-4 hours after death -starts in involuntary muscles (heart, intestine, etc) -progresses to head, neck, trunk and extremeties

danger in administration for pts receiving contrast

-stop 48 hrs prior to decreased risk of acute renal failure -metformin decreases hepatic production of glucose and reducing insulin resistance

differentiate between straight cath. and retention catheter

-straight catheter is removed after collection of pee -retention catheter: also known as indwelling cath. remains in place until the MD orders it to be D/C. it contain a balloon so that it remains in place and its attached to a closed drainage

oncology emergencies

-superior vena cava syndrome -spinal cord compression -pericardial effusion, cardiac tamponade -disseminated intravascular coagulation (DIC) -syndrome of inappropriate secretion of antidiuretic hormone -tumor lysis syndrome

s/s of hypoglycemia

-sweating -hunger -confusion -disoriented behavior -seizures -unconciousness TREATMENT -unconscious: glucagon 1mg or D50W IV -conscious: 15 grams fast acting CHO

treatment of hypoglycemia

-sweating -hunger -confusion -disoriented behavior -seizures -unconciousness TREATMENT -unconscious: glucagon 1mg or D50W IV -conscious: 15 grams fast acting CHO

body temperature regulating system

-temperature is regulated by 3 main systems: heat and cold sensors are found in - [the shell core], Hypothalamus: which signals to increase/decrease body temp. Effector system: adjusts the production of heat.

a nurse is reinforcing education about menstruation with ana dolescent female client. which of the following statements should the nurse inlude?

-the range for a typical menstrual cycle iss between 21 and 42 days = typically a cycle is 28 days, 21-42 is considered a normal range. -ovulation typically occurs around the 14th day of the menstrual cycle = the first half of the menstrual cycle is the follicular phase. the second half is the luteal phase. ovulation typically happens around the middle of the cycle, or day 14 in a 28 day cycle. -it is not unusual for a menstrual period to last as long as 7 days = typically a menstrual cycle lasts 4 - 7 days

What are the cognitive indicators of stress?

-thinking responses to find a solution -coping: dealing with change looking for adaptation. It can be successful or unsuccessful -coping strategy (or coping mechanisms): natural/learned way of responding to a changing environment, specific problem, or specific situation.

what is the drug of choice for hyperthyroidism

-thiomides such as propylthiouracil PTV or propacil -methimazole, tapazole [MMI]

purpose of physical examination

-to obtain baseline data about the pts functional abilities -to supplement, confirm or refute data obtained in the nursing history [pts may at times undereport their symptoms] -to obtain data that will help establish nursing diagnoses and plans of care -to evaluate the physiological outcomes of health care/nursing interventions; and the progress of a clients health status -to make clinical judgements about pts health status -to identify areas for health promotion and disease prevention -to clarify information: pts may be in denial about their illness. -for pts who have altered levels of consciousness/mental status, be sure to obtain the observations of relatives and friends

What are the 4 s/s of death?

-total lack of response to external stimuli -no muscular movement, especially breathing -no reflexes -flat encephalogram (eeg) for 24 hours in instance of artificial support

Two forms of iv orders

-total volume to infuse in a number of hours/ 1000cc D5W run in 8 hers. -volume per hr / 500 D5 1/2 NS at 50cc/hr

why do we keep a trach setup and calcium gluconate at the bedside with pts post thyroidectomy

-trach setup for breathing problems caused by bleeding occlusions or swallowing omplications. -calcium gluconate just incase calcium levels drop caused by inadvertent removal of the parathyroid glands during surgery.

s/s of cushings syndrome

-trunkal obesity -lassitude [weakness] -weight gain -buffalo hump -hyperglycemia -moon face -virilization [masculine traits] -increased susceptibility to infection note: these are signs of cushingoid like features

Pain

-unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage -perception not a sensation -multifactoral phenomenon -unique to individual -difficult to communicate -high priority problem -bodys defense indicating a problem -can be normal in certain situation [labor] -highly subjective [personal] -presents physiologic and psychological dangers to health and recovery

abnormal lab data

-urine, blood, sputum or other drainage cultures.

How does culture affect communication?

-use professional/official interpreters -avoid non-professional interpreters and family members as interpreters -gender/age differences: embarrassment about certain topics to be interpreted -consider political or social incompatibility -speak directly to client (not the interpreter) -speak slow and distinctly - do not use metaphors -observe facial expressions and body language

Describe colostomy irrigation

-used only with sigmoid or descending colostomy -distend bowel and stimulate evacuation -not routinely utilized for most patients -300-500 ml (some 1000 ml) -long-term use: may cause perforations, peristomal hernias

implementation strategies / to prevent infection

-using meticulous medical and surgical asepsis techniques -implement measures to support the defense of a susceptible host -teaching pt about protective measures to prevent spread -immunizations -hand washing

indirect transmission

-vehicle born: substance that serves as an immediate means to transport and introduce an infectious agent. ex: toys, handkerchiefs, soiled clothes, surgical instruments/dressings -vector born: animal / insect that serves as an immediate means to transport and introduce an infectious agent

normal breath sounds

-vesicular: low pitched "gentle sigh" created by air moving through smaller airways [bronchioles and alveoli] -bronchovesicular: moderate intensity and moderate pitched "blowing sounds" created by air moving through larger airway [bronchi] -bronchial [tubular]: high pitched, loud "harsh" sounds created by air moving through trachea

Steps in inserting a urinary catheter

-wash hands, provide privacy, adequate lighting, open kit, don gloves, drape patient, poour solution over cotton balls, check the balloon, lubricate tip, clean meatus, insert the catheter until urine flows, collect urine specimen if needed. -straight catheter: continue to drain until urine flow stops, then D/C, 750-1000mL to be drained at any 1 time -indwelling catheter: insert one more inch after start of urine flow, inflate balloon, pull out until resistance is felt to ensure balloon has inflated -attach tube to drainage and secure to thigh/leg to prevent trauma to the bladder -hang bag below level of baldder -assess flow of urine and document

airborne precautions

-wear a respiratory device -susceptible people should not enter the room

Nurses need to be aware of what time to a patient. Most cultures have all 3, but one is always more dominant

What are the characteristics of sleep?

.minimal physical activity .variable levels of consciousness .changes in body's physiological processes .decrease response to external stimuli

What is a health traditional model:

.views health holistically, complex, interrelated .considers balance of body and spirit .based on concept of holistic health and explains what people do from a traditional perspective -holistic/traditional perspective: .maintain health .proper diet .wearing proper clothing .using the mind .practicing religion .protect health: .wearing protective objects .restore health .herbal remedies, exorcism, healing rituals

pulse measurement

0 - absent 1- thready and weak 2- normal 3- bounding

describe the spiritual development of the individual across the life span

0-3 yrs acquiring qualities of trust, mutuality, courage, hope, love 3-7 yrs fantasy filled, imitative phased child realtes existence to stories, images, and fusion of facts and feelings 7-12 yrs (even into adulthood) demands proof or demonstration of reality able to learn beliefs and practices of culture and religion ADOLESCENCE: spiritual beliefs help understand extended environmental beyond family generally conforms to beliefs of those around them begins to examine beliefs objectively YOUNG ADULTHOOD: self identity differentiating beliefs from those of others develops personal meaning for symbols of religion and faith MID ADULTHOOD: respect for past and ones inner voice more awareness of differences because of social background attempts to reconcile contradictions in mind and experience open to others truths MID LATE ADULTHOOD: believes in, live with, participate in community works to resolve problems in society embraces life

What are three nursing diagnoses related to stress?

1) anxiety: -uneasy feeling of discomfort or dread -apprehension feeling caused by anticipation of endangerment -generates an automatic response -source nonspecific/unknown -helps the client to prepare to face threat 2)caregiver role strain: -difficulty in accomplishing the family caregiver role 3)ineffective coping: -inability to do proper evaluation of stressors -inadequate choice of responses -inability to use appropriate resources

What are 5 defense mechanisms?

1)compensation 2)denial 3)displacement 4)minimization 5)projection

Five concepts that lead to cultural competence:

1)cultural desire: motivation to engage in culturally competent care 2)cultural awareness: examination of ones own prejudices, biases, cultural/ethic background 3)cultural knowledge: education about other cultures 4)cultural skills: ability to collect culturally relevant data about clients health in a sensitive matter 5)cultural encounters: engage in face-to-face cultural interactions from different backgrounds, learning to modify own beliefs and prevent stereotypes

What are the 4 C's of culture in culturally responsive nursing care:

1)what do you CALL your problem? 2)what do you think CAUSED your problem? 3)how do you COPE with your condition? 4)what are your CONCERNS regarding the condition and/or recommended treatment?

two ways to evaluate pain

1-10 scale, COLDERR

Amputation Nursing Interventions

1. ** Bleeding (1st priority) 2. ** Infection: aseptic technique required at dressing change to prevent infection & osteomyelitis 3. Wound healing: handle gently 4. Prevent Hip & Knee Contractures in pat with a lower limb amputation - avoiding abduction - external rotation - flexion of the lower limb a. keep legs together to avoid abduction contractures. b. ** lay in a prone position for 24-48 hrs if amputation is below the knee, prevents knee flexion contracture 5. ** educate pt about phantom pain; can happen 2-3 months after surgery. - pain, numbness, tingling, muscle cramp, feeling extremity present

ileostomy nursing intervention priotities

1. ** Highest Priority F&E Preoperative: 1. Low residue diet 7-10 days before surgery to remove fecal matter from colon 2. Clear liquids 24-72 hrs before surgery 3. Antibiotics prophalactically 4. Laxative and enemas 5. NGT to remove stomach contents 6. Blood or protein replacement PRN 7. Abdomen is marked for proper placement 8. Arrange a visit with another ostomy pt Post -Op 1. NPO first 48 hrs, until peristalsis returns 2. NGT removed when peristalsis returns (passing gas, and feces) 3. Clear liquids, soft bland and progressing 4. Asses for peristalsis, flatus/belching, BS, abdominal distention, BM 5. Monitor IV usually maintained 4-5 days (fluid and electrolytes) 6. Pain assessment 7. Stoma site- collection device usually clear - Normal is pink, pale red and shiny - Deep purple- no blood supply. - Later it will shrink in size and less colored - Slight bleeding is normal - Observe for signs of edema - Fecal output does not occur for 2- 4 days due to pre op emptying and NPO status 8. Psychosocial Assessment - Pt's perception of their alter body image - Usual coping skills - Emotional state - Support systems; referral to Ostomy Association - Pre-surgery lifestyle - Perception of physical prognosis and impact on their life Nursing Interventions: 1. Nurses attitude influences pt's attitude and body image, not a pleasant task - Body image - Changes in self care - Dispensing waste - Matter of fact efficient approach - Facial expression of distaste 2. Measurement of I&O - Total of feces every 8 hrs- liquid - When stable and output is regular, nutrition and hydration status are normal d/c - I/O measurements - Prevent dehydration 3. Evacuation and Irrigation - When eating again bag is drained 2-3 hrs - Pouch should be emptied when ½ full - Unclamp pouch over toilet to empty - Ileostomies usually not irrigated unless blockage present - Appliance worn at all times- stool is liquid 4. - Continent Iliostomies have NGT tube post Sx to suction to prevent distention and allow healing, 2 weeks later training starts - Sigmoid colostomy- formed stool, irrigation or suppositories used to stimulate evacuation 5. Protect skin around stoma - Proper seal to prevent seepage of feces - Wash skin gently with soap and water, avoid rubbing or scrubbing- rise thoroughly and pat dry - Protective barrier 6. Changing Collection Bag Two kinds of pouches- temporary and disposable Drainable with clamped ends Attached to a face plate that is secured to the skin around the stoma with special adhesive Patient should return demonstration to ensure understanding Ostomy pts go through stages of grief and loss Active listening, emotional support, and understanding Encourage social interaction (support groups) Allow pt to express concerns about phsysical, sexual and social roles Concerns about odors, leakage and noise

Medications to give to prevent Migraine headaches

1. 2 Beta-blocking agents, propranolol (Inderal) and metoprolol (Lopressor) inhibit action of beta-receptors- cells in the heart and brain that control blood vessel dilation (Antimigraine action) 2. Other meds- Amitriptyline hydrochloride (Elavil), divalproex (Valproate), flunarizine (Sibelium), and serotonin antagonists (Pizotyline) 3. Calcium antagonists (Verapamil) widely used, but takes several weeks to work (Not as effective as beta-blockers, but more appropriate for some patients with bradycardia, diabetes mellitus, or asthma 4. Topiramate (Topamax), an antiseizure medication is shown to be effective, but ** Topamax and Neurontin may impair cognitive ability 5. Other prophylactic meds include antiseizure meds, ergotamine tartrate, lithium, and naproxen 6. ** Triptans (serotonin agonists) are most specific antimigraine agents available a. Cause vasoconstriction, reduce inflammation, and may reduce pain transmission b. 5 triptans currently in use; most widely used triptan is sumatriptan (Imitrex) and is ** effective for acute migraine and cluster headache in adults c. SQ form usually relieves symptoms within 1 hour; effective for moderate to severe headaches d. ** Contraindicated in patients with ischemic heart disease because it can cause chest pain - Be aware of adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety; do not give if taking St. John's wort 7. Ergotamine preparations may be effective in aborting the headache if taken early in migraine process. a. Acts on smooth muscle, causing prolonged constriction of the cranial blood vessels b. Side effects include aching muscles, numbness and tingling, nausea, and vomiting 8. Cafergot (ergotamine and caffeine) can arrest or reduce severity of headache if taken at first sign of attack

16. Know the clinical manifestations of glaucoma

1. Acute angle-closure glaucoma *Ocular emergency! a. Pain b. N & V c. Very high IOP 2. Subacute angle-closure glaucoma a. Temporary blurring of vision b. halos around lights c. headaches d. ocular pain 3. Chronic angle-closure glaucoma a. Significant visual field loss b. IOP normal or elevated c. ocular pain d. headache

TB Nursing care

1. Administer heated & humidified oxygen therapy as prescribed 2. Prevent infection transmission 3. Wear an N95 or HEPA respirator when caring for clients who are hospitalized. 4. Place pt in a negative airflow room, & implement airborne precautions 5. Use barrier protection when the risk of hand or clothing contamination exists 6. Have the pt wear an N95 or HEPA respirator when transporting; shortest & least busy route. 7. Teach pt to cough & expectorate sputum into tissue that are disposed of by pt into provided sacks. 8. Administer meds. as prescribed 9. Promote adequate nutrition. 10. Encourage fluid intake and a well-balanced diet for adequate caloric intake 11. Encourage foods rich in protein, iron, & Vit. C 12. Provide emotional support

What to have at Bedside for pt with Seizures

1. Airway/suction 2. Oxygen

20. Know the characteristics of Herpes Zoster

1. Also called shingles (infection caused by varicella-zoster viruses- DNA viruses) 2. Secondary to chickenpox 3. After a person has chicken pox, the VZV lies dormant inside nerve cells near the brain and spinal cord

Composition of Proteins

1. Amino Acids are the building blocks of Protein 2. C,H,O and N (nitrogen) combined to form protein and are considered essential and non essential 3. 22 Amino Acids: 9 are essential - can not be synthesized by the body; must be obtained from diet 13 non-essential: most are synthesized by the liver

22. Know the characteristics and clinical manifestations associated with Seborrhea

1. An excessive amount of sebum in face, scalp, eyebrows, eyelids, under breasts, gluteal creases, sides of nose, upper lip, axillae (underarm), groin 2 forms: oily & dry both start in childhood and continue throughout life. OILY: 1. moist or greasy w/ or w/o scaling slight redness forehead, nasolabial fold, beard area, scalp, and in axillae, groin, and breast areas 2. small pustules may appear on the trunk DRY: 1. Flaky desquamation of the scalp with fine powdery scales (dandruff) 2. With scaling comes itching, scratching, secondary infections, and excoriation

23. Know what to teach in regards to seborrhea

1. Avoid external irritants, excessive heat, & perspiration 2. Rubbing and scratching prolong the disorder 3. Air the skin and keep skin folds clean & dry 4. Frequent shampooing contraindicated for some cultural practices a. Be sensitive to pts differences b. Pts need to adhere to treatment

21. Know the clinical manifestations associated with Herpes Zoster

1. Burning, stabbing, or aching pain is present in some pts in affected peripheral nerves 2. Some pts have no pain, but itching and tenderness may occur over the area

Vitamins

1. Can not be manufactures in the body 2. Are essential for regulation of body process

Teaching of Compliance for Seizure pt

1. Changing to different meds may be needed if seizure control is not obtained 2. Sudden withdrawal of medications can cause seizures to occur with greater frequency or precipitate status epilepticus

treatment of glaucoma and S/E

1. Cholinergics: periorbital pain, blurry vision, difficulty seeing in the dark Note: never give Atropine (anticholinergic); causes pupillary dilation & worsens IOP 2. Adrenergic agonist: HTN, palpitations, headache 3. Beta Blockers: can have systemic effects, including bradycardia, COPD exacerbation, and hypotension - Don't give to pt's Severe COPD, use cautiously in COPD & Diabetes 4. Alpha-adrenergic agonist: red eyes, dry mouth and nose 5. Carbonic anhydrase inhibitors: oral medications (acetazolamide) are associated w/serious S/E including, anaphylactic reactions, electrolyte loss, depression, lethargy, GI upset, impotence, & weight loss. Topical form (dorzolamide) include topical allergy. - Don't give to pt with Sulfa allergies 6. Prostaglandin analogues: darkening of the Iris, conjunctival redness, possible rash Surgical Management: - when medications do not control IOP - Laser Trabeculoplasty - Laser Iridotomy - opening made in the iris to eliminate pupillary block

18. Know the different type of eye drops used for glaucoma and what to monitor, and how to instill eye drop.

1. Cholingerics (Miotics- Pilocarpine, carbachol) Increases aqueous humor outflow by constricting pupil * Blurry vision to be expected 2. Adrenergic agonists (Dipivefrin, epinepherine) Reduces production/outflow of aqueous humor S/E: HTN palpitations headache ** Teach punctal occlusion 3. Beta blockers (Betaxolol, timolol) Decreases aqueous humor S/E: Bradycardia hypotension COPD exacerbations **Teach punctal occlusion Caution: Do not use for patients with severe COPD, Emphysema, Chronic Bronchitis, bradycardia, hypotension, or heart block Use cautiously for patients with COPD/Diabetes

Parkinson's Teachings

1. Compliance 2. Support Group 3. Promote independance 4. Don't take Levodopa with - Vit.B6 or with - Narrow Angle Glaucoma, - Postural Hypotension 5. Take with meals

Functions of Fat

1. Concentrated source of energy - 9C/g therefor 2. Slow Digestion, thereby retarding hunger - giving satiety, and adding flavor 3. Promote absorption and storage of fat soluble Vitamins A, D, E, K)

how to give nitroglcerin

1. Cornerstone of treatment 2. Dilates veins causing the blood to pool in body - reducing preload 3. Increases coronary blood flow by causing coronary vasodilation Sublingual 1. Very sensitive to light a. inactivated by heat, light, air, moisture & time 2. Replace q6 months; if it doesn't burn, it means medication is expired 3. administer SL; DO NOT SWALLOW 4. NPO for 15 min a. May take up to 3 tabs, 5 minutes apart, if not relieved call 911 5. Make position changes slowly S/E hypotension/No BP, weakness Paste: slower onset longer duration (1% or 2%) 1. Rotate Sites 2. Remove old paste first 3. Take BP 4. Time & Date on paper Patch: Slower onset, 24 hr duration 1. Removed at night to prevent tolerance

s/e of nitroglycerin

Characteristics of Good Nutrition

1. Correct weight for height, bone size, age 2. Straight bones (not bowed or curved) i.e. rickets & kyphosis 3. Firm Muscles, flat abdomen 4. smooth, clear, moist skin (good color) 5. bright, alert expression, good vision 6. smooth glossy hair

27. Review clinical manifestations of Psoriasis

1. Cosmetic source of annoyance to a physically disabling and disfiguring disorder 2. Lesions are red, raised patches of skin covered with silvery scales 3. Patches are made up of live and dead skin

Total Hip Surgery Prevention of Complications

1. DVT 2. Infection 3. Constipation 4. edema 5. Injuries

What can happen with too much fiber

1. Diarrhea, fluid & electrolyte imbalances 2. Binding & elimination of FE and ZE

Teaching to Prevent Seizure

1. Do not drink anything with alcohol in it. 2. Do not stop taking anti-seizure meds 3. Wear medical alert bracelet 4. Follow-up with care

14. Know the treatment for cataracts

1. Early stages: glasses, contact lenses, magnifying glass, bifocals 2. Surgical management: surgical extraction of lens; done 1 eye at a time. If lens not replaced pt will require optical correction until lend replaced.

Foot Surgery Nursing Interventions

1. Elevate 2. Assistive devises 3. pain management

What are the 3 types of movements that occur in the large intestine?

1. Haustral churning: back and fort, mixing contents, aids in absorption of water, propels content 2. Peristalsis: sluggish wavelike movement which moves the chime forward and slowly 3. Mass peristalsis: waves caused by powerful muscular contraction after food ingestion (occurs a few times a day)

s/s of impending death? (4)

1. Loss of muscle tone 2. Slowing of the circulation 3. Changes in respiration 4. Sensory impairment

Neutropenia

1. Low levels of neutrophils 2. Most abundant WBC 3. Decreased production or increased destruction Management: corticosteroids, growth factor, cultures (blood, urine, sputum), broad spec antibiotic Neutropenic Precautions:

Role of Protein

1. Macronutrient - needed in large amounts 2. Repair or replace worn out tissue, leading to tissue growth anabolism vs catabolism & nitrogen balance, especial wounds, surgical incisions, burns 3. Can supply energy in an emergency 4C/g (same as CHO, 4 calories per gram)

Alzheimer's Improve Independence and prevent complications

1. Minimal cuing and guidance to create independence 2. As cognitive ability declines, family members must provide more assistance/supervision 3. A calm and predictable environment helps with surroundings and activities 4. Clocks and calendars important to enhance orientation to time 5. Patient should be assisted to remain functionally independent as long as possible (Provide booster seat for toilet, allow patient to make his/her choices, etc.) 6. ** To maximize patient's independence, make environment as familiar as possible by highlighting own doorway, etc. 7. Engage patient in short activities so there is a sense of accomplish 8. Direct supervision is sometimes necessary, but maintaining dignity and autonomy is important

care of pt post prostatectomy

1. Monitor & maintain strict I&O, irrigation fluid, electrolytes, turgor, edema. 2. Monitor VS every q2h then q4h 3. Monitor for pallor, rising pulse, & respiratory distress. 4. Monitor drainage tubing and irrigate for obstruction. Three way foley for TURP & Suprapubic Prostatectomy a. Connected to CBI with sterile NS to prevents clot formation b. drainage usually begins as reddish-pink and then clears to light pink within 24 hours after surgery c. bright red bleeding with increased viscosity and numerous clots usually indicate arterial bleeding d. venous blood is darker and less viscous hemorrhage most freq. seen in first 24 hours. e. persistent bleeding with many clots should be reported to doctor

Care of a patient pneumonia

1. Monitor C&S results antibiotic peak and through 2. Analgesics non-narcotic, antipyretics 3. Hydration (force fluids if not contraindicated CHF, CRF) 4. Antitussive agents 5. Antihistamines 6. CPT, before meal and position for postural drainage, base on lung area to be drained, IV fluids to rest from eating

nursing care post cardiac cath

1. NPO until gag 2. Bed Rest for 2-6 hr 3. Angio-seal may be used 4.* Assess femoral/distal sites (pedal) 5.* Assess BP & Pulse

28. Know the teaching involved from patient with Psoriasis

1. Need to have compliance to medication regimen 2. Do NOT pick at or scratch affected areas (cold compresses good to relieve itching) 3. Water should be warm and areas patted dry 4. Emollients have moisturizing effect (make sure skin is not completely dry before adding lotion) 5. Softening the skin prevents fissures 6. Education and support is important 7. Check skin every day for signs of infection (drainage, warmth, swelling, pain, etc.) 8. Humidifier good to humidify the air- prevents skin dryness 9. Wrap arms in plastic wrap after applying corticosteroid cream (flammable- NO SMOKING)

Normal sleep patterns through the life span:

1. Normal sleep patterns throughout the lifespan - Children a. Usually have some more hours of sleep b. 3 year olds need 12-14 hours c. Range covers between 10-18 hours including from newborns to school-age children - Adolescents a. Require 9-10 hours of sleep - Elderly a. Disturbed sleep leading to lower quality of life b. Awaken around 6 times at night c. Needs of sleep is the same as when younger

12. Know clinical manifestations of cataracts

1. Painless, blurry vision 2. Dim surroundings 3. Reduced visual acuity 4. Glare sensitivity 5. Diplopia (Double vision)

s/s cataracts

1. Painless, blurry vision 2. Dim surroundings 3. Reduced visual acuity 4. Glare sensitivity 5. Diplopia (Double vision)

17. Know what the nurse would teach the patient about the importance of eye drop medications for a patient with glaucoma

1. Patient education is important **long term care 2. KNOW IOP, keep a record 3. Strict adherence to medication (compliance) 4. Review all meds and know dosage 5. Let nurse observe pt applying drops 6. * Teach punctal occlusion

Maslow's Hierarchy of Needs

1. Physiological 2. Safety 3. Love & belonging 4. Esteem 5. Self-actualization

Sources of Fat

1. Plants and Animals

Nursing interventions associated with a patient with a laryngectomy

1. Pre-Op teaching 2. Reduce Anxiety 3. Maintain patent airway 4. Promoting Alternative Communication Methods 5. Promoting Adequate Nutrition & hydration

Role of Cholesterol

1. Production of Vit. D 2.UV light on the skin plus cholesterol = Vit. D 3. Good Fats contain essential fatty acids and are obtained from plant sources 4. Bad Fats are low density lipoprotein of L.D.L.; excesses deposit in artery walls leading to atherosclerosis. 5. Medications are given for high cholesterol

Ways to maintain normal urine elimination

1. Promote adequate fluid intake: normal adult should be 1,500mL/day, if they have UTI then 2,000-3,000mL 2. Maintain normal voiding habits: POSITIONING, assist to normal position (female:sitting, male:standing) if unable to ambulate bedside comode or urinal. RELAXATION and TIMING 3. Assisting with toileting

Seizures: Care/intervention of Pre and Post Ictal state of Seizures

1. Protect patient from injury (1st priority)- (Ease patient to the floor if out of bed; Protect the head with pillow) 2. Provide privacy 3. Loosen constrictive clothing 4. Push aside furniture 5. If the patient is in bed remove extra pillows(except for head)/raise side rails 6. If patient has an aura and is ambulating, get patient back to bed right away and maintain airway (Provide 2 liters Oxygen nasal cannula) 7. Do not restrain the patient 6. Turn the patient to the side Post ictal state of Seizures 1. Document the events leading to and occurring during a seizure 2. Side-lying position 3. Maintain seizure precautions 4. Side rails up and bed in low position 5. Stay with patient, reorient and reassure him or her

care of pt with seizures

Bone Marrow Transplant Priority Nursing Interventions

1. Risk for Bleeding 2. Risk for Infections

Composition and Types of Fats

1. Saturated fats have the most hydrogen atoms and are most often solid or semisolid at room temperature. i.e., butter, bacon, lard 2. Good Fats contain essential fatty acids and are obtained from plant sources

Assessment Interview

1. Sensation 2. Pain History 3. Medications 4. Medical History 5. Work History

Functions of CHO

1. Spares Protein for energy (protein has more important functions) 2. Aids complete oxidation (burning) of fats for energy

Education of a Alzheimer's patient

1. Stroking, rocking or distraction may quiet the pt. 2. to prevent playing with food, 1 dish is served at a time 3. Emotional burdens/burnout are high in caregivers due to guilt, nervousness, and worry over their loved ones - There are adequate resources in the community such as Alzheimer's Association to give support to loved ones, friends, etc.

List the Treatment for a nose bleed

1. Topical vasoconstrictors A. Adrenaline B. Neosynephrine C. Cocaine 4% using an applicator D. Nitrate applicator, gel form C. Phenylephrine one or two spray to act as vasoconstrictors 2. Packing of nasal cavity A. balloon inflated catheter a. Nasal Tampon

care of nose bleed

26. Know the treatment for fungal infection

1. Topical- mild conditions 2. Oral for severe

15. Know the teaching about activities post cataracts surgery

1. Verbal instructions how to protect eye, know 2. S/S of complications floaters, pain, increase in redness 3. No bending, lifting anything over 5 pounds, driving, etc 4. Metal shield at night for 1-4 weeks and eyeglasses indoors; 5. sunglasses on sunny days to prevent eye sensitivity

25. Know the care and nursing intervention of a child with Lice

1. Wash hair w/ shampoo (Kwell) or pyrethin compounds 2. Shampoo the scalp and hair according to directions 3. Dip comp in vinegar to remove any remaining nits or nit shells from hair shafts 4. All articles: clothing, towels, bedding should be washed in HOT water or dry cleans to prevent reinfestation 5. Upholstered furniture, rugs, and floors should be vacuumed frequently 6. Combs and brushes to be disinfected with the shampoo 7. Antipruritics,systemic antibiotics, and topical corticosteroids used for severe itching, pyoderma, & dermatitis 8. All family members and close contacts are treated 9. Pts with body lice to bathe with soap and water after lindane or permethrin applied to affected areas of shiny and hairy areas

care of pt with lice

Ask open ended questions Talk to me about today is for you?

1. What would you like to talk about today? 2. Tell me what you are thinking? 3. Describe your feelings?

Role of Fiber

1. aids elimination and some soluble forms may help to reduce serum cholesterol 2. requirements 25 - 30g/day

What are the 5 stages of the grieving according to Kugler-Ross?

1. denial 2. anger 3. bargaining 4. depression 5. acceptance

Identify the factors that affect defecation

1. development 2. diet 3. fluid intake/output 4. activity 5. psychological factors 6. lifestyle 7. defecation habits 8. medications 9. medical procedures 10. anesthesia and surgery 11. diseases 12. pain

Steps of how to administer tube feedings

1. introduce yourself and verify clients identity, explain to client what you are going to do, why it is necessary and how they can participate. Advise the client that it should not cause discomfort but may cause a feeeling of fullness 2. Perform hand hygiene and observe infection control procedure. 3. Provide privacy 4. Assess tube placement: - Apply gloves - Aspirate and check ph; should be higher than 6 (allow 1 hour to elapse before testing the ph for a pt that has received medications) 5. Assess residual eating contents - if the tube is in stomach, aspirate all contents and measure the amount before administering feeding. (if 100mL or more than 1/2 of the last feeding is withdrawn, check with the nurse in charge or refer to agency policy before proceeding) - Reinstill gastric contents into the stomach if its agency policy or provider's orders. (if on continuous feeding check gastric contents every 4-6 hours) 6. Administer the feeding: - check expiration date of feeding - warm to room temperature - if Feeding Bag (open system) clean the top of the feeding container with alcohol before opening - apply a label with date, time of start of feeding, initials - hang bag 30cm (12 inches) above the tubes point of insertion - clamp the tubing and add formula to bag - open the clamp, run the formula through the tubing and reclamp the tube - attach the bag to the feeding tube and regulate the drip if not placed on a pump

Nursing Intervention; Patient with migraine

1. pt to avoid specific triggers 2. Comfort measures such as quiet, dark environment, elevation of head of bed to 30 degrees, and symptomatic treatment 3. Prevention involves patient education regarding precipitating factors, possible lifestyle or habit changes, and pharmacologic measures 4. Migraine or cluster headache in early phase requires abortive meds as soon as possible 5. Local heat or massage for tension headache relief

Role of the DRI (Dietary Reference Intake)

1. recommended daily allowance 2. guidelines for food labeling 3. exceptions to the DRI include: premature birth, metabolic disorders, infections, surgical procedures, chronic disease states, use of certain meds. 4. required if a nutrient is added or a nutritional claim is made 5. used as a guide to determine food stamp allowance 6. evaluating food consumption, planning and to aquire of supplies 7. designing nutritional programs

What are 3 body changes that occur after death?

1. rigor mortis 2. livor mortis 3. algor mortis

Water

1. the Most essential nutrient 2. a principal constituent of the body, approx. 60% of the body on average 3. regulates body temperature 4. lubricates moving parts

care of pt post valve replacement

1.*Assess for pt risk for emboli 2.*Follow up care for anticoagulant therapy 3. Recovery from anesthesia 4. Teach pt ways to minimize infection * Pt with valve replacement will be on anticoagulants for the rest of their lives

What are the functions of the lower intestinal tract?

1.ABSORPTION of water and nutrients function. -Most waste products are excreted within 48 hours of ingestion -Chyme (waste product from stomach and small intestine) enters the large intestine from the small intestine through the ileocecal valve (1500 ml daily; only 100 ml of fluid are eliminated in feces; rest is reabsorbed in proximal colon) 2.PROTECTIVE FUNCTION(MUCUS): -mucous contains large amounts of bicarbonate ions -stimulated by parasympathetic nerves -mucous protects intestinal wall from chemical trauma (acids within feces) -serves as an adherent for holding fecal material together -mucous protects intestinal wall from bacterial activity 3.FECAL ELIMINATION: -transports flatus and feces -flatus: is air and byproducts of digestion of carbohydrates

Differentiate four levels of anxiety

1.Mild anxiety: - slight arousal that enhances perception, learning and productivity -prompts to seek information 2.Moderate anxiety: -person expresses feelings of tension, nervousness or concern -perceptual abilities are narrowed -attention focuses on particular aspect of situation 3.Severe anxiety: -consumes most of person's energy -requires intervention -perception is even more decreased -person unable to focus on real event -focuses only on specific detail of event 4.Panic:(least frequent) -overpowering -frightening level of anxiety causing the person to lose control -perception severely affected and person distorts -fear -anger -depression -ego defense mechanism

What are the nurses legal responsibilities regarding patient death? (6)

1.advanced directives 2.autopsy 3.organ donation 4.DNR orders 5.Certification of death or pronouncing someone dead 6.labeling of the deceased

1/3-1/2

when to change a colostomy

1/3-1/2

how many cc are needed to fill up a ballon?

10 cc

Treatment for cluster headaches

100% oxygen by face mask for 15 minutes, ergotamine tartrate, sumatriptan, corticosteroids, or percutaneous sphenopalatine ganglion blockade a. Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches

Fluid Intake

1500 - 3000 cc/day (food & liquids) 750 from food

what size foley catheter is normally used to insert in a patient?

16 French

when do most people feel the urge to void?

250 - 450 mL

how many inches do you insert the enema tubing into the rectum?

3-4 inches

Food group changes in lactation

4 or more servings of low fat milk to meet Calcium (Ca) requirements, increase fluids 2-3 qts/day

Daily CHO Requirements

45 - 65% of Kcal @ 4C/g thats, 200-330g/day for men 180-230g/day for women * spares protein & fats from being used to supply energy

list 5 signs of pheochromocytoma

5H's: -triad [Headache,Hyperhydrosis] -hypertension -hyperglycemia -hypermetabolism

What to Avoid in a Bland Diet (low residue, roughage)

6 S's String: celery, green beans Seeds: tomato, cucumber, squash, okra, eggplant, Kiwi, strawberries Skins: corn, grapes, peas, tomato, beans, berries Spices: pepper, garlic, etc. Stimulants: coffee, tea, ETOH, nicotine Smoking

diabetic diet

60% carbs, 20% fat, 20PRotein never skip meals careful with portions only substitute foods within group

carbohydrates serum level

70-10mg/dL

Essential Nutrients

9 Essential Amino Acids; Cannot be made by the body, must be obtained from diet

rectal temp

99.1F-99.6F The average normal oral temperature is 98.6°F (37°C). A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

a nurse is assisting with a well child visit with a child who is scheduled to receive the recommended immunizations for 4-6 yr olds. which of the following immunizations should the nurse administer? [SATA] a. diphtheria, tetanus, pertussis [DTaP] b. inactivated poliovirus [IPV] c. measles, mumps, rubella [MMR] d. pneumococcal [PCV] e. haemophilus influenza type b [Hib]

A DTaP is a recommended immunization for 4-6 yr olds, and should be administered by the nurse. B IPV is a recommended immunization for 4-6 yr olds, and should be administered by the nurse. C MMR is a recommended immunization for 4-6 yr olds, and should be administered by the nurse.

Projection

A Defence Mechanism - Attributing feelings or impulses unacceptable to one's self to another problem. Example: - Sue feels a strong sexual attraction to her track coach, and tells her friend, "he's coming on to me!" - Patient dislikes the nurse, will state, "She hates me!"

s/s of UTI

A burning feeling when you urinate A frequent or intense urge to urinate, even though little comes out when you do Pain or pressure in your back or lower abdomen Cloudy, dark, bloody, or strange-smelling urine Feeling tired or shaky Fever or chills (a sign the infection may have reached your kidneys)

Anemia Leukopenia: a reduction in the number of white cells in the blood, typical of various diseases.

A decreased capacity of blood to carry o2, not enough RBC or hemoglobin a. Impaired production of RBC's due to dietary deficiencies(iron) b. Destruction of RBCs faster than production c. Blood loss d. hereditary disorder

orthostatic hypotension

A drop in blood pressure which occurs when patient rises from lying to sitting :or from sitting to standing Patient at risk are those who are immobilized and are on prolong bed rest Assess BP and P in the supine position, then sitting position, then standing - when possible. Wait for one minute between positions before taking BP and P. A rise in pulse of 15-30 beats per minute or a fall in pressure of 10-20 mm Hg indicates abnormal orthostatic vital signs

CT scan

A narrow beam of x-ray to scan the head in successive layers. Lesions of brain are seen in variations to tissue density differing from the surroundings normal tissue. A. First done without contrast and then with contrast to detect: 1. Seizures 2. Brain lesions 3. Tumors or other masses 4. Infarction 5, Hemorrhage 6. Displacement of the ventricles 7. Cortical atrophy Teachings Pre Procedure: 1. Teach pt. to stay still during testing/sedation can be used. - Contrast Studies 2. Check for allergies to iodine/shellfish 3. Check Renal Functions; BUN & Creatine 4. NPO or Clear Liquids 4 hrs prior 5. Need patent IV site; 20 gage or power picc 6. NEED CONSENT

MRI

A powerful magnetic field to obtain images of different areas of the body. a. Can be performed with or without contrast; does not use Ionizing Radiation. Safe for Pregnant Women. b. Can identify Cerebral Abnormality easier and more clearly than other diagnostic testing. 1. Brain Tumor, Cancers, Pre Surgery 2. Stroke 3. MS 4. Inflammation or evaluating blood vessels 5. For further research of something found with an MRI without contrast and changes in MS C. Provides info. on Cell Changes, Tumor's response to treatment. Pre Procedure Teachings: 1. Pt is questioned about any implants or metal objects, such as: - Aneurysm clips - othropedic hardware - pacemakers - artificial hear valves - intrauterine devices - IV access port - Surgical clips * Can malfunction, be dislodged or heat up in body. 2. All metal objects must be removed. 3. No metal equipment allowed, such as: - Stethoscope - Oxygen tanks - IV poles - Ventilators 4. Pt must lay flat, sedation can be used, if pt becomes claustrophobic, agitated, or confused. Nursing Interventions: 1. MRI with contrast, check BUN and Creatine levels

Polycythemia

A proliferative disorder in which the myeloid stem has escaped normal control mechanisms. - RBC, WBC, and platelet counts in the peripheral blood are elevated. - RBC elevation is more predominant - Hematocrit can exceed 60% Clinical Manifestations 1. Increase in blood viscosity 2. Increase in total blood volume 3. Congestion of blood in body organs 4. Ruddy complexion 5. HTN / Dizziness / HA/Tinitus/ fatigue/paresthesias/blurred vision Elevated uric acid/gout/renal stone formation 6. Generalized pruritus 7. Erythromelalgia- burning sensation in fingers and toes 8. Bleeding 9. Nosebleeds, ulcers, frank GI bleed, hematuria, intracranial bleed 10. Thrombus formation- CVA, MI 11. Hepatomegaly / splenomegaly - increased blood flow to organs

Status Epilepticus

A series of generalized seizures that occur without full recovery of consciousness between attacks. - Considered a medical emergency because it interferes with respirations and possibly respiratory arrest, and anoxia to the brain that can lead to irreversible and fatal brain damage Factors that precipitate status epilepticus: - Sudden withdrawal of medications - Fever - Infection Nursing Interventions: - Stop the seizures as quickly as possible - Ensure adequate oxygenation to the brain - Maintain airway - Return the patient to a seizure free state - Assess respiratory status - Safety - Cardiac status is assessed - Document and monitor seizure activity - Turn patient to side lying position - Suction at the bedside - Assess IV site so it does not dislodge - Pad side rails Medications: - Ativan/Valium/Cerebyx IV - Anticonvulsant - Dextrose if the patient is hypoglycemia Diagnostic Test: - Blood samples - EEG - Vital Signs - Neuro status

Bone Marrow Aspirations

A small amount of marrow is removed to diagnosis: 1. Cause of Anemia 2. Presence of Leukemia or othe Malignancy NI: 1. Pt education 2. Consent 3. Risk for Bleeding 4. Infection - sterile dressing 5. Pain management 6. Avoid ASA

Provitamin or Precursor

A substance which is used by the body to convert into a Vitamin. i.e., Cholesterol and Sunlight = Vit. D Carotene = Vit. A

Illusion

A thought Disorder - An inaccurate perception or Misinterpretation of Reality. Ex. Feeling water pour down my legs. Seeing a rat when instead it's a stapler.

Syncope • Glasgow coma scale and what the number score indicates? • Intervention for level of consciousness

s/s of syncopal episode

A transient LOC that can last from seconds to 1-2min - most often occurs when the pt is standing There are three causes of a syncopal episode - Vasovagal: Most common, leading to a sudden loss of consciousness due to a sudden loss of resistance in the peripheral vessels - Orthostatic hypotension - Cardiac dysrhythmias Nursing Intervention Synope If the patient begins to feel dizzy, have them lie flat Raise the lower extremities Prior to the patient getting out of bed, have them dangle their feet

Fat Soluble Vitamins that can be stores in the body

A, D, E, K

Skills needed for developing self-awareness ASKED

A- Awareness: am I aware of my prejudices, biases, racism ideas and/or any other "isms"? S- Skills: do I have the skills to conduct a cultural assessment in a sensitive matter K- Knowledge: am I knowledgeable about the worldviews of diverse cultural and ethnic groups? E-Encounters: Do I see face-to-face and other types of interactions with people who are different from me D- Desire: Do I really "want" to become culturally competent?

Blood Transfusion

A. Febrile Nonhemolytic Reactions 1. Chills (minimal to severe) 2. Fever (usually begins within 2 hours after transfusion) * Not life threatening B. Acute Hemolytic Reaction - rupturing of circulating erythrocytes * MOST DANGEROUS * DC BLOOD FLOW 1. Chills, Fever 3. Chest tightness 4. Anxiety 5. Dyspnea 6. Nausea 7. Lower Back Pain 8. Hypotension, uncontrollable bleeding 9. Tachycardia 10. Diminished Renal Perfusion (decrease urine output, and hematuria) 11. Hemoglobinuria & Hyperbilirubin C. Allergic Reaction- hypersensitivity to antibodies in donor's blood 1. Uriticaria (hives) 2. Itching 3. Flushing Treatment: (antihistamines, corticosteroids) MILD REACTION- slow blood flow SEVERE- Discontinue blood flow D. Circulatory Overload - too much blood administered to quickly, hypervolemia can occur. 1. Dyspnea 2. Orthopnea 3. Tachycardia 4. Anxiety 5. ↑ BP, JVD 6. Crackles 7. Pink frothy sputum (Pulmonary Edema) * Patients at risk- administer diuretics btw units or after * SLOW RATE TRANSFUSION E. Septic - use blood within a 4 hr period, more common in platelets 1. Chills 2. Fever 3. Hypotention * DC BLOOD FLOW Treatment: 1. Iv. Fluids 2. Antibiotics 3. Corticosteroids 4. Vasopressors F. Transfusion Related Acute Lung Injury - idiosyncratic reaction occurring within 6 hrs after blood transfusion * POTENTIALLY FATAL G. Delayed Hemolytic Reaction Occurs within 14 days after transfusion 1. Fever 2. Anemia 3. ↑ bilirubin levels 4. Jaundice Usually not dangerous Complications of Long Term Transfusion Pt 1. Infections 2. Iron overload 3. Reactions Monitor 1. VS with baseline, including oxygen saturation 2. Respiratory status a. Note the presence of adventitious breath sounds 3. Use of accessory muscles 4. Extent of Dyspnea 5. Changes in Mental Status; including anxiety & confusion 6. Note chills, diaphoresis, JVD and report of back pain or Uticaria. 7. Cardiovascular & Renal status

Delayed Complications of a Fracture

A. Non-union: failure of the ends of a fractured bone to unite Management: 1. Bone grafting (Autograft is from the iliac crest, while Allograft id from a donor) to stimulate callus formation 2. Immobilization 3. Non-weight bearing exercises B. Malunion: healing of a fractured bone in a malaligned position Management: 1. Refractures surgically & reset C. Avascular Necrosis: bone loses blood supply & dies (femoral neck). S/S - Pain - decreased movement; ROM Medical Management: 1. x-ray 2. Bone Graft 3. Prosthetic Replacement 4. arthrodesis (joint fusion) D. Deep Vein Thrombosis (DVT): can happen at any time of fracture S/S - Swelling & pain - Homan's sign E. Disseminated Intravascular Coagulopathy (DIC): a sign of an underlying condition - bleeding F. Infection G. reaction of Internal Fixation Devices S/S - Pain - decreased function H. Complex Regional Pain Syndrome (CRPS) Reflexive Sympathetic Dystrophy (RDS) S/S - severe burning - local edema - hyperesthesia - stiffness - discoloration - vasomotor skin changes - trophic changes, muscle atrophy - osteoporosis I. Heterothrophic Ossification (Myositis Ossificans) S/S - muscle pain - limited movement

(IS) Incentive Spirometer Nursing Interventions

A. Positioning of patient, teach and encourage use, set realistic goals for the patient, and record the results. B. The patient should be encouraged to use an incentive spirometer approximately ten breaths per hour between treatments while awake.

Care of the patient with a larygecnctomy

A. Semi Fowler's or high Fowler's position to decrease edema B. Monitor for signs, symptoms of respiratory distress C. Tracheostomy or laryngectomy tube assessment D. Care of stoma E. Suctioning F. Keep HOB elevated during, after tube feedings G. Check gastric residual when administering tube feedings H. When patient begins oral feeding, maintain upright bed position during, after feedings I. Swallowing maneuvers to prevent aspiration J. Use of thickened liquids

Early Complications of a Fracture

A. Shock - hypovolemic shock: losing 20% or more of blood or fluid supply; traumatic blood loss - decreased blood volume, cardiac output, tissue perfusion Medical Management: - fluid replacement - Medication - dobutamine B. Fat Embolism: major cause of death; most frequent in young adults Source: long bones, pelvic, crushed injuries & multiple fractures ** S/S - personality changes - restlessness - irritability - confusion after fracture (ABG) - Hypoxia - Tachypnea - tachycardia - Prexia (fever) - crackles - wheezes - precordial chest pain - cough - increased pulmonary pressure - increased temp. Prevention: 1. Immediate immobilization 2. minimal fracture manipulation 3. adequate support during turning & repositioning 4. balance of F&E 5. Respiratory support - O2 high concentration 6. Report MD of any S/S C. Compartment Syndrome D.Thrombeombolic Complications (DVT) E. Pulmonary Embolus

S/E that best match up for a patient on antipsychotic medications

A. profound sedation; reduced in time initially it may be the desired effect if severely agitated but can later cause noncompliance. B. Anticholinergic S/E -blurred vision - dry mouth - constipation - urinary retention Example: greatest with chlorpromazine - Thorazine

purpose of ABG

ABG (arterial blood gases) Purpose: 1. Measurement of arterial oxygenation and carbon dioxide levels. 2. Assesses the adequacy of alveolar ventilation, the ability of the lungs to provide oxygen and remove carbon dioxide, assesses acid base balance Nursing Interventions Pre 1. Check with physician if ABG to be done on Room Air or oxygen 2. To check for baseline results Post 1. Apply pressure for 3-5 minutes after ABG 2. Longer for anticoagulants 3. Watch for signs of circulatory impairment: - Swelling - Pain - Numbness - Discoloration - Tingling

preventing injury in the health care agencies

ALL OF THE ABOVE : orient to surroundings explain call system -assign at risk pts near to the nurses station -place personal items within reach -keep bed in low position, wheels locked and side rails up -lock all beds, wheel chairs and stretchers

Sickle Cell Anemia

Abnormal inherited hemoglobin molecule cells. Crescent, rigid shaped. Function abnormally & cause small blood clots. Clinical Manifestations: 1. Joint, bone pain- enlargement of bones - face & skull 2. Fatigue, breathlessness, tachycardia 3. Murmurs, cardiomegaly, dysrythmias & heart failure 4. Delayed growth & puberty 5. High Risk for Infections 6. Ulcers in lower legs 7. Jaundice 8. Abdominal pain 9. Poor eyesight, blindness 10. Fever 11. Hematuria 12. Priapism - unwanted painful errection 13. Hematuria 14. Chest pain - potentially fatal - rapid Hgb drop - respiratory distress; tachypnea, cough, wheezing - fever - Chest xray, infiltrates - infarction of pulmonary vasculature 15. * Damage to Organs 16. * CVA 17. * Hypertension 18. * Ulcers 19. * Strokes Complications 1. Infections; pneumonia, osteomyelitis 2. Stroke 3. Renal Failure 4. Impotence 5. Heart Failure 6. Pulmonary Hypertension 7. Chronic lung Disease Crisis in Adults 1. Acute vaso-occlusive crisis a. Pain b. Tissue hypoxia & necrosis; inadequate blood flow 2. Aplastic Crisis a. from infection of parvovirus b. Rapid HGB fall 3. Sequestration Crisis a. organs pool the sickled cells b. liver/spleen/lungs Nursing Interventions 1. ** Hydration 2. ** Pain Management 3. Compliance w/Meds 4. Avoid Infections 5. Supplementation w/Folic Acid bcuz of the rapid RBC turnover 6. Antibiotics for Infections 7. Up to date vaccines 8. Eye Exam to monitor Retina damage 9. Bone Marrow transplant ** Priority 1. Pain Management w/analgesics & adequate fluid intake, monitor for infections

care of pt with sickle cell anemia

Pernicious Anemia

Absence of Intrinsic Factor- needed to absorb Clinical Manifestations 1. Anemia a. fatigue b. pallor c. dyspnea d. palpations 2. GI Symptoms a. Sore mouth; beefy red tongue b. weight loss c. Indigestion/mild diarrhea - due to atrophy of gastric mucosa 3. Neurological symptoms a. tingling, numbness of feet & hands b. progressive damage to spinal cord c. loss of proprioception; can lead to poor balance & coordination Diagnostics - Positive Schilling Test Management 1. Monthly Vit B12 IM injections for the rest of their lives 2. Folic acid & iron supplements 3. Avoid excessive cold or heat; sensitive to cold, use extra blankets 4. Good mouth care 5. eat small amounts of bland soft foods 6. Diet high in protein, multivitamins & minerals ** Potentially FATAL if untreated: can lead to HEART FAILURE ** If neurologic symptoms present 1. Neurological Assessment a. position sense of vibration b. Gait & stability c. Assistance with ADL's d. Safety, Canes, Walkers e. Physical & occupational therapy referral

Define urination (micturition)

Act of emptying the urinary bladder

MDI (Metered (measured) dose inhaler) Nursing Interventions

After you use a corticosteroid inhaler, rinse your mouth thoroughly with water and then spit out the water. Do not swallow. 1. Observe for side effects: - Tachycardia - dysrhythmia - CNS excitation - N&V 2. Evaluate effectiveness by: Monitoring for decreased SOB, wheezing, crackles, loosened secretions & anxiety. 3. Give treatment before meals to avoid N&V and to reduce fatigue that accompanies eating 4. Instruct & encourage pt in diaphragmatic breathing & effective coughing.

factors affecting blood pressure

Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process AGE: Aging tends to diminish arterial elasticity (hardening) EXERCISE: increases cardiac output, therefore BP is increased Note: a good nursing interventions would be to wait 20-30 minutes after any activity to take VS to get the most accurate results STRESS: causes stimulation of sympathetic nervous system which causes an increase in cardiac output and vasoconstriction of arterioles - an increase in BP RACE: African American males older than 35 have higher blood pressures than European American males of the same age group. OBESITY: pressure is increased do to the increased resistance. GENDER: Females have a lower BP than males (on average) until menopause - then it equals out MEDICATIONS: may increase or decrease blood pressure DIURNAL VARIATIONS: BP is lowest in the morning - metabolic rate is slowest BP is higher in evening hours along with metabolic rate Temperature: Because of increase metabolic rate, fever can increase BP. However, external heat causes vasodilation and decreases blood pressure. Cold- causes vasoconstriction and elevated blood pressure. DISEASE PROCESS: Any condition affecting cardiac output, blood volume, blood viscosity, and/or arterial compliance can increase or decrease blood pressure DIET: high fat/high salt can increase BP

factors affecting pulse

Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology AGE: as age increases, the normal resting pulse rate gradually decreases GENDER: after puberty, males have a slightly slower pulse rate than females. . EXERCISE: Pulse rate normally increases with activity - to meet the demands for the increasing need for oxygen. . FEVER: Elevated body temperature leads to peripheral vasodilation that leads to lowered blood pressure and increased heart rate. Increased metabolic rate due to fever also increases pulse. . MEDICATION: Increases or Decreases pulse rate depending on Medication. Cardiotonic (e.g., digitalis preparations) decrease the heart rate Epinephrine increases heart rate HYPOVOLEMIA: Will increase the pulse (i.e. hemorrhage) 7. STRESS: Increases pulse due to stimulation of the of the sympathetic nervous system (fear/anxiety/pain) POSITION CHANGES: Sitting or standing can cause blood to pool in dependent areas of the body - resulting in temporary decrease in blood pressure and an increase in the pulse rate.

factors affecting body temperature

Age Time of Day Exercise Hormones Stress Environment Medication AGE : young vs. Old The elderly have decreased thermoregulatory controls. (Inadequate diet, loss of subcutaneous fat, lack of activity, reduced thermoregulatory efficiency). TIME OF DAY DIURNAL VARIATION (Circadian Rhythms) Changes in body temperature throughout the day Highest between 1600 and 1800 and lowest during sleep between 0400- 600. EXERCISE: increases body temperature HORMONES: certain hormones affect heat production ex: progesterone @ ovulation STRESS: stimulates the sympathetic nervous system ENVIRONMENT: extremes in temperature

Diagnostic Test for Seizures

Aimed at determining the type of seizure that the patient is having, their frequency, and severity, and what factors that may precipitate a seizure 1. History (Developmental, alcohol use) 2. Illness\head injuries 3. MRI\CT scan: To rule out lesions, tumors 4. EEG: Helps to classify type

Alzheimer's

Alzheimer's Disease is a progressive irreversible degenerative neurological disease. Begins insidiously and is categorized by gradual losses of cognition, disturbances in behavior/affect

Cardinal Sign of Anorexia Nervosa in a Post-pubersim female

Amenorrhea: absence of menstruation

erroneously low BP

An abnormally low blood pressure A consistently low systolic reading between 85 and 110 mm Hg in an adult whose normal pressure is higher than this E.G.: 90/60

Cerebral angiography

An x-ray study of cerebral circulation after contrast has been injected, usually Femoral; Carotid & Brachial Arteries can be used as well. A. Arterial access used for interventional procedures, such as placing Coils in an Aneurysm or Arteriovenous malformation. Pre Procedure Nursing Interventions & Teachings: 1. Check pt Blood Urea Nitrogen; BUN and Creatinine levels to make sure kidneys will be able to clear contrast. 2. pt should be well hydrated; clear liquids until time of test. 3. pt instructed to void immediately before test. 4. Locations of Peripheral Pulses marked with felt tip pen. 5. pt to remain immobile during test 6. pt to expect a brief feeling of warmth in face, behind eyes, jax, teeth, tongue, & lips with a metallic taste as contrast agent is injected 6. Groin is shaved and prepared local anesthetic agent is given to minimize the pain at insertion site to reduce arterial spasm. 7. Fluoroscopy used to guide catheter to appropriate vessels ** Neurologic assessment is conducted pre & post to observe for embolism or arterial dissection. Post Procedure Nursing Interventions: 1. S/S of complications - LOC - one sided weakness - motor or sensory deficits - speech disturbance 2. Observe injection site for Bleeding or Hematoma formation 3. Monitor Peripheral pulses marked prior; for changes in pulse strength 4. Assess color and temp. of involved extremity to detect possible embolism

2 processes that are compromised in the body

Anabolism: building tissue Catabolism: breaking down tissue

Sources Protein

Animal Sources: - High Biological value: closely resembles amount and combination of amino acids in human body; most often are complete proteins i.e., meat, fish, poultry, eggs, milk, cheese Plant Sources: - can be made complete if eaten in the right combination at the same meal i.e., corn & beans, lentils & rice, peanut butter & bread, macaroni & Cheese (animal protein)

Medications for Seizures

Anticonvulsant therapy most effective - Important to follow-up with regular blood draws to measure medicine levels - Main goal to prevent episodes with the least amount of side effects - Start with one drug at a time - Medication is added according to the presence of side effects - Blood levels are drawn (If patient is on divalproex sodium (Depakote), then check for Liver Function Tests - Overdose causes Hepatotoxicity - Medications selected is dependent on the type of seizure that the patient is experiencing - Changing to different meds may be needed if seizure control is not obtained - Sudden withdrawal of medications can cause seizures to occur with greater frequency or precipitate status epilepticus Tegretol, Neurontin, Lamictal, Trileptal, Dilantin, Topamax, Depakote, and Klonopin (For patient receiving Klonopin for a seizure disorder and has very low platelet count, DO NOT use straight razor for shaving)

Dilantin (phenytoin)

Anticonvulsants for Seizures - Patients receiving phenytoin (Dilantin) have to have thorough oral hygiene after each meal (Gum massage, daily flossing, and regular dental care) - All important to prevent or control gingival hyperplasia - Normal Dilantin level is 10-20 mcg/mL (Monitor through regular blood draws)

What to give for an overdose of Anxiolytics; Benzodiazepines

Antidote, flumazenil (Romazicon)

Klonopin

Antiseizure agents used for Seizure & MS patients - patient receiving Klonopin for a seizure disorder and has very low platelet count, DO NOT use straight razor for shaving)

charting errors

Are all entries legible? Are there grammatical or spelling errors? Is the language objective? Are abbreviations approved by the agency? Are entries signed correctly? Are entries dated and timed? Is the chart free of erasures and other alteration Are all entries made in black ink? Are known allergies highlighted? Are all necessary flow sheets in the patient's medical record? Are flow sheets filled out completely?

care of pt post renal biopsy

Assess biopsy site for bleeding • Use aseptic technique to prevent infection • Educate patients and their families about the procedures and time required to obtain results • Educate patients and families how to care for the biopsy site and report any sign of infection

assessment before moving patients

Assess degree of exertion permitted Physical abilities Muscle strength, Presence of paralysis Ability to understand instructions Degree of comfort Clients weight Presence of orthostatic hypotension Assess nurse's strength and ability Pain medications Prepare supportive equipment Obtain require assistance Explain procedure to the patient Safe practice for moving and turning Pt Before moving, assess If indicated, use pain relief modalities Prepare any needed assistive devices Plan around encumbrances Be alert to the effects of any medications Obtain required assistance Explain the procedure to the client Provide privacy Wash hands Raise bed/Lock wheels Lower side rail if turning toward nurse/Raise side rail if opposite Face in the direction of the movement Broad stance of support Lean trunk forward by flexing hips, knees and ankles Tighten your gluteal, abdominals, leg and arm muscles before movement Weight shift from one leg to the other when pulling or pushing Assess patient (comfort, alignment, tolerance (HR, RR), safety precautions Head of bed flat as to tolerance Elicit patient's help (flexing hips and knees, using over head trapeze) Two nurses using forearm interlock or Two nursed using turn sheet

Care of a patient on oxygen

Assess for signs and symptoms of hypoxia, arterial blood gas results, and pulse oximetry. Oxygen administration systems

Multiaxial Evaluation Scale DSM IV/DSMV Be able to match up disorder with Axis

Axis I: Identifies the primary diagnoses of the pt. - Clinical Disorders, clinical attention - MDD - Single Episode, severe without psychotic features - mood disorder due to hypothyroidism, with depressive features - Alcohol Abuse Axis II: Personality Disorders, mental retardation. - Dependent Personality Disorder - No diagnosis, histrionic personality features - prominent maladaptive personality features (younger pts. exhibit traits of....) Axis III: any medical condition being experienced by the pt. general medical conditions - hyperthyroidism - HIV - Diabetes - Asthma Axis IV: reports any psychosocial & environmental problems experienced by the pt. - threat of job loss - support - housing - legal problems Axis V: Identifies the pt. current ability to function. Global Assessment of functioning Scale from 0-100 45 admission 65 discharge

a 9 year old child who hassickle cell anemia lives with her father, stepmother, and half sibling. which of the following describes this family's composition? a. nuclear family b. blended family c. extended family d binuclear family

B a blended family includes at least one stepparent, stepsibling, and/or half sibling

daignostic tests to diagnose cancer

BIPOSY: the most definitive cancer test result. incisional/excisional/needle aspiration -ENDOSCOPY: -DIAGNOSTIC IMAGING .bone scanning .computed tomography [CT] .radioisotope studies .ultrasound testing .magnetic resonance imaging [MRI]

Lab Tests Associated with BPH and CA of the Prostate Example DRE, PSA

BPH: Health history Urinary tract Previous surgeries General health Family history Fitness for surgery Voiding diary DRE PSA U/A and culture Urinary flow-rate recording Post void residual (PVR) Urethroscopy Ultrasound CBC Cardiac and respiratory function PROSTATE CA: DRE PSA Histologic tissue exam of tissue TURP Open prostatectomy US guided transrectal needle biopsy US guided TRUS with biopsy Bone scan Skeletal X-ray MRI CT scan

pulse locations

BRACHIAL:, at the inner aspect of the biceps muscles of the arm or medially in the antecubital space RADIAL:, where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist FEMORAL, where the femoral artery passes alongside the inguinal ligament POPLITEAL:, where the popliteal artery passes behind the knees POSTERIOR TIBIAL: on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus. PEDIAL: (dorsalis pedis), where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line

color of normal stoma

Beefy Red

Medication for Alcohol withdraw syndrome

Benzodiazepines: Librium PO and Valium IV for Seizures - Thiamine (B1)/ folic acid (folate)/ B12 - Naltrexone - opiod receptor antagonist; reduces alcohol cravings

Hemorrhagic Stroke

Bleeding into the brain tissue, ventricles or subarachnoid space # 1 cause HYPERTENSION

Discuss the purpose of digital removal of a fecal impaction

Breaking fecal mass and removing it in pieces. Order needed in some institutions.

a nurse is checking the vital signs of a 3 yr old during a well child visit. which of the following findings should the nurse report to the provider? a. temperature 37.2°C [99.0°F] b. pulse 104/min c. respirations 30/min d. BP 90/52 mm Hg

C resp of 30/min is above the expected reference range for a 3 yr old child and should be reported to the provider

Water Soluble Vitamins that can not be stored in the body

C, ascorbic acid, B complex

therapeutic diets in specific disorders

CHO 50-60% protein 10-20% fat 20-30%

Hyperchloremia

CL greater than 108 mEq/L Clinical signs: weakness, lethargy, metabolic acidosis

Hypochloremia

CL less than 95 mEq Clinical signs: alkalosis, which causes muscle twitching/tetany, tremors

a nurse is instructing a client who is being evaluated for PMS. to journal her symptoms to aid in the diagnosis. identify symptoms of PMS

CLIENT EDUCATION -irritability -impaired memory -depression -poor concentration -mood swings -binge eating -breast tenderness -bloating -weight gain -headache -back pain

What to delegate when caring for Alzheimer's patient

CNA can feed if no Dysphagia

6. Know nursing interventions for eye trauma: contusion & foreign body

CONTUSION: Damage to the orbit of the eye- Hematoma -assess for injury to the eye -place ice on the orbit if no injury to limit the bleeding and the swelling -after 24 hrs, use warm compresses for 15 minutes to promote the absorption of the hematoma FOREIGN BODIES: -Feels like something is in the eye. Profuse tearing and redness -Flush eye gently inside to outside with sterile saline -If object is embedded (protruding from eye), do not attempt to remove (See a physician)

What to teach about coumadin

COUMADIN PT TEACHING [DRUGGUIDE] -report unusual bleeding or bruising, black tarry stools -no ETOH or OTC drugs especially aspirin or NSAID's -frequent lab tests to monitor coagulation factors [PT and INR]

What do vegans have the must difficulty consuming

Ca & B12

Hypercalcemia

Ca greater than 10.5 mg/dL lethargy, weakness, urinary calculi, depressed deep tendon reflexes, anorexia, nausea, vomiting, constipation, polyuria, cardiac dysrhythmias (heart block)

Hypocalcemia

Ca less than 8.5 mg/dL numbness, tingling, muscle crampsm tremors leading to tetany (sustained contraction) cardiac dysrhythmias, confuison, anxiety, psychosis, Positive Trousseau's (hands) Positive Chvostek's (nerve 7)

What are psychological indicators of stress?

Can be helpful or harmful depending on situation and length of action: -anxiety

Essential Nutrients

Cannot be made by the body Water Carbs fats proteins minerals vitamins

What are energy foods

Carbohydrates i.e., grains, fruits, vegetables, legumes, sugar, syrups, root vegetables

care of a pt with a fracture including cast care

Cast Care Complications Compartment Syndrome ** Increased tissue pressure within a limited space; cast muscle, compartment leading to anoxia and necrosis. - Permanent lost of function > 6 hrs. - CMS checks S/S - exposed extremity is dusky, pale - cool skin temp. - delayed capillary refill - Not relieved by opiods - Passive stretching causes pain. - Nerve Ischemia & swelling continues - Paresthesia (numbness or tingling of skin) or paralysis - Hypoesthesia Management: 1. **Elevate extremity to heart level 2. **Notify MD 3. **Bi Valve Cast with MD order a. loosen or remove and bivalve cast (cut in half longitudinally) to reduce constriction and allow for inspection of skin. 2. Maintain limb alignment 3. Fasciotomy if pressured is not relieved or restored to relieve pressure within muscle compartment. 4. Debridement/grafting may be needed Post-Op 1. Sterile dressing: keep clean and free from infection 2. Limb splint 3. ROM 4. Elevate limb Cast Care Complications Pressure Ulcers Pressure on soft tissue Susceptible areas: - Heel - Maelleoli - Dorsum of toes - Patella - Lateral epicondyl - Ulnar stylid process S/S - Painful hot spot - Tightness - Drainage - Warmth - smell Management: 1. MD might cut an opening (window) to allow to assess and possible treatment Teaching: Cast Care Complications Disuse Syndrome/Atrophy Isometric muscle contraction exercises: tense or contract muscle without moving the underline bone. 1. Should be done hourly while pt is awake. 2. gluteal and quad sets

isometric exercise

Change in muscle tension No change of muscle length No change in movement Used with immobilized muscles (casts, traction), endurance Examples: Quadriceps sets, gluteal sets Moderate increase in heart rate and cardiac output

isotonic exercise

Characteristics Increase muscle strength Muscle shortens produce muscle contraction and active movement Example: Running, walking, swimming, cycling, ADL's (activity of daily living) Active ROM (range of motion) Increases muscle tone and mass Increase heart rate and cardiac output, increased general blood flow

Hodgkin Lymphoma

Chronic, progressive neoplastic disorder with enlarged lymph glands, spleen and liver. - Rapid proliferation of abnormal cells of the macrophage system called the Reed-Sternberg cell - The cells divide within the lymph nodes. - Spread of the disease is through the lymph and blood Diagnostics: 1. A lymph node biopsy 2. A bone marrow biopsy 3. A biopsy of suspected tissue Detection of Reed-Sternberg (Hodgkin's lymphoma) cells by biopsy Nursing Interventions 1. Monitor eating patterns 2. Skin reactions: (no heat, cold, lotions, rubbing) 3. Increase periods of rest \ sleep 4. Diversional activities 5. Provide psychosocial support 6. Anticipate the probability of nausea and vomiting and medicate as needed 7. Assess for s\s of infection 8. Instruct to avoid contact with persons with infection

care of pt with hodgkins disease

Systemic Lupus Erythematosis

Clinical Manifestations Nursing Interventions Medications Sun Exposure Risk for Infection

s/s of crohns disease

Clinical Manifestations: 1. Abdominal pain and cramping after meals because of peristalsis stimulation 2. Diarrhea (90% of cases)- bloody mucoid stool & dehydration 3. Weight loss due to anorexia, N/V; pt doesn't want to eat to avoid pain, secondary anemia 4. Intrabdominal abscesses resulting in fever & leukocytosis 5. Rectal bleeding; mild & severe bc of ulcerations 6. Malaise; thin, emaciated bc of decrease intake, malabsorption and fluid loss

11. Know nursing interventions for patient with retinal detachment

Clinical manifestation: 1. Sudden flashes of light, cobwebs, floaters or spots in front of the pts vision 2. Painless, sudden blurred vision w/ areas of lost light (central vision) 3. Appearance that a curtain is moving across the visual field 4. Progressive constriction of vision in one area Nursing intervention: 1. Positioning pt- specific to allow retina to fall back in place 2. Comfort 3. Complications: A. ↑IOP, endophthlmitis, more detachment, cataracts, loss of turgor B. Teach pt s/s of complications & follow -up care * Vision is never perfect after surgical attachment

19. Know the clinical manifestations and nursing interventions' associated with impetigo especially those nursing intervetions associated with hygiene

Clinical manifestations 1. Begin as small, red macules, which become thin walled vesicles that rupture: honey-yellow crust 2. Crusts are easily removed to reveal smooth, red, moist surfaces in which the new crusts develop 3. Scalp can become involved 1. Pt/family members should bath at least 1x daily with bactericidal soap 2. Wash, do not scrub skin to remove crusts/drainage 3. Apply warm and moist compresses to the area 4. Cleanliness and good hygiene practices help prevent spread of lesions from one skin area to another and from person to person

PET Scan

Computer-based nuclear imaging technique that produces images of actual organ functioning. A. Pt either inhales radioactive gas or is injected with radioactive substances that emits positively charged particles, which permits measurement of blood flow, tissue composition & brain metabolism B. Used to diagnose the following: 1. Metabolic changes in the brain disease; Alzheimer's 2. Locating Brain Tumors 3. Identifying blood flow & oxygen metabolism in Stroke pt's. 4. Reveals Biochemical Abnormalities associated with Mental Illness Pre Procedure Teachings: 1. Explain test to pt. 2. Show inhalation techniques and sensations, like dizziness, lightheadedness & headaches. Nursing Interventions: 1. Check Blood Sugar 2. Kidney functions 3. Maintain NPO 4. Relaxation exercises reduce anxiety

Signs of dig toxcitity

Confusion Irregular pulse Loss of appetite Nausea, vomiting, diarrhea Palpitations Vision changes (unusual), including blind spots, blurred vision, changes in how colors look, or seeing spots) Other symptoms may include: Decreased consciousness Decreased urine output Difficulty breathing when lying down Excessive nighttime urination Overall swelling

What is sleep?

Considered an altered state of consciousness. The individual perception of and reaction to the environment are decreased. -The individual during sleep displays: .minimal physical activity .variable levels of consciousness .changes in body's physiological processes .decrease response to external stimuli

how to administer and assess CBI

Continuous Bladder Irrigation - 3 way foley for TURP & Suprapubic Prostatectomy a. Connected to CBI with sterile NS to prevents clot formation b. drainage usually begins as reddish-pink and then clears to light pink within 24 hours after surgery c. bright red bleeding with increased viscosity and numerous clots usually indicate arterial bleeding d. venous blood is darker and less viscous hemorrhage most freq. seen in first 24 hours. e. persistent bleeding with many clots should be reported to doctor Precautions: a. check freq. to see that foley is draining, no kinks output is appropriate when cath removed b. monitor ability to void c. strict I&O; if distended may cause bleeding d. monitor incision sites and change dressings to keep dry and comfortable from urine exposure to skin e.Urine should be clear to light pink within 24 hours post op * Steps to follow: Empty bag Irrigate Medicate Call MD

S/S for lung cancer

Cough Dyspnea Hemoptysis (coughing blood) Pain

s/s of COPD

Cough Sputum collection Dyspnea on exertion (may be severe) Weight loss common Use of accessory muscle to breath Chronic hyperinflation-"barrel chest Respiratory insufficiency Respiratory failure Pneumonia Atelectasis Pneumothorax Cor pulmonale

a nurse is reinforcing teaching with a client who has chronic pyelonephritis. what information should the nurse include in the teaching?

DESCRIPTION OF DISORDER / DISEASE PROCESS -chronic pyelonephritis is a repetitive infection and inflamation of the kidney, pelvis, calyces, and medulla, which generally begins from bacteria that ascends from a lower urinary tract infection. POTENTIAL COMPLICATIONS: -septic shock caused by microorganisms entering the bloodstream from the infected kidney -CKD cause by inflammation, fibrosis, and scarring of the kidney filtration structure -hypertension [related to fluid and Na retention] indicating CKD caused by destruction of the filtration system of the kidney from infection MANAGEMENT OF CLIENT CARE -EDUCATION -encourage at least 3L of fluids daily -instruct client to take allmedications prescribed -to notify provider if having acute, rapid onset of pain -encourage verbalization of fears and anxiety -encourage balance of rest and activity

a nurse is reinforcing teaching to a client who is scheduled for extracorporal shock wave lithotripsy [ESWL]. what should be included in the teaching?

DESCRIPTION OF PROCEDURE use of sound, laser, or shock wave energy to break urinary calculi into fragments CLIENT EDUCATION -moderate [conscious] sedation is used, and the client is not fully awake. -the client will have cardiac monitoring during the procedure -hematuria will occur post procedure -bruising at the site where valves were applied is an expected finding

a nurse in a providers office is reviewing information with an older adult client who is to have prostate specific antigen PSA and a digital rectal exam DRE

DESCRIPTION OF THE PROCEDURES AND THE ORDER IN WHICH THEY ARE PERFORMED -PSA a blood sample is taken to measure a specific protein produced by the prostate gland that is present in the blood stream. the PSA is performed first because examination of the prostate DRE irritates the prostate and can cause the PSA to rise. -DRE with the cleint leaning over the exam table, placed on his side, or on a lithotomy position, the examiner uses a gloved, lubricated finger to palpate the prostate through the rectal wall to identify any abnormalities in size, shape and consistency NURSING ACTIONS: -african american descent -family history of prostate cancer

cause of DKA

know what causes DKA and HHNK

DIABETIC KETOACIDOSIS: an acute metabolic emergency characterized by hyperglycemia, dehydration, acidosis, and electrolyte imbalance. Cause: infection/illness, improper or inadequate insulin administration [missed dose], undiagnosed/untreated DM HYPERGLYCEMIA HYPEROSMOLAR NONKETOTIC COMA: only evident in type 2. pt is severly hyperglycemic and dehydrated no ketosis or acidosis. Cause: insulin levels are too low but high enough to prevent breakdown.

describe the influence of spiritual and religious beliefs about diet, dress, prayer, meditation, birth, and death on health care

DIET/NUTRITION many religions have dietary needs/restrictions considerations healthcare providers need to prescribe diet plans with awarness of the patients dietary and fasting beliefs including food and beverages, fasting examples: msulim: during ramadan no eating food during daylight hours, judaism: during yom kuppir, catholicism: for good friday examples: catholics choose not to consume meat on fridays jews/orthodox jews: may require kosher diet, food prepared according to jewish laws, no mixing of dietary and meat in the same meal. no shellfish/fish with scales or pork muslims: no alcoholic beverages or pork mormons: no caffeine or alcohol DRESS: -orthodox jewish: married women must cover their head with wig/scarf. Men: wear yarmulke/hats to cover head -islam: women cover body -some religions: women: conservatively dress: cover arms to elbows and skirts to cover knees. PRAYER: human communication with divine and spiritual entities. different types include thankfulness, requests, and reflection. examples for christians the lords rayer, for muslims first sutra [attributed to mohammed] MEDITATION: focusing ones thoughts or engaging in contemplation and self reflection examples: slow deep breathing, short meaningful, self selected mantras, extraneous thoughts or noise that interrupts. ill peaople usually increase prayer and/or meditation **provide uninterrupted quiet time** BIRTH: important event giving cause to celebrate, specific rituals a part of the celebration. examples: christians: christening/baptism anyone can do even when a child is very ill muslims: call to prayer recited in the childs ear jews: boys: mohel completes ritual circumsision on the 8th day after birth. Girls: named in the synagogue on the sabbath after birth DEATH: catholics: scarament of the sick, anointing [last rites] jewish: bury within 24 hrs muslims: turn head or body toward mecca hindu: cremate body within 24 hrs to release soul -religious symbols objects should be treated with respect and kept with the body. nurseshould provide environment conducive to clients familys performance of religious rituals.

S/E of dilantin and klonopin

DILANTIN: Anticonvulsants for Seizures - Patients receiving phenytoin (Dilantin) have to have thorough oral hygiene after each meal (Gum massage, daily flossing, and regular dental care) - All important to prevent or control gingival hyperplasia - Normal Dilantin level is 10-20 mcg/mL (Monitor through regular blood draws KLONOPIN: Antiseizure agents used for Seizure & MS patients - patient receiving Klonopin for a seizure disorder and has very low platelet count, DO NOT use straight razor for shaving)

Ischemic Stroke

Decrease in blood flow to an area of blood flow causing infarct to that tissue due mainly to constriction of the arteries that supply the brain

Aplastic Anemia

Decrease in or damage to marrow stem cells, damage to the microenvironment within the marrow, and replacement of the marrow with fat. Resulting In: Pancythopenia; Anemia, Leukopenia, Thrombocytopenia ** Practice Neutopenic Precautions Clinical Manifestations 1. Insidious or rapid onset depending on cause; symptoms can be severe due to low count of all 3 types of blood cells 2. Anemia a. fatigue b. pallor c. dyspnea 3. Cervical Lymphadenopathy, Splemomegaly 4. Retina Bleeding; Purpura Management 1, Blood Transfusion 2. Immunosuppressives 3. Bone Marrow transplant if autoimmune Nursing Interventions 1. Monitor for S/S of infection a. Neutropenic precautions 3. Bleeding Precautions a. good, gentle oral hygiene 4. Avoid IM or SC injections when pt is thrombocytopenic 5. Monitor bowel pattern; straining 6. Conserve energy

Thrombocytopenia

Deficiency of platelets in the blood. Causes 1. Bleeding into the tissues 2. Bruising, and 3. Slow blood clotting after injury

TIA

Defined as a transient or temporary episode of neurologic dysfunction manifested by a sudden loss of motor, sensory or visual function - It may last from a few seconds to no more than twenty-four hours NOTE: There is usually complete recovery between attacks and is usually a warning sign of impending stroke, which has the greatest chance in the first few months of the first attack

delirium

Delirium (hours-days): acute. Reversible. Characterized by change in cognition developing rapidly. Disorganized thinking. Speech: rambling, irrelevant, pressured, incoherent, and switches from subject to subject. Reasoning: impaired. Disorientation to time and place is common. Impairment to recent memory. Misperceptions of environment; illusions; and hallucinations. Psychomotor activity: restlessness, striking out at nonexistent objects. Emotional instability: fear, anxiety, depression, irritability. Ex: following head injury (stroke); seizure; substance induced.

Delirium vs. Dementia Cognitive Disorders

Delirium is acute. Can last hours or days. - Change in cognition developing rapidly. - disorganized thinking - Rambling, irrelevant, pressures, incoherent and switches from subject to subject. - reasoning impaired - disorientation to time & place - impairment to recent memory - misperception of environment; illusions; & hallucinations - restlessness, striking out of nonexistent objects - fear anxiety, depression, irritability Ex: following head injury, stroke, seizure, substance induced Dementia is chronic and irreversible. Has different stages: Primary: Alzheimer's, Vascular lesions Secondary: HIV/AIDS neurosphilis - Impairments in memory, cognition & personality, abstract thinking, judgement & impulse control - Behavior is unhibited or inappropriate. Persons appearance/hygiene may be neglected. - Aphasia: inability to understand of use language (severe dementia) - Apraxia: inability to carry out skilled & purposeful movements - Agnosia: inability to recognize familiar situations, people or stimuli - Personality: No longer to care for self

delusion

Delusion is a fixed false belief not based in reality.

Dependent and Non dependent Edema

Dependent Edema is found lower body parts. In supine position you will find in sacrum and buttocks, and when standing you will find in legs and feet. Non-dependent Edema is not focus on dependent body areas. Usually there is a specific cause or an illness

Life Style Affecting Fluid & Electrolytes

Diet, inadequate nutritional intake - decrease in protein including albumin, disrupts the body's ability to regulate effective water balance - high risk = anorexia, bulimia, laxative abusers Stress, affects the body's demand - increase production of ADH decreases urine production, results in increased cellular metabolism, increased blood volume Exercise - fluid and sodium loss occurs with perspiration - weight bearing exercises are beneficial for calcium balance

Methods of bodily fluid & movements

Diffusion, Osmosis, active transport, and filtration

cancer

Disease process that begins when abnormal cell is transformed by genetic mutation of cellular DNA • Normal cells mutate into abnormal cells which take over normal tissue eventually harm and destroy host • The exact cause of cancer is unknown, but viruses, physical and chemical agents, diet and genetics are some of the risk factors that triggers cancer • Cancer may arise from almost any tissue in the body • Example: leukemias are malignancies of the blood • Lymphomas arise from the lymph tissue

nursing care for pt with DIC

Disseminated Intravascular Disorder Tiny blood clots that deplete platelets and cause bleeding. Increased PT, PTT, decreased platelets Implement Safety & Bleeding precautions Auscultate breath sounds every 2-4 hrs Clinical Manifestations 1. Bleeding mild to severe 2. Renal Failure

Describe hemorrhoids

Distended veins in the folds because of repeated pressure

diverticulosis/diverticulitis clinical manifestations, nursing interventions and teaching

Diverticulosis (symptom free) Diverticulitis (inflamed or infected) Clinical Manifestations: 1. Esophagus a. Difficulty swallowing, foul breath, emesis of food 2. Intestines a. Diarrhea or constipation, abdominal pain (LLQ), fever and rectal bleeding 3. N/V, anorexia 4. Bloating, abdominal distention Nursing Interventions 1. Parenteral antibiotics x 7-10 days 2. NPO of solid foods to rest bowels- low fiber diet until S/S subside 3. IV hydration 4. Conservative management, high residue diet after S/S subsides. 5. Antidiarrheals 6. Stool softeners (Metamucil, Dulcolax, Colace) 7. Diet of regularity - Apple - Bananas - Bran cereals - Brown rice - Carrots (fresh) - Cornbread - Dried figs or apricots - Lettuce - Oatmeal - Peas - Seedless grapes - Whole-wheat bread 8. Add food slowly and in small amounts, increase as tolerated, liquids should be increased to 10, 8oz glasses/day. * during periods of inflammation, a low fiber diet should be followed 9. To prevent obstruction or exacerbation eliminate the following food items: - ETOH - Apple Skin - caffeine - Celery - Nuts - popcorn - seeds - strawberries - corn - tomatoes - cucumbers 10. NGT if necessary, for suctioning to prevent n&v or distention 11. Antipasmodics, which decrease peristalsis i.e., Probanthine ac and hs 12. Pain meds, opiod analgesics; parentral progressing to po Teaching 1. Conservative management, high residue diet after S/S subsides.

Barriers of Therapeutic Communication

Don't - Stereotype: offering generalized or oversimplified beliefs about groups of people based on experiences too limited to be valid. Example: "Women are complainers" "Men don't cry" - Defensive: seem like you are protecting a person or health care service from negative comments. These prevents the patient from expressing true concerns. Example: Pt: "Those night nurse most just sit around and talk all night, they didn't answer my call light for almost an hour." PN: "I'll let you know we literally run around all night, you are not the only pt., you know." - Challenging: giving a response that makes patient's point of view prove their statement. Example: Pt:"I believe my husband doesn't love me" PN: "you can't say that, why, he visits all the time. - Pass judgement - giving opinions and approving or disapproving responses, moralizing, or implying one's own values.Implying that the pt. must think like the nurse thinks - fostering pt. dependence. Example: Pt: "you shouldn't do that" what you did was wrong, right? - Give common advise: telling the pt. what to do. These responses deny the pt. right to be an equal partner. Giving expert advise is more therapeutic. Example: Pt: "Should I move from my home to a nursing home?" PN: "If I were you, I would go to a nursing home, where you'll get your meals cooked for you.

how to prevent dumping syndrome

Dumping syndrome, after gastric resection; rapid emptying of stomach contents into the small intestines. ** Prevent by eating small frequent meals without fluids water helps clear tubing and prevent clogging & decrease bacteria growth

two blood test to differentiate between acute and chronic

ESR: erythocyte sedimentation rate [chronic] CRP: C-reactive protein [acute]

Cancer of the Larynx Clinical Manifestation

Early Signs - Hoarseness is an early symptom - Persistent cough - Sore throat or pain, burning in throat - Lump in neck - Pain and burning when drinking hot liquids, citrus - Raspy voice Late Signs - Dysphasia - Dyspnea - Hoarseness - Foul breath

Clinical Manifestation of Alzheimer's

Early stages: - Forgetfulness - Memory loss (subtle) - Difficulty in work and social activity - Depression As the disease progresses : - Loses the ability to recognize familiar faces, places, and objects - Conversation becomes difficult - The ability to formulate concepts disappears (Abstract thinking). Thinking becomes concrete - Impulsive behavior becomes apparent - Personality changes Late Stage of AD - Speaking skills deteriorate - Agitation - High activity level - Wander at night - Dysphagia - Incontinence (If patient wants to use bathroom, both nurse and CNA can assist) Terminal Stages: - The patient needs total care - Immobile NOTE: Death occurs due to complications (Pneumonia, malnutrition, dehydration)

Early and Late signs of Breast CA:

Early: Lump in breast, usually painless but may have some tenderness, fixed or irregular borders. Late: Abnormal discharge, nipple retractions, dimpling (looks like the skin of an orange peel), swelling or enlargement due to obstructed lymph circulation, increased firmness, appearance of a reddened area or dry flaky area, more pain, asymmetry and elevation of affected breast.

signs of breast ca

Anaerobic Exercise

Endurance training for athletes: Example: weight lifting and sprinting The body uses anaerobic pathways to meet the high demand for oxygen over a short period of time

Medications not allowed to be given together to prevent vasoconstriction

Ergotamines with Triptans

identify factors which affect a persons perception and reaction to pain

Ethnic and cultural values Developmental stage Environment and support people Previous pain experiences Meaning of current pain Spiritual Social

identify desired outcomes for evaluating the clients spiritual health

Examples of Positive Outcomes: - Assessment clinical manifestations: • Inner peace • Compassion with others • Gratitude • Humor/Laughter - Interaction with spiritual leaders - Participation in spiritual rites - Ability to pray/meditation - Discusses spiritual/religious experiences - Discusses spiritual/religious concerns - Shares feelings about dying (if the case).

Describe flatulence

Excessive flatus (gas) in intestine (causes abdominal distention) -action of bacteria -swallowed air -gas that diffuses between the bloodstream and the intestine -caused by: foods, abdominal surgery, narcotics -rectal tube: inserted in rectum if abdom distension and patient cannot pass flatus

What is defecation?

Expulsion of feces from the anus and rectum (bowel movement)

Composition of Body Fluids

Extracellular & Intracellular fluids contain: oxygen from the lungs, nutrients from Gastrointestinal tract, waste of metabolism (CO2) Ions - electrolytes

positions

FOWLER: Semi sitting position Low Fowler's - Semi Fowler's- 15-45 degrees High Fowler's- up 90 degrees The position of choice for patient who have difficulty to breath allow chest expansion and lung ventilation ORTHOPNEIC: Over head table across the lap Allows maximum chest expansion- problem exhaling DORSAL RECUMBENT: Back lying, supine Comfort and promote healing- spinal surgeries PRONE: Head turned to side Full extension of hip and knees Promote drainage of the mouth Marked lordosis Plantar flexion Might be contraindicated with clients with cardiac and respiratory problems LATERAL: Side lying Hip and knee flexion of upper leg and in front of the body Good for resting and sleeping Pressure relieved from sacrum and heels SIMS: Semi-prone Lower arm behind Prevent aspiration Used for procedures - enemas, and for treatments and examinations of the perineal area TRENDELENBURG: Description Lying on back with arms at sides, bed positioned so that head is higher than the head Purposes During some type of surgeries to shift abdominal contents upward REVERSE TRENDELENBURG: Description: Lying on back with arms at side, bed positioned so that head is higher than foot, but with no flexion at waist Purpose After certain type of angiography procedures, allows head of the bed to be elevated without causing pressure on the femoral artery

factors affecting pulse oximetry

Factors that affect accuracy include: Hemoglobin level Circulation Activity Carbon monoxide poisoning

MS pt at Risk for

Falls

Assess for Abnormal Findings

Fasciculation Effusion Crepitus clonus Echymosis

Passive Range of Motion

Flexibility Point of slight resistance Never with discomfort Supine Explain procedure to the patient Use firm grip Support the joints (above and below) Avoid hyperextension

meaning of grading cancer

GX: Grade cannot be assessed G1: Well differentiated (less malignant) G2: Moderately differentiated G3: Poorly differentiated (high grade) G4: Undifferentiated or poorly differentiated or undifferentiated (most malignant)

gastrectomy nursing interventions and clinical manifestations

Gastrectomy: Removal stomach Clinical Manifestations: 1. Lack of B12 absorption which may lead to Pernicios Anemia 2. Dumping Syndrome - after gastric resection; rapid emptying of stomach contents into the small intestines. Nursing Interventions 1. Monitor incision for infection 2. Place the client in Semi Fowler's position to facilitate lung expansion 3. Monitor Nasogastric tube drainage. Scant blood may be seen in first 12 to 24 hrs 4. Notify the provider before repositioning, irrigating the nasogastric tube (disruption of sutures) 5. Monitor Bowel Sounds 6. Advance diet as tolerated 7. Administer meds as prescribed, analgesics, stool softeners Teaching: 1. Life long Vit B12 injections 2. Take Vit. D, calcium, iron & folate

GI bleeding

Gastritis, Peptic Ulcers, Ulcerative Colitis, Diverticular Disease may cause GI Bleeds Endoscopy locates site of bleeding, EGD - contraindicated if pt is already having a GI Bleed that is known, otherwise, it will find site of bleeding, especially for Peptic Ulcers

Teachings to patient on disulfiram - Antabuse

Given as an absence program. ** Do not drink alcohol, avoid foods with alcohol, avoid medications that contain alcohol. **Causes severe N&V. Can cause Death...

Ativan

Given to pt with Status Epilepticus

t-PA

HMG-CoA Reductase inhibitors (statins) for stroke patients Tissue Plasminogen Activator - Dissolves blood clot but, needs to be given within 3 hours, contraindicated in certain patients (Low platelet level, uncontrolled high blood pressure, etc.) - Contraindicated: symptoms greater than 3 hr before to admit, anticoagulated with INR greater than 1.7, or a patient who has recently had any type of intracranial pathology (previous stroke, head injury, and stroke).

32. Review treatment for herpes simplex I & II

HSV 1 GENERALLY OCCURS ON THE MOUTH HSV 2 GENERALLY OCCURS IN THE GENITAL AREA • BOTH CAN BE FOUND IN BOTH LOCATIONS 1. Intermittent treatment with 200mg ACYCLOVIR 5X A DAY for 5 DAYS 2. Use of acyclovir, valacyclovir, or famcuclovir suppresses 85% of recurrences 3. In severe infections of hospitalized pts IV acyclovir is prescribed 4. Suppression therapy for pregnant pts should be started in the 3rd trimester if they have HSV

types of solution

HYOERTONIC SOLUTION [enemas] -fleet enemas: exerts osmotic pressure - draws water into colon, volume 90-120ml[sodium phosphate], takes effect 5-10 min, adverse effect: retention of sodium HYPOTONIC SOLUTION lower osmotic pressure, water moves from the colon int the interstitial space, distends colon, stimulates paristalsis, and softens feces, 500-1000 tap water, takes effect 15-20 min. adverse effect: fluid and electrolyte imbalance, water intoxication [danger in cardiac and renal disease] ISOTONIC SOLUTION: same osmotic pressure than tissues, safest enema solution [normal saline]; no fluid movement, stimulates peristalsis, distends colon, softens feces, 500-1000ml, takes effect in 15-20 min. adverse effect is possible sodium irritation

treatment of hyperthyroidism and hypothyroidism

HYPERTHYROIDISM: -keep pt in AC because of poor heat tolerance -set pt apart because of body image disturbances -keep medication in check because when stopped symptoms come back and with them physical changes as well -thiomides such as propylthiouracil PTV or propacil -methimazole, tapazole [MMI] HYPOTHYROIDISM: synthroid [levothroid, levothyroxine] synthetic levothyroxine note: pt education: dosage is absed on the pts TSH levels. follow up is important. thyroid hormone increases the effect of dilantin, dig, glycosides, anticoagulants, tricyclic antidepressants and indomethacin [always ask if on]. hypnotic and sedatives can produce profound somnulence when on synthroid. may cause signs of hyperthyroidism. S/E = weight loss, [cardiac arythmias, palpations], insomnia, irritability. DONT STOP TAKING MEDICATIONS -alternate activity with rest periods -provide extra blankets or clothing to the pts to prevent chilling -teach importance of follow up. testing and follow up care -encourage pt to verbalize feelings of concern, possible depression. reassure symptoms will disappear with treatment

hallucination

Hallucination is a false sensory perception. Auditory most common, visual second most common, tactile, gustatory, olfactory.

how to treat stomatitis

Have pt. sucking on ice chips or popsicles • A combination of mouth rinse may help relieve discomfort

Nursing care for a patient with COPD

Health history Inspection and examination findings Review of diagnostic tests

Role of the WHO (World Health Organization)

Health: a state of complete physical, mental, social well being, not merely the absence of infirmity

herpes zoster

Herpes Zoster Characteristics 1. Also called shingles (infection caused by varicella-zoster viruses- DNA viruses) 2. Secondary to chickenpox 3. After a person has chicken pox, the VZV lies dormant inside nerve cells near the brain and spinal cord Herpes Zoster Clinical manifestations 1. Burning, stabbing, or aching pain is present in some pts in affected peripheral nerves 2. Some pts have no pain, but itching and tenderness may occur over the area Who should not care for a patient with Herpes Zoster Pregnant Women Seborrhea Characteristics 1. An excessive amount of sebum in face, scalp, eyebrows, eyelids, under breasts, gluteal creases, sides of nose, upper lip, axillae (underarm), groin

pt has heart burn, nausea, bloating. which is a contraindication for cimetidine [tagamet]

Hx of hepatitis. older cleints who have hepatic dysfunction are at greater risk for CNS effects such as confusion, hallucination, restlessness, and seizures. the nurse should report findings to pcp

Cultural health related practices

IF YOU HAVE THIS ONE LET ME KNOW

37. Know the symptoms of someone who has hearing loss

IN CHILDREN o Disinterest o Inattention to details o Failing grades IN ADULTS o Emotional changes o Speech deterioration o Fatigue o Seeming indifferent o Indecision o False pride o Dominates conversation

mechanisms of respiration

INHALATIONA: - diaphram contracts and flattens -ribs move up and out -sternum moves outward -thorax enlarges EXHALATION: -diaphram relaxes -ribs move up and inward -sternum moves inward -thorax decreases in size -lungs are compressed

define terms used in the context of pain management

INTRACTABLE: highly resistant to interventions, CA or sickle cell NEUROPATHIC PAIN IN PERIPHERAL CNS: sharp, stabbing. AIDS, diabetes PHANTOM PAIN: percieved in a body part that is missing [amputees], unable to be felt [paralyzed] PAIN TRESHOLD: least amount of stimuli necessary for a person to label a sensation as pain PAIN REACTION: involves the ANS protects body [hot stove] PAIN TOLERANCE: maximum amount of painful stimuli that a person is willing to endure without seeking avoidance/relieve of pain, varies from person to person, varies in the same person, can be influenced by psychosocial and sociocultural factors. HYPERALGESIA AND HYPERPATHIA: heightened response to painful stimuli, disproportionate response ALLODYNIA: pain sensation caused by non painful stimuli, ex: linen touching skin cause pain DYSESTHESIA: unpleasant abnormal sensation, pain that follows a stroke or spinal cord injury. *note EARLY RECOGNITION* prevention of incurable pain syndromes.

Nursing care post biopsy:

IV fluids administered to prevent clot formation.

care of pt with polyps

If less than 1 cm- plypectomy by fulguration via endoscopy; to prevent colorectal cancer Snare removal during colonoscopy If Ca or GI involvement is significant may need surgical resection and anastomosis or ileostomy

nursing care of a pt on MAOI

If someone is on a MAO inhibitor what do you avoid in the diet? * Tyramine free diet. Avoid: red wine, beer, aged cheese/fish, chocolate, processed meat, yeasts, yogurt, over-ripe fruit, avocados, bananas, fava beans, fermented foods, liver, caviar smoked meats, soy, diet/caffeine = cardiac effects/death. * Can cause HTN crisis: s/e h/a, nuctual rigidity, increase in BP. * Pheneizine - Nardil; Isocarboxazid - Marplan; tranylcypromine - Parnate.

Nursing Intervention Synope

If the patient begins to feel dizzy, have them lie flat Raise the lower extremities Prior to the patient getting out of bed, have them dangle their feet

illusion

Illusion is a misperception of reality.

Parkinson's Disease Complications

Immobility Dysphagia Aspiration Constipation Incontinence (Condom or Texas Catheter can help to prevent skin breakdown) Pneumonia UTI Consequences of falls - Accidents major cause of death

abnormal lab values for chronic ITP

Immune Thrombocytopenia Purpura (ITP) Low Platelet Count (norm: 150,000 - 400,000) Clinical Manifestations 1. Brusing 2. Nose Bleeds or oral bleeding 3. Bleeding into the skin; pinpointed red spots/petechial rash 4. Abnormally heavy menstruation Lab findings: 1. low platelets 2. Normal bone marrow biopsy 3. Normal PTT & PT (coagulation studies) 4. Detected platelet associated antibodies Nursing Interventions: 1. Immunosuppressive agents like prednisone or Decadron, Imuran, Cytoxan, Oncovin; effective in 89% of cases 2. Possible Splenectomy 3. High doses of IV immune globulin 4. ** Assess risk of bleeding; shaving, flossing, BM pattern 5. Med history; OTC, herbs & supplements 6. DO NOT administer Sulfa-containing medications, ASA or other NSAIDs 7. Monitor for H/A or visual disturbance, VS, neurological assessment 8. Avoid IM, SQ, IV, venipuncture, invasive interventions, rectal suppositories & temp. should be avoided

Dysphagia

Impaired speech

impetigo

Impetigo Clinical manifestations Clinical manifestations 1. Begin as small, red macules, which become thin walled vesicles that rupture: honey-yellow crust 2. Crusts are easily removed to reveal smooth, red, moist surfaces in which the new crusts develop 3. Scalp can become involved Impetigo Nursing interventions including Hygeine 1. Pt/family members should bath at least 1x daily with bactericidal soap 2. Wash, do not scrub skin to remove crusts/drainage 3. Apply warm and moist compresses to the area 4. Cleanliness and good hygiene practices help prevent spread of lesions from one skin area to another and from person to person Impetigo 1. Superficial skin infection (staphylococcistreptococci, or multiple bacteria) 1. Can occur in all areas of the body 2. Common in children living in poor hygienic conditions 3. Chronic health problems, poor hygiene, and malnutrition may predispose an adult to impetigo

Role of Folic Acid

Important for pregnant women

Demographic changes in the population

In 2008: -81.2% white (included 15.4% Hispanic Latino) -13.1% black or african american -4.7% asian/pacific islanders -1% native american indian & alaska native By 2050: -Hispanics/latinos 24% -whites non-hispanic wil decrease from 69% to 50%

Difference between Fluid volume deficit and Dehydration

In FVD you loose both water & electrolytes, with Dehydration you loose water but electrolytes are retained, particularly sodium is retained.

35. Know the nursing interventions associated with communication with someone hearing impaired and who is deaf

In patients with speech difficulty o Devote full attention o Engage in conversations where you reply o DO NOT TRY to appear as if you understand when you don't o When in doubt about reply have pt write o Talk slowly and clearly o Talk into less impaired ear o Avoid shouting o When face must be covered, write message In pts who lip read o Face pt directly o Face visible, well lit o Do not obscure your mouth o No objects in mouth o Make sure pt knows about the topic o Speak slowly and clearly o Check to make sure the pt understands what is being said o If face must be covered, write message

sublimination

In psychology, sublimation is a mature type of defense mechanism where socially unacceptable impulses or idealizations are unconsciously transformed into socially acceptable actions or behavior, possibly resulting in a long-term conversion of the initial impulse. Sigmund Freud believed that sublimation was a sign of maturity (indeed, of civilization), allowing people to function normally in culturally acceptable ways. He defined sublimation as the process of deflecting sexual instincts into acts of higher social valuation, being "an especially conspicuous feature of cultural development; it is what makes it possible for higher psychical activities, scientific, artistic or ideological, to play such an important part in civilised life".[1] Wade and Tavris present a similar view, stating that sublimation is when displacement "serves a higher cultural or socially useful purpose, as in the creation of art or inventions"

Osteomalacia

Inadequate mineralization of bone S/S - Pain - bowing of bones - pathological fractures - kyphosis - Risk for falls and fractures - Deficiency of activated vitamin D (promotes calcium absorption from GI) - Malabsorption syndrome Teach 1. Underlying cause, diet, sunlight 2. Exercise 3. Vit D, Calcium

CPT (Chest physiotherapy) including Postural drainage Nursing Interventions:

Includes postural drainage, chest percussion and vibration, and breathing retraining. Effective coughing is also an important component. A. Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles. 1. Postural drainage uses specific positions to use gravity to assist in the removal of secretions. 2. Vibration loosens thick secretions by percussion or vibration. 3. Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing * Perform before meals and after bronchodilator inhalants

Inappropriate effect

Incongruence: the facial expressions do not match the subjective data.

Non-invasive procedures used to eliminate kidney stones:

Increase fluid intake which increases hydrostatic pressure behind the stone, reduce urine concentration, dilutes urine and ensures increase urine output.

Aerobic Exercise:

Increase oxygen demand Large muscle groups, continuous, rhythmic Examples: Walking, jogging, running, bicycling, dancing, cross-country training skiing, jumping rope, rowing, swimming, skating Improve cardiovascular conditioning Physical fitness Target heart rate Talk test Borg test

Carotid stenosis

Increased blood velocity can indicate stenosis or partial obstruction

s/s of pneumonia

Inflammation of lung parenchyma caused by microbial agent Most common cause of death of death due to infections in the US Classed by causative agent 1. bacteria 2. viral 3. fungal 4. parasitic (protozoan= pneumocystis carini pneumoniae Risk factors- identify high risk for pneumonia Any condition which produces mucous a bronchial obstruction, COPD, cancer of the larynx or lung Immunosuppressed patients and dose receiving immunosuppressant drugs such as: steroids, chemo and radiation Long term antibiotics HIV/AIDS and systemic lupus Elderly patients Hospitalized patients receiving sedation Post-op patients especially thoracic and abdominal surgery Prevalent on pt with CHF, Diabetes, Alcoholism, COPD Prevention Promote coughing and expectoration of secretions Take special precautions against infection Encourage smoking cessation Reposition frequently to promote lung expansion Reposition to prevent aspiration Suction and chest physiotherapy Prevention Oral hygiene, NGT placement and proper positioning Check respiratory rate Encourage reduce or moderate alcohol consumption Frequent turning, early ambulation and mobilization Make sure respiratory equipment is cleaned properly Encourage yearly flu vaccine/pneumovac

Plantar fasciitis

Inflammation of the plantar facia -Heel pain-anterior medial Medical Management: - ** Gentle stretching - Shoes with support - Orthotic devices Causes: - Heel spurs: Abnormal growth at the calcaneus bone due to calcium deposits

assessment techniques and define each one

Inspection, palpation, percussion, auscultation. Except for abdomen: inspection, auscultation, percussion and palpation INSPECTION: Visual examination. Should be deliberate, purposeful, and systematic. Nurse inspects with the naked eye and with a lighted instrument (otoscope). In addition- olfactory and auditory cues are noted. Also use visual inspection to assess moisture, color, texture of body surfaces; shape, position, size, color, and symmetry of the body PALPATION: Using the sense of touch. Pads of the fingers are used d/t their high concentration of nerve endings- makes them highly sensitive to tactile discrimination: Texture of hair; Temperature of skin; Position, size, consistency, and mobility of an organ/masses; distention of bladder. Light palpation should always precede deep palpation. - LIGHT: using dominant hand, place fingers parallel to the skin surface and press gently. Skin is lightly depressed. If it is necessary to determine presence of a mass, the nurse presses lightly several times rather than holding pressure. -DEEP: (Practitioner skill). Done with two hands (bimanually) or one hand. Extend dominant hand and then place nondominant hand on the dorsal surface of the three middle fingers. Top hand applies pressure, while the lower hand remains relaxed to perceive the tactile sensations. PERCUSSION: The deliberate striking or tapping of a body part to elicit a specific vibration. • Three types of percussion: 1. Direct percussion: striking the area to elicit a specific sound 2. Indirectly: striking an object against the area 3. Fisted percussion: done to elicit tenderness - kidneys • It is used to determine : size and shape of an organ; and indicates whether the tissue is filled with fluid or air, or if it is solid. AUSCULTATION: Listening for sounds produced by the body that is of particular importance • Sound produced by Thoracic and Abdominal viscera • Movement of blood in cardiovascular system • Auscultated sounds are described according to four things: 1. Pitch (frequency of vibrations) 2. Intensity (amplitude) 3. Duration (its length) 4. Quality (the subjective description of the sound)

how does insulin work

Insulin helps your body turn blood sugar (glucose) into energy. It also helps your body store it in your muscles, fat cells, and liver to use later, when your body needs it. After you eat, your blood sugar (glucose) rises. This rise in glucose triggers your pancreas to release insulin into the bloodstream

Body Fluid Compartments

Intracellular & Extracellular

Nursing interventions and medical management associated with endometriosis including surgery, diagnostic tests and clinical manifestations:

Is a benign disorder, it is when to endometrial tissue (the lining of the uterus) is found outside of the uterus. Nursing interventions: healthy history and physical exam, patient teaching, psychosocial support and referrals to support groups. Medical & Surgery management: surgery depends on extent of dx, symptoms and desire for pregnancy routine exams, meds: NSAIDS, contraceptives (NOT SURE ABOUT WHAT SHE MEANS BY THIS, SHOULD THEY TAKE IT? SHOULD THEY STAY AWAY? KINDA CONFUSED- HELP!) Diagnostic and assessment test: health history including menstrual pattern, Bi-manual pelvic exam, and laparoscopic exam confirms diagnosis and staging. Clinical manifestations: Excessive bleeding, bleeding between periods, painful BM (dyschezia), painful coitus (dyspareunia), and dysmenorrhea: aching in lower back, vagina without menses and during, depression and infertility.

care of pt with severe endometriosis

Stoke

Is a sudden loss of brain function resulting from disruption of the blood supply to part of the brain - It is one of the primary neurological disorders in the USA and a leading cause of death - Ischemic- there are vascular occlusions and hypoperfusion(87%) - Hemorrhagic there is extravasations of blood into the brain (13%)

Nursing management of a patient with PID (Pelvic inflammatory dx):

Is any inflammation in the pelvic cavity. Give IV antibiotics, bed rest, semifowler's to promote depended drainage, heating back to abdomen, cath or tampons avoided, VS q4, proper disposal of pads, bedpans, and linens, hand washing, treat sexual patterns.

Cast Care Complications Disuse Syndrome/Atrophy

Isometric muscle contraction exercises: tense or contract muscle without moving the underline bone. 1. Should be done hourly while pt is awake. 2. gluteal and quad sets

categories of IV solutions

Isotonic - has the same concentration of solutes as blood plasma Hypertonic - greater concentration of solutes than blood plasma Hypotonic - a lesser concentration of solute than blood plasma

Difference between Fluid volume deficit and Fluid volume excess

Isotonic FVD is when the body looses both water and electrolytes in the ECF in Similar proportions. - fluid is lost from the intravascular compartment (HypOvolemia) FVE occurs when the body retains both water & sodium in the ECF in Equal proportions, aka HypErvolemia (increased blood volume) - both intravascular & interstitial (edema) have an increase in water & sodium

Multiple Sclerosis

It is a chronic, immune-mediated degenerative progressive disease of the CNS characterized by the occurrence of small patches of demyelination in the brain and spinal cord. - Seen onset in Ages 20-40 Pathophysiology - Sensitized T and B lymphocytes cross blood brain barrier - They normally check for antigens and leave - In MS, the T cells remain in the CNS and promote infiltration of other agents, damages immune system - Demyelination - Myelin destroyed - refers to the destruction of myelin; the fatty & protein material that surrounds certain nerve fibers. - results in impaired transmission of nerve impulses - Demyelination is irregularity scattered throughout the CNS - Myelin is lost, axons degenerate - The plaques or patches become hardened in the involved areas interrupting the nerve impulses and resulting in a variety of manifestations, depending on which nerves are affected

Hyperkalemia

K greater than mEq/L Clinical signs: irritability, confusion, hyperactive GI tract, diarrhea, cardiac dysrhythmias/arrest, muscle weakness/areflexia (absence of reflexes), parasthesias/numbness in extremities Spiked T wave & widened QRS on EKG

Hypokalemia

K less than mEq/L Clinical signs: muscle weakness, leg cramps, cardiac dysrhythmias, anorexia, nausea, vomiting, decreased bowel motility, depressed deep tendon reflexes

discuss the nurses role in assessing pain

Known as "Fifth" Vital Sign Assess pain as a routine with vital signs Comprehensive Pain Assessment includes: Physiological Psychological Behavioral/Emotional Sociocultural: Integral/holistic pain assessment Extent and frequency of pain assessment depends on organizational policy and situation Pain history Direct observation of behaviors

Difference between right and left sided heart failure

LEFT SIDED HEART FAILURE: -pulmonary congestion due to increase in pulmonary pressure that causes dyspnea, cough, crackles and low oxygen saturation. -orthopnea -frothy pink tinged sputum RIGHT SIDED HEART FAILURE: -edema to lower extremeties -ascites -weight gain

s/s of local infection and systematic infection

LOCAL INFECTION S/S: redness warmth increased swelling tenderness to touch drainage SYSTEMATIC INFECTION: fever elevated WBC

identify the cahracteristics of pain according to location, origin [etiology], and duration

LOCATION: specific site: head back, chest, knee, etc. -nociceptive pain: 2 categories: somatic and visceral pain: -somatic: originates in skin, muscles, bone, connective tissue examples: sprained ankle, paper cut on finger -visceral pain:results from activation of pain receptors in the organs and/or hollow viscera. characteristics: cramping, throbbing, pressing, aching. examples: labor pain, angina pectoris, irritable bowel -neuropathic pain: associated with damaged or malfunctioning nerves due to illness, typically chronic difficult to treat. examples: post-hepatic neuralgia, diabetic peripheral neuropathy, phantom limb pain, spinal cord injury pain.. neuro pain characteristics include: burning, electric shock, tingling dull, aching, sharp, shooting. -neuro subtyoes: central and sympathetically mantained pain. central is from mafunctioning CNS, while sympathetical is abnormal connections between pain fibers and sympathetic NS. affects circulation, temp., and edema.

Different types of vegeterians

Lacto-ovo- no meat, but dairy and eggs are acceptable Lacto - dairy is acceptable, no eggs, meat Total Vegan - all animal food sources are excluded including dairy and eggs

difference between right sided and left sided heart failure

Left Heart Failure 1. Pulmonary congestion due to increase in pulmonary pressure that causes dyspnea, cough, crackles, & low oxygen saturation 2. SOB 3. Orthopnea 4. Frothy pink tinged sputum 5. High BNP Right Heart Failure 1. Edema in lower extremities 2. Ascities 3. weight gain

Auscultation

Listening for sounds produced by the body that is of particular importance • Sound produced by Thoracic and Abdominal viscera • Movement of blood in cardiovascular system • Auscultated sounds are described according to four things: 1. Pitch (frequency of vibrations) 2. Intensity (amplitude) 3. Duration (its length) 4. Quality (the subjective description of the sound)

Aphasia

Loss of speech

Immune Thrombocytopenia Purpura (ITP)

Low Platelet Count (norm: 150,000 - 400,000) Clinical Manifestations 1. Brusing 2. Nose Bleeds or oral bleeding 3. Bleeding into the skin; pinpointed red spots/petechial rash 4. Abnormally heavy menstruation Lab findings: 1. low platelets 2. Normal bone marrow biopsy 3. Normal PTT & PT (coagulation studies) 4. Detected platelet associated antibodies Nursing Interventions: 1. Immunosuppressive agents like prednisone or Decadron, Imuran, Cytoxan, Oncovin; effective in 89% of cases 2. Possible Splenectomy 3. High doses of IV immune globulin 4. ** Assess risk of bleeding; shaving, flossing, BM pattern 5. Med history; OTC, herbs & supplements 6. DO NOT administer Sulfa-containing medications, ASA or other NSAIDs 7. Monitor for H/A or visual disturbance, VS, neurological assessment 8. Avoid IM, SQ, IV, venipuncture, invasive interventions, rectal suppositories & temp. should be avoided

Role of MD in Nutritional Planning and the Nurse

M.D. writes prescription Nurse, assesses appetite, likes & dislikes, feedings, reinforce teaching

What to Avoid in your diet when on an MAO Inhibitors

MAO Inhibitors - phenelzine Nardil - lsocarboxazld - Marplan - tranylcypromine - Parnate Used less frequent because of interaction with some foods, drugs and S/E: - Anticholinergic - Orthostatic hypotension - Hypertensive Crisis (life threatening increase in BP, HA , Nuchal rigidity) may result with other drugs or with tyramine in the diet low tyramine diet - Foods to Avoid - red wine, beer, yeast - aged cheeses, chocolate, yogurt, soy - over riped fruit, bananas, Avocados - processes meat, smoked meats, liver fava beans, - fermented foods, Fish, caviar - caffeine = cardiac effects/death

Modifiable vs non modifiable risk factors

MODIFIABLE: something you can change i.e;DM, hypertension, weight, diet NON-MODIFIABLE: cant change, gender, family history

Significance of MONA and why it is done

MONA is done to relieve pain, reducae anxiety, decrease tachypnea, and decrease preload/afterload M - Morphine [(MS or MSO4) IV for rapid effect] O - Oxygen N - Nitrogylcerin A - Ace Inhibotrs

purpose of morphine in MI

MORPHINE: a. relieves pain b. reduces anxiety c. decrease preload: amount of blood going to heart O2: administer O2; 6L NITROGLYCERIN IV a. need to start 2 IV lines ACE INHIBITORS; administer

Clinical manifestation of MS

MS is a chronic illness and there are periods of remission and exacerbation - Remissions: Symptoms decrease or disappear. - Exacerbations: New symptoms occur and existing ones worsen. - Some patients go into periods of relapsing and remitting with complete recovery between relapses - Some patients have a chronic progressive decline in function S/S - Fatigue - Muscle weakness - Numbness - Visual disturbances - Difficulty in coordination - Loss of balance - Blurring of vision - Patchy/total blindness - Diplopia - Spastic weakness - Heat * complain of being cold - Loss of abdominal reflexes - Depression - Cerebellar ataxia tremors - Tremors - Emotional lability - Bladder,bowel & sexual problems - Cognitive and psychosocial problems as to memory loss, and decreased concentration

s/s of MS

effects of immobility

MUSCOSKELETAL: Disuse osteoporosis: without weight bearing the bone demineralize and become spongy Disuse atrophy: decrease in size looses normal function Contractures: permanent shortening of the muscle Stiffness and pain in the joints- ankylosis CARDIOVASCULAR: Diminished cardiac reserve Increased use of Vasalva maneuver Orthostatic (postural) hypo tension Venous vasodilation and stasis Dependent edema Thrombus formation Thrombophlebitis (impaired venous return, hypercoagulability, injury to a blood vessel) Thrombus (clot) Embolus ESPIRATORY: Decreased respiratory movement Shallow respirations and decreased vital capacity Pooling of secretions Hypostatic pneumonia Atelectasis METABOLIC: Decreased metabolic rate Basal metabolic rate Negative nitrogen balance Anabolism/catabolism Anorexia Negative calcium balance URINARY: Urinary stasis: lack of gravity Renal calculi: Increase calcium salt Urine become alkaline Urinary retention accumulation of urine Urinary incontinence: involuntary urine Urinary infections: static in the urine is a source for bacterial growth Escherichia Coli Urinary reflux EXERCISE: Improves the appetite Increases GI tract tone Facilitates peristalsis IMMOBILITY: constipation PSYCHONEUROLOGIC: Apathetic Withdrawn Regression Anger Aggressive Problem solving, decision making

7. Know the difference and clinical manifestations between myopia, presbyopia, hyperopia, and macular degeneration

MYOPIA: or Nearsightedness (Far objects are blurred) • Some people have deeper eyeballs or cornea with too much curvature • Visual image falls in front of the retina • Correction: Thick glasses or total radial keratotomy of cornea HYPEROPIA: or Farsightedness (Difficulty seeing near) • Eyeball shorter than normal or cornea with not enough curvature • Focus falls behind the retina • Correction: Made with glasses PRESBYOPIA Old Eyes (Difficulty focusing on near/far objects) • Part of the normal aging process and common in people over 40 years of age • Slower accommodation occurs • Reading material held at distance to see them better • Correction is made with use of bifocals • Caused by decreased elasticity of the lens of the eye AGE RELATED MACULAR DEGENERATION: - Common cause of visual loss pts. > 60 - Age-related macular degeneration (AMD) - Characterized by tiny, yellow spots (Drusen) under the retina - Central vision most affected Risk Factors -Increased age Wet AMD -Arthritis -Smoking Thyroid -hormones Genetics -Hypertension -Hydrochlorothiazides -Overweight/Obesity -Hyperopia Two types: -Dry (nonexudative) (85-90% people have this type) - Outer layers slowly break away - No known treatment Wet (exudative) - Abrupt onset - Affected vessels leak fluid and blood ¡V elevate retina - Treatment ¡V laser for some ¡V photodynamic therapy Nursing Management - Amsler Grids for patients

OCD Reason for ritualistic behavior; compulsive behavior

Made by the person to relieve anxiety caused by obsessive thoughts

select appropriate nursing diagnoses for patients with pain

Main Diagnostic Labels: Acute Pain Chronic Pain Etilogy/Defining Chraracterstics: Specify the location Related factors, when known, can include physiological and psychological factors Client Examples: Acute vs Chronic Other Nursing Diagnostic Labels related to Pain: Ineffective Airway Clearance Hopelessness Anxiety Ineffective Coping Ineffective Health Maintenance Self-Care Deficit (Specify) Insomnia Impaired physical mobility Deficient knowledge of pain management

Rationalization

Making excuses or formulating logical reasons to justify unacceptable feelings or behaviors. Example: I drink because it's the only way I can deal with my bad marriage and my job.

Multiple Myeloma

Malignancy of the B Cells. Overactivity of Bone Marrow, compromising the whole system. - * Prone to Infections Clinical Manifestations 1. Bone pain that increases with activity and decreases with rest 2. Back pain / spinal fractures (bone destruction) 3. Hypercalcemia - excessive thirst - Dehydration - Constipation - altered mental status, confusion, coma 4. Renal failure Later in disease 1. Anemia (fatigue, weakness) 2. Increased blood viscosity (bleeding, h/a, blurred vision, paresthesias, heart failure Nursing Care: - Pain management - Assist with mobility / devices - Monitor for hypercalcemia - Monitor renal function - Prevent infection - Safety - S/E of drugs

Differentiate the Medical and surgical management for a patient with lung cancer

Management: lung resection, radiation, chemo Surgical: a. Lobectomy = surgical removal of one of the lobes of the lung b. Bilobectomy surgical excision of two lobes of the right lung c. Sleeve resection a section of the bronchus or trachea is remove d. Pneumonectomy = removal of the entire lung

Describe fecal impaction

Mass or collection of hardened feces in the folds of the rectum, results from prolonged retention and accumulation of fecal material. - passage of liquid fecal seepage (diarrhea) - non productive desire to defecate - rectal pain - anorexia - abdominal distention - vomiting CAUSES - constipation - poor defecation habits - barium

care of pt post BE (Barium Enema)

May experience gas pain Assess for abdominal distention, tenderness Inspect stool for blood presence Push fluids Monitor for barium elimination Laxative may be ordered to help clear bowel

Nursing Interventions Alcohol Withdraw Dillirium

Medical Emergency - 1:1 during Detox to protect patient from physical injury

teaching about glucophage

Metformin: immediate release, also known as Glucuphage; it acts by decreasing hepatic production of glucose (gluconeogenesis) and reducing insulin resistance; should be taken with food; must stop metformin-glucophage 48 hours before contrast procedure to prevent acute renal failure

Bronchodilator medications Nursing Interventions

Methylxanthines (Theophylline) - Used for long-term control and prevention of symptoms in mild-persistent asthma, or with Inhaled corticosteroids in moderate or persistent asthma Theophylline (Theo-Dur) relaxes smooth muscle. Normal blood levels=5 to 15 micrograms/mL. Patient is to breathe with slow, deep breathes through mouth and hold a few seconds at the end of inspiration. Coughing exercises may be encouraged to mobilize secretions after a treatment. Assess patent before treatment and evaluate patient response after treatment.

Hypermagnesemia

Mg greater than 2.5 mEq/L N/V, peripheral vasodilation - flushed, muscle weakness, paralysis, hypotension, bradycardia, depressed of DTR, lethargy, drowsiness, respiratory depression, coma, respiratory & cardia arrest, AV block EKG, prolonges QT interval

Hypomagnesemia

Mg less than 1.5 mEq/L neuromuscular irritability, tremors, convulsions, increased reflexes, tachycardia, hypertension, cardiac dysrhythmias, Positive Trousseau's (hands) Positive Chvostek's (nerve 7), confusion, vertigo

Types of Migraine headaches

Migraines - dysfunction of the brain stem pathways that normally modulates sensory input. Rise in plasma serotonin dilates the cerebral vessels. - can be triggered by: menstrual cycle, bright lights, stress, oral contraceptives, certain foods, fatigue, overuse of certain meds, sleep deprivation - migraines without aura is the most common type - its unilateral with moderate pain; may cause photophobia, phonophobia & nausea Tension-type - steady & constant feeling of pressure that usually begins in the forehead, temple or back of neck. - often bandlike or may be described as " a weight on top of my head" Cluster Headache - severe form of vascular headache. - Unilateral and come in clusters of 1 to 8 daily - excruciating pain localized to the eye & orbit, radiating to the facial & temporal regions - pain accompanied by watery eyes and may have crescendo-decrescendo pattern - attacks last from 15min to 3 hrs - pain described as penetrating Cranial arteritis - - fatigue, malaise, weight loss & fever. - inflammation; heat redness, swelling, tenderness, or pain, over involved artery - sometimes a tender, swollen, or nodular temporal artery is visible. - visual problems caused by ischemia of involved structures - cranial arteritis thought to be immune vasculitis

Ultimate Goal of taking care of a Mentally ill patient? What is Milieu Therapy?

Milieu Therapy: To manipulate the environment so that all aspects of the patient's hospital experience is therapeutic by ensuring a Safe environment, by identifying rules & boundaries and orienting pt to clinical setting. - Safety - Basic physiological needs are met (maslow's) - responsibilities are assigned according to pt's capabilities - structured program of structure and work related activities is scheduled - Community & family are included in an effort to facilitate discharge - Care for the pt is directed by an Interdisciplinary tx. team

discuss barriers to effective pain management

Misconceptions: Severe pain is only experienced with major surgery Nurse is the authority about patient's pain Giving medications regularly will lead to addiction Extent of tissue injury is directly related to amount of pain Behavioral Signs/Visible Physiological accompany pain and can be utilized to validate pain presence • Other barriers: Inadequate assessment Believing client's report of pain OR not following it Many clients do not voice pain Lack of knowledge about pain management (patient, family)

Modifiable and Non- Modifiable Risk Factors for Stroke

Modifiable - Hypertension - Smoking - Obesity - Hyperlipidemia - Diabetes mellitus - Atrial fibrillation - Asymptomatic carotid stenosis - Excessive alcohol consumption Non- Modifiable - Age 55 and older - Gender-male - Race- African-American

Therapeutic Nutrition

Modification of the normal diet according to the needs of the individuals treatment of a disease. i.e., can't chew it, puree it

Nursing Interventions for Client with Fever

Monitor VS Assess skin color and temperature Monitor labs Remove or provide blankets Provide nutrition and fluids Measure I&O Reduce physical activity Antipyretics Provide oral hygiene Tepid sponge bath Dry clothing and linens Remove heavy blankets cover Blood consists of three basic blood cell types: red blood cells, white blood cells, and platelets. Blood cells are produced from specialized cells in the bone marrow and are regularly released into the circulatory system. A complete blood count (CBC) is a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia A complete blood count test measures several components and features of your blood, including: Red blood cells, which carry oxygen White blood cells, which fight infection Hemoglobin, the oxygen-carrying protein in red blood cells Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in your blood Platelet count 150-450 billion/L (150,000 to 450,000/mmol****) Fever with high counts may suggest infection. Common sites where infection can occur in children are throat, ear, chest urine or some other site An elevated white cell count and/or a fever generally indicate that there is an infection somewhere in the body. See your doctor for a thorough check up and locate the cause of infection and have it treated asap. Once the treatment is complete, temperature and blood count should return to normal

Hemophilia

Most common defective factor VIII Impaired coagulation; risk for bleeding. Clinical Manifestations: 1. Bruising 2. Spontaneous bleeding 3.bleeding into joints & associated pain & swelling 4. Gastro-Intestinal tract & urinary tract hemorrhage 5. Blood in urine or stool 6. prolonged bleeding from cuts, toot extraction & surgery 7. X-linked recessive disorders Management: IV infusion of factor VIII to replace the defective clotting factor. Depends on severity of bleeding, site and pt size.

renal failure jsut wen through their first hemodialysis treatment. which is a geat concern for nurse in findings?

N/V risk for disequilibrium syndrome.

NC (Nasal Cannula) Venti mask Nursing Interventions

NC: Low-flow Systems Nasal cannula low o2 concentration 2L/min for patient with chronic lung disease Venti Mask: High-Flow Systems Setting: 4-6 L/min Rate 02% 24,26,28 The venturi mask is the most reliable and accurate method of oxygen delivery The mask is constructed in a way that allows a constant flow room air blended with a fixed flow of oxygen It is primarily use for COPD patients A. Nursing responsibility is to check the oxygen flow meter every shift to ensure that client (patient) is receiving the correct amount of oxygen. B. Assess for signs and symptoms of hypoxia, arterial blood gas results, and pulse oximetry * Too much oxygen kills healthy cells and raises CO2 levels.

Medical Treatment Affecting Fluid & Electrolytes

NGT/PEG, surgery, medications - diuretics (Lasix) medications that cause seide effects of N&V and diahrrea, chemotherapy, corticosteroids

Need of assessment for swallowing

NPO patients moved to a puree diet

List the stages of sleep

NREM: 4 Stages: 1) Stage 1: relaxed and drowsy, usually lasts only a few minutes, eyes roll from side to side, very light sleep, HR and RR decreased slightly, readily awakened, individual may deny sleeping. 2) Stage 2: lightly asleep, requires touching or shaking to arouse, constitutes 44% to 55% of total sleep. Only lasts 10-15 minutes, process continues to slow down, eyes are still, HR and RR continue to decrease, body temperature falls. 3/4)Stage 3 &4: deeper stages of sleep, different online in % of delta waves, HR and RR drop 20-30% below rates at waking hours, not disturbed by sensory stimuli, difficult to arouse, skeletal muscles very relaxed. Reflexes diminished, snoring most likely, swallowing/saliva production decreased, essential stages for restoring energy and releasing hormones

Hypernatremia

Na greater than 145 mEq/L Clinical Signs: thirst, dry mucous membranes, red swollen tongue, disorientation, restlessness, convulsions, postural hypotention

Hyponatremia

Na less than 135 mEq/L Clinical Signs: lethargy, confusion, anorexia, nausea, vomiting, headache

EMG

Needle electrodes introduced into Skeletal Muscles to measure changes in electrical potential of the muscles & the nerves leading to them. A. Detects: 1. Neuromuscular disorder 2. Determines weakness from neuropathies

Lumbar Puncture

Needle inserted into the subarachnoid space btw L3 and L4 or L4 and L5 to withdraw CSF. 1. Examines CSF 2. Measure and reduces amount of CSF 3. Determines presence or Absence of blood 4. Medication is inserted intrathecally; into the spinal canal. 5. CSF could be clear & colorless 6. if pink, blood tinged or grossly bloody CSF may indicate a subarachnoid hemorrhage. 7. May be initially bloody and become clearer as drained 8. Specimen obtained for Cell count, Culture, Glucose, Protein & other tests. 8. Taken to Lam Immediately Pre Procedure Nursing Interventions & Teachings: 1. If done with Contrast- need consent 2. pt lies in fetal position Post Procedure Nursing Interventions & Teachings 1. Headache ranges form mild to severe from few hours to days after procedure. Caused by CSF leakage at puncture site. Insufficient supply to maintain proper mechanical stabilization of brain a. occurs in 15-30% of pt. b. Throbbing bifrontal or occipital headache, dull and deep in character c. severe on sitting or standing; lessens or disappears when pt lies down. * Headache may be avoided if a small gauge needle is used and if pt remains prone after procedure for 2-3 hrs. e. When more than 20ml is removed pt is positioned supine for several hours. ** f. Managed with Bed Rest, Analgesic agents, & hydration. g. If headache persist an epidural blood patch technique may be used. - blood withdrawn from antecubital vein & injected into epidural space; acts as gelatinous plug to seal the hole in the dura, preventing further loss of CSF Other Complications: 1. Voiding problems 2. Elevation in temp. 3. Backache or spasms 4. Stiffness in neck Rare Complications: 1. Herniation of intracranial contents 2. Spinal Epidural Abscess 3. Spinal Epidural Hematoma 4. Miningitis

Group antipsychotic medications

Neuroleptics phenothiazines - chlorpromazine - Thorazine - fluphenazine - Prolixin - perphenazine - Trilafon - prochlorperazine - Compazine -trifluoperazine - Stelazine - thioridazine - Mellaril * may cause cardiac dysrhythmias - thiothixene - Stelazine Antipsychotics: most act to block the action of dopamine in the brain. - haloperidol - Haldol - ziprasidone - Geodon - aripiprazole - Abilify - risperidone - Risperdal - quetiapine - Seroquel - olanzapine - Zyprexa - clozapine - Clozaril: limited to schizophrenia unresponsive to other therapy (risk for agranulocytosis - WBC production failure; lab for WBC & differential every week and up to 4 weeks for treatment) Anxiolytics: calm, relax, reduce muscle tension, reduce anxiety. Fast acting; 30 min PO; faster IM Benzodiazepines: Xanax Librium Tranxene Valium Ativan Serax Klonopin * Romazicon for antidote

Therapeutic Communication

Never Lie to, honesty is the key to create a safe, secure, controlled environment.

45. Know the medications that should not be taken with a patient with glaucoma

Never give ATROPINE (anticholinergic) to pt w/ glaucoma: causes pupillary dilation and worsens IOP (pressure in the eye)

treatment of psoriasis

No known cure - Manage stress - remove scales by baths (Balneotherapy) - olive or mineral oil, aveeno oatmeal, or coal tar preparations can be added to bath water - a soft brush may be used to gently scrub the psoriatic plaques - Emollient creams applied to skin after bath to soften the thick scales - regular skin care routine important Pharmacological Therapy Biologicals, Topical Corticosteroids & nonsteroidals, coal tar products, medicated shampoos, intralesional therapy, systemic therapy, photochemotherapy

Traction How to Move & Position Patient

No turning - slight weight shift - non surgical site

Average weight gain during pregnancy

Normal - 25-35 lbs Obese women - no more than 15 lbs

Abnormal Gait Patterns

Not symetrical not steady

diagnostic for MI

Nursing Diagnoses appropriate for MI 1. Chest Pain 2. Ineffective breathing 3. Altered tissue perfusion 4. Anxiety Diagnostic Evaluation MI 1. Physical Findings a. decrease BP, increase Pulse - Shock b. cold, clammy, ashen or severe pallor 2. ECG Changes c. ST elevation d. ST depression 3. Lab findings 1. CK-MB is the most specific a. begins to elevate after 2-4 hrs b. peak elevation 12-24 hrs c. over 24 - came back 2. Troponin - Good to assess Silent MI a. pt has no symptoms or pain (seen in DM pt)

UGI series nursing implications and teaching

Nursing Implications Pre 1. Explain procedure (pt education) 2. Diet starts w/clear liquids & then NPO after midnight- including medications Post 1. Laxative may be needed to facilitate removal of barium, stool will be gray until barium is cleared 2. Monitor and TEACH pt, elimination of barium 3. Increase fluids 4. If gastrografin used, pt may have diarrhea

Hip Fracture

Nursing Intervention Priority: 1. Neurovascular Status - CMS 2. Immobilization

Diagnostic Procedures

Nursing Interventions Arthroscopy - Compression dressing - Ice - CMS checks - Pain medications - Weight bearing status - Patient education Bone Scan - Isotope- IV, 2-3 hrs - Allergies, pregnancy - drink fluids - empty bladder before Myelogram helps find the cause of pain when MRI & CT fails by x-rays and a special dye.

care of pt with TPN

Nursing Interventions Priorities - Weight gain/F&E/Infection * Sudden stop = Hypoglycemia * Glucose test q6hr 1. Change tubing with each new bag per protocol 2. Change dressing, sterile technique (q72 hr) observe signs of infection (only LPN IV certified) 3. Monitor VS, fluid and electrolytes balance 4. Daily weights 5. Frequent mouth care 6. Blood glucose monitoring with sliding scale 7. TPN is ** titrated (decreased gradually) to adjust to decreasing glucose

Knee Replacement

Nursing Interventions: Priorities 1. Manage Pain 2. Reduce swelling 3. Regain Range of Motion by 1. Compression Bandage 2. Elevate and Ice to reduce edema & bleeding 3. Monitor wound suction (200-400ml/24 hrs) less than 30 ml DC wound vac 4. Quad sets, active ROM, Isometric exercises 4. Continuous Range of Motion (CPM) to prevent DVT 6. Autotransfusion 7. Knee Immobilizer 8. Weight bearing status 9. Pain Control - need 90-120 degree of motion for minimum function

24 hrs after abd sx. immediate attention if:

O2 is low ABC priority

When to feed baby

On Demand, when baby is hungry

Questions to ask in regards to migraine headaches.

Onset, frequency, location, duration, type of pain, factors that relieve and precipitate the event, & associated symptoms. 1) Location- Unilateral or bilateral? Radiates? 2) Quality- Dull, aching, steady, boring, burning, intermittent, continuous, paroxysmal? 3) Precipitating factors- Environmental (Sunlight, weather changes), types of food, exertion, other? 4) How many headaches occur during a given period of time? 5) What makes the headache worse (coughing or straining)? 6) What time (day or night) does it occur? 7) How long does a typical headache last? 8) Are there any associated symptoms, such as facial pain, lacrimation (excessive tearing, or scotomas (blind spots in field of vision) 9) What relieves the headache (aspirin, NSAIDS, Ergot preparation, foot, heat, rest, neck massages)? 10) Does nausea, vomiting, weakness, or numbness in the extremities accompany the headache? 11) Does the headache interfere with daily activities? 12) Do you have any allergies? 13) Do you have insomnia, poor appetite, loss of energy? 14) Is there a family history of headache? 15) What is the relationship of the headache to your lifestyle or physical or emotional stress? 16) What medications are you taking? Antihypertensives (vasodilator), diuretics, anti-inflammatory agents and MAO inhibitors can provoke headaches. 17) Any recent changes in your headache?

1. Know the clinical manifestations for glaucoma

Open- Angle Glaucoma - Bilateral ¡V anterior angle is open and appears normal Three types Chronic open-angle glaucoma (COAG) - IOP is greater than 21 mm Hg - Optic nerve damage - Visual field defect - If symptoms - Pain, Headache, Halos Normal tension glaucoma - IOP is less or equal than 21 mm Hg - Optic nerve damage, visual field defects Ocular Hypertension - Elevated IOP - Possible ocular pain or headache Treatment goals: - Lowering IOP; if unsuccessful, Laser trabeculoplasty (LT) Angle-Closure (pupillary block) Glaucoma -Obstruction of aqueous humor outflow -Result of complete or partial closure of angle -Increased IOP Three types: Acute angle-closure glaucoma (AACG-Ocular Emergency!) - Progressive visual impairment -Pain with N/V, bradycardia - Severely elevated IOP - Profuse sweating - Corneal edema Subacute angle-closure glaucoma - Transient blurry vision - Halos around lights - Temporal headaches - Ocular pain Chronic angle-closure glaucoma - Significant visual field loss - IOP normal or elevated - Ocular pain - Headache

opthalmoscope

Ophthalmoscopy (funduscopy or fundoscopy) is a test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope (or funduscope). It is done as part of an eye examination and may be done as part of a routine physical examination.

orthopnea and its nursing interventions

Orthopnea- The inability to breathe easily unless one is sitting up straight or standing erect. Choose a suitable time Observe\ palpate\ count respiration rate 30 seconds and multiply x 2 if regular, for 60 seconds if irregular Assess depth\ rhythm\ character (quality) Document

Describe the basic principles and patterns of growth and development.

PATTERNS: -Cephalocaudal: growth and development begins in the head and moves down towards the feet. [head to tail] -Proximodistal: motor development proceeds from the center of the body toward the extremeties [midline to peripheral] -mass to specific: muscle development and control proceeds from the mass to the specific [from simple to complex] PRINCIPLES: -Differences occur in growth and development .each child is on his/her own schedule -variations of growth rates occur for different body structures .not all body parts mature at the same rate ..the brain is completely grown by age 7 but it is not matured until years later -growth and development is a total process .the growth and development of a child is a physical, mental, socail, and emotional process

identify factors associated with spiritual distress and manifestations of it

PHYSIOLOGIC PROBLEMS: illness, loss of function TREATMENT RELATED CONCERN suctioning, amputation SITUATIONAL CONCERNS death or illness of loved one embarrassment inability to appreciate rituals

Hyperphosphatemia

PO4 levels greater than 2.6 mEq/L numbness, tingling around the mouth & fingertips, muscle spasms

Hypophosphatemia

PO4 levels less than 1.8 mEq/L muscle weakness, pain, paresthesias (loss of sensation) mental changes, seizures

Nursing care post diagnostic tests

POST CARDIAC CATHERIZATION -assess femoral/distal sites -assess BP and pulse -NPO until gag -BR for 2-6hrs post based on the size of the catheter used -angio seals may be used (provide mechanical compression at site) [cork at site where tubes are inserted so pt does not bleed] POST PERCUTANEOUS CORONARY INTERVENTIONS -assess site of insertion -assess for bleeding -Frequent VS, BR 2-6hrs -assess femoral/distal sites -assess distal pulse POST PACEMEAKER INSERTIONS -minimize pt activity initially since activity may dislodge the pacemaker [2weeks] -make sure pt receives all identification information about the pacemaker -teach the pt signs of pacemaker dislodgement -be careful with anything magnetic -maybe set off during airport screening -after surgery be careful with raising arm above head -assess insertion site for infection -CXR after to assess placement of device and leads -avoid friction over the insertion site -wear a medic alert band -initially no soaking in the tub

a nurse is assisting with the plan of care for a client who is to have a total abdominal hysterectomy.

PRE PROCEDURE: -mantain NPO status -ensure informed consent has been obtained -instruct client to turn, cough, deep breath and to use the incentive spirometer and the importance of early ambulation -reinforce information about pre op and post op medications -rule out pregancy -ensure that clients who have been taking anticoagulants medications, aspirin, NSAIDs, or vitamin E discontinue their use -administer pre op antibiotics -place anti embolism stockings -measure psychological status POST PROCEDURE -monitor vaginal bleeding. the client should have no more than one saturated pad in 4 hrs -mantain indwelling urinary catheter and monitor urine output. the client should have at least 30mL/hr -measure VS -monitor breath sounds and use of spirometer -assist with ambulation -auscultate bowel sounds -provide IV fluids and electrolyte replacement -check the client incision -monitor clients Hgb and Hct. -observe for signs of thrombosis and take thromboembolism precautions. -instruct clients to restrict activity -if ovaries have been removed, discuss issues related to hormone therapy -instruct pt to notify the surgeon if the temperature is over 37.8C or 100F, foul smelling drainage from incision, pain, redness, swelling in calf and burning on urination -measure psychological status

identify data to be collected when assessing pain

Pain location Quality Patterns Precipitating factors Intensity (scale) Associated symptoms Alleviating factors

factors that affect pain

Past pain experiences Meaning of Pain Anxiety and Stress

Parkinson's Disease

Pathophysiology - Parkinson's Disease is associated with decreased levels of dopamine resulting from destruction of pigmented neurons in the Substantia Nigra - These particular cells have significant impact on the neurotransmitters that are key in the control of complex body movements * Autopsy of the brain is said to be the only reliable way to confirm a diagnosis of PD (Lewy bodies present in substantia nigra)

Gout

Pathophysiology Purines for animal protein Uric Acid Nursing Interventions Teaching 1. Fluids 2. Diet

Agitated patient

Patient feels threaten, paces, clenched jaw and or hands. Move to a quiet room away from other patients or remove other patients. - do not be afraid - do not threaten or manhandle - give brief, calm, explicit instruction - call Code Gry as per individual facility policy only if necessary - medicate as needed

Mental Health Patients Rights (Select all that applies)

Patients with a psychiatric diagnosis are guaranteed the same civil rights as any other citizen. - The right to human tx and care (medical and dental) - The right to vote in national, state and local government elections. - The right to refuse medication - The right to the least restrictive alternative - Confidentiality and right to privacy - A written plan of care/tx that includes discharge follow up, as well as participation in the care plan and review of that plan - Care with respect, dignity, and without discrimination - Adequate supervision by a trained tech

29. What is the characteristics of Pediculosis, scabies and impetigo

Pediculosis- lice infestation 1. Head lice found on back of head and behind ears 2. Eggs look like silvery and glistening oval bodies 2. The insect bite causes intense itching and can lead to secondary infection (impetigo or furunculosis) Scabies 1. Takes 4 weeks for symptoms to appear from time of contact 2. Severe itching occurs 3. Raised burrows can be seen with magnifying glass and penlight 4. Burrows may be straight or wavy lines, brown or black, threadlike lesions b/w fingers and on the wrists 5. Mites affect the fingers, and hand contact may produce infection Impetigo 1. Superficial skin infection (staphylococcistreptococci, or multiple bacteria) 1. Can occur in all areas of the body 2. Common in children living in poor hygienic conditions 3. Chronic health problems, poor hygiene, and malnutrition may predispose an adult to impetigo

prevent pressure ulcer

Perform pressure ulcer assessment within 24 hours of admission to the unit Develop and post a turning schedule Assess pressure point daily Monitor intake and output Use trapeze and foot boards Protect friction to area prone to pressure ulcer

Compulsion

Performance of some behavior - action of OCD

PPN

Peripheral Parenteral Nutrition - a superficial vein usually in arm

Discuss the differences between permanent and deciduous teeth and list the times of their eruption.

Permanent teeth are teeth that grow after the deciduous teeth. deciduous teeth [primary] begins approximately at 6 months and shedding of them begin at approximately 6 years of age

care of pt with pernicious anemia

Pernicious Anemia Absence of Intrinsic Factor- needed to absorb Clinical Manifestations 1. Anemia a. fatigue b. pallor c. dyspnea d. palpations 2. GI Symptoms a. Sore mouth; beefy red tongue b. weight loss c. Indigestion/mild diarrhea - due to atrophy of gastric mucosa 3. Neurological symptoms a. tingling, numbness of feet & hands b. progressive damage to spinal cord c. loss of proprioception; can lead to poor balance & coordination Diagnostics - Positive Schilling Test Management 1. Monthly Vit B12 IM injections for the rest of their lives 2. Folic acid & iron supplements 3. Avoid excessive cold or heat; sensitive to cold, use extra blankets 4. Good mouth care 5. eat small amounts of bland soft foods 6. Diet high in protein, multivitamins & minerals ** Potentially FATAL if untreated: can lead to HEART FAILURE ** If neurologic symptoms present 1. Neurological Assessment a. position sense of vibration b. Gait & stability c. Assistance with ADL's d. Safety, Canes, Walkers e. Physical & occupational therapy referral

Obsession

Persistent unwanted thought - the thinking part of OCD

Highest Priority to be seen or admitted first.

Person in active danger to themselves or significant property

identify medical and nursing interventions in the management of pain

Pharmacologicals: o Non-narcotics/nonopioids (NSAIDS): Over the counter (OTC)/Prescription Common side effect indigestion o Narcotics (opioids): Opioids for mild to moderate pain Opioids for moderate to serve pain Examples: codeine, hydrocodone, tramadol, morphine, codeine, Demerol, dilaudid • Adjuvant analgesic/coanalgesic: medications used for other reasons but can indirectly reduce pain Main Goal: Align proper analgesics with pain intensity Nonpharmacologic Pain Control Interventions • Consists of variety of pain management strategies Physical Cognitive-behavioral Lifestyle pain management Target body, mind, spirit, and social interactions Medical and Nursing Management Non-pharmacological/non-invasive: Physical Interventions: Cutaneous stimulation releases endorphins and block nerve fibers Types: o Massage: o Decrease muscle tension, increase relaxation, increase circulation to the area o Heat/cold application: o Vasodilatation and/or numbing o Cold first 24 hours/Heat used for more chronic pain o Examples: Warm bath, Heating pads, Ice packs, Warm or cold sitz bathes o Acupressure and reflexology: relieve tension -Types: -Immobilization: Restricting movement Transcutaneous electrical nerve stimulation (TENS): Electrical stimulation to the area - Cognitive-Behavioral Intervention: Mind-body intervention o Distraction (Music, TV) o Relaxation, imagery, mediation hypnosis - Spiritual: prayer -Non-pharmacological/non-invasive: Auditory: Music, Humor Visual: Watching TV, Guided Imagery Tactile: Massage (Text: Chapter, p. 1238), Stroking/holding pet or toy, breathing Intellectual: Computer games, card games, puzzles, hobbies -Nerve blocks: Chemical interruption of nerve pathways by injecting local anesthesia Example: dental work - Interrupting conduction pathways: Surgically by serving pain conduction pathways Done as last resort

What are diagnostic procedures used to assess problems with fecal elimination

Physical Examination: .inspection .auscultation (prior to palpation) .percussion .palpation .examination of the rectum and anus (inspection and palpation) Inspection of Feces: .color .consistency .shape .amount .odor .presence of abnormal constituents Diagnostic Studies: .direct visualization (colonoscopy) .indirect visualization (lower GI series) .Laboratory: Hemocult or guaiac (to detect occult blood in feces); C&S (micro)

Pitting edema

Pitting edema is a small depression or pit after finger pressure is applied to the swollen area caused by movement of fluid to adjacent tissue. Non pitting edema, does not pit, fluid is edematous tissue can not be moved to adjacent spaces

General Guidelines for Transferring a Client

Plan what to do and how to do it Obtain essential equipment before starting Remove obstacles Explain transfer to client and assistive personnel Support or hold client rather than equipment

Back Pain

Poor Body Mechanics Pathophysiology Nursing Interventions Teaching 1. Good body mechanics 2. rest 3. proper lifting 4. proper sitting, posture

Mineral needed in Muscle Contraction

Potassium (K) and Sodium (Na)

Loss

Potential or actual situation/circumstance in which something that is valued is no longer available, is changed and/or is gone

13. Know the nursing interventions associated with cataracts

Pre-Op 1. Stop anticoagulation therapy 2. Have patient use dilating eye drops 3. Antibiotics, NSAIDS, corticosteroids Teachings: 1. Sleep on non-operative side 2. Mild analgesic for pain (Aspirin, Tylenol) 3. Little discharge/scratchy sensation normal 4.Vision improves in 6-12 weeks

Cast Care Complications Pressure Ulcers

Pressure on soft tissue Susceptible areas: - Heel - Maelleoli - Dorsum of toes - Patella - Lateral epicondyl - Ulnar stylid process S/S - Painful hot spot - Tightness - Drainage - Warmth - smell Management: 1. MD might cut an opening (window) to allow to assess and possible treatment Teaching:

Nursing Interventions Stroke Patient

Prevent Complications Improve Independence Homonymous Hemianopsia- Loss of 1/2 of visual field, permanent or temporary Nursing Intervention: - Place objects within intact field of vision (unaffected side) - Approach patient from side of intact field of vision - Encourage use of eyeglasses if available - When teaching the patient, do so within patient's intact visual field - Encourage use of cane or other object to identify objects in periphery of visual field - Explain to patient location of object when placing it near patient - Consistently place patient care items in same location - Do not tell patient to ignore affected side - Driving ability will need to be evaluated Dietary Education

prevention and treatment or renal calculi

Prevention - Protein intake restricted to 60 g/day - Sodium intake of 3-4g /day - Low calcium only for those with hypercalciuria - Avoid oxalate-containing foods: spinach, tea, strawberries, peanuts, chocolate, wheat bran - Avoid activities that cause excessive sweating and dehydration - Increase fluid (water) intake every 1-2 hours during day - 2 glasses of water at bedtime - an additional glass each night time when awakened prevents urine concentration during the night Treatment: - Increase fluid intake - Surgical intervention or Chemolysis to remove the obstruction if stone does not pass spontaneously Uretroscopy: visualization of the stone destroying the stone Lithotripsy: - Instrument, machine, or probe to break stones into tiny particles that can be passed naturally Ultrasonic Lithotripsy - High frequency sound waves delivered through electronic probe inserted into the ureter Electrohydraulic Lithotripsy: electrical discharge creates a hydraulic shock to break up stones - Flexible probe passed through the cystoscope - Tip of the lithotriptor positioned close to stone - Strength of electrical discharge varies - Performed under topical anesthesia - Nephrostomy tube placed to ensure ureter patency - Tube removal: spontaneous closure - Common complications Hemorrhage Infection Urinary extravasation Extracorporeal shock wave Lithotripsy (ESWL) - Non-invasive method to break up non-passable stones in the Calyx - High energy shock waves pass through the skin and fragment the stones - High amplitude shock wave generates a release of energy - Transmitted through water and tissue - Difference in density encountered - Compression wave causes stone to fragment - X-ray monitoring used during procedure - Stones are spontaneously voided. - All urine is strained - Stones, fragments are sent to lab. - Monitor patient for urinary obstruction - Shock waves may cause discomfort and damage to surrounding tissues minimal Endourologic; Percutaneous Stone removal; used when other methods fail - Stones that don't spontaneously pass - Nephroscope introduced into renal parenchyma - Stone retrieved using forceps or basket - Ultrasonic waves may be used to pulverize large stones - Small stone fragments and dust then removed

Total Hip Replacement Nursing Interventions

Priorities 1. ** Prevention of Hip Dislocation - Flat position, legs slightly abducted - Turn as ordered- with abduction pillow - Trochanter roll on unaffected leg, to prevent external rotation - avoid flexion > 90 degrees internal & external rotation, adduction 2. Monitor wound drainage 3. Prevent DVT: - CMS check- surgical leg 4. Prevent infection 5. Promoting of Home & Community based care - Self-Care -Continuation Care in the Home and Community Teaching - affected leg should not cross center of body - hip should not bend more than 90 degrees - affective leg should not turn inward - commode above toilet seat

care for a pt with hip replacement

Types of Fractures

Priority - Open/Compound/Complex: bony fragment protrudes into soft tissue * can develop osteomylitis (bone infection) - Avulsion: a fragment of the bone has been pulled aways by a tendon and it's attachment - Comminuted bone splintered into several fragments - Greenstick or Incomplete: one side of the bone is broken and the other bent Nursing Interventions: 1. ** Early immobilization (to prevent Fat embolism- life threatening) 2. ** Priority CMS checks: Neurovascular Assessment - Circulation: capillary refill <3 sec, color distal to affected site, pulse distal to affected site - Motion: movement distal from injury - Sensation: distal from injury 3. Safety

40. Know the hearing loss that occurs with Meniere's disease

Progressive unilateral nerve deafness

Care of patient post repair due to cystocele and uterine prolapse:

Prolapse is when the supportive structures of the uterus have weakened and the muscles of the pelvic floor can no longer adequately support adjacent organs due to aging and childbirth. Uterine prolapse is when the uterus protrudes downward into the vagina. Cystocele is when the bladder is bulging into the vagina. Nursing Management: Prevention of complications of infection by performing perineal and incision care, relieve pressure of the suture line by giving stool softeners, encouragement to void and catheterization, pain control with ice packs, meds, antiseptic and anesthetic solutions.

Attempted Suicide Patient What's the first thing you do when patient is admitted?

Provide a safe environment. - 1:1 constant supervision no more than arm's length - Remove: belts, shoe laces, sheets, shaving supplies, hangers, cosmetics, mirrors. Search room for any items that can be of danger. -

Nursing care post renal angiography:

Provides an image of the renal arteries. Check injection site for swelling, hematoma, and bleeding, assess extremities for peripheral pulses distal to the injection site, color and temp, compare with uninvolved extremity, cold compresses to injection site to increase edema and pain, monitor VS.

PERRLA

Pupils Equal , Round and Reactive to Light and Accomodation

care of a pt with gout

Purine metabolism- disease of the joints caused by deposit of uric acid crystals in the joints. - Foods rich in purines (steak, shell fish, caviar and organ meats Nursing Interventions: - Rest to the inflamed joint - If not contraindicated push fluids (help remove uric acid) - Can produce kidney stones if stasis in kidneys - Recurrent in pt not compliant with diet - Tophi: Deposits of uric acid on ear cartilage (seen as bumps on lobes) Anti gout drugs: - colchicine - allupurinol (for patient at risk for renal insufficiency) - Corticosteroids

ABG (arterial blood gases)

Purpose: 1. Measurement of arterial oxygenation and carbon dioxide levels. 2. Assesses the adequacy of alveolar ventilation, the ability of the lungs to provide oxygen and remove carbon dioxide, assesses acid base balance Nursing Interventions Pre 1. Check with physician if ABG to be done on Room Air or oxygen 2. To check for baseline results Post 1. Apply pressure for 3-5 minutes after ABG 2. Longer for anticoagulants 3. Watch for signs of circulatory impairment: - Swelling - Pain - Numbness - Discoloration - Tingling

INH (Isoniazid)

Purpose: A bactericidal that inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall S/E: - Hepatitis most significant, but not common - Hepatotoxicity: hepatic enzyme elevation More Common - Neurotoxicity: peripheral neuritis a. Numbness/tingling in hands & feet ** Can treat with Vitamin B6 Pyridoxine Nursing Interventions 1. Taken on an empty stomach 2. Monitor for Hepatotoxicity & Neurotoxicity, such as tingling or numbness of the hands & feet

Rifampin (RIF)

Purpose: A bacteriostatic & bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells. S/E: - Hepatitis - Febrile reactions - Nausea, vomiting - Body fluids turn orange - Discoloration of contact lenses Nursing Interventions 1. observe for hepatotoxicity 2. Monitor yellowing of skin, pain or swelling of joints, loss of appetite, malaise

Ethambutol (EMB)

Purpose: A bacteriostatic that works by suppressing RNA synthesis, subsequently inhibiting protein synthesis S/E: - Optic neuritis (lead to blindness - rare) - Skin rash Nursing Interventions - Caution with renal disease - Monitor vision acuity - not to be given to children under 13 yrs old

Streptomycin

Purpose: An aminoglycoside antibiotic. It potentiates the efficacy of macrophages during phagocytosis S/E: - 8th cranial nerve damage (deafness) ototoxicity - Vestibular dysfunction (vertigo) - Nephrotoxicity Nursing Interventions: - Monitor BUN and Creatinine - Monitor hearing function and tolerance - Urine output & renal functions - 2 - 3 L of fluid daily

Steroid inhaler

Purpose: S/E: Nursing Interventions

Bronchoscopy

Purpose: 1. Technique for observing the larynx, trachea, and bronchial tree 2. can visualize foreign bodies, bleeding, tumors, or inflammation Nursing Interventions Pre 1. Obtain consent pre-procedure 2. NPO for six hours prior to procedure 3. Explain the procedure to the patient and family members to decrease fear and anxiety Post 1. Remain NPO until cough reflex return 2. Offer Ice chips and eventually fluids 3. Monitor patient's respiratory, observe for hypoxia, tachycardia, dysrhythmias, hemoptysis dyspnea and hypotension 4. Instruct pt to report bleeding and SOB immediately

Sputum culture

Purpose: C&S A. Most reliable test to determine if patient is infectious. B. Results are monitored for effectiveness of treatment and compliance. C. Only method to absolutely confirm diagnosis D. Dr. orders sputum for AFB (acid fast bacilli) E. Actual identification of mycobacterium may take as long as 2 weeks; treatment is begun with a positive AFB smear F. An early morning specimen Nursing Interventions Pre Post

Thoracentesis

Purpose: Invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. Most common causes for pleural effusions include: - cancer - congestive heart failure - pneumonia, - recent surgery - tuberculosis Contraindications: Uncooperative patient Coagulation disorder Nursing Interventions Pre 1. Ensure chest X-ray has been obtained 2. Assess for allergies 3. Administer sedation and monitor effects 4. Inform the patient about the procedure 5. Positioning a. Sitting at edge of bed & leaning over table b. Lying on unaffected side w/ HOB elevated 30-45 degrees c. Pressure sensations d. Remaining still (pg 488-489) e. Assist in exposing the chest & maintaining aseptic technique f. Gather the necessary supplies 1. 20 ml syringe 2. Needles 3. Drainage bag and tubing Post A. Apply pressure & sterile occlusive dressing B. Record amount, color, consistency of fluid drained C. Send specimen to lab & obtain CXR post- procedure D. Monitor VS, LOC, respiratory status pre, during, & post procedure E. Monitor for bloody cough, faintness, chest pain, s/s of hypoxia F. Provide emotional support

PFT (Pulmonary function test)

Purpose: assesses respiratory function & determine extent of dysfunction. Nursing Interventions: Pre 1. Pt that smoke, stop 6-8 hrs prior to test 2. Pt that uses inhaler, withhold 4-6 hrs prior to test) Post

Aminophylline

Purpose:Used for long-term control and prevention of symptoms in mild-persistent asthma, or with Inhaled corticosteroids in moderate or persistent asthma. A bronchodilator which relaxes smooth muscle. S/E: Nursing Interventions: Normal blood levels=5 to 15 micrograms/mL.

V-Q scan (Ventilation Perfusion Scan)

Purpose:Ventilation is the movement of air in and out of the lungs. Air must reach the alveoli to be available for gas exchange. Perfusion is the filling of the pulmonary capillaries with blood. Adequate gas exchange depends upon an adequate V/Q ratio, a match of ventilation and perfusion. ** Shunting occurs when there is an imbalance of ventilation and perfusion. This results in hypoxia. In healthy lung the ratio is 1:1 Nursing Interventions Pre Post

Treatment for asthma

Quick-relief medications See Table 24-4, Page 630 Beta2-adrenergic agonists Anticholinergics (Atrovent) are used in patients who do not tolerate SABA's well (Reduce vagal tone of the airway) Long-acting medications See Table 24-3, Pages 624-625 Corticosteroids/Methylxanthines Long acting beta2-adrenergic agonists Leukotriene modifiers Use SABA- Short Acting Beta2 agonists (Bronchodilators) a. These relax smooth muscles and are the medications of choice for acute symptoms and prevent of exercise-induced asthma e.g.,- Albuterol (Proventil, Ventolin, Xopenex, Maxair. Methylxanthines (Theophylline) Used for long-term control and prevention of symptoms in mild-persistent asthma, or with Inhaled corticosteroids in moderate or persistent asthma Theophylline (Theo-Dur) is a bronchodilator which relaxes smooth muscle.

State the order of assessing vital signs.

R.A.B.T. respiration, apical pulse, blood pressure, temperature

Erythrocyte

RBC's

Discharge teaching for patients post MI, surgery and Coumadin therapy

REHAB CONSISTS OF: -physical conditioning under supervision [PT] -instruction on all medications: nitrates, beta blockers, Ca+ channel blockers, antiplatelets, lipid lowering agents -modifications in diet: decrease saturated fat and cholesterol, decrease Na, limit ETOH -stress reduction techniques -sexual activity resumed when pt can climb stairs without symptoms -some MD's recommend NTG SL before sex may need to make modifications of time of day and position. POST PERCUTANEOUS CORONARY INTERVENTIONS -assess site of insertion -assess for bleeding -Frequent VS, BR 2-6hrs -assess femoral/distal sites -assess distal pulse POST PACEMEAKER INSERTIONS -minimize pt activity initially since activity may dislodge the pacemaker [2weeks] -make sure pt receives all identification information about the pacemaker -teach the pt signs of pacemaker dislodgement -be careful with anything magnetic -maybe set off during airport screening -after surgery be careful with raising arm above head -assess insertion site for infection -CXR after to assess placement of device and leads -avoid friction over the insertion site -wear a medic alert band -initially no soaking in the tub COUMADIN PT TEACHING [DRUGGUIDE] -report unusual bleeding or bruising, black tarry stools -no ETOH or OTC drugs especially aspirin or NSAID's -frequent lab tests to monitor coagulation factors [PT and INR]

respitory control mechanisms

RESPITORY CENTERS: -medulla oblongata -pons CHEMORECEPTORS: -medulla -carotid and aortic bodies BOTH RESPOND TO: O2, CO2, H+ in arterial blood

9. Know the clinical manifestations and nursing intervention for patient diagnosed with retinal detachment and what are nursing managements for sclera buckling preparation and positions for patient

RETINAL DETACHMENT: -CLINICAL MANIFESTATIONS Sudden flashes of light, cobwebs, floaters or spots in front of the person's vision Painless, sudden blurred vision with areas of lost sight (central vision) Appearance that a curtain is moving across the visual field Progressive constriction of vision in one area -NURSING INTERVENTIONS: -comfort -specific positioning to allow retina to fall back in place SCLERA BUCKLING: -NURSING MANAGEMENTS: -(Compress sclera with silicone band to bring 2 retinal layers in contact with each other) -Argon laser photocoagulation -Cryotherapy -Vitrectomy -POSITIONS FOR PATIENT: NOT FOUND

Know the different types of incontinence:

Reflex: urination when the person in unaware that they need to urinate. Stress: urination when sneezing, jumping, or coughing. Overflow: involuntary release of urine from an overly full bladder, often without feeling an urge to urinate. Urge: strong, sudden need to urinate due to bladder spasms or contractions.

Improve independence on a pt with MS

Rehabilitation - Physical therapy (PT) - Occupational therapy Referrals - Psychological - Social worker - Support group

Purpose of group therapy

Relationship with others can be recreated. To discuss problems and concerns through regular meetings with a leader, learn new bxs/coping skills

Care of a patient post mastectomy:

Relieve pain and discomfort by positioning the patient semi fowlers with arm elevated, this aids gravity in removing fluid, monitor for complications such as lymphedema, hematoma, infections and excessive draining. Start exercises first day post op but ROM starts on the 2nd post op day: This increases circulation, increases muscle strength, prevents joint stiffness and prevents contractures. ROM at home TID for 20 minutes until ROM is restored (4-6wks) Administer analgesics 30 minutes before exercises for pain and discomfort. Lymphedema: Inadequate lymph channels to ensure return flow of lymph which causes chronic swelling. Risk factors are age, obesity, extensive axillary dx, radiation, injury and infection. Patient teaching: No BP blood draws or injections and use electric razor. Warm showers before exercise helps loosen stiff muscles and provide comfort. Specific exercises include: wall hand climbing, rope turning, rob or broomstick lifting and pulley tugging.

care of pt post mastectomy

Carotid Endarterectomy

Removal of the atherosclerotic plaque or thrombus (carotid artery stenosis) from the carotid artery to prevent stroke

care of pt post chemotherapy

Report immediately c/o pain • Observe for S/S infection, report temp >100 • Maintain adequate nutritional/fluid intake. • Report any unusual bleeding, bruising, visual disturbances, other side effects. • Gentle and systematic oral hygiene • Report immediately if infusion site looks infected, infiltrated, leaking, etc. • Follow up between therapy sessions should include a complete physical assessment, blood studies and liver function tests to rule out organ damage

how to control the s/s of chemo

EEG

Represents electrical activity generated in the brain. A. Detects: 1. Seizure disorders 2. Screen of OBS: Organic Brain Syndrome 3. Determine if a person is Brain Dead 4. Tumors 5. Brain abscesses 6. Blood Clots 7. Infection might show abnormal patterns in electrical activity

isokinetic exercise

Resistive exercise: involves both isometric and isotonic exercise Provides movement or tension against resistance Used for physical conditioning Strengthening/muscle building Includes weight lifting

Regretion

Responding to stress by retreating to an earlier level of development & the comfort measures associated with that level of functioning. Example: 2 year old Jay drinks from a bottle after tonsillitis although he has been drinking from a cup for 6 months.

Parkinson's crisis

Result of a sudden withdrawal of meds or emotional trauma - Severe exacerbation of tremors - Rigidity - Acute anxiety - Tachycardia - On-off syndrome (Sudden periods of near immobility followed by sudden return of effectiveness of medication) -Considered a medical emergency (Hospitalization) Drug holiday - A planned interruption in medication to reduce toxicity/effect/cost - reduces symptoms like: Insomnia Hallucinations Confusion Delirium

Vitamin A

Retinol, precursor - carotene Sources: dark yellow & orange vegetables Functions: improves resistance to infection; vision

nursing diagnosis associated with constipation and diareah

Risk for Deficient Fluid Volume r/t Prolonged diarrhea Abnormal fluid loss through ostomy Risk for Impaired Skin Integrity r/t Prolonged diarrhea Bowel incontinence Bowel diversion ostomy Low Self Esteem r/t Ostomy Fecal incontinence Need for assistance Deficient Knowledge (Bowel Training, Ostomy Management) r/t lack of previous experience Anxiety r/t Lack of control of fecal elimination secondary to ostomy Response of others to ostomy

S/S Lithium Intoxication

S/E - anticholinergic - extra-pyramidal effects ** High Risk of toxicity if diuretics is given Toxicity - decreased coordination - extreme diarrhea - vomiting - drowsiness - slurred speech - muscle weakness - polyria - polydipsia - arrhythmias - delirium ** Maintain moderate sodium intake. - Low sodium causes kidneys to reabsorb lithium - High sodium level will cause loss of lithium (renal) - Encourage fluid intake if pt is an athlete, loosing lots of fluids

s/s and care of a pt with SLE (Systemic Lupus Erythematosis)

S/S - Onset may be insidious or acute - May remain undiagnosed for many years. - Clinical features involve multiple body systems - Arthralgias and arthritis (synovitis), is a common presenting feature - Joint swelling, tenderness, morning stiffness, and pain on movement are common. Skin manifestations: Subacute cutaneous lupus erythematosus - polycyclic lesions (subcutaneous) - chronic rash - Scaling / scarring / pigmentation changes - The most familiar skin manifestation is an acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks (50% of patients) - Made worse by sunlight Oral ulcers - occur in crops - Pericarditis is the most common cardiac manifestation - At risk for early atherosclerosis. - Renal involvement - leading to hypertension - CNS involvement is widespread, encompassing a range of neurological disease - Subtle changes in behavior patterns or cognitive ability - Depression and psychosis Nursing Interventions: - Sensitivity to the psychological reactions of the patient - Avoid sunlight / ultraviolet light - Wear sunscreen / protective clothing - Dietary instructions (atherosclerosis) Medication compliance Meds: - NSAIDs used for minor symptoms - Corticosteroids - most important medication; used topically for cutaneous manifestations; low oral doses for minor disease activity; high doses for major disease activity - Antimalarial medications are effective for managing cutaneous, musculoskeletal, and mild systemic disease. - Immunosuppressive agents reserved for patients who have serious forms of SLE and have not responded to conservative therapies

small bowel obstruction clinical manifestations and nursing interventins

S/S: -sharp brief pains -increased bowel sounds in area above obstruction -vomiting with rapid dehydration and acidosis -slight abdominal distention due to fluid/gas/stomach contents - this decreases in venous and arterial blood flow - edema, congestion, necrosis - perforation - peritonitis -may pass bloody stool and mucous, but no feces or gas -if obstruction is complete the peristaltic waves will reverse direction and intestinal content is propelled to mouth. eventually pt will go from vomitting bile stained contents -> vomiting fecal matter INTERVENTIONS: -fowlers position to help relieve pressure and gas due to the pressure of distended abdomen on diaphragm -managing NGT and suction prior to surgery -possible IV and electrolyte replacement -monitor nutritional status and assessment for surgery of improvement. .bowel sounds in all 4 quadrants .decreased distention and pain .bowel movement or gas .I&O, daily weights, electrolyte balance, H&H, skin turgor and mucous membranes.

Clinical manifestations with a person with bladder cancer including nursing interventions:

S/S: Hematuria, pain and mass in flank area, painless hematuria, infection, frequency, urgency, dysuria, change in voiding pattern, pelvic/back pain with metastasis. Nursing interventions: NOT FOUND

s/s of peptic ulcer

S/S: may last few days, weeks, months; can have remissions & exacerbations - Epigastric pain; described as burning, gnawing, cramping, or aching. Diminished in the AM when secretions are low and after meals when food is in stomach or after taking antacid. Most severe before meals & at bedtime. - Nausea - loss of appetite - weight loss - vomiting (rare) - mostly with duodenal ulcer due to obstruction by spasms or scar tissue - pyrosis (heartburn) - reflux of stomach, especially on an empty stomach - Constipation - diet & meds, bleeding from ulcer

gastric tubes miller-abott and salem sump

SALEM PUMP: shorter and only reach the stomach called NGT -single lumen -fluid / gas samples -admisnister meds / feedings -double lumen [blue vent] to prevent pressure from exceeding 25mmHg -decompression MILLER ABBOTT: longer they go past the stomach into the small intestine -naso enteric tubes -mostly for decompresision -have weight at the end INTERVENTION: -explain procedure to pt -talk about sensations [gag reflex] -assisst M witth insertion .semi fowlers .lubrication water soluble .swallow with skin prep -observe for abdominal distention -observe for n/v, without fullness or bloating -SOB -mantain proper suctioning -check for proper placement -check nostril for signs of presure / ulceration -frequent mouth care and lubricate lips, MD order for humidifier, limited ice chips, hard candy allowed by MD order -clamp intermettently for 24 hrs before removing.

therapeutic techniques

SILENCE: Pause Being silent EXAMPLE: sitting quietly, walking and waiting until the client is able to relate his thoughts and feelings into words PROVIDING GENERAL LEADS: statements used to encourage the patient to verbalize EXAMPLE - Would it help to discuss your feelings? "Where would you like to begin?" "Perhaps you would like to talk about..." USING OPEN ENDED QUESTIONS: asking broad questions that lead or invite the patient to explore feelings invites answers that are longer than one or two words EXAMPLES - "Tell me about..." "I'd like to hear more about that." "What brought you to the hospital." USING TOUCH: appropriate form of touch to reinforce caring RESTATING/PARAPHRASING: actively listening then repeating in a similar way EXAMPLE- Client - "I did not get any sleep last night." Nurse - "You had difficulty sleeping last night?" SEEKING CLARIFICATION: making a patients broad overall meaning of their message more understandable restate basic message confess confusion or poor understanding EXAMPLE - "Would you please say that again?" "I'm not sure I understand that." OFFERING SELF: offering of one self without demands EXAMPLE- "I will help you to get dressed if you would like." " I will stay with you until your family arrives." GIVING INFORMATION: simple and direct EXAMPLE - "Your surgery is scheduled for 9:00 a.m. tomorrow." "I don't know the answer to that but I will find out for you from the doctor." ACKNOWLEDGING: giving recognition without judging EXAMPLE- "I notice that you keep squinting your eyes. Are you having difficulty seeing?" "You took a shower and combed your hair."

what side do you place your client on?

SIMS or left lateral

define the concepts of spirituality and religion as they relate to nursing and health care

SPIRITUALITY: -the part of being human seeking meaningful connections through: intrapersonal relationships, interpersonal relationships, transpersonal awareness. -involves a belief in a relationship with: some higher power, creative force, divine being, infinite source of energy -it includes connecting and relating to others, nature, and universe. transcendence, becoming, hope, meaning, value -feeling alive, purposeful, and fulfilled -happiness through actual personal intentionality not by chance. -nurses should be aware and comfortable with their own spirituality and remove their own biases RELIGION CONCEPTS: faith, transcendence, forgiveness, FAITH -to believe in or to be committed to something or someone -gives life meaning -provides the individual with strength in times of difficulty -HOPE definition: a feeling of expectations and desires for certain things to happen, hope is incorporated into spirituality, in the absence of Hope patients give up, patients lose spirit, patients illnesses are most likely to progress faster.

Management for Hypertension - stair step approach

STAGE 1: one of these: -diuretics [1st ad solely] as well as above life style changes -beta- blockers, ACE inhibitors, Calcium channel blockers STAGE 2: BP>160/>100 -diuretics + ________ [Plus one of the follwoing]: -beta-blockers, ACE inhibitors, Calcium channel blcokers [only 1]

nonn therapeutic communication

STEREOTYPING: generalized or oversimplified beliefs about groups of people EXAMPLE- "All confused people are hard to take care of." "All Hispanics are loud." AGREEING/DISAGREEING: judgmental response EXAMPLE- Client- "I don't think Dr. Broad is a very good doctor. He doesn't seem interested in his patients." BEING DEFENSIVE: Being defensive attempting to protect a persons health with negative comments EXAMPLE- Client- "Those night nurses must just sit around and talk all night. They didn't answer my light for over an hour." Nurse- "I'll have you know we run around all night. You are not my only client, you know." CHALLENGING: making a patient prove their statement EXAMPLE Client- "I feel like I am dying." Nurse - "How can you feel that way when you are breathing fine and your pulse is 60." PROBING: Probing asking for information out of curiosity WHY? REJECTING: refusing to discuss certain topics EXAMPLE "I don't want to discuss that. Let's talk about..." PASSING JUDGEMENT: giving ones own opinions or values EXAMPLE "That's good."

pt is getting packed RBC's. temp increases to 102.3°F. what does the nurse do?

STOP THE TRANSFUSION! an elevated temp means there is a rxn. it is a great risk for the cleint.

list two components of the respiratory system

STRUCTURE: the respiratory system is divided into the upper and lower respiratory system. mouth, nose, pharynx, and larynx are part of the upper system. the lower system includes the trachea which branches into the bronchi and bronchioles, alveoli, pulmonary capillary network and pleural membranes, also the lungs. PROCESS: involves 4 phases. pulmonary ventilation, alveolar gas exchange, transportation of CO2 and O2, systemic diffusion

what is the management of a pt with hyperparathyroidism

SURGICAL: removal of the abnormal parathyroid tissue [parathyroidectomy][minimally invasive] MEDICAL: -hydration: to prevent stone formation [2000 ml or more encouraged, cranberry juice] -mobility: gives up less Calcium [walking, rocking chair], weight bearing.

Common pathogens that cause Food Bourne Illness

Salmonella - raw/undercooked eggs, cookie dough, salad dressing and mayonnaise and the foods made with them, left at room temperature. E coli - contaminated ground beef, vegetables grown in fields irrigated with contaminated water or manure Listeria - pregnant women are at risk, 20 times more susceptible; can cause miscarriage & still birth. i.e., reheated hot dogs, other liquids from packages drip into other foods, unpasteurized milk & juice, soft cheeses, like brie, feta & blue cheese

What is Echolalia and Echopraxia

Schizophrenia/Catatonic Symptoms: - Echolalia: involuntary repetition of words spoken by others. - Echopraxia: meaningless imitation of motions made by others

seborrhea

Seborrhea Characteristics 1. An excessive amount of sebum in face, scalp, eyebrows, eyelids, under breasts, gluteal creases, sides of nose, upper lip, axillae (underarm), groin Seborrhea Clinical manifestations 2 forms: oily & dry both start in childhood and continue throughout life. OILY: 1. moist or greasy w/ or w/o scaling slight redness forehead, nasolabial fold, beard area, scalp, and in axillae, groin, and breast areas 2. small pustules may appear on the trunk DRY: 1. Flaky desquamation of the scalp with fine powdery scales (dandruff) 2. With scaling comes itching, scratching, secondary infections, and excoriation Seborrhea Teaching 1. Avoid external irritants, excessive heat, & perspiration 2. Rubbing and scratching prolong the disorder 3. Air the skin and keep skin folds clean & dry 4. Frequent shampooing contraindicated for some cultural practices a. Be sensitive to pts differences b. Pts need to adhere to treatment

Delusion

Sensory/Perceptual Alteration Delusions - False fixed belief Not based on Reality that the subject holds with total conviction. They are regarded as being unshakable.

Hallucination

Sensory/Perceptual Alteration Hallucination - A False sensory perception - Auditory is the most common - Visual is the 2nd most common

Laboratory data used to identify electrolyte imbalance

Serum electrolytes CBC Osmolality Urine PH ABG

Risk factors for PID:

Sexually active women, women with multiple partners, frequent intercourse, intercourse without protection, hx of previous STD's or pelvis infection, IUD use aggravates the problem, early age at first intercourse, intercourse with someone with STD or hx of STD and previous pelvic infection.

Clinical Manifestation Hemorrhagic Stroke

Similar to ischemic stroke +may have: - Sudden severe headache - LOC - Nausea or vomiting - Neck rigidity, visual disturbance - Dizziness, tinnitus - Hemiparesis - Coma-death

Types of Traction

Skin Traction: to reduce muscle spasms & immobilize a body part before surgery a. foam boot b. Weight - extremities 4.5 - 8lbs (approx 5) - pelvic traction 10 - 20lbs c. Buck traction, Pelvic or Head Halter, Russel's Nursing Interventions: - ** Assess skin 3x/day, at least every shift - avoid wrinkles and slipping of bandages - maintain counterbalance - proper neutral positioning is needed - CMS Skeletal Traction: applied to the bone, distal to the fracture. - fracture of femur, tibia & cervical spine - 15-25 lbs - balance suspension used - Thomas leg splint w/Pearson attachment Nursing Interventions: - Monitor for Infection - assess for good alignment - don't stop skeletal - change linens from top to bottom - do not turn pt towards surgical site

s/s of pt with small bowel obstruction

Small Bowel Obstruction 3 High in intestinal tract; 85 % due to to adhesions Clinical Manifestations: 1. Sharp, brief pain 2. Increased Bowel Sounds above obstruction (hyperactive) 3. * N & V, rapid dehydration, acidosis 4. * slight abdominal distention due to fluids & increased lumen pressure causing decrease in venous & arterial blood flow- edema, congestion, necrosis, perforation, peritonitis 5. may pass bloody stool & mucous, but * no feces or flatus. 6. If obstruction is complete, the peristaltic waves will reverse direction & intestinal content is propelled to mouth. Eventually pt will go from vomiting bile to * vomiting fecal matter. NO BOWEL SOUNDS under obstruction.

Electrolytes

Sodium (Na+) Range 135-145mEq/L Chloride (Cl-) 95-108 mEq/L Potassium (K+) 3.5-5.0 mEq/L Calcium (Ca2+) 8.5-10.5 mg/dL or 4.5-5.5 mEq/L Magnesium (Mg2+) 1.5-2.5 mEq/L Phosphate (PO4-) 1.8-2.6mEq/L Bicarbonate (HCO3-)

Define enema

Solution introduced in the rectum and large intestine -distends the intestine -imitates the mucosa -increasing peristalsis -cause excretion of feces and flatus

Calcium (Ca) (mineral)

Sources: Dairy Functions: blood clotting, bone & teeth

iodine (I) (minor mineral)

Sources: Saltwater fishes Function: regulates energy metabolism as part of the thyroid hormone thyroxin

Potassium (K) (mineral)

Sources: apricots, bananas, oranges, carrots functions: muscle contraction and heart beat

Vitamin C

Sources: citrus fruits, strawberries Function: together with folic acid - RBC formation, improves Iron absorption

Phosphorus (P) (mineral)

Sources: dairy Functions: strong bones & teeth

Vitamin K

Sources: dark green leafy vegetables, and synthesized by intestinal bacteria Function: formation of blood clotting

Magnesium (Mg) (mineral)

Sources: dark green vegetables Functions: regulates heart beat

Vitamin D

Sources: fortified dairy Function: bones & teeth

iron (Fe) (minor mineral)

Sources: lean red meats Functions: component of Hemoglobin

Vitamin E

Sources: legumes, nuts Function: antioxidant

Sulfer (S) (mineral)

Sources: meat products Functions: help with inflammation

Chloride (CI) (mineral)

Sources: table salt Functions: acid-base imbalance

Sodium (Na) (mineral)

Sources: table salt, MSG, Soy sauce Functions: muscle contraction and heart beat

Vitamin B

Sources: whole grains, enriched breads, cereals Functions: energy metabolism, stress - Specific Vit. with known DRI B6 - pyridoxine must be supplemented for patients receiving INH - isoniasid TB B9 - folacin or folic acid - very important for pregnant women

log rolling

Spinal injury, spinal surgery, or hip surgery Pull patient to the side of the bed All staff move together to keep pt's alignment Using pull sheet Use head to support head It is necessary to move patient body as one unit post spinal surgery

Trauma

Splint, contusion Sprain Strain Rest Ice C E

tube feeding assessment and nursing interventions

Steps 1. Elevate bed to 30-45 degrees 2. put gloves 3. Pinch the tube & remove the plug, cap, clamp 4. Verify placement by aspirating small amounts 5-10ml. If no fluid is obtained, check the tube and listen to the left of xiphoid, verify that placement has been checked by a radiograph. Check that mark at the nose entrance is still in place. 5. Reinstall aspirated fluid Intermittent Feedings: - If a Gavage bag is used, fill it with the prescribed amount of formula and regulate it to run over 10-15 min. - If a Syringe is used, pinch tube, attach syringe, & pour formula into the barrel of the syringe, keeping it more that 18" above the level of entry into stomach or intestines, unpinch the tube to start flow. Continuous Tube Feeding: - Fill the feeding bag with the prescribe amount of formula, clear the tubing of air, and attach it to an IV pole or feeding pump and set the the correct rate. - Verify enteral, gastrotomy or Jejunostomy placement - Check amount of residual from previous feeding, by aspirating w/syringe - reinstall the fluid - attach tubing from feeding bag, prime and turn on pump, check drip rate & begin feeding 1. Assessment a. Placement b. Residual c. Weight 2. F&E 3. Dehydration Complications: Dumping Syndrome Diarrhea * water helps clear tubing and prevent clogging & decrease bacteria growth

how to care for angina

Strangling of the chest; a decrease blood flow to the heart. 1. Insufficient Coronary Blood Flow & inadequate O2 to myocardium (demand exceeds supply) 2. Sudden onset, Short Duration, Precipitated by exertion or stress; relieved by rest and/or NTG A. Stable Angina: relieved readily with NTG & Rest (after exercise sit & then give NTC) B. Unstable Angina: aks as pre-infarction angina, crescendo angina, impending MI C. Silent Ischemia: history of DM Nursing Process: Assessment 1. History & precipitating events (What were you doing that caused you to have chest pain?) 2. Description of pain - tightness, choking, squeezing, pressure) 3. Severe apprehension "sense of impending death" Lab Test to rule out MI: 1. Troponin 2. CKMB MED Treatment: 1. Nitrogylcerin 2. Calcium Channel Blocker: a. Longer acting 3. Beta-adrenergic blockers: a. added when NTG alone fails b. decrease HR (if HR is less than 50, hold & recheck prior to administration) c. DO NOT STOP ABRUPTLY! Rebound Angina, increased BP & Pulse 4. Antiplatelets: keep the blood thinner, which will promote coronary Artery Perfusion 5. surgical Management: a. PTCA - Stents c. CABG - Coronary Artery Bypass graft REDUCE RISK: LOOSE WEIGHT - QUIT SMOKING

Alzheimer's Nursing Interventions

Support cognitive function Promote physical safe Reduce anxiety and agitation Improve communication Promote independence Provide for socialization Promote adequate nutrition Promote balanced activity and rest Educate family members

Amputations

Surgical removal a body part or limb. The site of amputation is determined by the circulation and functional usefulness for prosthesis Nursing Pre and post op care: 1. wrapping to shape residual limb 2. ** Prone position 24-48 hrs if amputation is below the knee, prevents knee flexion contraction. 3. ** No pillows 4. ** 1st Priority is to monitor for bleeding 5. VS 6. Bed flat to avoid hip flexion contractures 7. elevate 1st 24 hours 8. legs together to avoid abduction contractures 9. overhead trapeze 10. Tourniquet at bedside - bleeding 11. Wound care 12. sandbag, rolled towels, trochanter roll to prevent external rotation 13. psychological support

Catatonia

Syndrome of Schizophrenia - Not moving, motor immobility: waxy flexibility; stupor daze; bizare body postures. - not moving for hours and days at a time Example: pt assumes, bizarre unusual posture. Pt lays with their head a few inches away from pillow

Nursing interventions associated with administration of ppd and how and when to read

TB skin test (Mantoux or PPD) Determines if person infected with TB bacillus Tubercle bacillus extract (tuberculin), purified protein derivative (PPD) Injected intradermally into inner aspect of forearm about 4 inch below elbow with bevel of needle up Test is read 48 - 72 hours after injection Reaction of 0 - 4 mm not significant A positive reaction is an area of induration of 10 mm or more; frequently but not always, accompanied by erythema In HIV/AIDS and those with close contact with active case 5mm or > is positive 5 - 9 mm induration is suspicious and should be repeated A positive reaction (10 mm or greater) indicates exposure; does not mean active disease (90% of positive reactors do not develop clinical TB) All reactors however are candidates for active TB

10. Know the teaching immediately post-surgery for a patient undergoing repair of a retinal detachment what proper position, and what activities to avoid

TEACHING: -Complications - Increased IOP, endophthalmitis, more detachment, cataracts, loss of turgor -Teach signs and symptoms of complications -Importance of follow-up care

identify the variation in normal body temperature pulse respiration and blood pressure that occur from infancy to old age

TEMPERATURE: -infancy: unstable, newborns must be kept warm to prevent hypothermia -elder: tend to be lower than that of middle aged adults, decreased thermoregulatory controls PULSE: -infancy: newborns may have heart murmurs that are not pathological -elder: often have decreased peripheral circulation RESPIRATIONS: -infancy: some newborns display "periodic breathing" -elder: anatomic and physiologic changes cause respiratory system to be less efficient BLOOD PRESSURE: -infancy: arm and thigh pressures are equivalent under 1 year of age-elder: clients medication affect how pressure is taken.

identify normal ranges for each vital sign

TEMPERATURE: 98°.6-100°F 36°-37.5°C BLOOD PRESSURE: 120/80 (Typical blood pressure for a healthy adult) PULSE: range: 60-100 PAIN: assesment scales Range: 0-10, Mild- 1-3 range Moderate- 4-6 range Severe- 7-10 range PULSE OX: Normal SpO2 85-100%; < 70% life threatening HEART RATE: 60-100 beats/min RESPIRATORY RATE: 500 (Tidal Volume)

a nurse is reinforcing teaching with a client who has a new prescription for finasteride [proscar] about the medication

THERAPEUTIC USES finasteride inhibits 5-alpha reductase and enzyme, which converts testosterone to dihydrotestorone. production of testosterone in the prostate gland is reduced, which in turn reduces the size of the prostate tissue CLIENT EDUCATION: -the medication must be taken on a longterm basis. it can take as long as 1 yr before the effects of the medication are evident. - impotence and decreased libido are possible adverse effects -report breast enlargement to the provider -finasteride is teratogenic to the male fetus. the medication can be absorbed through the skin. pregnant women should not be in contact with the tablets.

a nurse is preparing to review teaching with a client on medications used to treat fibrocysti breast condition therapeutic uses. identify three classes of medications that are used to treat the condition, and provide a brief description of the purpose of medications in treating fibrocystic breast condition

THERAPEUTIC USES: -analgesics such as acetaminophen [tylenol], or ibuprofen [motrin], are used to relieve pain -oral contraceptives supress estrogen / progesterone secretion -diuretics decrease breast engorgement -androgen / anabolic steroids [danazol] suppress ovarian function -vitamin E reduces pain

Discuss different types of urinary diversons

THERE ARE TWO TYPES : INCONTINENT & CONTINENT INCONTINENT -ureterostomy: ureter connected directly to surface of skin to form small stomas -nephrostomy tubes: from kidneys to stoma -vesicostomy:bladder wall surgically attached to opening in skin forming an incontinenet stoma -ileal conduit(ileal loop):most common, segment of ileum is removed, intestinal ends are re-attached, one end is closed with suture and other end is brought through abdominal wall to create stoma CONTINENT -kock pouch:creation of pouch connected to skin and intermittent catheterization -neobladder: replaces damaged bladder with a piece of ileum; connected to urethra and voiding is contolled by pt.

know the difference between type 1 and type 2 DM, including treatment.

TYPE 1: usually a complete deficiency of insulin due to destruction of the pancreatic cells. treatment: insulin TYPE 2: usually obese at diagnosis [muffin top]. decrease amount of insulin production [insulin deficiency] or a decreased sensitivity to insulin by the cells [insulin resistant]. treatment: loose weight, diet pills and insulin

teaching about the diet in a pt with gout

Teaching 1. Fluids 2. Diet - avoid steak, shell fish, caviar and organ meats

Discuss bowel diversion ostomies

Temporary: -traumatic injuries -inflammatory conditions of the bowel Permanent: provide means of elimination when rectum or anus is non functional -birth defect -cancer Anatomical Location: -Ileostomy: .opens at distal end of the small intestine .liquid, digestive enzymes, minimal odor, constant elimination -Cecostomy: cecum (constant liquid elimination) -Colostomy: opens into colon Colostomy Type by Location: -Ascending colostomy: .liquid, digestive enzyme presents, odor is a problem, constant -Transverse colostomy: .malodorous, mushy, not control -Descending colostomy: .increasingly solid fecal drainage -Sigmoid colostomy: .formed consistency, can be regulated -Over time stool becomes more formed, residual colon compensates with water re-absorption Surgical Construction of Stoma: a) single b) loop c) divided d) double-barrel colostomies

Loose Association

Terminology of Speech - Problem in the logical order of thought. continuity of speech is disrupted an incoherent. No logic can be discerned. May be filled with neoglism

rectal temp

The average normal oral temperature is 98.6°F (37°C). A rectal temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

percussion

The deliberate striking or tapping of a body part to elicit a specific vibration. • Three types of percussion: 1. Direct percussion: striking the area to elicit a specific sound 2. Indirectly: striking an object against the area 3. Fisted percussion: done to elicit tenderness - kidneys • It is used to determine : size and shape of an organ; and indicates whether the tissue is filled with fluid or air, or if it is solid.

Difference between emphysema and chronic bronchitis

The primary symptom of emphysema is wheezing. Sputum and productive cough are the primary symptoms of chronic bronchitis

Ideas of Reference

Thought disorder in Schizophrenia - believe innocuous things refer to them. Example: the people on the television may be talking about them or to them personally.

Disseminated Intravascular Disorder

Tiny blood clots that deplete platelets and cause bleeding. Increased PT, PTT, decreased platelets Implement Safety & Bleeding precautions Auscultate breath sounds every 2-4 hrs Clinical Manifestations 1. Bleeding mild to severe 2. Renal Failure

Purpose of Anti-Anxiety Medication

To calm, relax, reduce muscle tension, reduce anxiety - Xanax - Librium - Tranxene - Valium - Ativan - Serax - Klonopin

What does TPN mean

Total Parenteral Nutrition: aka hyperalimenation - a major central vein is used; subclavian or juglar - HIGH ALERT - long term support or high metabolic needs

treatment for mitral valve prolapse

Treatment for mitral valve replacement: • Between right and left atrium ,can cause migraines, blood regurgitates into the left atrium, mostly congenital and often in females. • To control symptoms put on antiarrhythmic (beta blockers and calcium channel blockers) • Valve replacement when meds no longer work (if valve replacement, patients must be on anticoagulants for the rest of their life) Care of the patient post valve prolapse: • Will be on anticoagulants for the rest of their lives • Assess for patients risk for emboli • ensure the pt recovers from anesthesia • Teach pt ways to minimize infection • Follow up care of anticoagulant therapy

Sumatriptan (Imitrex)

Triptans (serotonin agonists) are most specific antimigraine agents available and most widely used for acute migraine & cluster headaches in adults - Cause vasoconstriction, reduce inflammation, and may reduce pain transmission - SQ form usually relieves symptoms within 1 hour; effective for moderate to severe headaches - Do not take ergotamines with triptans because of potential for prolonged vasoactive reaction (Vasoconstriction) - Contraindicated in patients with ischemic heart disease because it can cause chest pain - Be aware of adverse reactions such as increased blood pressure, drowsiness, muscle pain, sweating, and anxiety; do not give if taking St. John's wort

What to Delegate when caring for a Stroke Patient

Turn pt Apply A.E. hose

Identify sources and types of loss:

Types of Loss: 1. Actual - can be identified by others. Such as death and amputation. 2. Perceived - experienced by only one person but cannot be verified by others. Such as loss of independence or freedom. 3. Anticipatory - experienced before the loss actually occurs. Such as when an individual prepares ahead of time for a beloved one's death. 4. Situational - losses caused by unexpected or unusual circumstances. Such as a job loss or a child's death. 5. Developmental - losses that predictably occur during life cycle or process of normal development. Such as death of aged parents or departure of grown children. **Both actual and perceived losses can also be anticipatory because people can live the experiences before it really happens** Sources of loss: **Not always associated with physical death** 1. Loss of an aspect of oneself - body image, trauma, burns, divorce, etc. 2. Loss of an object external to oneself - inanimate: house, job, car, jewelry. Animate: a pet 3. Separation from an accustomed environment: child's first day of school or a new college freshman going away to school. 4. Loss of a loved or valued person: due to illness, separation or death.

nursing care in pts with migraines

Types of Migraine headaches Migraines - dysfunction of the brain stem pathways that normally modulates sensory input. Rise in plasma serotonin dilates the cerebral vessels. - can be triggered by: menstrual cycle, bright lights, stress, oral contraceptives, certain foods, fatigue, overuse of certain meds, sleep deprivation - migraines without aura is the most common type - its unilateral with moderate pain; may cause photophobia, phonophobia & nausea Tension-type - steady & constant feeling of pressure that usually begins in the forehead, temple or back of neck. - often bandlike or may be described as " a weight on top of my head" Cluster Headache - severe form of vascular headache. - Unilateral and come in clusters of 1 to 8 daily - excruciating pain localized to the eye & orbit, radiating to the facial & temporal regions - pain accompanied by watery eyes and may have crescendo-decrescendo pattern - attacks last from 15min to 3 hrs - pain described as penetrating Cranial arteritis - - fatigue, malaise, weight loss & fever. - inflammation; heat redness, swelling, tenderness, or pain, over involved artery - sometimes a tender, swollen, or nodular temporal artery is visible. - visual problems caused by ischemia of involved structures - cranial arteritis thought to be immune vasculitis Clinical Manifestation of Migraine Headaches - Recurrent headaches that last 4-72hrs - Has 4 parts 1. Prodrome (pre-headache) - depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea or constipation 2. Aura - Unilateral with moderate pain; may cause photophobia, phonophobia & nausea - last less than 1 hour - visual disturbance, numbness, tingling of lips, face, hands, mild confusion, slight weakness of extremity, drowsiness & dizziness 3. Headache - throbbing, intensifies over several hours. - severe & incapacitating - photophobia, nausea & vomiting - last 4 to 72 hours 4. Postdrome - pain subsides - muscle contraction in neck & scalp, with muscle ache & localized tenderness, exhaustion & mood changes - physical exertion exacerbates the headache pain. Foods to Avoid in Migraines - Foods containing tyramine, monosodium, glutamine, nitrates, wine, chocolate & milk products

use of IS

Types: volume and flow Device insures that a volume of air is inhaled and the patient takes deep breathes. Used to prevent or treat atelectasis/pneumonia. Nursing care Positioning of patient, teach and encourage use, set realistic goals for the patient, and record the results. Sit up as straight as possible. Do not bend your head forward or backward. Hold the incentive spirometer in an upright position. Place the target pointer to the level that you need to reach. Exhale (breathe out) normally and then do the following: Put the mouthpiece in your mouth and close your lips tightly around it. Do not block the mouthpiece with your tongue. Inhale slowly and deeply through the mouthpiece to raise the indicator. Try to make the indicator rise up to the level of the target pointer. When you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 3 seconds. Exhale normally. Repeat these steps 10 to 12 times every hour when you are awake, or as often as directed. Clean the mouthpiece with soap and water after each use. Do not use a disposable mouthpiece for longer than 24 hours. Keep a log of the highest level you are able to reach each time. This will help caregivers see if your lung function improves.

Complications of MS and to prevent them

UTI, constipation - Set schedule to promote bowel & bladder control, various drugs, intermittent self catheterization, Vit. C, antibiotics when needed Pressure ulcers, Contractures, Pneumonia - promote physical mobility, improve gait by minimizing spasticity & contractures - Prevent injury (MOST IMPORTANT) (Use of assistive devices) - Support sensory and cognitive functions Emotional\familial\marital\vocation problems may occur - strengthen coping mechanism with support groups - Home Care considerations Fatigue - Adequate rest periods - Avoid hot and cold environments (cool environments are recommendable) - Do not increase dosage on sedation/muscle relaxant medications

Seizure Pathophysiology

Uncontrolled and abnormal discharges that occur repeatedly resulting in dysfunction

Fluid Ouput

Urine - 1400 - 1500 or 0.5 ml/kg/hr Insensible lungs & Skin 300-400 mL/day Sweat 100 ml/day Feces 100-200 ml

Therapeutic Lithium level

Used as an antidepressant for Bipolar Disorder 0.6 - 1.2 mEq/L

EST most effective

Used primarily for Depression unrelived by other therapy or "treatment resistant depression"

attentive listening

Using all senses; listen actively Most important technique in nursing Requires energy and concentration Paying attention to total message Nurse focuses on clients needs Conveys an attitude of caring and interest Encourages client to talk Do not interrupt speaker Take time to respond appropriately

Palpation

Using the sense of touch. Pads of the fingers are used d/t their high concentration of nerve endings- makes them highly sensitive to tactile discrimination: Texture of hair; Temperature of skin; Position, size, consistency, and mobility of an organ/masses; distention of bladder. Light palpation should always precede deep palpation. - LIGHT: using dominant hand, place fingers parallel to the skin surface and press gently. Skin is lightly depressed. If it is necessary to determine presence of a mass, the nurse presses lightly several times rather than holding pressure. -DEEP: (Practitioner skill). Done with two hands (bimanually) or one hand. Extend dominant hand and then place nondominant hand on the dorsal surface of the three middle fingers. Top hand applies pressure, while the lower hand remains relaxed to perceive the tactile sensations.

dx of PE

Ventilation Perfusion Scan (V-Q Scan)

Inspection

Visual examination. Should be deliberate, purposeful, and systematic. Nurse inspects with the naked eye and with a lighted instrument (otoscope). In addition- olfactory and auditory cues are noted. Also use visual inspection to assess moisture, color, texture of body surfaces; shape, position, size, color, and symmetry of the body

Chronic Alcoholics have deficiency in what Vitamins.

Vit B & C

2 types of admissions in the USA

Voluntary Admission - up to 72hrs - pt agrees to hospitalization - may leave if desired - unless deemed unsafe to self and other (determined by psychiatrist) Involuntary Admission - minimum 72 hours - Baker Act by nurse practitioner, police officer, physician, judge because of risk to themselves or others - Marchman Act - mainly for substance abuse, petitiones mainly by a familymember or judge

Granulocyte

WBC with secretory granules in its cytoplasm, e.g., an eosinophil or a basophil.

Stress Vitamins

Water Soluble vitamins, like Vit. C, ascorbic acid, and B complex

diet in reference to DM

Weight reducing diet by reducing calorie intake. - Complex Carbs 60% (100% converted to sugar) - Fats 20% (10% converted to sugar) should be less than 30% of total calories, limit Sat. Fats to 10% of total calories, cholesterol less than 300 mg/day - Proteins 20% (50% converted to sugar) Meal Considerations: a. pt preferences, lifestyle, usual eating times, ethnic & cultural backgrounds b. high fiber diet decreases glucose levels by decreasing the rate of glucose absorption. c. grill or broil d. can only substitute within a group, crackers for bread, carrots for beans.

care of psychiatric pts

What is the ultimate goal of psychiatric nurse in taking care of a mentally ill patient? What is Milieu therapy? - Milieu Therapy: therapeutic environment; increase self-awareness; adaptive coping; relationship skills.

Need for increase in protein in diet

Wound, surgeries, burns

Medications for OCD

Xanax Buspar Klonopin Prozac Luvox Anafranil Zoloft

cyanosis

a bluish tinge to skin caused by decreased oxyhemoglobin (iron containing oxygen) binding in the blood or by decreased oxygen concentration of the blood

define tetany

a condition marked by intermittent muscular spasms, caused by malfunction of the parathyroid gland and a consequent deficiency of calcium

hospice

a coordinated program of interdisciplinary care and service, provide primarily in home

anemia

a decrease in RBC resulted in low hemoglobin and hematocrit

hyperpyrexia

a high fever such as 41c or (105.8F)

scoliosis

a lateral deviation of the spine

polyps

a mass of tissue from the mucosal surface that protrudes into the lumen of the bowel and can be found anywhere in the intestinal tract and rectum. S/S: rectal bleeding, lower abdomen pain and if large enough can cause an obstruction TESTS: history of s/s, digital rectal exam, barium enema, sigmoid or colonoscopy CLASSIFICATIONS: -neoplastic: carcinomas - sign of colorectal cancer is rectal bleeding and change in bowel habits -non-neoplastic: mucosal and hyperlastic -adenomatous [ benign epithelial growths]

definition of transcendence

a persons recognition that there is something other or greater than the self and seeking and valuing of the greater other, wheather it is an ultimate being force or value

a nurse is reviewing the laboratory findings ofr urinalysis of a client who reports urgency and nocturia. which of the following findings should the nurse report to the provider?

a positive leukocyte esterase = the client who has a positive leukocyte esterase indicates 68%-88% positive urine for UTI and the nurse should report this finding to the provider

hernia pathophysiology and nursing interventions

a protrusion of internal body organs through the muscular wall COMMON ISTES: -umbilicus - children and obese -groin [inguinal] - males -hiatal [epigastric] opening of diaphragm where esophagus passes through, becomes enlarged and stomach moves up and through this opening along a healed incision site. RISK FACTORS: -lifting heavy objects -chronic cough -straining to void/defecate -sneezing S/S: -lump or local swelling at the site -pain when peritoneum becomes irritated or w/ incarcerated and strangulated -possible intestinal obstruction -hiatal hernia: more GI symptoms [heart burn, regurgitation and dysphagia] CLASSIFICATION: -reducible - protruding organ can be returned to its proper place -irreducable [incarcerated] - organ is tightly wedged outside cavity and cannot be pushed in -strangulated - part is not replaceable and blood supply is cut off completely INTERVENTION: surgical release if s/s are severe. treatment [hiatal hernia] -weight reduction -small frequent meals -avoid tight fitting clothes around abdomen -antiacid - only for intermittent symptoms -elevate HOB at meals -do not eat before bed -avoid etoh, chocolate, fat, spices and smoking

pancytopenia

a reduction in the number of red and white blood cells as well as platelets

vertigo

a sensation of whirling and loss of balance, associated particularly with looking down from a great height, or caused by disease affecting the inner ear or the vestibular nerve; giddiness.

jaundice

a yellow or green hue to the skin occuring

abducton and adduction

abduction: Movement of the bone away from the midline of the body adduction: Movement of the bone toward the midline of the body

mobility

ability to move freely, easily, rhythmically and purposefully in the environment

treatment for pancytopenia in cancer pts

abnormal decrease in WBCs, RBCs, and platelets

pleural effusion

abnormal fluid that expands in the pleural space leading to compression or collapse of lung such as dyspnea, cough, chest pain, anxiety/fear of suffocation, general malaise and weight loss

tachypnea

abnormal rapid breathing

a nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. which of the following data collection findings should the nurse report to the provider immediately?

absent urine output for 2hr = requires immediate intervention by the nurse. this indicates kidney disfunction or obstruction and the provider should be notified immediately

How to identify food allergies or intolerance on infants

add one food every 5 days

a nurse is caring for a client who has a urinary tract infection. the client reports pain and burning sensation upon urination, and cloudy urine with an odor. which of the following is the priority intervention by the nurse?

administer antibiotic = the greatest risk to the client is injury to the renal system from the UTI. therefore the priority intervention is to administer antibiotics.

a nurse is caring for a 13 month old toddler. cellulitis. tylenol 120 mg q4h for fever >101°F. whats the action to take?

administer as prescribed within the normal range for a 13 mnth old.

what is addison crises?

affects the cortex, too little steroids. sudden with withdrawal of steroid therapy. never just stop steroid therapy, slowly take the drug off!

MDI inhaler use

after using inhaler, rinse mouth thoroughly with water and split out. do not swallow 1. observe for side effects: -tachycardia, dysrhythmia, cns excitation, n/v 2. evaluate effectiveness -monitor for decreased SOB, wheezing, crackles, loosened secretions and anxiety 3. give treatment before meals to avoid n/v and reduce fatigue that accompanies eating

antiseptic

agents that inhibit the growth of some microorganisms; primarily used on skin or tissue

wheezing

air passing through a constricted bronchus as a result of secretions, swelling tumors -continuous , high pitched, squeeky musical sounds. best heard on expiration. not usually altered by coughing

crackles

air passing through fluid or mucous in any air passage -fine short, interrupted crackling sounds; alveolar rales are high pitched. sound can be simulated by rolling a lock of hair near the ear. best heard on inspiration but can be heard on both inspiration and expiration may not be cleared by coughing

gurgles [rhonchi]

air passing through narrowed air passages as a result of secretions, swelling tumor. continuous, low pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. best heard on expiration but can be heard on both inspiration and expiration

Dietary problems

allergies, chewing, swallowing

influenza vaccine

allergy to eggs should not take flu shot

patients at risk for skin breakdown

altered hydration [dehydrated]

brady therapy

an advanced cancer treatment that places radioactive seeds or sources in or near the tumor, giving a high radiation dose to the tumor while reducing the radiation exposure in the surrounding healthy tissues. it is given at a short distance: localized, precise and high tech

an ileostomy produces liquid fecal drainage, constant and cannot be regulated. contains some digestive enzymes which are damaging to the skin for this reason clients must wear and appliance continuously to prevent breakdown. colostomy is opening to the colon large bowel

stool from a colostomy vs an ileostomy

Overweight/Obesity

an imbalance between food eaten & energy expended

Time orientation

an individuals focus on the past, present or future.

otoscope

an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses.

immobility

an interruption of mobility

Nursing Care Interventions for a Patient with UTI

antimicrobial therapy, antispasmodic therapy, analgesia, heat to perineum, liberal amounts of fluid, avoid urinary irritants, frequent voiding

acute

appear suddenly or last short time

exacerbation of RA swelling and warmth at site, relieve discomfort by:

applying cold packs to reduce inflamation

touch and communication

appropriate forms of touch to reinforce caring, it is non verbal, therapeutic touch for pt w/ hearing impaired or AMS or comatose pt to insure message intended is recieved, handshake or touching shoulder,

Complications of MI

arrhythmias especially sudden deat VT or VF -cardiogenic shock -pericarditis -chronich CHF and pulmonary edema -ventricular rupture

client has terminal Ca. will give opiods. pts sister says he used to get IV meds and wants to know why pills?

as long as you can swallow this is the best route for this you can not be vomitting, it is best because it is inexpensive, convinient, and noninvasive.

a nurse will admin dilaudid [hydromorphone] 4 mg PO to a postop pt. after the nurse opens the packet the pt syas no meds. what do you do?

ask another RN to witness you throwing it away this is a schedule 2 controlled substance that requires 2 licensed nurses to witness the disposal of unused doses.

client is 2hr postop and has received ipiod analgesic. what action should provide the nurse with the best data to determine the clients need for analgesia?

ask the client to rate her pain level asking the cleints to rate her pain level will provide a verbal report of pain, which is the best indicator of the need for pain medication

guidelines when applying restraints

assess every 30 min remove and do ROM and assess skin every 2-4 hrs if temporarily removed, do not leave unattended

insulin

at 90° angle

primary open angle glaucoma and scheduled for sx. what medication to report to the charge nurse?

atropine in the presence of primary open angle glaucoma, increased intraocular pressure occurs. atropine is contraindicated for a cleint who has primary open angle glaucome because it increases the intraocular pressure

prevent gastroesophageal reflux with a pt who has a hiatal hernia.

avoid alcohol and milk

tetracycline hydrochloride [sumycin] for h pylori. what to reinforce?

avoid exposure to sunlight this medication causes photosensitivity and increased sunburn.

spirinolactone [aldactone] teaching

avoid using salt substitues K sparing diuretic. salt substitutes are high in K. and can place client at risk for hyperkalemia.

most common work related threat for healthcare providers

back and shoulder injuries

national patient safety goals

based on recent reports, national rganizations [JCAHO] have increased their awareness of the need to improve pt safety. - reconcile medications across the continuum: [ meds pt is taking at home compared to those that the pt is taking while hospitalized]

how to collect a time urine specimen

before collecting empty bladder. then wait to collect in bucket for 24 hrs

how to collect a time urine specimen

before collecting empty bladder. then wait to collect in bucket for 24 hrs also if catheter is in place you may use syringe to collect specimen and then place into cup or tube.

Cultural Competence

being capable of understanding, respecting, and attending to the total context of the clients situation and use a complex combination of knowledge, attitudes and skills to deliver effective care

a client who is menopausal asks the nurse about the use of herbal therapy to treat hot flashes. which of the following herbal supplements should the nurse recomend?

black cohosh = the action of black cohosh is unknown. however, research studies indicate is is useful in the treatment of menopausal symptoms, including hot flashes

MS teaching

bladder training

hematuria

blood in the urine

normal FBS

blood sugar <100 mg/dL diabetic BS greater than or equal to 126mg/dL

common artery used to access BP

brachial artery

Protein Digestion

broken down into Amino Acids

Clinical Manifestations for UTI

burning when urinating, frequency, dysuria, hematuria, nocturia, urgency, incontinence, supra-pubic/pelvic/back pain

care of pts and s/s of UTI

burning when urinating, frequency, dysuria, hematuria, nocturia, urgency, incontinence, supra-pubic/pelvic/back pain antimicrobial therapy, antispasmodic therapy, analgesia, heat to perineum, liberal amounts of fluid, avoid urinary irritants, frequent voiding

colorectal cancer pathophysiology and nursing interventions

cancer of the colon or rectum, located at the lower end of the digestive tract. COLOSTOMY: -ascending: .watery/uniformed stool .usually temporary and helps the bowel to rest and heal -transverse: middle of abdomen .also temporary .stool is semi-liquid and discharge is unpredictable -sigmoid: lower portion of abdomen .most common permanent colostomy .treat cancer of rectum .stool is well formed .movement may occur only once a day or every other day ILEOSTOMY: -performed to drain fecal matter -stool is liquid and contains digestive enzymes that are highly irritating to the skin -pouch ilesotomy frees pt from the need to wear a collection device INTERVENTIONS: -have a positive and cheerful attitude toward the pt. do not make faces when cleaning the ostomy bags -measure I&O -empty and clean pouch when half full -clean peristomal area -provide active listening, emotional support and understanding -allow pt to express themselves -pt education: .controlling odor .preventing blockage

intervention to prevent catheter associated with UTI

catheterize only when necessary aseptic technique sterile equipment mantain closed system dont disconect unless absolutely needed good handwash perineal care prevent cntaminaion in incontinent pt

Review the components of related to chain of infection.

causative organism reservoir route of transmission susceptibility portal of entry

opportunistic pathogen

causes disease only in a susceptible host. [someone at risk for infection]

dysplasia

cells that are different in size

COLDERR

character onset location duration exacerbation relief radiation

urge incontinence

characterized by loosing a considerable of urine for no apparent reason after feeling a certain urge need to void. ex: urinating more than 8x a day or 2 times a night. pee alot!

after discontinuing a foley, what is important for you to check?

check for discharge on tip of catheter, make sure they void

assessment for skin turgor

check skin under clavivle where there is usually no exess; should return immediately

what is a carcinogen?

chemicals, physical factors, and other agents that cause cancer

chk for skin irritation if red around area when stoma is out its bad where you put the actual bag you cut 1/16 to 1/18 bigger than stoma if stoma looks purple or brown report normal is red beefy to empty the pouch from 1/3-1/2

ostomy care

ulcerative colitis

chronic inflamation and ulceration of the mucosal layer of the colon and rectum with periods of remission and exacerbation PATHOPHYSIOLOGY: lesions are continuous

crohns disease pathophysiology, clinical manifestations, and nursing interventions/priorities

chronic inflammation and ulceration of the mucosal layer of the colon and rectum with periods of remission and exacerbation PATHOPHYSIOLOGY: inflamation extends thru all layers of bowel [ transmural] lesions are not continuous [ cobblestone appearance] S/S: -prominent abdominal pain and cramping after meals because of persitalsis stimulation -diarrhea occurs in 90 % of cases, blood, mucoid stool and dehydration. -weight loss due to anorexia and n/c [pt does not want to eat to avoid pain] and secondary anemia -intraabdominal abscesses resulting in fever and leukocytosis -rectal bleeding mild or severe because of the ulcerations -malaise begins to look thin and emaciated because of the ulcerations -malaise - begins to look thin and emaciated because of decresed intake and malabsorption and fluid loss INTERVENTIONS: -observe number and character of stools; determine if there is a relation between diarrhea and foods eaten or meal times. -auscultate bowel sounds -measure I and O .asses for FVD .encourage oral intake or mantain IV -daily weight -monitor for s/s of internal bleeding and anemia -monitor labs for electrolyte imbalance -bed rest to decrease peristalsis and consere energy [still do ROM and joint excercises] -relieve pain: anticholinergic med 30 mins before meals to decrease motility, analgesics, change positions, heat and diversional activities. -give antidiarrheals -preventing skin breakdown: perineal care, barrier cream and pressure reducing devices used and frequent turning of bedridden pts

differentiate between chronic hypoxia and late sign of hypoxia

chronic is due to insufficient oxygen content of inspired air. a sign of such are dubbed fingers. cyanosis is the late sign of hypoxia where distal parts turn blue such as fingers, toes, lips, and face

a client who has pseudomonas aeruginosa is admitted to the hospital and is started on a therapeutic dose of gentamicin [garamycin]. when reviewing the medical history of the cleint, which of the following should cause the nurse to notify the primary care provider?

chronic renal insufficiency gentamicin is nephrotoxic. therefore it is important for the nurse to notify the provider in order to monitor the cleint BUN and serum creatinine levels.

how do you obtain a sterile specimen?

clean catheter w/ alcohol swab and then use the correct syringe

mix insulin

clear to cloudy R to NPH = withdrawal NPH to R = put in Air

behavioral management

client is danger to self and others

a client comes into an ambulatory clinic and announces with great enthusiasm "i am an expert at all things medical as they apply to me and i require ambien" the pupils are dilated and his HR and BP are elevated. the nurse should suspect intoxication of

cocaine typically have tachycardia, an elevated BP, and dilated pulis; also they display grandiosity and euphoria. this clients behavior and physiological data indicate cocaine intoxication.

stool softening medications

colace and surfak

atelectasis

collapse of the air sacs

hx fo breast Ca. birth control Q,

combination of oral contraceptives this type of contraception is contraindicated because it increases estrogen which may lead to growth of remaining breast Ca, cells.

polycythemia

condition that increases lematocrit value; increase in RBC concentration in the blood in CCOPD, the body attempts to improve O2 carrying capacity by producing increasing amounts of RBC

Prevention of Spread of STD:

condoms, abstinence, education, wash hands

skin

considered first line if defense

Planning/Implementation of diet

consult a dietician, social service

fever for whatever reason comfort measures

cooling blanket to cool and keep normal temp

counting for unstable pt and assessment

count for one full minute

counting pulse for unstable pt and assessment

count for one full minute

dehydration

creatinine is elevated

toddlers

curious like to feel and touch. you need a toddler proof home

melena

dark sticky feces containing partly digested blood

What is coping?

dealing with change looking for adaptation. It can be successful or unsuccessful

teaching to a pt who has fam hx of CAD.

decrease red meat because of saturated fat limit ti 5 oz per day

Describe constipation

decreased activity, low liquid and fiber, muscle weakness - fewer than 3 bowel movements per week - dry, hard stool or no stool - additional re-absorption of water (slow peristalsis) - increased effort or straining - decreased appetite - headache - abdominal pain, cramps or distention - sensation of incomplete bowel evacuation - painful defecation CAUSES OF CONSTIPATION: - insufficient fiber intake - insufficient fluid intake - insufficient activity or immobility - irregular defecation habits - change in daily routine - lack of privacy - chronic use of laxatives or enemas - irritable bowel syndrome - pelvic floor dysfunction or muscle damage - poor motility or slow transit - neurological conditions (stroke, paralysis) - emotional disturbance medications (opiates, iron salts)

a client aks the nurse how metformin [glucophage] helps manage DM

decreases glucose in the liver

large intestine [colon]

defined as a muscular tube lined with mucous membrane. it has muscle fibers that are circular and longtitudonal. it also has Haustra: that are pouches in the large intestine due to the longtitudonal muscles being shorter than the colon the colon main functions include absorption of water and nutrients, mucoid protection of the intestinal wall, and fecal elimination

a nurse is reviewing instructions with a client before a mammogram. which of the following should the nurse instruct the client to avoid prior to the procedure?

deodorant or powders = can affect the accuracy of a mammogram by causing a shadow to appear

Care of People with BPH

depends on the cause, severity of obstruction and pts condition. MEDICAL: catherize if pt is unable to void, treat for UTI, alpha adrenergic receptor blockers [hytrin] relaxes smooth muscle of bladder and prostate, hormonal manipulation with proscar SURGICAL: same as for Ca.

Complication of overweight

diabetes

a nurse is assisting with the admission assessment of a client who has a kidney stone. which of the following is an expected finding?

diaphoresis = a clinical manifestation associated with a kidney stone

dietary factors play a huge role fiber give fecal vol fluid daily income 2000-3000 activity promotes bowel movement peristalsis

teaching patient about how to mantain normal bowel habit [fluids, activity, diet]

dietary factors play a huge role fiber give fecal vol fluid daily income 2000-3000 activity promotes bowel movement peristalsis

dyspnea

difficult or labored breathing

dyspnea s/s

difficult or labored breathing : SOB

dysuria

difficult or painful orination

after bronchoscopy what to report?

diminished breath sounds may indicate pneumothorax or laryngeal edema

how does an enema work

distends the intestine irritates the mucosa increasing peristalsis cause excretion of feces and flatus

care for a pt who is taking digoxin [ lanoxin ] for s/s of HF. which of the following meds ic=ncrease risk for digoxin toxicity?

diuril the combo fo digoxin and chlorothiazide increases the risk of developing toxicity due to the chance of developing hypokalemia

a nurse is assisting with discharge of a client who has had an anterior and posterior colporrhaphy. which instructions should the nurse provide?

do not engage in intercourse for at least 6 weeks = to allow time for surgical site to heal

care of a retention catheter and a condom cath

do not make tight because of circultion reasons

inflamatory bowel disease mesalamine [asacol].

do not stop medication should be taken for at least 3-6 wks daily

what info do you need before you insert a foley?

doctors orders, and last time voided

Anemia in adolescent girls

due to the start of meneses

guillain-barre syndrome, what s/s confirm cranial nerve involvement?

dysphagia, dysphasia, diplopia

elders have alot of constipation reduceced activity low liquid and fiber, muscle weakness

physiological changes in the elderly when it comes to fecal patterns

elders have alot of constipation reduceced activity low liquid and fiber, muscle weakness

signs and symptoms of diarrhea and what can occur

electrolyte imbalance, loss of potassium

CT scan with IV contrast. lab to report?

elevated creatinine risk for developing contrast induced nephropathy

Junk foods

empty calories; high calorie, low nutrient ratio

What is narcolepsy?

excessive daytime sleepiness

factors affecting respirations

exercise, stress, environmental temp., medications, increased altitude

murmur

exessive blood flow through the heart valves

Purpose of cardiac rehab

extend and improve quality of life -return to normal or as near normal life-style. -not to change life but only make modifications -center on what you can do not what you cant. -answer questions honestly -begins as soon as pt is symptom free.

biggest inhibitor in communication

failing to listen

diagnostic test for DM

fasting plasma glucose DM equal to or greater than 126mg/dL -casual plasma glucose greater than or equal to 200 mg/dL -oral glucose tolerance test 2 hrs greater than or equal to 200mg/dL

lisinopril [zestril]

fcan cause build up of bradykin. resulting in a nonproducting cough.

Malnourished pregnant woman

fetal & infant morbidity increased

Clinical Manifestations associated with TB

fever - low grade weakness, malaise cough with mucopurulent sputum (rust color) weight loss recurring fever with chills, night sweats anemia hemoptysis

constipated stool

fewer than 3 bowel movemnts per week, dry, hard or no stool -additional reabsorption of water [slow peristalsis -increased effort or straining -decreased appetite -headache -abdominal pain, cramps or distention -sensation of incomplete bowel evacuation -painful defecation

Extracellular fluid

fluid found outside the cells 1/3 of all body fluids 15 Liters - responsible for carrying nutrients and waste products to and from the cell - principal electrolytes are Na+ (sodium), Cl- (chloride), and bicarbonate (HCO3-)

Intracellular fluid

fluid found within the cells of the body 2/3 of all body fluids 25 Liters - metabolic processes of cell take place, oxygen, glucose, potassium, magnesium - Principal cations K+ (potassium), Mg+ (magnesium) -Principal anions HPO4- (phosphate), SO42- (sulfate)

exudates [drainage]

fluid that escapes from the blood vessels and include dead phagocytes, dead cells and serious sanguouns fluid

What ETOH intake prevents

food intake, impaired absorption, reduced storage, increased metabolic needs, impaired use of nutrients, especially water soluble vitamins C & B complex

base of support

foundation on which the body rests. widening base of support, spreading feet apart.

diarrhea

frequent passage of liquid / semi-liquid stool for more than 3 days CAUSES: illness, food poisoning [viral/bacterial infection], excessive stress, and inflammation of the bowel or certain meds. -mild diarrhea is NOT treated; persistent [24-48] hrs. risk of dehydration and electrolyte imbalance and is treated. INTERVENTIONS: -monitor I&O -medications -fluid/electrolyte replacement [po/iv] -monitor for s/s of dehydration -avoid coffee, tea and carbonated drinks. they are gastric stimulants and increase peristalsis -handwashing and PPE -rectum must be protected from excoriation -0relieve odor w/ deodorizing spray and cleaning bedpans / commodes quickly

snellen chart

from 20 feet, one eye is covered; the line with the smallest letters able to be read is not. -test with glasses, then without -20/20 OD and 20/20 OS and 20/20 OU -numerator is number of feet = 20 -Denominator is the distance at which the eye can read it compared to the norm. 20/40 = at 20 feet from the chart, the person can read from 40 feet away) this chart is for people who cannot read

how do you clean the perineal area?

front to back

self care for pt with amstectomy after radiation therapy

gently wash with soap and water

non verbal communication

gestures/ facial expressions/ touch, more widely used, important for nurses to learn

allopurinol

given to chemo pts to reduce the formation of uric acid in association with tumor lysis syndrome

a nurse is monitoring a client who is receiving repaglinide [prandin] for type 2 DM. which of the following lab tests should thenurse plan to review to obtain information about the long term therapeutic effect of this medication?

glycosylated HbA1c measures the average of blood glucose levels over the past 2-3 months. therefore the nurse shoul review this lab test to obtain information about the long term therapeutic effect of repaglininde

Care of the Patient with a Urinary Diversion and Stoma:

good hygiene is necessary, make sure collection pouch is well fitting, when cleaning a gauze may be placed inside the stoma to prevent leakage, most collection bags are used for 3-7 days and should be emptied when 1/3 to 1/2 full so it does not pull off. Nurse must asses color and mucous, monitor patency of drainage tube, wash stoma and asses stoma and area around stoma, if cecostomy catheter is performed must be irrigated 2-3 times daily to remove mucous, catherization is done with a water soluble catheter

active ROM exercises

head tilts/ turns shoulder movements [up/down/ side to side/ rotations] wrist bends finger bends hip and knee bends leg lifts and rotations

How to assess for anemia

hemoglobin

drive to breathe in healthy individuals

high levels of CO2 in pts with COPD: low levels of oxygen

Nursing diagnosis for morning sickness

high risk for fluid volume deficit

Foods eliminated in High Blood Pressure

high sodium foods

foo drop / prevention

high top sneaker? wtf did she say?

spinal chord injury. what can assist in preventing the development of an achiles tendon contracture?

high top tennis shoes prevent footdrop by keeping the clients feet in proper alignment

nosocomial infection

hospital acquired

55 yr old has vaginal dryness and hot flashes. what is a contraindication to hormone therapy?

hx of blood clots estrogen increases risk for blood clots.

Increased water in take is necessary when

hyperventilation - rapid breathing diaphoresis - profuse sweating from heat, exercise or fever diarrhea & vomiting

a nurse is caring for a cleint who has beent aking celecoxib [celebrex] for the past month. the nurse should recognize that which of the following statements by the client indicates a therapeutic response to this medication

i am able to move without feeling pain cyclo-oxygenase [COX-2] inhibitors acts by suppressing inflamation and relieveing pain. this will allow the client to move more easily.

`a nurse is collecting data from a client admitted for an anterior colporrhaphy. the nurse should recognize that which of the following client statements validates the need for this type of surgery?

i have had a frequent UTI = due to urinary stasis associated with cystocele, this finding is consistent with a cystocele. the surgery of a cystocele is an anterior colporhhaphy

discharge teaching, phenytoin [dilantin]

i should massage my gums regularly decrease the likely hood of the cleint developing gingival hyperplasia

teaching about risk for falls further teaching

i understand all 4 siderails will be up in bed remember if all 4 are up it is a restraint. nurse should raise only 2

reinforce teaching with a client who has had an exacerbation of rheumatoid arthritis and has been prescribed 40 mg prednisone daily. understanding of teaching?

i will call dr if i have a sore throat it is an early sign of infection. glucocorticoids, such as prednisone, suppress the body's immune response, increasing the risk for infection. the cleint should notify the provider.

a nurse is reinforcing teaching with client who becomes easily fatigued and dysneic. further teaching if:

i will complete personal hygene in the AM no because you will be tired a.f. do one by one with a schedule take yo time

teaching about a PICC line. needs further teaching if:

i will get a cxr before procedure false: it is after the procedure to make sure it is in place.

furosemide [lasix] for HF. client needs further instruction if they state:

i will see my pcp every week for BP they should know how to take their own BP or have a family member monitor it twice a week. notify only if it is out of range

pathophysiology of DM

if BS is not managed, glucose can attack organs and other systems

know the complications of DM

if blood sugar is not managed, glucose can attack organs and other systems

Clinical Manifestations of Testicular Cancer

if it's in the early stages there are no signs, later signs include urinary obstruction, hematuria, bloody semen and painful ejaculation

graphestesia

if motor impairment is present draw a number on pts hand and ask to identify

correct height of a walker

if the handle bars are slightly below the waist and the elbows flexed its a good height

neurogenic bladder

impaired neurological function can interfere with the normal mechanism of elimination

Role immigration plays on culture

in 2007, 38.1 million were foreign born. 12.6% of the U.S. population

pallor

inadequate circulating of blood or hemoglobin and subsequent reduction in tissue oxygenation. Absence of normal skin color (whitish grey tinge). In brown-skinned patients pallor may appear as a yellowish brown tinge, patients may also appear ashen gray. • Pallor is most evident in areas with the least pigmentation: conjunctiva, oral mucous, nail beds, palms of the hand, and soles of the feet

Constipation intervention in pregnant women

increase fluids, fiber, avtivity

cardiovascular exercise

increase heart rate, increase strength of heart muscle contraction,, increase cardiac output 30L/min - 5L/min

albuterol [proventil] s/e

increase in HR activates beta 2 adrenergic receptors in the heart

a nurse is caring for a cleint who is taking phenylephrine [neo-synephrine]. the nurse should plan to monitor the cleint for which of the following s/e?

increased HR due to cardia effects, phenylephrine may cause tachycardia and other cardiac arrhythmias

cirrhosis of the liver, late s/s

increased serum ammonia

a cleint is taking furosemide sulfate [feosol] orally. what indicates a desired outcome when said by the cleint?

increased tolerance to exercise it may be prescribed to treat iron deficiency anemia. clients with anemia experience fatigue and SOB. improvement of Hgb lvls increase O2 transport to the tissues and increase activity tolerance.

What is anger?

individual or family may direct anger to staff or nurse about things that normally wouldn't trouble them

a nurse is providing support to a client who has a recent diagnosis of endometriosis. the nurse should reinforce with the client that which of the following conditions is a complication of endometriosis?

infertility = a complication of endometriosis because endometrial tissue overgrowth can block fallopian tubes

conjuctivitis

inflamation of the bulbar and palpaebral conjuctiva. may result from bodies, chemicals, allergenic agents, bacteria and viruses. redness, itching, macropurulent discharge during sleep, the eye may become encrusted and malted together

s/s of conjunctivitis

gastritis nursing interventions, pathophysiology and nursing interventions

inflammation of the mucous membrane lining the stomach PATHOPHYSIOLOGY: gastric mucous membranes become edematous and hyperemic [fluid blood]; there is also a superficial erosion; can lead to hemorrage INTERVENTIONS: Acute: -NPO untilsymptoms subside than a non irritiating diet -IV for severe dehydration or N/V -antacids to dilute and neutralize stomach environment -avoid caffeine, ETOH, and nicotine -surgery to remove gangenous or perforated tissue [extreme case] Chronic: -avoid foods that produce attacks -H2 receptors antagonist to decrease acid secretions and change pH -Rest

appendicitis assessment, s/s, nursing interventions/management, nursing priorities and complications

inflammation of the vermiform appendix due to obstruction and eventually infection CAUSE: bacteria passes through the intestinal tract and infects the pouch; common in males and teenagers. S/S: -pain in lower right side [McBurneys point] -low grade fever -N/V -increased WBC [>10,000 leukocytosis] -possible anorexia -rebound tenderness -rovsing sign: tenderness felt on right side when palpating left side -abdominal distention if ruptured TREATMENT: -Pre-op: .NPO .ice bag for inflammation and avoid rupture .no laxatives or heat .antibiotics and IV fluids -Post-op: .semi flowlers to decrease tension on sutures .narcotics for pain relief .diet advanced as tolerated COMPLICATIONS: perforation that can lead to peritonitis and abscess formation

the sequence used to examine the abdomen

inspection auscultation [prior to palpation] percussion palpation examination, of the rectum and anus [inspection and palpation]

venturi mask

instruct and encourage pt in diaphragmatic breathing and effective coughing

what contributes to consipation

insufficient fiber intake, insufficient fluid intake, insufficient activity or immobility, irregular defecation habits, change in daily routine, lack of privacy, chronic use of laxatives or enemas, irritable bowel syndrome, pelvic floor dysfunction or muscle damage, poor motility or slow transit, neurological conditions [stroke, paralysis], emotional disturbance, medications such as opiates, iron salts.

what is the purpose of an enema?

intended to remove feces: prevent the escape of feces during surgery, prepare the intestine for certain diagnostic tests, remove feces [constipation, impaction], generally- height: NO higher than 30 cm [12in] above rectum

Define urinary catheterization (indwelling catheter)

intro of catheter through the urethra into the bladder (last resort)

infection

invasion of body tissue by micro organisms and their proliferation [growth] -asymptomati: no evidence of disease no s and s - infectious: presence and evidence of disease

urinary incontinence

involuntary leakage of urine or loss of bladder control

stress

involuntary loss of urina associated w/ activities that increase stress in the abdomen and bladder ex: sneezing, coughing, lifting, sex, laugh, and abs,

stress incontinence

involuntary loss of urine associated w/ activities that increase stress in the abdomen and bladder ex: sneezing, coughing, lifting, sex, laugh etc.

enuresis

involuntary urination in children beyond the age when voluntary bladder control is normally acquired usually 4-5 year of age

nocturnal enurisis

involuntary voiding during sleep [bed wetting]

Nutritional deficiency in preschoolers

iron deficiency anemia

metoclopramide [reglan]

is a treatment for gastroesophagea reflux. should administer 30 min prior to meals and at bedtime.

cleaning

is chiefly done for hygiene

PSA prostate specific antigen

is ised in screening for prostate used for cancer progression

What is sleep deprivation?

itchy eyes, headache, blurred vision, decreased judgment and concentration, difficulty remembering things

amoxicillin [amoxil]. which finding should the nurse report to the provider?

itchy rash life threatening allergic response such as anaphalaxis. itchy rash is a s/s. withold the med!

How to assess improvements

labs: CBC

anuria

lack of urine production output less than 50mL/day

how to assess for mental status / memory

language: expressing self by verbal / written / signs defects due to disease / injury are called aphasia sensory or receptive aphasia = loss in ability to comprehend spoken / written words MEMORY: immediate recall = information presened seconds ago. recent memory =information presented earlier in the day long term memory = info from months or yrs ago MENTAL STATUS: orientation, person, place, time and situation -aphasia: partial or total loss of the ability to articulate ideas or comprehend spoken or written language resulting from damage to the brain caused by injury of disease -ataxia: loss of the ability to coordinate muscular movement

Food contradictions for infants

large pieces or hard texture (can't chew)

nursing intervention/patient falling while ambulating

let the patient smoothly drop to the floor use your foot. call for help

a nurse is caring for a cleint with neutropenia.

limit visitors to healthy adults limiting visitors to healthy adults minimizes the cleints risk of exposure to infection

local infection

limited to the specific part of the body where micro organisms remain

care of pt pre and post thyroidectomy

list 2 things that the nurse may be worried about post thyroidectomy surgery -airway status [resp., cough, swallowing] -> blood. -difficulty breathing [airway] -tetany caused by inadvertent removal of the parathyroid glands during surgery NOTE: calcium gluconate and trach kit at bedside, monitor Ca levels q8h why do we keep a trach setup and calcium gluconate at the bedside with pts post thyroidectomy -trach setup for breathing problems caused by bleeding occlusions or swallowing omplications. -calcium gluconate just incase calcium levels drop caused by inadvertent removal of the parathyroid glands during surgery.

location for apical pulse

listening at the bottom of the heart

CRF and hyperkalemia

look for bradycardia an irregular slow heart rate can occur as a result of hyperkalemia

pt is taking digoxin [lanoxin] for 1 mtnh. s/s of toxicity?

look out for vomitting

incontinence

loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter, at specific times [after meals] or irregularly, there are 2 types: partial and major. partial: cannot control flatus, or minor soiling. major: cannot control feces of normal consistency. causes emotional distress and/or social isolation dysfunction of anal sphincters- vaginal delivery, surgical procedures [repair or colostomy], trauma, tumors. decreased rectal compliance. impaired rectal rectal sensation: diabetes mellitus, multiple sclerosis, dementia, meningomyelocele, spinal cord injuries

What can malnutrition cause in the 2nd and 3rd trimester in a malnourished pregnant woman

low birthrate (LBW) and a higher incidence of complication.

oliguria

low urine output, usually less than 500mL a day or 30mL an hour for an adult

teaching about regular insulin humulin R. cleint states understanding

make sure insulin is clear before drawing it up. regular insulin is clear, and if it is cloudy do not use!

how many inches do you expect to insert the urinary catheter on a male or female?

male: lube 6-7" insert 7-9" female: lube 1- 1 1/2 insert: 2-2 1/2

chrons disease, reinforce what?

mantain a low fiber and little residue to control pain and inflamation in the small instestine

pt type 1 DM. post op amputation of right big toe.

mantain normal glucose lvl diet high in protein wear soft cotton socks

impacted stool

mass or collection of hardened feces in the folds of the rectum, results from prolonged retention and accumulation of fecal material

airborne transmission

may involve droplets / dust that contains infectious agent

why rotate insulin sites

may lead to trophy or hypertrophy of local tissue and leads to decrease of insulin absorption

chronic

may occur slowly over a long period of time and last several months/ years

Food high in iron

meat, raisins, spinach, beets, beans, peanut butter, whole grains, iron fortified cereals, eggs

Nursing Interventions Associated with PMS Including Diet:

meditation, imagery, creative exercises, moderate exercise, PMS support groups; diet - avoid caffeine, high fat foods, alcohol, nicotine, refined sugars and salt and should consume whole grains, fruits, veggies, increase water, vitamin b, e, calcium, MG and oil of evening primrose capsules

treatment for PMS

black tarry stool

most common for newborns

Birth weight

most important predictor of subsequent development

Osmosis

movement of water molecules across a semipermeable membrane, from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane

a cleint is prescribed atorvastatin [lipitor] and fenofibrate [tricor] for hypercholestoremia. which of the following should the nurse recognize as an adverse effect of this medication combination?

muscle pain both these medications can cause myopathy; therefore, the cleint is at an increased risk for myopathy than if either medication is taken alone.

post thyroidectomy, parathoid gland injury?

muscle twitching common complication is parathyroid injury leading to hypocalcemia. may have twitching and numness and tingling of fingers, toes, and around the mouth

legal implications of restraints

must be properly documented by institutions standards

MRSA pt visitor warnings

must wear gown and gloves

4. Know what medications can harm the eyes and vision

mydriatics: produce mydriases= pupil dilation action: vasodilate causing dilation of the pupil note: caution when used in glaucoma because it will increase the intraocular pressure corticosteroids and NSAIDs: topical, oral, and perenteral routes -shake topical eye drop suspensions several times side effects: glaucoma, cataracts, infection, impaired wound healing, mydriases, ptosis, high IOP

pallor

nadequate circulating of blood or hemoglobin and subsequent reduction in tissue oxygenation. Absence of normal skin color (whitish grey tinge). In brown-skinned patients pallor may appear as a yellowish brown tinge, patients may also appear ashen gray. • Pallor is most evident in areas with the least pigmentation: conjunctiva, oral mucous, nail beds, palms of the hand, and soles of the feet

older adults

need reular vision tests and hearing tests

Anions

negatively charged electrolytes Cl-, HCO3-, HPO4-, SO42-

total incontinence

no pee no poop at all ._. complete loss of urinary or fecal control.

Clinical Manifestations for a Patient with Pyelonephritis

no symptoms unless exacerbation they include - fatigue, headache, anorexia, polyuria, excessive thirst, weight loss

Purpose of a echocardiogram

non invasive ultrasound test that is used to measure the ejection fraction of the heart and the size, shape and motion of the cardiac structures. may take from 20 to 30 minutes. done at the chest wall to record signals. -TEE: transesophageal: provides clearer images because the ultrasound waves pass through less tissue. <-invasive.

eupnea

normal quiet breathing

Nursing diagnoses associated with culturally responsible nursing care

nursing diagnoses developed by NANDA are based on western culture. Incorporate clients understanding their diagnoses

Non Essential Nutrients

nutrients than can be made by the body

Nutritional requirement of an adolescent

nutritional needs are higher, including calories, protein, calcium, & vit B to metabolize increase in nutrients eaten

adventitious breath sounds

occurs when air passes through narrowed airway or airways filled with fluid / mucus; or when pleural linings are inflamed. absence of breath sounds over some lung areas is also a significant finding associated with collapsed and surgically removed lobes; or severe pneumonia [crackles aka rales, gurgles aka ronchi, friction rub, wheezing]

Nutrients

organic & inorganic substances found in food needed by the body for proper functioning and have three main functions. 1. provide energy for body processes and movement 2. provide structural materials for body tissue 3. regulate body processes

stool for occult blood

originates in upper GI tract, has blood

hyperthyroidism

over production of the thyroid hormone. NOTE: most common form is graves disease [auto immune response]

mucossitis and nursing intervention

painful inflammation and ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiation treatment for cancer NURSING INTERVENTION: teach pt on oral care protocols

a nurse in a providers office is reviewing the medical record of a client who has fibrocystic breast condition. which of the following is an expected finding?

palpable rubber like lumps in the upper outer quadrant = typically have breast pain and rubbery lumps in the upper outer quadrant

hx of enlarged prostate and is experiencing discomfort

palpate abdomen get data from cleint, to determine urinary retention

aphasia

partial or total loss of the ability to articulate ideas or comprehend spoken or written language resulting from damage to the brain caused by injury of disease.

vitiligo

patches of hypopigmintated skin caused by the destruction of melanocytes in the area

assess the spiritual needs of clients and plan nursing care to assist clients with spiritual needs.

patients assessment data must include spiritual beliefs/practices. -general history and nursing history. clinical observation of patient behavior -questions to ask for obtaining data about spiritual/religious practice: would you like to have someone to visit you for spiritual supporting/counseling? do you have any spiritual or religious concerns that may affect your health care? -* do not assume that the client follows all rituals of their stated belief system. -environment: religious items in room -behavior: prayer before meals / other times, negative towards religious representative/diety -interpersonal relationships: visit from religious advisor -verbalizations in conversations: talks about a higher being, mentions church/synagogue, spiritual leader, and/or religious topics -affect and attitude: mood/anxiety/depression/preoccupation resource for assessment FICA F: faith / beliefs, do you have any spiritual beliefs important to you? I:implications/influence: how does your faith affect your current situation/coping? C: community: is there a group you meet with that you would like to visit you? A: address: how would you like your health care team to support you spiritually?

Who have the most influence on a school age childs nutrition

peers, teachers, yet parents are the most important role model

contractures

permanent shortening of the muscle

contractures

permanent shortening of the muscle, develops when the elastic tissues are replaced with inelastic fiber like tissue, makes it hard to stretch area and prevents normal movement

how to assess for orientation

person / place / time / situation

pt is old and recieved 500 ml of IV fluids. what to look for highest priority?

pink frothy sputum using ABC priority setting framework, pink, frothy sputum is the highest priority finding.

epoetin alfa [ procrit] desired outcome?

pink nail beds

tonic clonic seizure while in bed

place on side to prevent aspiration from mouth secretions

scopolamine for motion sickness. what indicates understanding of teaching?

place patch behind ear

reinforce teaching. nitroglycerin [transderm-nitro] patch.

place the patch on a different site for each application to prevent skin irritation

Cations

positively charges electrolytes Na+. K+, Ca+. Mg+

a nurse is monitoring a client who is going to start therapy with spironolactone [aldactone] which of the following serum lab results should the nurse report to the provider?

potassium that is high the client is at risk for muscle weakness N?V and cardiac dysrrhythmias. the nurse should report this finding.

Smaller quantities of electrolytes in ECF

potassium, calcium, & magnesium

medical asespsis

practices intended to confine a specific micro organism to a specific area in order to limit number, growth and transmission

surgical asepsis [sterile]

practices that keep an area/object free of all micro organisms

31. Know who should not care for a patient with herpes zoster

pregnant women

sepsis

presence of infection

systolic

pressure of the blood as a result of contraction of the ventricles

tumor staging

process of finding out how much cancer is in a persons body and where it is located. helps determine the "stage" of a persons cancer

respiration

process of gas exchange between the individual and the environment

bone marrow transplant:

process of replacing diseased or damaged bone marrow with normally functioning bone marrow

care of pt with bone marrow transplant

process of replacing diseased or damaged bone marrow with normally functioning bone marrow -Administer immunosuppressants initiation of corticosteroid therapy - for Phlebitis, monitor for jaundice, abdominal pain, liver enlargement. Check daily weight & abdominal girth to monitor fluid retention. - vital signs and blood oxygen saturation; assessing for adverse effects, such as fever, chills, shortness of breath, chest pain, cutaneous reactions, nausea, vomiting, hypotension or hypertension, tachycardia, anxiety, and taste changes; and providing ongoing support and patient teaching. - Psychosocial assessments

sterilizing

process that destroys all micro organisms including spores and viruses

polyuria

production of abnormally large amount of urine by the kidney

intervention to promote urinary eliminaion

promote adequate fluid intake normal adult about 1500mL/day, mantain voiding habits: position, relax, timing. assist w/ toileting: weak or impaired for safecty. for bedbound pts who cant move move head of bed 30-45 degrees or small pillow on back and then flex hips and knee to urinate comfortably.

Nursing interventions associated with preventing UTI:

proper hygiene, void every 2-3 hours, void after intercourse (women), and fluids. Wipe from front to back.

role of mucous in the large intestine

protective function: mucous contaions large amounts of bicarbonate ions. stimulated by parasympathetic nerves, mucous protects intestinal wall from chemical trauma [acid within feces], serves as an adherent for holding fecal material together, mucous protects intestinal wall from bacterial activity.

pt has c diff, how does it spread?

provide disposable utensils and sishes for meals leave BP things in room clean with bleach

3 Symptoms of Extrapyramidal S/E (EPS)

pseudo-Parkinsonism - Dystonia: muscle rigidity - Akathisia: motor restlessness/agitation - Tardive dyskinesia: uncontrolled rhythmic bizarre facial movements, worm like tongue movement, stiff neck, difficulty swallowing, lip smacking, chewing Others: pill rolling, shuffling gate Medications to treat S/E - diphenhydramine - Benadryl - benztropine - Cogentine

signs of EPS and how to treat

romberg test

pt stands feet together arms at side first with eyes open and then closed. results are negative if pt is able to mantain balance and positive if not heel to toe / toe to heel / finger to nose and others listed in book. not typically done by LPN. abnormal if they need i wider gait to stay upright

what do you do if you feel resistance?

pull the tube back.

tachycardia

pulse rare of greater than 100, heart not filled with blood quickly enoguh

cathartics

purgative drug: laxative, chiefly of a drug or med tending to facilitate evacuation of bowel

after opening the sterile field and before inserting the catheter into the patient what do you do next?

put on sterile gloves, and clean area with iodine or sterile water

Fast food diet

quick, convenient, relatively low cost

heat loss

radiation conduction convection vaporization

characteristics in respiratory assessment

rate depth rhythm quality sound effectiveness -count respirations for 30 sec. and timed (x) by 2; for very sick pt. 1 full minute.

erythema

redness

Foods to reduce intake

reduce daily sodium to less than 2300 mg/day

Low protein diet

reduced intake of protein; prescribed to those with liver and kidney disease

leucopenia

reduction in the number of white cells in the blood

nursing intervention associated with hyperparathyroidism

remember to assess for droping calcium levels due to the removal of the parathyroid glands, although the body recovers quickly

new hearing aid

remove battery when not in use

R side HF and is prscribed a beta blocker. mantain fluid status?

report a weight increase of 3 or more lbs per wk to pcp

skin lessions,

report irregular borders

cefazolin [ancef] by IV bolus. allergy rxn?

restlessness: behavioral s/s of anaphalaxis include apprehension, uneasiness, restlessness, and anxiety

understanding of budenoside [pulmicort] and albuterol [proventil] inhalers

rinse mouth record of how many times i have used the MDI and use before activities that are sure to induce s/s

friction rub

rubbing together of inflamed pleural spaces -superficial grating or creeking sounds heard during inspiration and expiration. not relieved by coughing

Teaching post mastectomy:

s/s of complications, specific ROM exercises, wound care, drain care, no lotions, creams or deodorant, pain meds, activity restrictions, follow up visits and support groups.

body mechanics

safe and efficient use of muscle groups mantain balance reduce energy required reduce fatigue decrease risk of injury Center of gravity Lowering the center of gravity Flexing knees and hips (squatting) Base of support Widening base of support Spreading feet apart Avoid rotation (twisting), stooping (bending without bending knees and hips) LIFTING: Use major muscle groups Thighs, knees, upper and lower arms, abdomen, pelvis Keep feet at least 30 cm (12 inches) Keep load close to the body No hazards on the floor, clear path PULLING/PUSHING AND PIVOTING: Pulling and Pushing Enlarged base of support in the direction on movement Pulling weight shift away from the object Pushing weight shift towards the object Pulling is better than lifting, pushing better than pulling PIVOTING: To avoid twisting of the spine Weight on the ball of the feet

clarity

say what is meant

how to measure for edema

scale to describe 1+ barely detectable 2+ indentation of <5mm 3+ indentation of 5-7 mm 4+ indentation of >7mm dependent edema: check other areas [sacral, arms] look for trauma, induced bruises, scabs, lacerations, scars

Modifiable risk factors for obesity

sedentary lifestyle

What is bargaining?

seeks to bargain to avoid loss. Patient says "let me live some more days and then I will be ready to go"

signs of fecal impaction

seepage! little things in liquid that cause pain and discomfort. like diarrhea but not diarrhea. something is stuck and tiny bits and pieces are SEEPING through. Seepage! :)

How to do Self Breast Exams and Self Testicular Exam Including When to Do It

self-breast exams should be done monthly, 5 to 7 days after menstruation or after a specific date each month after menopause; self-testicular exams should be done monthly after a warm shower or bath when relaxed, examine each testicle separately, gently roll between fingers and thumb to check for lumps, nodules, extreme tenderness, swelling or change of appearance

positioning for lower back pain

semi fowlers with knees flexed

characteristics of spiritual health

sense of inner peace compassion for others reference for life gratitude humor wisdom generosity capacity for unconditional love • Faith - Complete and unquestioning acceptance of a belief that cannot be demonstrated or proved by the process of logical thought • Hope - A concept that incorporates spirituality, that involves the anticipation directed towards a future fulfillment • Value - Having cherished beliefs and standards • Meaning - Having purpose, making sense of life CONNECTING: relating to others, nature, inner self, universe BECOMING: involves refelction, allowing life to unfold and knowing who one is experiencing

barium enema nursing interventions

series of xrays visualize the colon to determine presence and location of polyps, tumors and diverticula INTERVENTIONS: PRE-OP: -explain procedure -clear liquids for lunch/dinner day before -1 glass of water every 8 - 10 hrs -strongcathartic at 2pm day before -administer 3 bisocodyl tab at 7pm -NPO at midnight -cleansing enema given day of at 6am [fecal return must be clear] POST OP: -explain procedure - may experience gas pains -assess for abdominal distention/tenderness -inspect stool for blood -push fluids -monitor for barium elimination -laxative may be ordered to help clear bowel

Anasarca

severe generalized edema, weight gain, facial/body puffiness, skin is cool and pits when touched

What is parasomnias?

sleepwalking, sleep terrors, sleep talking, nightmares, broxism, enuresis

pt had a colectomy resulting in a colostomy 48 hrs ago. when inspecting the stoma what to expect?

small amount of effluent discharge discharge from the stoma is expected to begin 2 - 4 days post op and is a sign the cholostomy is functioning and bowel motility is returning

fullness in rectum and abd cramping, what indicates a fecal impaction?

small liquid stools

provide immediate skin care to incontinent pt

so moisture doesn't increase bacterial growth and irritation

Why is breakfast important in a school aged child (6-12yrs)

so that they don't become inattentive and restless, easily fatigued or have diminished problem-solving abilities

Principal electrolytes of ECF

sodium, chloride, bicarbonate

a nurse is reviewing information with a client who is scheduled for a transrectal ultrasound [TRUS]. what information should the nurse include?

sound waves will be used to create a picture of your prostate = a TRUS uses sound waves to create images of a prostate

Foods high in Sodium

soy sauce, pickled foods, processed canned and frozen foods, such as soups, hot dogs, ham, boloney, salami, cheese

Purpose of Prenatal Vitamins

special formulation to meet the essential increase in vitamins especially Iron (FE) and folic acid.

infant baths

sponge baths are suggested and immediately dry after bath once the umbilical cord falls off

systematic infection

spreading of micro organisms damaging different parts of the body -bacteremia: bacteria in the blood -septicemia: bacteria results in systematic infection

principles of surgical asepsis

sterile items that are out of vision or below the waist level of the nurse are considered unsterile

pre op dose of cephapirin [cefadyl] 10 min later there is itching. what do you do?

stop the infusion IV is immediate, an allergic response can prgress rapidly/

a nurse is reinforcing teaching with a client who is scheduled for extacorporal shock wave lithotripsy [ESWL]. which of the following statements made by the client indicates understanding of the teaching?

straining my urine following the procedure is important = done to verify that the stone has passed.

Active transport

substance can move across cell membranes from a less concentrated solution to a more concentrated one using metabolic energy

tumor markers

substances found at higher than normal levels in the blood, urine, or body tissues of some people c cancer

alopecia

sudden hair loss that starts with one or more circular bald patches that may overlap

urinary diversion

surgical diversion to reroute urine from kidney and bladder

debulking

surgical removal of part of malignant tumor which cannot be completely excised. so as to enhance the effectiveness of radiation or chemo

Assessment that the medication for MI has been effective

symptom free pt.

what is the drug of choice for hypothyroidism

synthroid [levothroid, levothyroxine] synthetic levothyroxine note: pt education: dosage is absed on the pts TSH levels. follow up is important. thyroid hormone increases the effect of dilantin, dig, glycosides, anticoagulants, tricyclic antidepressants and indomethacin [always ask if on]. hypnotic and sedatives can produce profound somnulence when on synthroid. may cause signs of hyperthyroidism. S/E = weight loss, [cardiac arythmias, palpations], insomnia, irritability. DONT STOP TAKING MEDICATIONS

what makes the s1 and s2 sounds

systole: ventricles contract. begins with s1 and ends s2. normally shorter than diastole diastole: when ventricles relax. starts with s2 and ends with s1. no sounds are audible during the periods

client is old and long term facility, took insulin but no wantbreakfast, what do you do?>

take the glucose lvl asap! nursing process includes data collection

What is cultural responsible nursing care?

taking into consideration: -context in which client lives -situations in which clients health problems arise -clients health beliefs and practices -clients cultural needs Allows the nurse to have a proper cultural understanding of client's healthcare beliefs and practices

a nurse is caring for a client who has a new diagnosis of Benign prostatic hyperplasia [BPH]. the nurse should anticipate a prescription for which of the following medications?

tamsulosin [flomax] =an alpha adrenergic receptor antagonist that relaxes the bladder outlet and the prostate gland, which improves urinary flow.

what types of fluids do you use?

tap water normal saline oil -> enema?

Nursing Interventions Associated with Kidney Stones:

teach nutritional therapy to prevent further stones from forming, sodium intake of 3-4 grams per day, low calcium only for those with hypercalciuria, avoid excessive exercise or activities that may increase dehydration and increase water intake, avoid oxalate containing foods such as spinach, tea, coffee, strawberries, peanuts, chocolate, wheat bran

Nursing Management for a Patient with Kidney Stones Including Diet, Straining of Urine, Fluids and Ambulation, Etc.:

paralytic ileus

temporarily sedation of parastalsis [bowel sounds]

denial

the action of declaring something to be untrue.

withold digoxin if

the cleints plasma lvl for digoxin is above therapeutic lvls. the nurse should withold the medication and notify the pcp.

albinism

the complete lack of melanin in the skin

etiologic agent [microorganism]

the extent to which any microorganism is capable of producing an infectious process; depends on number, virulence, ability to enter body, susceptibility

When is breast milk produced more

the more frequent feedings and complete emptying;supply and demand

Diffussion

the movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration

to remove a NG tube and decrease risk for aspiration

the nurse should pinch the ng tube to prevent secretions from draining into the throat.

Nutrition value

the nutrient content of a specified amount of food

Define culture

the pattern of information composed of thoughts, values, beliefs, actions, attitudes, communications and customs shared by a group of people and passed from one generation to the next

symmetrical

the quality of being made up of exactly similar parts facing each other or around an axis

metastasis

the spread of cancer cells from the original tumor side to distant organs

urgency

the sudden, strong desire to void

a nurse in a clinic is reviewing the facilities testing process and procedures for human immune deficiency virus [HIV] with a new employee. which of the following information should the nurse include in the review?

the western blood clot assay is used to confirm diagnosis of HIV. = confirming HIV is a 2 step process. western blot is done if the EIA is positive

what is the purpose of iodine therapy prior to thyroid surgery

there are two types of thyroid therapy. oral and radioactive RADIOACTIVE IODINE THERAPY: partially destroys the overactive thyroid cells resulting in reduction of hyperthyroid state. NOTE: administered by a radiologist it destroys thyroid tissue which in turn decreases vascularity and size of the thyroid gland. done before procedures and lessens bleeding during surgery

a nurse is caring for a cleint who has difficulty swallowing. prevent aspiration

thicken liquids to prevent aspiration and better swallowing

Regulation of body fluid

through input and output

fistulas

tiny, tubuluar, fibrous tract that extends into anal canal from an opening located beside the anus. CAUSE: infection; may also develop from anything that can create an opening fissures or regional enteritis [chrons] -s/s: leakage of pus or stool, passage of flatus or feces from the vagina/ bladder depending on the fistula tract. -management: surgery because of few fistulas heal on their own [fistulectomy], and several enemas given to evacuate lower bowel pre-op

Illness Affecting Fluid & Electrolytes

tissue trauma, renal disorders, cardiovascular disorders, altered level of consciousness, sepsis, burns, diabetes mellitus, chronic obstructive lung disease

Purpose of Self-Exam of the Testes and of the Breast

to catch breast or prostate cancer early

correcting charting errors

to correct a charting error simply draw a line across error and initial after.

definition of forgiveness

to give up resentment against offender positive way to deal with an offense that results in reduction of negative emotions and enhancement of positive emtions

medication that causes constipation

too many laxatives, analgesics like morphine and narcotics

cause of cushings disease

too much steroids! excess function of adrenocortical activity [hyperfunction] can occur due to one of four things: MOST IMPORTANT: administration of corticosteroids [prednisone or ACTH] others: -tumor in pituitary that produces ACTH and stimulates the adrenal cortex to increase its hormone secretion -hyperplasia of adrenal cortex -ectopic production of ACTH by tumors in other organs such as lungs and pancreas

what is the cause of cushings syndrome

risk assessment tools

tools that are utilized to summarize risk for injury

TPN nursing interventions

total parentral nutrition - patients who cannot ingest foods / liquids or has a problem with malabsorption INTERVENTIONS: -change tubing with each new bag per hospital protocol. -change dressing using sterile technique q72h and observe site for s/s of infection [only iv certified lpns] -monitor for vs, fluid and electrolyte balance -daily weights to best indicate the efficiency of therapy -frequent mouth care -blood glucose monitoring with sliding scale coverage -tpn is titrated [decreased gradually] to allow pt to adjust to decreasing glucose

stool softening medications

tranquilizers [morphine, codeine] for constipation, iron [acts locally] for constipation, laxatives, stool softeners, suppress peristalsis [treatment of diarrhea], appearance of feces [aspirin, iron, antibiotics, antiacids, pepto-bismol]

heat conduction

transfer of heat from one molecule to a molecule of low temperature objects

a nurse in a providers office is reviewing a clients laboratory results. the cleints rapid plasma regain [RPR] is positive. which of the following tests confirm the diagnosis of syphillis?

treponema pallidum particle agglutination assay = used to confirm the diagnosis of syphillis

red area over sacrum

turn q2h

peptic ulcers nursing interventions, teaching, complications, and priorities

ulcer [excavation] with loss of tissue of the upper GI tract [esophagous, stomach, duodenum], 80% are duodenal. they develop when the mucosa cannot protect itself from corrosive substances, such as gastric acid, pepsinogen, ETOH, bile salts and irritating foods. CAUSE: H.pylori: bacteria rich in an enzyme that may cause corrosion of the upper GI tract by damaging its mucous coating. S/S: -epigastric pain .burning, gnawing, cramping or aching .comes in waves .diminished in the AM whens ecretions are low and after meals when food is in the stomach or after taking antacids .most severe before meal and at bedtime. -nausea -loss of appetite -weight loss -vomiting is rare -pyrosis [heart burn] constipation COMPLICATIONS: -hemorrage -perforation .sudden severe pain in upper abdomen .signs of shock .rigid/board like tender abdomen -obstruction: because of scarring and anemia TREATMENT: -relief of symptoms: medications include: .antacids .antibiotics - H.Pylori .carafate .histamine 2 receptor antagonist -diet: .restrict foods that trigger an onset of symptoms .ETOH and caffeine and milk/cream .eat at frequent and regular intervals .do not skip meals TEACHING: -pt must understand how and why the ulcer developed -avoid factors that predispose disorder -change lifestyle COMPLICATIONS OF GASTRIC SURGERY: -lack of B12 absorption - pernicious anemia -dumping syndrome - after gastric resection; rapid emptying of stomach contents into the small intestines -prevention - small frequent meals without fluids

alternative to restraints

unsafe client close to nursing station. -stay with confused/sedated client when using bedside bathroom

when do individuals get the urge to void

urine collects in the bladder as it fills voiding happen special nerve ending s on the bladder wall called stretch receptors, adult 250-400ml thats when voiding happens. stretch receptors transmit impulse to spinal cord that is called the voiding reflex center. internal sphincter :relaxes and you have the urge to void. external sphincter: relaxes concious brain relaxes voluntary internal sphincter and voiding occurs

residual urine

urine remaining in the bladder following voiding

cane use

use cane on the stronger side

chemotherapy

use of medications to kill tumor cells by interfering with cellular functions and reproduction

therapeutic communication

use open ended questions, promote understanding, nurse must understand pt. view and feelings before responding, PHYSICAL ATTENDING: mantain good eye contact / face to face, being silent and patient until client ___ <- ._. thanks jaz! promotes understanding and can help establish nurse-client relationship ATTENTIVE LISTENING

working phase

use thought and feelings. what are they feeling? what are their thoughts?

radiation therapy

used to ionizing radiation to interrupt the growth of the malignant cells

Cardiogenic Embolic Stokes

usually associated with cardiac arrhythmia, afib, vascular disease, & thrombi in the Left side of heart

Dysrhythmias that cause sudden death

v-tach/v-fib: considered as a true emergency if not treated promptly pt will die. only way to save is to shock. !!!the difference between the 2 is the rate: fibrillation is chaotic quivering over 300/min -treatment of VT is IV lidocaine or cordarone - second goal is to find the cause and treat it. - hypokalemia, silent MI is the #1 cause. NOTE: to defribrillate means to depolarize the myocardial cells that will cause the SA node to recapture its role as the eharts pacemaker which will hopeful cause the heart to be in sinus rhythm. -ICD: implantable cardioverter defibrilation shocks inside of th4 heart.

reflex incontinence

variation on urge incontinence in which you feel no need to urinate but urine is lost when bladder begins to contract uncontrolably

hemorrhoids pathophysiology, nursing interventions, and teaching

varicosities of the veins of the rectum; internal [inside or above the sphincter muscle] and external [outside or below] S/S: local pain and itching -bleeding with defecation swelling CAUSE: -constipation/straining -prolonged sitting/standing -pregnancy due to pelvic congestion and during labor INTERVENTIONS: -analgesics -cold/warm compress -sitz bath b.i.d. -donut ring to sit on and support butticks -stool softeners -high fiber diet -meticulous hygiene

procedure for inserting a foley catheter

verify orders verify allergies equipment wash hands provide privacy adequate lighting open package using sterile technique prepare patient open gloves clean patient check balloon insert catheter inflate balloon pull back attach securely to leg obtain specimen check residual

frequency

voiding at frequent intervals that is more than four to six times per day

nocturia

voiding two or more times a night

best assessment for BP if abnormal

wait 15 - 30 minutes before taking blood pressure again

pt is prescribed ciproflaxin [cipro] what should the nurse reinforce?

wait 2 hrs after taking an iron supplement before taking this medication the client should avoid products that contain cations such as antacids, iron salts, milk, and other dairy products because they can reduce the absorption of ciproflaxin

Principles of food safety

wash hands & surfaces often

hep a, prevent disease to others. understanding of teaching>?

washing my hands can help prevent spreading food handled by infector can infect the innocent and stuff. hand washing helps prevent that nasty stuff

Important issue in adolescents

weight control and fad diets; an attempt to gain control over a rapidly changing body

Clinical Signs of FVD

weight loss postural hypotension dryness of mucous membranes decreased skin turgor (normal is brisk) weak, rapid pulse sunken eyeballs subnormal temperature decreased capillary refill decreased urine output, Oliguira pale skin increase in specific gravity <1.030 (urine more concentrated) increased HCT increased BUN

Cachexia/cachectic

weight loss and wasting away

message

what is actually said/written, body language that accompanies words, type of medium used [face to face/ writting/ telephone], non verbal: highly effective, touch

osteoporosis

when bones are brittle because of loss of calcium, happens as person ages, demineralizes and becomes spongy

urinary retention

when emptying of bladder is impaired, urine accumulates and the bladder become over distended

when to place pt on neutropenic precautions

when pt ANC is less than <1500 because they are at a greater risk for infection

when to change a colostomy bag

when the bag is either half full or one third full

Neoglism

word or phrase invented by patient

a nurse is preparing a client for her first papanicolau test [pap. what statement is appropriate for the nurse to make?

you may experience some bleeding after the procedure = due to scraping of the cervix

a nurse is reviewing post op information with a client who is scheduled for a transurethral resection of the prostate [TURP]. what should the nurse include in the discussion?

you may have a continuous sensation of needing to void even though you have a catheter = to reduce the risk of post op bleeding, the client will have a catheter with a large balloon that places pressure on the internal sphincter of the bladder. pressure on the sphincter causes a continuous sensation of needing to void.

a nurse is reinforcing teaching regarding newborn immunizations to a client who is 24 hr postpartum. which of the following teachings should the nurse plan to include?

your baby will receive the first hep b shot before discharge hep b shots are given in three seperate injections, starting at birth, with the next two doses at least two months apart

34. Know the drugs that cause hearing loss

• ASA • STREPTOMYCIN • LASIX • GENTAMYCIN

How to assess for stereognosis

• Ability to recognize objects by tough. • Place small familiar object in hand with eyes closed

care of a pt with degenerative joint disease

• Arthroplasty is repair and replace joints • Arthrodesis is fusing joint together causing immobilization • Osteoarthritis: i. Anti-inflammatories ii. Splinting of the joint iii. Unilateral iv. Last resort is arthroplasty • Rheumatoid arthritis: i. Bilateral ii. NSAIDS, steroids and gold salts, methotrexate iii. No cure • Nursing interventions for both: i. Pain management ii. Rehab iii. Exercise remission with rest (exacerbation) periods iv. Nutrition

s/e of coumadin

• Assess PT & INR & Avoid Vitamin K (Green leafy vegetables) • Pt is at risk for bleeding (bruising)

care of a pt with a femur fracture

• At risk for fat emboli • Immobilize /stabilize • If needed ORIF (open reduction & internal fixation) • If in traction cannot be moved

assessment and abnormal findings of the head and neck

• During assessment of the head: inspect, palpate and auscultate. • Examine the skull, face, eyes, ears, nose, sinuses, mouth, teeth, tonsils, jaw and pharynx. • Normal sizes head is referred to as normocephalic. • If the size appears to be outside the range- size can be compared to standard size tables. • Measurements more than two standard deviations from the norm for the age, sex, and race of the patient are abnormal; this should reported to the primary care provider. • Names of areas of the head are derived from names of the underlying bones: frontal, parietal, occipital, mastoid process, mandible, maxilla, and zygomatic. o Many disorders cause a change in facial shape or condition. Edema in the eyelids - can be caused by kidney or cardiac disease. o Hyperthyroidism causes exophthalmos - protrusion of the eyeballs with elevation of the upper eyelids, resulting in startled or staring response. o Hypothyroidism or myxedema can result in dry, puffy face with dry skin and coarse features and thinning of scalp hair and eyebrows. o Increased adrenal hormone production or administration of steroids can cause a round face with reddened cheeks- referred to as moon face; excessive hair growth on upper lips, chin, and sideburn areas. o Prolonged illness, starvation, and dehydration can result in sunken eyes, cheeks, and temples. • Examination of the neck includes: the muscles, lymph nodes, trachea, thyroid gland, carotid arteries, and jugular veins. • Lymph nodes in the neck that collect lymph from the head and neck stuctures are grouped and referred to as chains

classic pain for MI

• Elephant on chest • Sudden onset of pain that does not get released with use of meds • Nausea with or without vomiting • Pallor, cool diaphoretic • Palpitations, weakness, dizziness • SOB • Pain may be atypical in the elderly, they may report jaw pain

care of a pt with a CPM machine (Continuous Passive Motion)

• Helps with edema and improves ROM • You still need active ROM, this DOES NOT PREVENT DVT • Check alignment and positioning of the leg frequently and inspect the skin for areas of redness or irritation

how inspection of the ear is done

• Includes direct inspection and palpation of the external ear • Should be able to draw a horizontal line from the corner of the eye to the top of the ears o Look for alignment -should be in line with corner of the eye o Discharge- inflammation, and areas of tenderness and pain o Hearing-assess o Tragus-monitor for tenderness by pushing on tragus and moving auricle o Mastoid process of temporal lobe- assess for infection/injury

Know assessments and abnormal findings of ear.

• Increased cerumen can interfere with hearing. • Redness and swelling indicates infection. • Non tender nodular swelling deep in the ear canal indicates osteoma • Red budging ear drum indicates acute purulent Otitis media • Whitish appearance on the eardrum indicates pus in the middle ear. • Scarring on the ear drum indicates chronic Otitis media • Mastoiditis usually occurs from an inadequately treated middle-ear infection. • An ear abscess is a serious infection, usually caused by bacteria that have invaded the area called the mastoid processes, the spongy sections

30. Know the gerentological changes of the skin in the elderly

• Increased dryness • Uneven pigmentation • Variety of lesions • 20% loss of dermal thickness • Reduction of subcutaneous fat • Decrease in muscle tone • Slow cap. Refill leads to delayed wound healing • Reduced barrier function due to thinning • ↓sweat & oil • Decrease in hair growth

Know assessments and abnormal findings of mouth/oropharynx • Inspect tongue, buccal cavity

• Inspect tongue, buccal cavity • Inspect teeth • Inspect gums- ask pt to remove dentures • Assess mucous membranes • Assess for o Pallor, cyanosis o Blisters, lesions o Dryness, excessive salivation o Missing teeth o Redness, swelling o Deviation • Abnormal findings may include: o Pigmentation o increased redness o Cyanosis o Ulcers o White patches o Swelling o Bleeding o Too much or too little saliva

How to assess the abdomen and abnormal findings.

• Inspection, auscultation, percussion, palpation • Asses all 4 quadrants for one full minute if no bowel sound is heard you must listen for at least 5 minutes • Ask patient to inhale to view liver/spleen • Tense/shiny abdomen= ascites • Asymmetry= hernia/tumor • Dilated veins= liver disease, ascites • Bruits=abnormal finding • Inspect for: color, scars, flat/round, enlarged spleen/liver, abdominal girth, asymmetry, vascular pattern

assessment of bowel sounds

The sequence of assessment techniques for all systems

• Inspection, palpation, percussion, auscultation. Except for abdomen: inspection, auscultation, percussion and palpation

methods of examining

• Inspection: Visual examination. • Palpation: Using the sense of touch, pads of finger • Percussion: The act of striking the body surface to elicit sounds that can be heard, or vibrations that can be felt. Two types: direct/indirect. • Auscultation: process of listening to sounds produced within the body

43. Know the consequence of untreated glaucoma

• Leading cause of irreversible blindness • No cure • Increase in IOP leads to optic nerve damage

care of pt with HIV

• Maintain a caring presence • Maintain standard precautions • Monitor VS- Elevated BP- pneumonia; tachycardia- dehydration/sepsis; fever- infection • Maintain and push hydration unless CHF or renal issues • Aseptic technique for IV access procedure

44. Know what to teach for glaucoma in regards to medications

• Medical/surgical management slows glaucoma, but does not cure or restore already lost vision • Pt education is important—long term care • Know IOP and keep record of it • Strict adherence to meds (compliance) • Review all meds and know dosage • Let nurse observe you applying drops

foot care for pt with DM

• Monitor daily for wounds • Do not use hot water to wash feet, dry adequately especially between toes • Wear white socks to monitor for bleeding • Do not use commercial remedies to remove anything from your foot Ex: Calluses (Consult podiatrist)

Know assessments and abnormal findings of nose/sinuses

• Normal- no flaring or narrowing or nares • Assessment includes: inspection and palpation of the external nose, patency of the nasal cavities, and inspection of the nasal cavities. • If the patient reports difficulty or abnormality in smell, test the patient's olfactory sense by having the patient to identify common odors (coffee, mint).inspect and palpate the facial sinuses. • May be tender with allergies- ask patient • Assess for pain of facial sinuses and nasal septum deviations • Abnormal findings o Symmetry discharge o Flaring o Color o Lesions o Redness o Air movement o Tenderness o Snoring

purpose of the Glasgow coma scale and three things that are assessed in the Glasgow coma scale

• Original used to predict head injury recovery- now assess Level Of Consciousness • Tests 3 areas: eye response, motor response, verbal response • Total points= 15, less than 7= comatose

purpose of the Glasgow coma scale and three things that are assessed in the Glasgow coma scale.

• Original used to predict head injury recovery- now assess Level Of Consciousness • Tests 3 areas: eye response, motor response, verbal response • Total points= 15, less than 7= comatose

how inspection of the eye is done

• P.E.R.L.A= Pupils Equally Round and React to Light and Accomodation • Shine penlight from side in one eye- should constrict , shine again in same eye and second eye should also restrict- consensual • Hold an object 4 inches from the nose and ask pt to look at top of object then at a distant object and alternate- pupils should constrict when looking at the near object and dilate with the distance object- accommodation • Move object toward the bridge of the nose -pupils should converge • Pupils size 1-10 normal is 3-7

purpose of positioning for post amputation

• Prone position (24-48 hrs post) if amputation is below the knee = prevents knee flexion • Bed flat = avoid hip flexion contractures • Legs together = avoid abduction contractures • If you're going to elevate Only FOR THE FIRST 12 HOURS. • Sterile dressing • Anti-inflammatory meds • Risk for infection & bleeding

36. Know the symptoms of otitis media

• Sense of fullness in the ear (otalgia) • Severe throbbing like pain • Tinnitus (ringing in the ears) • Fever • Erythematous. Bulging eardrum • Purulent drainage

cause of tachycardia in cardiac disease

• Shock from any cause • Pain • Fear • Fever • Stress • Drugs- especially: cold and flu, cocaine, amphetamines

Know different patient positions

• Sims: side-lying, lowermost arm behind the body, uppermost leg flexed at hip and knee • Prone: lies on abdomen, head turned to side • Sitting: seated position, back unsupported, legs hanging freely • Lithotomy: back lying, feet supported in stirrups, hips in line with the edge of the table • Dorsal recumbent: back-lying, knees flexed, hip externally rotated • Supine: back lying, legs extended

care of a pt with laminectomy

• Surgical removal of a posterior portion of the vertebra • Pain and infection are important • VS • CMS • Activity level • Bowel and bladder function • Log rolling • Interventions: • Medications (flexeril) • Semi-fowlers with knees flexed = relieves pressure • Traction/bedrest • Heat/cold • Corsets/braces • Proper body mechanics (most important)

Review assessment and abnormal finding of cardiovascular and Peripheral Vascular Systems.

• The Pericardium: area of the chest overlying the heart. It is inspected and palpated for the presence of abnormal pulsations or lifts or heaves. • 'Lift' and 'heave': used interchangeably to refer to a rising along the sternal border with each heartbeat. • A lift occurs when cardiac action is forceful. • This should be confirmed by palpation with the palm of the hand.

Review assessments and abnormal findings of breast/axillae

• The breasts of men and women must be inspected and palpated. Men have some glandular tissue beneath each nipple, a potential site for malignancy. Mature women have glandular tissue throughout the breast. • During assessment, localize specific findings by using quadrants and the axillary tail. • Mammogram and breast exam annually from 40 years of age

nursing care for pt with CHF

• Treatment = diuretics, digoxin and calcium channel blockers, ace inhibitors • Atherolosclorosis is primary cause • Left sided = affects lungs • Right sided = affects rest of the body • Low sodium diet • Fluid restriction • Nursing care: promote activity tolerance, administer diuretics in the AM, 3 daily weights, low sodium diet, assess for hypokalemia, smoking cessation,

38. Know care and what to teach for hearing aids

• Wash ear mold or plug daily in mild soap and water using a pipe cleaner to cleanse the cannula • Dry ear mold or plug thoroughly before reconnecting it to the receiver • Keep an extra battery and cord available at all times

difference between rinne and weber test

• Weber Test - activate fork and place on head - ask patient where he hears the sound • Rinne Test - compares air conduction to bone conduction- ask pt. to block hearing in one ear; activate the fork and place base on mastoid process; ask pt to report when he can no longer hear the sound; place fork in front of ear. Normal is sound in front of ear (air conduction) should be longer than sound heard at mastoid process (bone conduction)

Discuss the genetic inheritance disorder patterns of autosomal dominant; autosomal recessive; X-linked recessive; and X-linked dominant, including identifying and discussing examples for each genetic inheritance disorders.

**AUTOSOMAL DOMINANT INHERITANCE:** -defect is limited to a single gene -one parent has the single gene problem .dominates the other gene located on the other chromosome in the pair -male and female offspring are equally affected -one parent is affected .offspring: 50% chance of becoming affected -both parents are affected .all offspring will be affected -HUNTINGTON DISEASE: -progressive, selective [localized] neural cell death s/s: .choreic movements ..involuntary writhing movements of extremeties and/or facial muscles .dementia -MARFAN SYNDROME: -disorder of fibrous connective tissue -effects 3 body systems: -cardinal features [clinical manifestations] .skeletal: increased height; disproportionately long limbs and digits; spinal deofrmity .cardiovascular: mitral valve prolapsed; mitral regurgitation; dilation of the aorta; aneurysm of the aorta .eye: lens subluxation **AUTOSOMAL RECESSIVE INHERITANCE:** -both parents must contribute one gene [trait] in order for the disorder to be expressed -parents usually have one defective gene and one normal gene which dominates .they do not show any sign of the disorder themselves -offsprings: 25% affected - 50% carriers - 25%not afected -TAY SACHS DISEASE: progressive central nervous destruction due to a lipid enzyme metabolism deficiency -sickle cell anemia -PHENYLKETONURIA .inability to metabolize the amino acid phenylalanine .leads to build up an ultimate cerebral damage and mental retardation .special diets -CYSTIC FIBROSIS -PITUITARY DWARFISM **X-LINKED DISORDERS:** -each individual has two sex chromosomes - XX for female and XY for male -X linked inheritence genetic disorders .caused by genes located on the sex chromosomes -Y chromosomes are not known to carry these disorders -terms: X-linked and sex-linked are interchangeable -males have only one X chromosome, a single x-linked recessive gene can cause disease in a male -females need two copies of the diseases gene -resulting in males being more commonly affected **X-LINKED RECESSIVE INHERITANCE** -a defective x-linked recessive gene .comes from the mother to the son .father only gives the Y chromosome to males -recessive x-linked gene .in females a normal dominant gene is matched with an other X chromosome .resulting in females not express the disorder -males are only potentially affected .no gene on the Y chromosomes to counter the effects of the defective gene on the X chromosome -if father is affected and mother is normal: .all daughters will carry the recessive gene -unaffected sons cant transmit the disorder -when the mother is carrier .daughter may be a carrier 50% .son may be affected 50% -no male to male transmission occurs -disorder transmission .mother to son -ex: hemophilia **X-LINKED DOMINANT INHERITANCE:** -affected child: .one affected parent .single gene causes disorders -father is affected .all of his daughters .none of his sons will be affected -mother is affected . 50% chancethat each of her children will be affected -x-linked dominant disorders .commonly lethal in males -examples: .rickets: vitamin D deficiency [congenital] .rett's syndrome

Discuss the role and function of play in the development of the child.

*Functions of play* not always an educational lesson, Parents can encourage toy play- know that play teaches skills and abilities that are the center of intelligence; respect your child's likes and dislikes. *Content of Play* Infant: social-affective play, sense pleasure play, skill play; Toddler: dramatic play (starts at toddler , but perfected as preschooler); Preschool: unrelated play; School age: interactive play/games *Social Affective Play* Infant: talking, cuddling, nuzzling from adults elicit responses in the infant (ex: erickson's trust vs mistrust) skill play - the ability of the infant to grasp and manipulate the object and persistently demonstrate and exercise their new skill.; Dramatic Play- Toddler/preschool: fantasizing and imagining are very important (play dress/imaginary friends are ok); Unoccupied Play- preschooler: daydreaming , fiddling objects, walking aimlessly (play less organized); Interactive Play/games- schoolage: board games, organized play, competitive play *Onlooker Play* Infant 0-6 months- child watches other children play but does not take part in any of the activities *Solitary Play* Infant 6-12 months- does better alone, children play alone and part with toys which are not being used, their own activity is most important- not concerned w/ anyone else *Parallel Play* Toddler: playing with same toys but not together (side by side)- children play independently but not among other children *Association Play* Preschool- children play together and are engaged in a similar or even identical activity, there is no group or rules about sharing of equipment occurs. *Cooperative Play* School Age- organized play with groups of children which have discussed definite purposes to the play and end result is to win

Identify guidelines for toy safety.

*Guidelines for Toy Safety* must be suitable for age; nontoxic; discard broken toys; maintain toys in good repair; remove all outer packaging; must be safe for age; all parts must be present; unplug electrical toys properly; check for breakage periodically *Appropriate Toys* [ birth to 6 mths] soft blocks, simple rattles, books (may enjoy listening to story being read); [7-12 months] puzzles (10 mth) brightly colored, small hand held manipulables, unbreakable mirrors, roly poly toys, rounded wood blocks. Motor control- pincer grasp.; [1 year old] stacking blocks, pounding and hammering toys, peg boards with large pegs; [Active toddler 3 yr] tricycle or pulling a wagon

Identify and discuss the factors that influence the physical and emotional development of the child, including three different temperaments.

*HEREDITY:* -attitudes and expectations with respect to the sex of the child can be somewhat different depending on the culture -correlation between parents and child in regards to physical appearance -personality, activity level, responsiveness and even shyness can be inherited *NEUROENDOCRINE FACTORS:* -hormones - growth and development .human growth hormone .thyroid .sex hormones .androgens *NUTRITION:* -single most important influence on growth -malnutrition detrimental to development -malnutrition can be poor quality of food, stress and disease *SOCIOECONOMIC LEVEL:* -discrepancies exists between all levels of the socioeconomic classes .eating .sleeping .exercising *DISEASE:* *INTERPERSONAL RELATIONSHIPS:* -quality and quantity of contacts with other people .emotional, intellectual and personality development .parents, siblings, peers *MASS MEDIA:* television radio movies books internet

Discuss the current immunization schedules for children

*Hepatitis B virus- HBV- 3 doses* 1st- before leaving the hospital (birth- 2 months) IM- Vastus lateralis- avoid dorsogluteal 2nd- 2-4 months 3rd- 6-18 months Adverse Reactions- fever & local reactions *Dtap- Diphtheria, Pertussis, Tetanus* IM Total of 5 doses -3 doses 2 months, 4 months, 6 months -2 booster doses 12 months, 4-6 years A.R.- fever, local reactions, seizures (rare) Children older than 7- Tdap (tetanus and diphtheria) *IPV (Inactivated Polio Vaccine)* 4 doses 2 months, 4 months, 6-18 months IM Booster dose- 4-6 years A.R.- fever, local reaction *Hib- Haemophilus influenza type b* Usually strikes children under 5 years 2 months, 4 months, 6 months, 12-14 months IM A.R.- fever, local reactions *PCV- Pneumococcal Conjugate Vaccine (Streptococcus Penumoniae)* Given to infants and toddlers 4 doses, IM 2 months, 4 months, 6 months, Booster 12-15 months A.R.- fever, local reactions *Pneumococcal Polysaccharide Vaccine* (PPV) Anyone over 2 years of age (high risk groups- chronic diseases and immune suppression) All adults 65 years of age or older Usually one dose IM Second dose: Children under 10 in 3 years Children and adults over 10 second dose in 5 years *MMR- Measles, Mumps, Rubella* First dose between 12-15 months SQ Second dose: 4-6 years prior to school entry A.R.: fever, local reactions, transient rashes and thrombocytopenia, Encephalitis (extremely rare) Autism no evidence Orchitis, parotitis (rare) Transient arthralgia/arthritis, peripheral neuritis *V, Var- Varicella/Chickenpox* Two doses 1st 12- 15 months 2nd 4-6 years of age SQ A.R.- fever, local reactions, rash, mild case of varicella, pneumonia (rare) *HAV- Hepatitis A (oral-fecal route- contaminated foods)* For children 1st dose 12-23 months 2nd dose at least 6 months apart IM Recommended for states with high incidence (West and Midwest) *Rota- oral tetravalent rotavirus vaccine (severe diarrhea)* 1st dose 2 months 2nd dose 4 months 3rd dose 6 months *Inactivated Influenza Vaccine (IM)* All children 6 months and older and all adults Live Intranasal Influenza Vaccine (spray) For people from 2 through 49 years of age *MCV4, MPSV4 (Meningococcal Conjugate Vaccine, Meningococcal Polysaccharide Vaccine)- for high risk groups* MCV4: for people 2 through 55 MPSV4: used when MCV not available and for people older than 55 *Palivisumab (Synagis):* Immune globulin for children at high risk for Respiratory Syncytial Virus (RSV) Monthly IM injection

identify the principles of psychological preparation for procedures and guidelines for the nursing care based on the different developmental age groups.

*INFANCY* -involve parents/familiar object -use analgesics-topical -perform painful procedures in separate rooms *TODDLER* -explain procedure in relation to senses -use distraction techniques -restrain adequately: mummy wrapping -give one direction at a time -teach what they need to know 5-10 minutes before the procedure -allow choices [2 or less] *PRESCHOOLER* -demonstrate use of equipment -use role play with miniature equipment -encourage "playing out" - use of anatomically correct dolls -teach about the procedure 1-15 minutes before *SCHOOL AGE* -use more scientific terminology -use diagrams -teach 20 minutes before -allow child to take responsibility in simple tasks of procedure -encourage ways to maintain control [i.e: deep breathing] *ADOLESCENCES* -explain consequences -encourage questioning -provide privacy -discuss body image if affected

Discuss the nursing implications and reaction of hospitalization on the different stages of development

*INFANCY* PRIMARY CONCERN/REACTION [SEPARATION ANXIETY] -fear of strangers -crying, clinging -blank facial expression [they don't know whats going on] *TODDLER* [PRIMARY CONCERNS] -increase in separation anxiety -changes in rituals and routine -inability to communicate -loss of autonomy and independency -decrease in mobility [REACTIONS] -protest -despair- withdraws and is apathetic -denial- enjoys the staff-may ignore parents [which are the phases of separation anxiety] *PRESCHOOLER* [PRIMARY CONCERNS] -separation -abandonment and punishment -fear of intrusive procedures -anxiety [REACTIONS] -regression- bed wetting -repression -aggression -projection -fantasy *SCHOOL AGE* [PRIMARY CONCERNS] -mutilation fantasies -loss of peer group -anxiety over loss of privacy -fear of losing mastered skills [REACTIONS] -repression -regression -depression -obsessive- compulsive behaviors -phobias *ADOLESCENCE* [PRIMARY CONCERNS] -body image and sexuality -separation from the security of peers and family -independence threatened -feelings of punishment [REACTIONS] -embarrassment -anxiety -insecurity -intellectualization -secondary gain -depression -denial and withdrawal -anger

Describe the development of the child through the different stages according to Freud, Erikson, Piaget and Kohlberg.

*Piaget stages:* * Sensorimotor infancy (birth to 2 yrs) Curiosity and experimentation; object permanence (when you stick something under the blanket and child looks for it) language develops at the end of this stage; * Preoperational toddler and preschoolers (2 to 7 years); Two phases toddler 2-3 yrs old and preschooler 4 to 7 yrs old; Toddler phase 2-3 yrs old: dominant characteristics EGOCENTRICITY(egocentricity best described as ME ME ME- not being able to put themselves in another person's place), cannot see another point of view; Concrete thinking- unable to make deductions or generalizations; Preschooler phase: Dominant characteristics- Perceptual(4 to 7 years); ; capable of some reasoning/meaningful patterns; concentrates on only one aspect of a situation at a time. * Concrete Operations (7 to 11 yrs); School aged; logical and coherent thinking; children are able to organize, classify, sort and order which is used in problem solving.; Conservation (the clay example)- certain quantity remains constant even if the shape is changed.; able to deal with different aspects of a situation, not able to deal with the abstract concepts; Reasoning is Inductive - other points of view now have relevance. * Formal operations (11-17 yrs); Puberty 12-15 yrs; adaptability & flexibility; Abstract thinking and conclusions can be drawn from observation hypotheses can be formulated and tested. * Freud:* (sensual pleasure) during childhood different parts of the body assume significance. * Oral Stage (0-1) (everything goes in the mouth) Safety Issues: ex- marbles/pebbles * Anal Stage (1-3) (toilet training) the climate of toilet training is important aspect here for the development of personalities (anal repulsive vs anal expulsive) * Phallic Stage (3-6) (diffs in body parts- boys vs girls) the genitals become interesting part of the body and are very sensitive. * Latency Period (6-12 yrs) (achievers) physical and psychic energy directed towards new knowledge and play; energy is directed at school. * Genital Stage (12 yrs and older) all energy is directed towards friendships with the hope of marriage and family or relationships. * Erickson Theory:* describes key conflicts or problems which must be mastered during critical periods of personality developmental. * Trust vs mistrust: (infancy) Birth to 1 year: hold baby while feeding them; establishes of trust dominates the first yrs of life & describes all satisfying experiences; maternal or mothering person- development of trust * Autonomy vs Shame and doubt: toddler 1-3 years: Autonomy: child wants to control their bodies, themselves and their environment; it corresponds to Freud's anal stage during the sphincter muscle control. Independence is important - allow the toddler to do things on his/her own when capable; Shame and Doubt: develops when they are forced to be dependent on others, criticized, made feel small, become self conscious. ; Rituals are very important = means security and stability * Initiative vs Guilt: preschooler 3-6 yrs; (fantasyland years) strong imagination; exploration of their world brings them to undertake goals and activities which are contrary to their parents, imaginary friends common. * Industry Inferiority: school aged 6-12 yrs; children are not ready to be workers/producers; begin and complete tasks and activities; achievement is very important during this stage; sense of industry- COMPETENCE * Identity vs Role confusion: puberty or adolescence 12-18 yrs; characterized by rapid physical changes; children become preoccupied with the way they look in the eyes of others; struggle to fit into roles they play and the roles of their peers; Confusion * Kohlberg Theory:* three levels: * Preconventional Level : infancy- cannot distinguish between right and wrong; toddler- performance based on fear of punishment; preschooler 4-7 yrs, breaking rules results in punishment, behavior based on rewards * Conventional Level; school age 7-11 yrs old * Principled Morality/ Postconventional Level: Adolescents 12yrs and on; acceptance of right and wrong on basis of own perceptions of world and personal conscience

Discuss clinical manifestations, diagnostics, medical and nursing management of sepsis and meningitis.

*SEPSIS* [clinical manifestations] INITIALLY: -poor sucking/feeding -lethargy -irritability SUBSEQUENT: -cyanosis -hypotension -tachycardia -jaundice -dehydration -seizures -tremors [Lab/Diagnostics: ] Blood cultures Urine cultures CSF analysis for infectious organisms CBC- elevated WBC and immature neutrohpils ESR/CRP (C-Reactive Protein)- increases [Nursing Management] Maintain airway Administer antibiotic therapy as ordered Provide adequate nutrition Monitor for signs/symptoms of shock *MENINGITITS*

a nurse is providing anticipatory guidance to the parents of a school age child.

*developmental stage* [piaget] concrete operations [erikson] industry vs inferiority *physical development* -gain 2 to 3kg [4.4 to 6.6 lb] per year -grow about 5 cm [2 in] per yr -bladder capacity is variable with each child -immune system improves -bones continue to ossify *nutrition* -avoid using food as a reward -emphasize physical activity - ensure a balanced diet is consumed -encourage children to select healthy foods and snacks -avoid eating fast foods frequently -avoid skipping meals -model healthy behaviors

a nurse is preparing an educational program for a group of parents of adolescents

*developmental stage* [piaget] formal operations [erikson] identity vs role confusion *cognitive development* -able to think through more than two categories of variables concurrently -capable of evaluating the quality of own thinking -able to maintain attention for longer periods of time -highly imaginative and idealistic -increasingly capable of using formal logic to make decisions -think beyond current circumstances -understand how the actions of an individual influence others *injury prevention* [bodily injury] -keep firearms unloaded and in a locked cabinet or box -teach proper use of sporting equipment prior to use -insist on helmet use and/or pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and snowboarding -be aware of changes in mood. continuously monitor adolescents at risk for self harm [motor vehicle injuries] -encourage attendance at drivers education courses -emphasize the need for adherence to seat belt use -discourage use of cell phones while driving and enforce laws regarding use -teach the dangers of combining substance abuse with driving -role model desired behavior

a nurse is assisting with a well child visit with a 2 yr old.

*developmental stage* [piaget] preoperational stage [erikson] autonomy vs shame and doubt *nutrition* -can switch from whole milk to low fat milk after the age of 2 yrs. - trans fatty acids and saturated fats should be avoided -diet should include 1 cup of fruit daily -limit fruit juice to 4 to 6 oz per day -cut food into small, bite size pieces to prevent choking -do not allow drinking or eating during play activites or while lying down *injury prevention* [bodily harm] -keep sharp objects out of reach -lock firearms in a cabinet or box -teach toddler stranger safety -do not leave toddler unattended with animals [drowning] -do not leave toddler unattended in bathtub -keep toilet lids closed -begin teaching toddler water safety and to swim -keep bathrooms doors closed [burns] -check bath water temperature prior to toddler contact with water -set hot water heaters to 49°C [120°F] or below -keep pot handles pointed to back of stove when cooking -cover electrical outlets -keep working smoke detectors in the home -apply sunscreen when toddler will be outside [falls] -keep doors and windows locked -place crib mattresses in lowest position waith rails all the way up -use safety gates at the top and bottom of stairs.

a nurse is assisting with an educational program for a group of parents of infants.

*developmental stage* [piaget] sensorimotor stage [erikson] trust vs mistrust *cognitive development* [separation] learning to separate themselves from other objects in the environment [object permanence] understanding that an object still exists when it is out of the view [mental representation] ability to recognize symbols *age appropriate activities* -rattles, teething toys, nesting toys, playing pat a cake, playing with balls, reading books, mirrors, brightly colored toys, playing with the blocks *injury prevention* [aspiration] -avoid small objects -provide age appropriate toys -check clothing for hazards such as loose buttons [poisoning] -keep toxins and plants out of reach -place safety locks on cabinets where cleaners/chemicals are stored -use a carbon monoxide detector in the home -keep medications in childproof containers and out of reach [drowning] - do not leave unattended around any water source -secure fencing around swimming ppol [suffocation] -avoid plastic bags -ensure crib mattress fits snugly -remove crib mobiles by 4 to 5 months of age -keep pillows out of the crib -back to sleep

a nurse is providing anticipatory guidance to the parents of a preschool age child

*physical development* [weight] preschoolers should gain about 2 - 3 kg [4.4 to 6.6 lb] per yr [height] preschoolers should grow about 6.5 to 9 cm [2.6 to 3.5 in] per year *cognitive development* -vocabulary increases to more than 2,100 words by the end of the fifth year -speak in sentences of three to four words at the ages of 3 and 4 yrs -speak in sentences of four to five words at the age of 4 to 5 years -enjoy talking, and language becomes primary method of communication *age appropriate activites* -putting puzzles together -playing pretend and dress up activites -painting -simple sewing -reading books -wading pools -skating -electronic games *injury prevention* -stand back from curb while waiting to cross the street.-before crossing the street look left, then right, then left again. -walk on the left, facing traffic, when there are no sidewalks - at night, wear light colored clothing with fluorescent materials attached

a nurse is reinforcing anticipatory guidance to the mother of a toddler. the nurse learns that the household includes the mother, the toddler, an older brother, and a grandmother.

*related content* [family composition] this is an extended family, which includes at least one parent, one or more children, and other individuals who are either related or not related *underlying principles* [positive parental influences] -have a good mental health -maintain structure and routine in the household -engage in activities with the child -validate the childs feelings when communicating -monitor for safety concerns with special considerations for the childs developmental needs [promoting acceptable behavior] -validate the childs feelings, and offer sympathetic explenations -provide role modeling and reinforcement for acceptable behavior -set clear and realistic limits and expectations based on the childs developmental level -focus on the behavior when implementing discipline *nursing interventions* [family data collection] -medical hx on parents, siblings, and grandparents -family structure for roles/position within the family, as well as occupation and education of family members -developmental task a family works on as the child grows -family characteristics, such as cultural religious, and economic influences on behavior, attitudes, and actions -family stressors, such as expected [birth of a child] and unexpected [illness of a child, divorce, disability or death of a family member] events that cause stress -availability of and family interactions with community resources -family support systems, such as availability of extended family, work and peer relationships, as well as social systems and community resources to assist the family in meeting needs or adapting to a stressor

a nurse is preparing to examine a preschool age child

*underlying principles* [child is ready to cooperate] -interacting with nurse -making eye contact -permitting physical touch -willingly sitting on examination table -accepting and handling equipment *nursing interventions* [actions to take if child is uncooperative] -engage both the child and the parent -be firm and direct about expected behavior -complete data collection as quickly as possible -use a calm voice -reduce environmental stimuli -limit the people in the room [actions to enhance child's comfort] -perform examination in nonthreatening environment -take time to play and develop rapport prior to beginning examination -keep the room warm and well lit -keep medical equipment out of sight until needed. -provide privacy -explain each step of the examination of the child -examine the child in a secure, comfortable position -examine the child in an organized sequence when possible -encourage the child and family to ask questions during the examination

List the four areas of development evaluated by the DDST.

-The 4 major areas of development evaluated are: -personal social -fine motor adaptive -language -gross motor skills

State the different methods of medication administration to children of different age groups.

-establish a constructive relationship with child -supportive care before, during, and after procedure -avoid safe places -constant reassurance is necessary -the nurse should: .involve the child .provide distraction if necessary .allow expression of feeling *general issues* Never more than adult dose One gram rule- anything > 1 gram=question Pain Medication • Titrate the dose- inadequate respiratory reserve • No aspirin containing products • Maximum doses of Tylenol < 12 years of age = 2 grams > 12 years of age= 4 grams Watch for Different Concentrations Elixir (solution vs suspension) Junior Strength Tabs/ Adult Tabs *ORAL* [INFANTS/TODDLERS] • Infants will generally accept medication put into their mouths if it is in a form they can swallow • Toddlers will resistant oral medications more • Give slowly to prevent chocking • Hold the child on your lap if possible • Raise HOB • Plastic syringes/small medicine cup -Crushed pills and capsules (if not contraindicated): can be placed in small amount of pureed fruit, check for food likes/allergies first. -Nurse should not show any distaste or negative feeling about medication -Child remains uncooperative and/or vomits: report it to the physician *IM INJECTIONS* -First intramuscular injection- attitude toward future injections -Explain procedure if old enough -Develop a rapport -Second person to assist in holding (caregiver/other nurse) -No more than 1 cc if < 3 years old -Vastus lateralis (< 3years) -No deltoid administration until 6 -Ventrogluteal site- walking for one year -Nurse should comfort the child after procedure

List the principles of establishing a therapeutic relationship between the nurse, child, and family.

-first contact -all behaviors are meaningful -accept the parents and their child exactly as they are -have EMPATHY for parents and children -acknowledge the parents and children -permit both parents to express negative emotions -use lay terms: language understandable to the parents and child -question limit to a single idea or reference -promote unity among healthcare team

a nurse is collecting data from a cleint who has been taking propylthiouracil [propyl-thyracil] for hyperthyroidism for the past 3 months. which of the following findings indicate to the nurse the medication is effective? [SELECT ALL THAT APPLY]

-heart rate 72/min: hyperthyroidism = tachycardia from increased levels of thyroid hormone; therefore a HR of 722/min is within expected reference range and indicates the medication is effective. -reduced serum T-4 levels: increased t-4 lvls. therefore a decrease means meds are working -improved sleep pattersns: hyperthyroid have increased CNS stimulation that leads to imsonia. if the pt sleeps better meds are working -increased attention span: since the CNS is constantly stimulated the client tends to not pay attetion aswell. if meds are working this will also improve.

Discuss the child's emotional reaction to hospitalization.

-new experience for the child and the parents -reasons for hospitalization should be told the child, if approved by the caregiver -the truth may be less frightening than the imaginations

Discuss the stress of bodily injury-pain and its relationship to hospitalization.

-stress is present due to concern about bodily injury and pain are prevalent among children -research has shown the young children including newborns react to painful stimuli

a nurse is conducting a well child visit with a child who is scheduled to receive the recommended immunizations for 11 to 12 yr olds. which of the following immunizations should the nurse administer? [SATA] a. trivalent inactivated influenza b. pneumococcal [PCV] c. meningococcal [MCV4] d. tetanus and diphtheria toxoids and pertussis [Tdap] e. Rotavirus [RV]

A TIV is a recommended immunization for 11 - 12 yr olds, and should be administered by the nurse C MCV4 is a recommended immunization for 11- 12 yr olds, and should be administered by the nurse D Tdap is a recommended immunization for 11-12 yr olds, and should be administered by the nurse

a nurse is assisting with a developmental screening of a 3 yr old child. which of the following skills should the child be able to perform? a. ride a tricycle b. hop on one foot c. jump rope d. throw a ball overhead

A a 3 yr old child should be able to ride a tricycle

a nurse is providing anticipatory guidance to the parents of a toddler. which of the following should the nurse include? [SATA] a. develop food habits that will prevent dental caries b. meet caloric needs results in an increased appetite c. expression of bedtime fears is common d. behaviors associated with negativism and ritualism e. importance of annual screenings for phenylketonuria

A because the toddler is developing taste preferences, the development of food habits that will prevent dental caries should be included in the anticipatory guidance C expression of bedtime fear is common for toddlers and should be included in the anticipatory guidance D negativism and ritualism are exhibited by toddlers as they seek autonomy. associated behaviors should be included in the anticipatory guide

a nurse is collecting neurological data on an adolescent. which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? [SATA] -a. clenching teeth together tightly -b. recognizing sour tastes on the back of the tongue -c. identifying smells through each nostril -d. detecting facial touches with eyes closed -e. looking down and in witht he eyes

A clenching teeth together tightly is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve D detecting facial touches with eyes closed is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve

a nurse is reinforcing teaching about expected changes during puberty to a group of parents of early adolescent females. which of the following statements by one of the parents indicates an understanding of the teaching? a. females usually stop growing about 2 years after menarche b. females are expected to gain about 65 pounds during puberty c. females experience menstruation prior to breast development d. females typically grow more than 10 inches during puberty

A females usually stop growing about 2 yrs after menarche. this statement by the parent indicates an understanding of the teaching

when collecting data from an infant, which of the following techniques should the nurse use to elicit a stepping reflex? a. hold the infant upright with his feet touching a flat surface b. strike a flat surface on which the infant is lying c. place an object in the infant's palm d. stroke the outer edge of the sole of the infant's foot up towards the toes

A holding the infant upright with his feet touching a flat surface will elicit a stepping reflex. the infant will make stepping movements

a nurse is preparing to collect data from a preschool age child. which of the following is an appropriate action by the nurse to prepare the child? a. allow the child to role play using miniature equipment b. use medical technology to describe what will happen c. separate the child from her parent during examination d. keep medical equipment visible to child

A the nurse should allow the child to role play or manipulate actual or miniature equipment to reduce the anxiety and fear related to the examination

a nurse is collecting data from the parents of two school age children. which of the following should the nurse include? [SATA] -a.grandparents health status -b. parents educational level -c. childrens physical growth -d. support systems -d. childrens nutritional intake

A the nurse should include a medical history of the parents, siblings, and grandparents when performing a family assessment B the nurse should include the family structure, which includes family members, roles/positions within the family, and occupation and education of family members, when performing a family assessment D the nurse should include support systems to determine the availability of extended family, work and peer relationships, and social systems and community resources to assist the family in meeting needs when performing a family assessment

a nurse is providing anticipatory guidance to the parent of a 13 yr old. the nurse should recommend which of the following screenings for the adolescent? [SATA] a. body mass index b. blood lead level c. height d. weight e. scoliosis

A the nurse should recommend that the adolescent have a BMI screening annually C recommend height screening annually D recommend weight screening annually E recommend scoliosis screening anually

when collecting data from a toddler, which of the following characteristics should the nurse expect to find? [SATA] -a. bowlegged gait -b. abdominal breathing -c. established eye color -d. absent red reflex -e. bowel sounds heard every 2-3 min on auscultation

A the toddler should appear bowlegged or have a knock knee appearance B the toddler should show abdominal breathing C the toddler should have established permanent eye color by 6 - 12 months of age

a nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. the nurse hears one parent state, "my son knows he better do what I say." which of the following parenting styles is the parent exhibiting? a. authoritarian b. permissive c. authoritative d. passive

A this parent is exhibiting an authoritarian parenting style. using this style, the parent controls the adolescents behaviors and attitude through unquestioned rules and expectations

a nurse is assisting with a developmental screening on an 18 month old. which of the following skills should the toddler be able to perform? [SATA] a. build a tower with six blocks b. throw a ball overhand c. walk up and down stairs d. draw circles e. use a spoon without rotation

B an 18 month ol should be able to throw a ball overhand D an 18 month old should be able to use a spoon without rotation

a nurse is reinforcing teaching about dental care and teething to the parent of a 9 month old infant. which of the following statements by the parent indicates an understanding of the teaching? a. "i can give my baby frozen, fluid filled teething ring to relieve discomfort" b. "i should clean my baby's teeth with a cool, wet wash cloth" c. "i can give advil for up to 5 days while my baby is teething" d. "i should dilute juice with water in the bottle my baby drinks while falling asleep"

B it is appropriate to use a cool, wet wash cloth for cleaning the infants teeth.

a nurse is assisting with preparation for an education program about nutrition for preschool age children for a group of parents. which of the following should the nurse include? a. saturated fats should equal 20% of total caloric intake b. average daily intake should be 1,800 calories c. finicky eating habits develop around 5 yrs of age d. healthy diets include 8 g of protein each day

B preschool age children should consume an average of 1,800 calories each day.

a nurse is caring for an adolescent whose mother expresses concerns about her son sleeping such long hours. the nurse should inform the mother that additional sleep is needed during adolescence due to which of the following? a. sleep terrors b. rapid growth c. elevated zinc levels d. slowed metabolism

B rapid growth during the adolescent years results in the need for additional sleep

a nurse is checking a 2 1/2 yr old toddler at a well child visit. which of the following findings should the nurse report to the provider a. height increased by 7.5 cm [3 in] in the past year b. head circumference exceeds chest circumference c. anterior posterior fontanels closed d. current weight equals four times the birth weight

B the head and chest circumference should be equal by 1 - 2 yrs of age, with the chest should be equal by 1 to 2 years of age, with the chest circumference continuing to increase in size until it exceeds the head circumference. the nurse should report this finding to the rpovider

a nurse is assisting with a well baby visit with a 4 month old infant. which of the following immunizations should the nurse administer to the infant? [SATA] -a. measles, mumps, rubella [MMR] -b. polio [IPV] -c. pneumococcal vaccine [PCV] -d. rotavirus vaccine [RV]

B the nurse should administer an IVP vaccine to a 4 month old infant C the nurse should administer a PCV vaccine to a 4 month old infant E the nurse should administer an RV vaccine to a 4 month old infant

a nurse is reinforcing teaching about safety during the school age yrs to a group of parents. which of the following information should the nurse include? [SATA] a. gating stairs at the top and bottom b. wearing helmets when riding bicycles or skateboarding c. riding safely in beds of pickup trucks d. implementing firearm safety e. wearing seat belts

B the nurse should include information about wearing helmets when riding bicycles or skateboarding when reinforcing teaching about safety in the school age years D the nurse should include information about implementing firearm safety when reinforcing safety in the school age years E the nurse should include information about wearing seat belts when teaching about safety in the school age years

a nurse is reinforcing teaching about introducing new foods to the parents of a 4 month old. which of the following foods should the nurse recommend the parents introduce first? a. strained yellow vegetables b. iron-fortified cereals c. pureed fruits d. whole milk

B the parents should first introduce iron-fortified cereals because of their high iron content. the order of introducing solid foods after this is variable

a nurse should withold the prescribed dose of furosemide [lasix] for a cleint when which of the following findings is noted?

BP is 85/60 mm Hg furosemide can cause a drop in BP. a BP of 85/60 mm Hg before dosing warrants witholding the medication and notifying the pcp

a nurse is caring for a preschool age child who says she needs to leave the hospital because her doll is scared to be at home alone. which of the following characteristics of preoperational thought is the child exhibiting? a. egocentrism b. centration c. animism d. magical thinking

C animism occurs when the child gives living qualities to inanimate objects, such as a doll feeling scared

a nurse is observing a 2 yr old child during a routine visit to the clinic for a check up. which of the following activities should the nurse expect the child to do? a. tie his shoelaces b. ride a tricycle c. kick a ball forward d. use blunt scissors

C kicking a ball forwards is typical behavior of a 2 yr old.

a nurse is instructing a class about puberty in males. which of the following should the nurse include as the first manifestation of sexual maturation? a. pubic hair growth b. vocal changes c. testicular enlargement d. facial hair growth

C testicular enlargement is the first manifestation of sexual maturation in males

a nurse is checking a 6 month old infant prior to administering the diphtheria, tetanus, and acellular pertussis [DTaP] vaccine. for which of the following findings should the nurse delay administering the vaccine? a. family hx of sudden infant death syndrome [sids] b. temp of 38.5°C [101.3°F] following the 4 month vaccinations c. acute bilateral ear infection d. living with a family member who is immunocompromised

C the nurse should delay administering the DTap vaccine in the presence of an acute infection, with or without fever, because this decreases the infants ability to develop good immunity

a nurse is discussing prepubescence and preadolescence with a group of parents of school age children. which of the following information should the nurse include in the discussion? a. initial physiologic changes appear during early childhood b. changes in height and weight occur slowly during this period c. growth differences between boys and girls become evident d. signs of sexual maturation become highly visible in boys

C the nurse should include in the discussion that growth differences between boys and girls become evident

Discuss causes, clinical manifestations and management of fever.

Clinical Findings Temperature > 100.4° F axillary Skin flushing/diaphoresis/chills Restlessness/lethargy Nursing Management Goal: maintain stable body temperature Administer antipyretics- Tylenol/Ibuprofen (usually not aspirin) Tepid Bath Teach parents how to take temperature

Discuss clinical manifestations, diagnostics, medical and nursing management of febrile seizures.

Clinical Manifestations Seizures associated with a high fever 102-104° F Affects 3-5% of children Usually occurs after 6 months and before 3 years Most often associated with URI/UTI/Roseola Usually last from 1-15 minutes Lab/Diagnostics EEG- rule out Seizure disorder Lumbar puncture- r/o meningitis CT/MRI- r/o other abnormalities Nursing Management: Prevent injury Administer anticonvulsant therapy as prescribed

a nurse is speaking with the mother of a month old during a well baby visit. the mother asks the nurse if her infant is developing normally. which of the following developmental milestones should the nurse expect the infant to perform? a. smiles and laughs out loud b. rolls from back to side c. visually searches to locate sounds d. turns head from side to side

D from birth, an infant is able to lift the head and turn it from side to side when lying prone

a nurse is reinforcing teaching about methods to promote sleep to the parent of a preschool age child. which of the following statements by the parent indicates an understanding of the teaching? a. "i will sleep in the bed with my child if she wakes up during the night" b. "i will let my child stay up an additional 2 hrs on weekend nights" c. "i will let my child watch television for 30 minutes just before bedtime each night" d. "i will keep a dim lamp on my child's room during the night"

D leaving a light on in the child's room is an appropriate method to promote sleep for a preschool age child. this statement by the parent indicates an understanding of the teaching

a nurse is reinforcing education about sleep and rest to a group of parents of school age children. which of the following statements by a parent indicates a need for further teaching? a. my child's age influences the number of hours of sleep he needs b. my child's level of activity during the day influences the number of hours of sleep he needs c. my child's health status influences the number of hours of sleep he needs d. my child's family history of sleep apnea influences the number of hours of sleep he needs

D the child's family history of sleep apnea does not contribute to the number of hours of sleep he needs. this statement by the parent indicates a need for further teaching

Describe the influence of genetic and environmental factors on growth and development

GENETIC INFLUENCES: 23 pair of chromosomes and 22 autosomes [ non gender determining chromosomes] and 1 pair of sex chromosomes labeled X and Y .gametes [ova and sperm cells]-chromosome-DNA-Gene -genetic problems can be categorized into three types .monogenic: problem with one gene .multifactorial disorders: involves many genes .chromosomal abnormalities: deviation in structure of number of chromosomes ENVIRONMENTAL INFLUENCES: -environmental factors play a role in the overall growth and development of the child interacting with genetic forces within the child .FACTORS: -family dynamics - interrelationships .culture and life style .accessibility of caregiver .stimulation by caregiver .love/feeling of belonging [maslows] -types of families: .nuclear .extended .single parent .foster parent .alternative [communal] .dual career .blended .polygamous .homosexual .cohabitation -nutrition .inadequacies affect growth .makes the child prone to disease -diseases .any disease whether acute or chronic can have a lasting effect on the child

Explain the differences between growth, development, maturation and learning.

GROWTH: -increase in structure [size] -physical changes in the anatomy of the child -increased in number and size of cells .this is a quantative change -can be measured in feet/meters/pounds/kilograms .example: height/weight DEVELOPMENT: -increase in function -changes occur in the physiological aspect of the child -involves the changeing from a lower to a more advanced stage of complexity .example: a baby's ability yo digest a solid -development is achieved through growth, maturation and learning MATURATION: -the process of the unfolding of genetic or inherited tendencies within the child .qualitive change .children mature at their own rate .some children are late matures while others are rapid matures .also described as an increase in competence and adaptability LEARNING: -results from experience, experimentation, and training -results in a change of behavior -the ability to learn is dependent upon the inborn capacity for mental development *NOTE: -maturation and learning are interrelated -no learning can take place unless the child is mature enough to understand -the learning process is hindered if the child is not given the opportunity to learn by experience and from others when the time is optimum

State the three phases of separation anxiety.

PHASES OF PROTEST -aggressive reaction to the separation PHASE OF DESPAIR -no crying but depression is evident PHASE OF DETACHMENT -also called denial-child appears to accept the situation, resignation not contentment

a nurse is monitoring a cleint who has just returned to the unit following surgery. the cleint received an initial dose of morphine 5mg IV bolus for pain relief. which of the following adverse effects should the nurse report immediately to the provider?

a low respiratory rate when using the airway, breathing, circulation [ABC] approach to the cleint care, the nurse determines the priority finding is a respiratory rate that is low indicating res depression

a client who is experiencing nausea related to chemotherapy is being discharged with a prescription for ondansetron [zofran]. the nurse should include which of the following information when reinforcing discharge teaching?

avoid driving while taking this medication s/e of ondansetron include h/a and dizziness. the client should avoid driving or using heavy machinery

a nurse is caring for a client who asked her provider what he should take to treat motion sickness. the provider suggested taking dimenhydrinate [dramamine]. which of the following disorders in the clients medical record should the nurse report to the provider as a contraindication?

benign prostatic hypertrophy dimenhydrinate, an antihistamine, is inappropriate for cleints who have prostatic hypertrophy because it has anticholinergic properties. anticholinergic medications can cause urinary retention, thus compounding the urinary tract symptoms associated with prostatic hypertrophy and making it a contraindication for the use of dimenhydrinate.

a nurse is caring for a client who has TB and will be taking isoniazid [INH]. which of the following actions should the nurse take?

determine the cleints daily alcohol intake isoniazid [INH] can cause liver damage; therefore it is important for the nurse to determine the cleints daily intake because alcohol use increases this risk. the nurse should instruct the cleint to reduce or avoid all use of alcohol.

a nurse is collecting data from a client who is receiving transdermal nitrate therapy for angina. which of the following findings should the nurse recognize as a side effect of this therapy

dizziness when the client stands up nitrates cause relaxation of the vascular smooth muscle, resulting in pooling of blood in the veins and decreased venous return to the heart. this decreases cardiac output, ahich causes BP to fall and orthostatic hypotension to occur with a change in position.

a nurse is caring for a pt who has chronic renal failure and has been receiving epoetin alfa [epogen] for 2 weeks. which of the following indicates to the nurse that the medication is having the desired therapeutic effect?

hemoglobin rises 0.5 g/dL initial effects occur within the first 2 weeks of therapy. hemoglobin reaches target levels [10-12 g/dL] in 2-3mnths

a nurse is reinforcing teaching with a client who is prescribed alendronate [fosamax] 70 mg weekly. which of the following responses from the cleint indicates and understanding of the teaching?

i will take the medication with a full glass of water 30 minutes before breakfast clients should take alendronate on an empty stomach with 8 oz of water to make sure it does not lodge in the esophagus, which can result in esophageal ulcerations. the cleint should also mantain an upright position for 30 min after administration

a nurse is reinforcing teaching for a client whop is being discharged with a prescription for propanolol [inderal]. which of the following should the nurse include in the teaching?

if your pulse is less than 60 bpm, notify pcp bradycardia is a common adverse effect of beta blockers. of this occurs, the leint should withold the dose of medication and call the pcp.

a nurse is reviewing the history of a cleint who is about to start taking cefotetan [cefotan] to treat a bacterial infection. which of the following information from the clients medical record should the nurse report to the provider before the cleint begins receiving this medication?

penicillin allergy cefetotan is a cephalosporin, a group of antibiotics that are structurally similar to penicillins. it is possible that a client who is allergic to penicillin could evelop cross sensitivity and have an allergic rxn to cephalosporins.

a ten year old with a viral infection. why is aspirin a contraindication? at risk for?

reye syndrome aspirin is contraindicated in children or adolescents who have a viral illness because it is associated with the development of reye syndrome. the risk for children and adolescents to develop reye syndrome if they take aspirin following a viral illness

a nurse is reinforcing discharge teaching for an adult female client who has a new prescription for doxycycline [vibramycin] for acne. which of the following should the nurse include in the teaching?

take the medication with a full glass of water doxycycline should be taken with a full glass of water to ensure it passess into the stomach, which will prevent esophageal ulceration.

a nurse is collecting data from a client who has been taking levadopa/carbidopa [ sinemet]. which of the following findings should indicate to the nurse that the medication is effective?

the client is able to wash his face levadopa is a dopaminergic medication that works by activating dopamine receptors, restoring nerve transmission in the basal ganglia for clients with parkinsons disease, carbidopa enhances these effects by inhibiting the decarboxylation of levadopa in the intestine and periphery. this allows the cleint to move freely and resume activities of daily living

a nurse is caring for a client who is taking phenytoin [dilantin] to control seizures. the nurse should recognize that phenytoin may decrease the desired effect of which of the following prescribed medications

warfarin [coumadin] phenytoin stimulates synthesis of hepatic drug metabolizing enzymes. as a result, phenytoin can decrease the effects of warfarin

NCLEX - PN MERCY REVIEW

Related study sets

Consumer Behavior Chapter 8

Naturfagsprøve

Entrep Final Vocab

Community Nutrition - Exam 2; Table 10-4

1. Basic Economic Concepts

RT4 Exam 1 Final

DNA and Replication

Management of Patients with Chest and Lower Respiratory Tract Disorders

ELA Eleanor Roosevelt

Policy Provisions and Contract Law

Macro 3

National PreTest

Abraham Notes

Anatomy Quiz 11: CH 25

Bible Final

Microeconomics Chapter 3, 4, 5, 6, 8, and 10 Exam 1

Principles of Marketing Study Guide for Midterm 1

Civilizations in North and South America

CHEM 212--Quiz 1: Safety Review

practice insurance questions