NCLEX study guide

MMR vaccine

The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of the child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is also utilized as post-exposure prophylaxis. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years.

Black cohosh

is a herbal supplement used by perimenopausal clients experiencing hot flashes

Bumetanide

is a potent loop diuretic (eg, furosemide, torsemide) used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question the bumetanide prescription as the client with heart failure has hypokalemia (potassium <3.5 mEq/L [3.5 mmol/L]) and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance.

Azathioprine

is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication due to high risk for infection.

Long-term use of proton pump inhibitors (PPIs)

is common as these medications are available over the counter. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias.PPI use may also increase the risk for clostridium difficile-associated diarrhea (CDAD); currently the cause is unclear. A safety alert has been issued by the US Food and Drug Administration (FDA) advising health care providers to consider CDAD for unresolved diarrhea in PPI users. This client would be receiving antibiotics for a urinary tract infection, further increasing the risk for C difficile infection

Hypokalemia

(<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia. Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. causes muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distention, decreased bowel sounds) are common. Cardiac arrhythmias is the most serious complication.

Polypharmacy and physiologic changes associated with aging

(eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity, balance and gait problems) place the elderly at increased risk of adverse drug effects. The Beers criteria provide a list that classifies potentially harmful drugs to avoid or administer with caution in the elderly due to the high incidence of drug-induced toxicity, cognitive dysfunction, and falls. Some commonly used medications in this list include antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiazepines, diuretics, opioids, and sliding insulin scales. Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias. Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms.

Opioid analgesics

(eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for falls from sedation or hypotension and should not get out of bed unassisted. Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of daily stool softeners) should be implemented. IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of opioid analgesics can cause severe hypotension and respiratory or cardiac arrest. Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing, incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing and lead to atelectasis and pneumonia.

Medications commonly prescribed for a client with an open fracture include:

-Cefazolin (Ancef), a bone-penetrating cephalosporin antibiotic that is active against skin flora (Staphylococcus aureus); it is given prophylactically before and after surgery to prevent infection -Cyclobenzaprine (Flexeril), a central and peripheral muscle relaxant given to treat pain associated with muscle spasm; carisoprodol (Soma) or methocarbamol (Robaxin) can also be prescribed -Tetanus and diphtheria toxoid, an immunization given prophylactically to prevent infection (Clostridium tetani) if immunizations are not up to date (>10 years), unavailable, or unknown -Ketorolac (Toradol), a nonsteroidal anti-inflammatory drug given to decrease inflammation and pain -Opioids (eg, morphine, hydrocodone [Vicodin]), given for analgesia

CBT involves 5 basic components:

-Education about the client's specific disorder -Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity -Physical control strategies - deep breathing and muscle relaxation exercises -Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts -Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety -provoking situations or events

Selective estrogen receptor modulators

(eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer. Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important.

Trismus

(inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus). Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. This abscess can occlude the airway, making it a medical emergency. Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an adequate airway is essential.

Calcium channel blockers

(nifedipine, amlodipine, felodipine, nicardipine) are vasodilators used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure. Adverse effects of calcium channel blockers include dizziness, flushing, headache, peripheral edema, and constipation. The reduced blood pressure may initially cause orthostatic hypotension. The client should be taught to change positions slowly to prevent falls. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids, fruits/vegetables, and high-fiber foods.

Clients receiving treatment for depression and suicidal ideation must be carefully monitored for indications of increasing intent. During the client interview, the nurse should assess:

-Access to psychiatric medications -Availability of help during a crisis (eg, counselor, family) -Future goals and plans -Home and work environment risks -Overall affect and level of energy -Possible access to weapons Clients who articulate long-term personal goals and family milestones are less likely to commit suicide

UAP

-Activites of daily living -Hygiene -Linen change -Routine, stable vital signs -Documenting input/output -positioning

In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include:

-Adherence to a high calorie diet (4000-5000 calories per day). -Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals. -Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. -Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). -Avoidance of spicy foods as these can also increase GI stimulation.

Major predisposing factors for the development of delirium in hospitalized clients include:

-Advanced age -Underlying neurodegenerative disease (stroke, dementia) -Polypharmacy -Coexisting medical conditions (eg, infection) -Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) -Metabolic and electrolyte disturbances -Impaired mobility - early ambulation prevents delirium -Surgery (postoperative setting) -Untreated pain and inadequate analgesia

Initial interventions in emergency management of chest pain are as follows

-Assess airway, breathing, and circulation (ABCs) -Position client upright unless contraindicated -Apply oxygen, if the client is hypoxic -Obtain baseline vital signs, including oxygen saturation -Auscultate heart and lung sounds -Obtain a 12-lead electrocardiogram (ECG) -Insert 2-3 large-bore intravenous catheters -Assess pain using the PQRST method -Medicate for pain as prescribed (eg, nitroglycerin) -Initiate continuous electrocardiogram (ECG) monitoring (cardiac monitor) -Obtain baseline blood work (eg, cardiac markers, serum electrolytes) -Obtain portable chest x-ray -Assess for contraindications to antiplatelet and anticoagulant therapy -Administer aspirin unless contraindicated

Self-administering nasal sprays

-Assume a high Fowler's position with head slightly tilted forward -Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger -Point the nasal spray tip toward the side and away from the center of the nose -Spray the medication into the nose while inhaling deeply -Remove the nozzle from the nose and breathe through the mouth -Repeat the above steps for the other nostril -Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation

The examination for skin cancer follows the ABCDE rule:

-Asymmetry (eg, one half unlike the other) -Border irregularity (eg, edges are notched or irregular) -Color changes and variation (eg, different brown or black pigmentation) -Diameter of 6 mm or larger (about the size of a pencil eraser) -Evolving (eg, appearance is changing in shape, size, color)

Nonpharmacological strategies for improving sleep hygiene include:

-Avoiding naps throughout the day -Engaging in physical activity or exercise, preferably at least 5 hours before bedtime -Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns -Avoiding caffeinated beverages after noon -Avoiding alcohol and/or smoking at bedtime -Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) -Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet -Avoiding heavy meals or large amounts of fluids at bedtime -Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness

The correct order of assessment in infants is:

-Before handling the infant, the nurse first observes the infant for activity level, skin color, and respiratory rate and pattern to obtain findings during a calm state. -Auscultation is performed next while the infant is still quiet, allowing the nurse to hear sounds clearly. -Palpation and percussion are then performed while the infant remains relatively still. This allows the nurse to accurately assess the abdomen while the abdominal muscles are relaxed. The fontanelles are also palpated while the infant is calm, as crying can cause temporary bulging. -Traumatic procedures (eg, examine eyes, ears, mouth) are performed near the end

To perform postmortem care

-Maintain standard or isolation precautions in place at the time of death. -Gently close the client's eyes. -Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. -Straighten and wash the body and change the linens. -Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. -Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in. -A towel folded under the chin may be needed to keep the jaw closed. -Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters. -Place a pillow under the head to prevent blood from pooling and discoloring the face. -Remove equipment and soiled linens from the room. -Give client's belongings to a family member or send with the body.

Treatment of Frostbite:

-Remove clothing and jewelry to prevent contriction -Do not massage, rub, or squeexe the area involved. Injured tissue is easily damaged -Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temp do not sig. decrease rewarming time but can intensify pain -Avoid heavy blankets or clothing to prevent tissue sloughing -Provide analgesia as the rewarming procedure is extremely painful -As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema. -Keep wounds open immediately after a water a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings -Monitor for signs of compartment syndrome.

Nurses assisting a client to collect sputum should instruct the client to

-Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora -Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin -Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume -Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection -Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions.

interventions to manage norepinephrine extravasation:

-Stop the infusion immediately and disconnect the IV tubing. -Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. -Elevate the extremity above the heart to reduce edema. -Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine).

Major side effects of angiotensin-converting enzyme (ACE) inhibitors include:

-Symptomatic hypotension -Intractable cough -Hyperkalemia -Angioedema (allergic reaction involving edema of the face and airways) -Temporary increase in serum creatinine -For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites.

Instructions for proper NTG administration include:

-Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months. -Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment. -Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline):

-Take on an empty stomach -for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals -Avoid antacids or dairy products -tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption -Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion -Photosensitivity, severe sunburn can occur with tetracycline. The client should use sunblock. -Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed

Typical characteristics of child abuse perpetrators include:

-Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child -Confusion between punishment and discipline; having a stern, authoritative approach to discipline -Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation -Low self-esteem—a sense of incompetence or unworthiness as a parent -A history of substance abuse; use of alcohol or drugs at the time the abuse occurs -Punitive treatment and/or abuse as a child -Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age -Resentment or rejection of the child -Low tolerance for frustration and poor impulse control -Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury

APTT range that corresponds to the heparin therapeutic range

0.2 - 0.4 U/mL by protamine titration is the established heparin therapeutic range (56 - 84 seconds).

normal urine output

0.5-1 ml/kg/hr or over 30 mL/hr

Creatinine normal levels

0.6-1.3 mg/dL [53-115 µmol/L]

Albumin normal level

normal: 3.5-5.0 g/dL [35-50 g/L] is a protein formed in the liver. is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. Causes pitting edema

B-type natriuretic peptide (BNP) normal level

normal: <100 pg/mL [100 pmol/L]

The occipital lobe

of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse should notify the health care provider immediately and document the finding. The frontal lobe controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes. The temporal lobe integrates visual and auditory input and past experiences. The parietal lobe integrates somatic and sensory input.

Petechiae

small pinpoint red/purple spots on mucus membrane or skin can be a sign of blood dyscrasia, including thrombocytopenia due to a severe drug response.

DKA

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival. When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketones in the urine

MAP

Mean Arterial Pressure = Systolic Blood Pressure + (Diastolic Blood Pressure × 2)/3A normal MAP is 70-105 mm Hg.

Lactic acidosis

Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is confirmed

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs:

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

Should NPH insulin be IV push?

NPH insulin should always be a subcutaneous injection and never be administered IV push. Regular insulin is the only insulin that can be IV push

ARF indicates

PaO2 < 60 mm Hg or PaCO2 > 50 mm HG

Loose associations

rapid shifting from one idea to another, with little or no connection to logic or rationality

Normal White Blood Cell Count (WBC)

normal 4,000-11,000/mm3 [4.0-11.0×109/L]

Thrombolytic agents

(alteplase, tenecteplase, reteplase) ordered to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemmorrhagic stronk and uncontrolled hypertension (>180/110 mm HG)

Ptosis

(drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve.

Procedure for measurement of orthostatic BP

-Have the client lie down for at least 5 minutes -Measure BP and HR -Have the client stand -Repeat BP and HR measurements after standing at 1- and 3-minute intervals -A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal

To prevent pressure injuries

-Use emollients and barrier creams to hydrate, protect, and strengthen the skin. -Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences. -Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin. -Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur.

Magnesium level:

1.5-2.5 mEq/L

serum vancomycin trough levels therapeutic range

10-20 mg/L [6.9-13.8 µmol/L]

how many mL to a tbsp

15

Bicarbonate (HCO3)

22-26 mEq/L

Infant growth

Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. During the first year, birth length increases by approximately 50%. At birth, head circumference is slightly more than chest circumference, but these equalize by age 12 months.

PaCO2

35-45 mm Hg

heparin therapeutic range

56 - 84 seconds

PAWP (Pulmonary artery wedge pressure) normal value

6-12 mm Hg

BUN normal range

6-20 mg/dL [2.1-7.1 mmol/L] Elevated BUN may indicate dehydration and could impair wound healing.

pH:

7.35-7.45

PaO2:

80-100 mm Hg

O2 Saturation (SaO2):

95%-99%

Chest drainage

>100 mL/hr should be reported to the HCP. Collection chamber should be inspected every hour for the first 8 hours following surgery, the every 8 hours until it is removed.

Theophylline toxicuty

>20mcg/mL

acute tumor lysis syndrome (TLS)

A potential complication of chemotherapy is acute tumor lysis syndrome (TLS), a rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorus) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phosphorus binds calcium, producing calcium phosphate mixture but lowering serum calcium levels. Both calcium phosphate and uric acid are deposited into the kidneys, causing renal injury. Allopurinol (Zyloprim) blocks the nucleic acid catabolism and prevents hyperuricemia but would not affect potassium, phosphate, and calcium levels. Chronic gout and uric acid calculi also require the administration of allopurinol to decrease uric acid accumulation. A normal blood uric acid level for an adult male is 4.4-7.6 mg/dL (262-452 µmol/L) and female is 2.3-6.6 mg/dL (137-393 µmol/L).

A reduction or energy expenditure

A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal).

Sjogren's syndrome

An autoimmune disorder affecting the salivary and lacrimal glands. It is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help

Bacterial meningitis

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: -Fever or possible hypothermia -Irritability, frequent seizures -High-pitched cry -Poor feeding and vomiting -Nuchal rigidity -Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis.

Submersion injury

Clients with morbidity related to immersion in water are described as having submersion injury. Even if an individual was submerged for a very brief time, it is possible that water may have been aspirated, which can lead to respiratory compromise. Observation for at least 6 hours is recommended as the majority of significant respiratory problems will manifest in this time period.

Dumping syndrome

Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. Recommendations to delay gastric emptying include: -Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates. These foods also help meet the body's energy needs. -Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. -Slowly consume small, frequent meals to reduce the amount of food in the stomach. -Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates Avoid sitting up after a meal

The sequence for donning PPE includes

Hand hygiene -Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist -Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator -Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) -Gloves - don and extend to cover wrist of

People in emergencies

Individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services. Clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness, grief, survivor guilt, and anxiety. Mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster. Services may be provided in shelters, food distribution centers, churches, "pop-up" disaster relief centers, schools, and/or in homes. However, finding and reaching potential clients and family members in the aftermath of a disaster can be challenging because: -Clients may not know where or how to seek help -Clients may be afraid or unable to leave their homes -Telephone services and other lines of communication may be disrupted -Potential clients may leave their homes and go to shelters or alternate housing -Transportation may be severely limited -It is essential to coor

Individuals with metabolic syndrome (insulin resistance syndrome)

Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: -Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women -Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension -Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides -High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C -Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose The mnemonic for metabolic syndrome is "We Better Think High Glucose" .... Waist circumderence, Blood pressure, Triglyceride level, High-density lipoprotein, Glucose

Epiglottitis

inflammation of the glottis. Symptoms:High-grade fever with toxic appearance, severe sore throat, and 4 Ds: -Dysphonia (muffled voice) -Dysphagia (difficulty swallowing) -Drooling -Distressed respiratory effort

MRSA care

MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following: -Place client in a private room (preferred) or semi-private room with another client with the same infection -Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) -Wear gloves when entering the room -Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) -Wear gown with client contact and remove it before leaving the room -Place door notice for visitors -Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures)

Physiologic anorexia

Physiologic anorexia (ie, a decrease in nutritional need and appetite) occurs when the very high metabolic demands of infancy slow to keep pace with the moderate growth during toddlerhood. During this phase, toddlers are increasingly picky about their food choices and eating schedules. Parents sometimes fear the child is not consuming enough calories, but intake over several days usually meets nutritional and energy needs. Parents should avoid forcing food or pressuring toddlers to eat more, which can lead to poor eating habits in the future. Strategies to promote intake for toddlers include the following: -Offering 2 or 3 high-quality food choicesKeeping food portions small (1-2 tablespoons per serving) -Exposing the child to new foods repeatedlyAvoiding distractions (eg, television, toys) during meals/snacks

Breastfeeding

Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: -Breastfeed every 2-3 hours on average (8-12 times/day) -Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) -Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body -Ensure a proper latch (ie, grasps both nipple and part of areola) -Feed for at least 15-20 minutes per breast or until the newborn appears satisfied -Insert a clean finger beside the newborn's gums to break suction before unlatching -Alternate which breast is offered first at each feeding

Cushing syndrome

a disorder with physical and mental changes that result from having too much cortisol in the blood for a long period of time. Cortisol is a steroid hormone produced by the adrenal glands, located above the kidneys. Purple struae, hirsutism (increased facial and body hair) and a supraclavicular fat pad (buffalo hump)

Word salad

a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple."

The rehabilitation phase

begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: -Counseling or other psychosocial support -Gentle massage with water-based lotion to alleviate itching and minimize scarring -Planning for reconstructive surgery -Pressure garments to prevent hypertrophic scars and promote circulation -Range-of-motion exercises to prevent contractures -Sunscreen and protective clothing to prevent sunburns and hyperpigmentation

Sodium polystyrene sulfonate (Kayexalate)

can be used to treat hyperkalemia.

Chronic hyperglycemia

can cause microvascular damage in the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults.. A partial retinal detachment may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters or lines, and sudden flashes of light. An unrepaired complete retinal detachment can cause blindness.

celiac disease

cannot eat BROW Barley Rye Oats Wheat

Tangentiality

going from one topic to the next without getting to the point of the original idea or topic

St John's wort

has been used to treat depression. May cause hypertension and serotonin syndrome when used with other antidepressants

Paroxysmal supraventricular tachycardia (PSVT)

heart rate can be 150-220/min. With prolonged episodes, the client may experiance evidence of reduced cardiac outpit such as hypotension, palpitations, dyspnea, and angia. TX includes vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT tx. Adenosine is administered rapidly via IVP over 1-2 seconds and followed my a 20 ml saline bolus. And increased dose may be given twice if previous administration is ineffective.

The pursed-lip breathing technique

helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease (COPD). Clients with COPD are taught to use this technique when experiencing dyspnea as it increases ventilation and decreases work of breathing. Regular practice (eg, 5-10 minutes 4 times daily) enables the client to do pursed lip breathing when short of breath, without conscious effect. Clients are taught the following steps: -Relax the neck and shoulders -Inhale for 2 seconds through the nose with the mouth closed -Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling

A normal hemoglobin A1C

is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

A pessary

is a vaginal device that provides support for the bladder. Clients can remain sexually active

Patent ductus arteriosus (PDA)

is an acyanotic congenital defect causes a loud machine-like systolic and dystolic murmur

a therapeutic aPTT level

is between 46-70 seconds (1.5-2.0 times the baseline value).

Ethambutol (Myambutol)

is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination.

Neologisms

made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox."

Addison's disease

or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids

Echolalia

repetition of words, usually uttered by someone else

Clang associations

rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike

Hyponatremia

symptoms include irritability, lethargy, and, in severe cases, hypothermia and seizure activity.

The following are at greatest risk for respiratory depression related to opioid use for analgesia:

the elderly; those with underlying pulmonary disease, history of snoring (with or without apnea), obesity, or smoking (more than 20-pack-year history); the opiate naïve, especially if treated for acute pain; and post surgery (first 24 hours).

Phototherapy

use of flourescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine. Newborn should be fully exposed, except for a diaper, when placed under the lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with freuency. Newborns's eyes should be covered. Temperature should be monitored closely and adequate hyration given.

A gestational age assessment

A gestational age assessment assists the nurse in providing developmentally appropriate care to preterm newborns. This assessment uses indicators of neuromuscular and physical maturity that are assessed, scored, and added, which correlates to an estimation of gestational age. Lanugo, a fine, downy hair found mostly on the backs and shoulders of preterm newborns, begins disappearing around 36 weeks gestation. At 28 weeks, the newborn has abundant lanugo over most of the body. The 28-week newborn also has smooth, pink skin with visible veins as skin is thin and transparent with lack of subcutaneous fat. The areolae of extremely premature infants may be barely visible, with no raised breast buds. Palpable, raised breast buds measuring 5-10 mm would be expected in newborns closer to term gestation.

Bile

made by the liver is green and is released into the duodenum on eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, it may come back up as green vomit. A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. Newborns vomit or spit up frequently as they adjust to eating and digesting food. They also have a loose lower esophageal sphincter that allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. It is not uncommon for a newborn to have vomiting through the nose because the esophagus is connected to the nose and mouth.

Symptoms of Theophylline toxicity

manifest as CNS stimulation (headache, insomnia, seizures), gastrointestinal disturbances (nausea, vomiting) and cardiac toxicity (arrhythmia)

Preventing the spread of pediculosis capitis (head lice)

may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs).

A client with cirrhosis

may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching. Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin. Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications.

Brain edema or increased intracranial pressure (IICP)

may not be evident immediately. The client should return to the emergency department or notify the primary care provider if any of the following signs/symptoms are present in the next 2-3 days: -Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) -Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics -Visual changes (eg, blurring) -Motor problems (eg, difficulty walking, slurred speech) -Sensory disturbances -Seizures -Nausea/vomiting or bradycardia (indicates IICP) The client is also to abstain from alcohol, check before taking medications that can affect level of consciousness (eg, muscle relaxants, opioids), and avoid driving or operating heavy machinery

Phosphorous normal level

normal phosphorous: 2.4-4.4 mg/dL [0.78-1.42 mmol/L]

magnesium normal level

normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]

advanced chronic obstructive pulmonary disease (COPD)

Consuming adequate nutrition is difficult for clients with advanced chronic obstructive pulmonary disease (COPD), as chewing and swallowing increase work of breathing and a full stomach increases pressure on the diaphragm. As a result, clients often lose weight because their energy expenditure is greater than their nutritional intake. To optimize nutritional intake, clients should: -Drink fluids between meals, rather than before or during, to prevent stomach distension and decrease pressure on the diaphragm while eating. -Eat small, frequent meals, snacks, and supplements that are high in calories and protein. Smaller meals require less energy to chew and swallow, resulting in less fatigue and dyspnea -.Perform oral hygiene before meals. Chronic mouth breathing leads to dry mouth; excessive sputum and medication side effects can alter the taste of food, decreasing the appetite

Cranial nerve IX (glossopharyngeal)

Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: -Inhale deeply. -Hold breath tightly to close the vocal cords -Place food in mouth and swallow while continuing to hold breath -Cough to dispel remaining food from vocal cords -Swallow a second time before breathing

Otic medications

Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum. The general procedure for instilling ear drops includes the following steps: -Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used -Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear -Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes -Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old -Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in

paracentesis

Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: -Verify that the client received necessary information to give consent and witness informed consent -Instruct the client to void to prevent puncturing the bladder -Assess the client's abdominal girth, weight, and vital signs -Place the client in the high Fowler position or as upright as possible -Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. -NPO status is not required for paracentesis,

target range for glucose control in clients receiving nutritional support

The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP).

IV changes in an older adult

The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. -Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance. -Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. -Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. -Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client

When to call a rapid response:

acute change in any of the following: -Heart rate <40 or >130/min -Systolic blood pressure <90 mm Hg -Respiratory rate <8 or >28/min -Oxygen saturation <90 despite oxygen -Urine output <50 mL/4 hr -Level of consciousness

TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira])

block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests afterward.

Cerebral vascular accidents (strokes)

can cause visual and perceptual deficits depending on which part of the brain is affected. Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-neglect.

A client with a traumatic head injury from blunt force

can have delayed symptoms if there is bruising in the brain and subdural hematoma/cerebral edema develops. A subdural hematoma is typically a slower venous bleed, and symptoms appear 24-48 hours later. Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if the condition is not recognized and treated.

Stress-induced hyperglycemia (gluconeogenesis)

can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended.

The creation of an AVF for hemodialysis access

involves an anastomosis between an artery and a vein (usually the cephalic or basilic vein). The fistula permits the arterial blood to flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood to flow at high pressures. After the AVF is placed, it takes 2-4 months for it to mature to accommodate the repeated venipunctures necessary for hemodialysis access.The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: -Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage -Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis -Avoid wearing restrictive clothing or jewelry to prevent thrombosis Do not use the arm on the affected side

Pheochromocytoma

is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: -Hypertension is difficult to treat and is often resistant to multiple drugs. -The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). -Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis.

Placenta accreta

is a condition of abnormal placental adherence in which the placenta implants directly in the myometrium rather than the endometrium. Prenatal ultrasound usually detects placenta accreta, although detection can rarely occur after birth when the placenta is adherent (ie, retained placenta). A cesarean birth before term gestation at a facility with adequate resources (eg, blood products, intensive care unit) is recommended for clients with placenta accreta. The major complication of placenta accreta is life-threatening hemorrhage, which occurs during attempted placental separation. At least two large-bore IVs (eg, 18-gauge) and a blood type and crossmatch are priority concerns in case blood transfusions are necessary

Red man syndrome (RMS)

is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response.

Isoniazid

is a first-line antitubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests (eg, alanine aminotransferase, aspartate aminotransferase) can indicate development of drug-induced hepatitis.

Gout

is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications. Suggested modifications include: -Increasing fluid intake (2 L/day) to help eliminate excess uric acid -Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) -Limiting alcohol intake, especially beer -Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates

Licorice root

is an herbal remedy sometimes used for gastrointestinal disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypertension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia. Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered "potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate the potassium loss. The nurse should discourage the client from using this herbal remedy and report the client's use to the PHCP.

An asthma action plan

is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): -Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing -.Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed. -Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not retu wo groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis.

A vaginal hematoma

is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematomas are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma.

Developmental Dislocation of the Hip (DDH)

is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required.The Pavlik harness maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development. Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable. The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip. Care of the infant wearing a Pavlik harness includes the following: -Regularly assess skin for redness or breakdown under the straps -Dress the child in a shirt and knee socks under the harness to protect the skin -Avoid lotions and powders to prevent irritation and excess

Clients with a diagnosis of chronic congestive heart failure

experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure.Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client.

Lithium

has a very narrow therapeutic index (0.6-1.2 mEq/L [0.6-1.2 mmol/L]); levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity

Signs of a transfusion reaction

include chills, fever, low back pain, flushing, and itching. Nursing interventions include: 1.Stop transfusion immediately and disconnect tubing at the catheter hub. 2.Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse. 3.Notify health care provider (HCP) and blood bank. 4.Monitor vital signs. 5.Recheck labels, numbers, and the client's blood type. 6.Treat client's symptoms according to the HCP's prescription. 7.Collect blood and urine specimens to evaluate for hemolysis. 8.Return blood and tubing set to the blood bank for additional testing. 9.Complete necessary facility paperwork to document the reaction.

Burn injuries

increase vascular permeability and fluid shifts (second and third spacing). In the emergent phase after the burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the interstitium, causeing decreased intravascular oncotic pressure and decreased intravascular volume, which causes hypovolemia. Potassium is released when cellular damage occurs, resulting in hyperkalemia.

Wound Irrigation

Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: -Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect. -Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. -Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. -Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area.Use continuous pressure to flush the wound, repeating until drainage is clear. -Dry the surrounding wound area to prevent skin breakdown and irritation. -Immunization history is reviewed to determine tetanus vaccination status

Glucogen in pregnancy

During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal. A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. Normal newborn respiratory rate is 30-60 breaths per minute. Breathing may be slightly irregular, diaphragmatic, and shallow. Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks.

Normal lymph nodes

Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy.

Hypernatremia

causes increased thirst with dry mucous membranes

Aphasia

refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice. The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual. Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing)

When administering bolus enteral feedings

the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk. Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent. Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well. Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance

RN

-Clinical assessment -Initial client education -Discharge education -Clinical judgment -Initiating blood transfusion

Clients taking long-term corticosteroid replacement should be taught the following:

-Do not discontinue glucocorticoid therapy abruptly. Abrupt discontinuation could lead to addisonian crisis, a life-threatening complication. -Report any signs and symptoms of infection to the HCP immediately. Corticosteroid use can cause immunosuppression, and infection can develop quickly and spread rapidly. Corticosteroids' anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. -Stay attuned to signs and symptoms of stress and increase dose of corticosteroid during times of stress. A stress response (surgery, trauma) can cause a sudden decrease in cortisol levels, triggering addisonian crisis. -A side effect of corticosteroid therapy is hyperglycemia. Report signs of hyperglycemia, including increased urine, hunger, and thirst. Clients with diabetes mellitus must be vigilant in checking blood glucose

A chest tube is removed when

-Drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: -Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal. -Provide the health care provider (HCP) with sterile suture removal equipment. -Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space. -Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space. -Perform a chest x-ray within 2-24 hours after chest

Foods rich in iron include:

-Meats (eg, beef, lamb, liver, chicken, pork) -Shellfish (eg, oysters, clams, shrimp) -Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal

LPN/LVN

-Monitoring RN findings -Reinforcing education -Routine procedures (eg, catheterization) -Most medication administrations -Ostomy care -Tube patency and enteral feeding -Specific assessments (limited assessments)

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed:

-Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) -The client may feel warm or flushed while the contrast dye is being injected -Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis

Certain individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These include the following:

-Prosthetic heart valve or prosthetic material used to repair heart valve -Previous history of IE -Some forms of congenital heart disease -Unrepaired cyanotic congenital defect -Repaired congenital defect with prosthetic material or device for 6 months after procedure -Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device -Cardiac transplantation recipients who develop heart valve disease -Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. -Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures

The following neutropenic precautions are indicated:

-Protection against infection is the most important goal for this client. All risks for infection should be minimized in a client with neutropenia. -A private room -Strict handwashing -Avoiding exposure to people who are sick -Avoiding all fresh fruits, vegetables, and flowers -Ensuring that all equipment used with the client has been disinfected -having <500 cells/mm3 (0.5 ×109/L) indicates severe neutropenia and increases the risk of infection. -Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. all visitors should wear a mask.

When a pregnant client arrives at the hospital and birth is imminent, the nurse should collect a brief, focused history to elicit essential information relevant to potential newborn resuscitation, including:

-Recent medication or illicit drug use (especially within the last 4 hours): Certain medications and illicit drugs (eg, opioids) may cause respiratory depression in the newborn. -Current pregnancy diagnoses (eg, multiple gestation, placenta previa): Preparation for multiple newborns or high-risk maternal conditions requires more resuscitation equipment and staff. -Color of the amniotic fluid: Meconium-stained fluid may indicate fetal stress or hypoxia during labor, which could require newborn resuscitation after birth. -Expected due date (EDD) or estimated gestational age: A newborn at preterm gestation (<37 weeks gestation) is at risk for respiratory immaturity and may have respiratory distress after birth

Safety is the immediate priority in a client experiencing a seizure. Nursing interventions include:

-Remain at the client's bedside while noting duration and symptoms of the seizure -Call for help so that other team members can assist with care of the client -Protect client from hitting hard surfaces by padding the side rails -Turn client on the side if possible to allow for drainage of secretions and prevent the tongue from occluding the airway -Loosen clothing around the neck and chest to promote ventilation -Use suction equipment after the seizure subsides as needed to maintain a patent airway

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following:

-Wash hands thoroughly and regularly -Perform routine perineal hygiene with soap and water each shift and after bowel movements -Keep drainage system off the floor or contaminated surfaces -Keep the catheter bag below the level of the bladder -Ensure each client has a separate, clean container to empty collection bag and measure urine -Use sterile technique when collecting a urine specimen -Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder -Avoid prolonged kinking, clamping, or obstruction of the catheter tubing -Encourage oral fluid intake in clients who are awake and if not contraindicated -Secure the catheter in accordance with hospital policy (tape or Velcro device) -Inspect the catheter and tubing for integrity, secure connections,

interventions and prescriptions for a client with sepsis and meningitis may include:

-iv fluid administration -Administer vasopressors. -Obtain relevant labs and blood cultures prior to administering antibiotics. -Administer empiric antibiotics, preferably within 30 minutes of admission. This client will continue to decline without antibiotic therapy. -Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation -Assist with a LP for cerebrospinal fluid (CSF) examination and cultures. CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy.

Following a needlestick injury, the nurse's immediate actions should be to

-remove their gloves and thoroughly wash the affected area with soap and water. -Exposure should be reported to the nurse's supervisor and the facility exposure hotline as soon as possible to facilitate the evaluation process. -The nurse should then seek evaluation and treatment from the employee health clinic or emergency department. -Blood should be drawn for baseline testing, and postexposure prophylaxis will be given based on the risk of exposure. - Postexposure prophylaxis for HIV infection is most effective when given within two hours of an exposure incident.

The 6 Ps of compartment syndrome include

1.) Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia. 2.) Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. 3.) Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia. 4.) Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. 5.) Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late 6.) Poikilothermia is described as a change in temperature or the presence of coolness in the affected extremity.

Normal Absolute Neutrophil Count

2,200-7,700/mm3 [2.2-7.7 ×109/L]

CVP (Central venous pressure) normal value

2-8 mm HG

The normal range for a WBC count is

4,000-11,000/mm3 (4.0-11.0×109/L)

Hepatic encephalopathy

Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels.

Fetal Monitor patterns

A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: -Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity -Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted -Administering oxygen at 8-10 L/min via nonrebreather mask V: Variable Deceleration C: Cord Compression E: Early Deceleration H: Head Compression A: Acceleration O: Okay L: Late Deceleration P: Placental Insufficiency

Management of a client with PKU

A low-phenylalanine diet is essential in the treatment of PKU. Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL [120-360 µmol/L] for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health. -Monitoring serum levels of phenylalanine -Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet

client with ulcerative colitis

A low-residue, high-protein, high-calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration. Small, frequent meals are encouraged to lessen the amount of fecal material present in the gastrointestinal tract and to decrease stimulation. Caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided. The prescribed sulfasalazine should be continued even when symptoms

Hirschsprung Disease

Bilious vomiting, Abdominal distension, faliure to pass meconium, and failure of internal anal sphincter relaxation (tight anal sphincter)

Blood transfusions

Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: -Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider. -Ensure that blood type and Rh type are compatible. An Rh-positive client can safely receive Rh-positive or Rh-negative blood. -Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells. -Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). -Transfuse blood products within 4 hours due to the risk for bacterial growth. -The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to mointor

CVP (central venous pressure)

CVP is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects fluid volume problems. The normal CVP is 2-8 mm Hg. An elevated CVP can indicate right ventricular failure or fluid volume overload. Clinical signs of fluid volume overload include the following: -Peripheral edema -Increased urine output that is dilute -Acute, rapid weight gain -Jugular venous distension -S3 heart sound in adults -Tachypnea, dyspnea, crackles in lungs -Bounding peripheral pulses

Carbon monoxide poisoning

Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen.The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. Requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemialegal level for driving under the influence is 80 mg/dL (0.08 mg% [17.4 mmol/L]). Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. To help identify elevated CO levels in the home, the nurse can ask about the following: -Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time -Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space

Bleeding risk (herbal supplements)

Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba, Garlic, Ginseng, Ginger, Fever few. Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding.

When caring for a client receiving mechanical ventilation, the nurse should:

Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: -Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). -Maintain the head of the bed at 30-45 degrees to reduce aspiration risk. -Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). -Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator. -Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy. -Perform tracheal suctioning as needed. -Monitor correct endotracheal tube placement by noting insertion depth. -Place emergency equipment at bedside (eg, manual resuscitation bag Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and impairment of natural defenses (eg, coughing) by artificial airways. Interventions to reduce the risk of VAP include: -Elevating the head of the bed 30-45 degrees (ie, semi-Fowler position) -Providing oral care with antiseptic solutions (eg, chlorhexidine mouthwash) and suctioning subglottic secretions -Performing scheduled daily sedation vacations and maintaining appropriate client sedation levels -Practicing strict hand hygiene

Discharge teaching for pneumonia

Clients should be taught to understand that symptoms of pneumonia (eg, cough, sputum production, shortness of breath, fatigue, and activity intolerance) remain after discharge even though the bacteria are no longer present and will dissipate over a 2-4 week period, depending on current health status and preexisting conditions. Discharge teaching includes the following instructions: -Avoid the use of over-the-counter cough suppressant medicines. Unless prescribed by the HCP, cough suppressants are avoided as they impair secretion clearance, especially in clients with chronic bronchitis. -Schedule a follow-up with the HCP and chest x-ray. Follow-up is needed at about 2 weeks after completion of antibiotic therapy. X-ray may be needed at a later time in certain high-risk clients to make sure the pneumonia is resolved with no underlying cancer. -Use a cool mist humidifier in your bedroom at night. Humidifiers keep mucus membranes moist, maintain effectiveness of the mucociliary escalato Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: -Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions -Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration -Ensuring adequate hydration through increased oral fluid intake (≥2-3 L/day) and administration of prescribed IV fluids, which thins pulmonary secretions to promote improved secretion clearance -Positioning the head of the bed to 45-60 degrees (ie, Fowler position) to promote effective coughing and optimal lung expansion

Diverticular disease

Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement

The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following:

The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. -Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance. -Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. -Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. -Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the patient

anticoagulant heparin

The anticoagulant heparin has to be administered intravenously or subcutaneously. The duration is 2-6 hours intravenously and 8-12 hours subcutaneously. It is measured by the aPTT (activated partial thromboplastin time) laboratory value. Warfarin (Coumadin) is taken orally, with onset/therapeutic effects reached after 2-7 days. It is measured by prothrombin time (PT) or International Normalized Ratio (INR). The therapeutic range for aPTT or PT/INR is generally 1.5-2.0 times the control value (up to 3 times the control value at times). An aPTT value above the therapeutic range places the client at risk for excess bleeding. The heparin administration would need to be stopped or decreased.

Signs and symptoms of acute appendicitis include the following:

The appendix is a blind pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine (cecum). When infected or obstructed (foreign body, fecal material, tumor, lymph tissue), the appendix becomes inflamed, causing acute appendicitis. -Pain: Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point (one-third of the distance from the right anterior superior iliac spine to the umbilicus) -Gastrointestinal symptoms: Anorexia, nausea, and vomiting -Rebound tenderness and guarding -Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation) and lying still with the right leg flexed.

lymph node contraindications

The client's medical history should be reviewed prior to starting an IV line so that the nurse can identify any contraindications to specific anatomical sites. Lymph node removal during a mastectomy may affect lymphatic fluid drainage on the affected side and cause lymphedema or other complications such as infection, venous thromboembolism, or trauma to the affected arm. The nurse must avoid any needlesticks, IV insertions, or blood pressure measurements in the affected arm.The nondominant side is preferred when no medical contraindications exist. However, in this case, the right forearm is best because the client had a left-sided mastectomy. Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.

neonatal abstinence syndrome (NAS)

The newborn of a mother who is opioid-dependent (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome (NAS) or drug withdrawal secondary to in utero exposure to maternal substance abuse. Opioid withdrawal typically manifests within 24-48 hours after birth. Clinical manifestations of withdrawal include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding.The newborn with NAS is at risk for skin excoriation from excessive movement caused by hyperactivity and restlessness. The nurse should swaddle the newborn with the arms and legs flexed to prevent skin damage from excessive movement and minimize stimulation. If signs of overstimulation (eg, sneezing, arching) continue, then gentle, rhythmic rocking may soothe the newborn

The rule of nines

The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial burns (first-degree burns) are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to all anterior body surfaces below the neck, TBSA is calculated as follows: TBSA = [anterior torso] + [anterior arms] + [anterior legs] + [perineum]TBSA = [18] + [4.5 + 4.5] + [9 + 9] + [1]TBSA = 18 + 9 + 18 + 1 = 46% Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (eg, Parkland formula [4 mL × kg of body weight × TBSA]). TBSA also determines the required level of care.In general, clients require transfer to a burn center for specialty care for:Full-thickness burnsPartial-thickness burns >10% TBSA Electrical or chemical burns Inhalation injuries

A client who has undergone ostomy surgery must become independent in self-care.

This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: -Supportive counseling and assistance in psychosocial adjustment -Teaching and facilitating self-care -Providing information about the reason for the surgery, prognosis, potential complications, and community resources -The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.

Total knee replacement

Total knee replacement (knee arthroplasty) is a surgery that replaces the knee joint with an artificial implant. Knee arthroplasties are primarily performed for clients with severe pain or mobility impairment from arthritis. Following a knee arthroplasty, the nurse must plan care to reduce the client's risk of complications while promoting comfort and recovery. Contracture of the operative joint is a serious complication of knee arthroplasty that impairs the client's mobility. To prevent contracture formation, the nurse should maintain the operative knee in an extended position with a knee immobilizer or pillow placed under the lower leg or heel. Placing a pillow behind the knee causes joint flexion, which increases the risk of contracture

Intercranial pressure (ICP)

Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

aPTT value

Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed.

treat death rattle

Use atropine drops to help treat death rattle

Clonidine patch instructions:

Used to treat high blood pressure -Apply patch to a dry hairless area on the upper arm or chest -Wash hands before and after application -Rotate sites with each new patch application -Discard patch away from children or pets with sticky sides folded together -Never wear more than 1 patch at a time -Never stop using the patch abruptly

IV vancomycin

When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: -Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. -Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). -Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications. -Monitor blood pressure during the infusion. Hypotension is a possible adverse effect -Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities. -Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). -Observe IV site every 3 hours Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile. Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal). Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving aminoglycosides, and who are >60 years old. It is important to know the baseline values of BUN and creatinine to monitor trending and identify if there is an increase.Before administering this drug, the nurse should notify the HCP that the client's BUN (60 mg/dL [21.4

Caring for client in restraints

When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): -Provide skin care and range-of-motion exercises; ensure basic needs are met (eg, fluids, nutrition, elimination). -Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin. -Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible

Calcium

When client is taking more than 500 mg of calcium have them take divided doses.food increases calcium absorbtion constipation is a common side effect of calcium Hypercalcemia - causes constipation and polyuria. Calcium has a diuretic effect. Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign). A serum calcium level should be drawn, and the nurse should ensure that calcium gluconate is readily available in case this complication occurs.

Pulmonary edema

a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: -A history of orthopnea and/or paroxysmal nocturnal dyspnea -Anxiety and restlessness -Tachypnea (often >30/min), dyspnea, and use of accessory muscles -Frothy, blood-tinged sputum -Crackles on auscultation -The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema. -Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). Vasodilators decrease preload thus improving

A RAIU test involves

administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease).Important nursing considerations: -Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. -Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland.

Terazosin

alpha-adrenergic blocker -can relieve urinary retention -relaxes smooth muscle which may lead to hypotension contraindicated with erectile dysfunction medication

Clients with chronic kidney disease (CKD)

are at risk for fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia. To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: -Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings. -Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice. -Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg, popsicles, gelatin), because fluid is often restricted. -Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein

Advance directives

are prepared by a client prior to the need to indicate the client's wishes. A living will gives instructions about future medical care and treatment if the client is unable to communicate. A medical power of attorney is the individual designated to make health care decisions should a client become unable to make an informed decision. It allows more flexibility to deal with unique situations. Because the client has indicated specific desires, these should be honored. This is especially true as the client has a terminal condition (versus, for example, an acute choking episode that could be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal cannula.

Serum cardiac markers

are proteins released into the bloodstream from necrotic heart tissue after a myocardial infarction (MI). Troponin is a highly specific cardiac marker for the detection of MI. It has greater sensitivity and specificity for myocardial injury than creatine kinase (CK) MB. Serum levels of troponin increase 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline after 10-14 days. A troponin value of 0.7 ng/mL (0.7 mcg/L) indicates cardiac muscle damage and should be the priority and immediate focus of the nurse. Normal values: troponin I <0.5 ng/mL (<0.5 mcg/L); troponin T <0.1 ng/mL (<0.1 mcg/L).

Cystoscopy complications

are urinary retention, hemorrhage, and infection. Notify the HCP immediately if bright red blood when urinating, blood clots, inability to urinate, fever above 100.4 and chills, or abdominal pain unrelieved by analgesia. Expected findings: Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Clients are instructed to increase fluids, drink 4-6 glasses of water daily to help dilute the urine, and avoid alcohol and caffeine for 24-48 hours as these can irritate the bladder. Abdominal discomfort and bladder spasms may occur for up to 48 hours following the procedure. Clients are taught to take a mild analgesic (eg, acetaminophen, ibuprofen) and a warm tub/sitz bath (except with recurrent urinary tract infections) for pain relief.

BNP levels

are usually elevated (normal <100 pg/mL [100 ng/L]) in clients with heart failure, and the prescription for furosemide (Lasix), a loop diuretic, is expected. Brain (or b-type) natriuretic peptide (BNP) is secreted in response to ventricular stretch and wall tension when cardiac filling pressures are elevated. The BNP level is used to differentiate dyspnea of heart failure from dyspnea of noncardiac etiology. The level of circulating BNP correlates with both severity of left ventricular filling pressure elevation and mortality.The nurse would expect a high BNP in a client exhibiting symptoms of acute decompensated heart failure.

The Romberg test

assesses client's perceptions of their head in space and body in space. Used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation.

Colonoscopy

evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: -Clear liquid diet the day before -Nothing by mouth 8-12 hours prior to the examination -The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status.

Internal radiation (brachytherapy)

involves direct application of a radioactive implant to the cancerous site or tumor for a short time, usually 24-72 hours. This technique is used to treat cervical and endometrial cancer and delivers a high dose of radiation to the cancerous tissues with a limited dose to adjacent normal tissues. Implementation of the following nursing measures is vital as the client receiving brachytherapy emits radiation. -Following the principles of time, distance, and shielding provides staff and visitors protection from exposure to radiation. -Time spent near the radiation source is restricted. The guideline is to limit staff time spent in the room to 30 minutes per shift. -Cluster nursing care to minimize exposure to the radiation source -Rotate daily staff responsibilities to limit time spent in the client room -All staff must wear a dosimeter film badge when assigned to care for a client receiving internal radiation -No individuals who are pregnant or under age should provide care

Transurethral resection of the prostate (TURP)

involves the insertion of a scope to remove obstructing prostate tissue. Continuous bladder irrigation (CBI) with a 3-way Foley catheter is initiated after the procedure. The catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots are also expected for up to 36 hours after surgery. However, the nurse should adjust the irrigation rate with these normal findings so that the urine remains light pink without clots

Midazolam (Versed)

is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines. Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide. Naloxone (Narcan) is the antidote drug to reverse the effects of opioids.

Hemophilia

is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention. Clients with hemophilia who are injured should be monitored closely for bleeding (eg, intracranial bleeds, bleeding into joints). Signs of an intracranial bleed include lethargy, headache, irritability, and vomiting. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan. Ondansetron (Zofran) can be given to treat nausea/vomiting, but administration of factor VIII is the priority. Laboratory studies, particularly hemoglobin and hematocrit levels, are necessary, but the priority is to administer factor VIII. A CT scan should be performed for diagnostic purposes, but the bleeding must be stopped emergently.

Digoxin (Lanoxin)

is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL).Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness . Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider .Other manifestations of digoxin toxicity that clients should report include: -Visual symptoms (eg, alterations in color vision, scotomas, blindness) -Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms -Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion

Polycythemia vera (PV)

is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis (eg, swelling and tenderness in the legs). Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity

Oxygen

is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead. Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breath

Peritonitis

is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity.The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity. Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously.

Macular degeneration

is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact

Cancer

is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole Nagging cough or hoarseness Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss. Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage

Saw palmetto

is a herbal preparation in which clients most often use to treat benign prostatic hyperplasia

Thyroid storm

is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident (truama, surgery, infection), such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include -a rapid onset of fever (104-106 F) -tachycardia -elevated blood pressure. -cardiac arrhythmias (atrial fibrillation) -The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary. Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures.

Hypertensive crisis

is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction (MI), renal failure, aortic dissection, or retinopathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3.MAP = (2 x DBP + SBP) / 3

Glargine (Lantus)

is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12 hours, the provider may hold it. Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes. Lispro is prescribed in two ways: -Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines. -Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is below 150 mg/dL (8.3 mmol/L). Both glargine and lispro would be given according to schedule, as the client is not NPO and plans to eat immediately, and glucose is above 70 mg/dL

Autonomic dysreflexia (autonomic hyperreflexia)

is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the injury, bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring immediate intervestion. Management includes rasing the head of the bed and then treating the cause.

Levetiracetam (Keppra)

is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication.

Propranolol

is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP)

Systemic inflammatory response syndrome (SIRS)

is a pathophysiologic response mediated by the release of large quantities of inflammatory cytokines from the inflammatory cascade. Overwhelming release of inflammatory cytokines triggers vasodilation and capillary leakage, leading to hypotension and impaired end-organ perfusion. SIRS may occur in response to trauma, tissue ischemia, infection (ie, sepsis), and shock and can rapidly progress to hemodynamic instability, respiratory failure, and multiorgan dysfunction.Clinical manifestations of SIRS include fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea (often associated with a low PaCO2 value). Clients who develop multiple symptoms of SIRS require aggressive fluid resuscitation and treatment to address possible causes (eg, antibiotics for infection) as SIRS may be life-threatening

Calcium acetate (PhosLo)

is a phosphate binder used to treat hyperphosphatemia in clients with chronic

Refeeding syndrome

is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: -Obtaining baseline electrolytes -Initiating nutrition support cautiously with hypocaloric feedings -Closely monitoring electrolytesI -increasing caloric intake gradually

Air embolism

is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions: -Apply an occulsive dressing to the insertion site to prevent entry of additional air into the bloodstream -Administer 100% oxygen via non-rebreather mask to improve oxygenation Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds -continuously monitor vital signs and client respiratory effort to identify changes in client status -Notify the health care provider immediately

Posttraumatic stress disorder (PTSD)

is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: -Reexperiencing the traumatic event -Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) -Avoiding reminders of the trauma -Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event -Increased anxiety and emotional arousal -Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy

Albuterol

is a short-term beta-adrenergic agonist used as a rescue inhaler to treat reversible airway obstruction associated with asthma. Dosing in an acute asthma exacerbation should not exceed 2-4 puffs every 20 minutes x 3. If albuterol is not effective, an inhaled corticosteroid is indicated to treat the inflammatory component of the disease. Albuterol is a sympathomimetic drug. Expected side effects mimic manifestations related to stimulation of the sympathetic nervous system, and commonly include insomnia, nausea and vomiting, palpitations (from tachycardia), and mild tremor.

FTT or Failure to Thrive

is a state of undernutrition and inadequate growth in infants and young children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: -Poverty - most common -Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing -Cognitive disability or mental health disorder -Lack of nutritional education - parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child

Sulfasalazine (Azulfidine)

is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response. Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including: -Crystalluria causing kidney injury - client should drink 8 glasses of water daily to maintain adequate urine (eg, 1200-1500 mL/day) -Photosensitivity and risk for sunburn - client should avoid sun exposure and apply sunscreen -Folic acid deficiency (megaloblastic anemia and stomatitis) - client should eat folate-rich foods and take 1 mg/day folic acid supplement -Rarely life-threatening agranulocytosis (leukopenia) -client should be monitored for complete blood count at the start of therapy and report fever or sore throat

A ruptured cerebral aneurysm

is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival.

Dopamine (Intropin)

is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. Enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. The lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Sig. adverse effects include tachycardia, dysrhythmias, and myocardial ischemia.

Lactulose

is a syruplike liquid that decreases intestinal ammonia absorption in clients with liver disease and hepatic encephalopathy. Hepatic encephalopathy occurs when the failing liver does not adequately detoxify ammonia in the body, leading to changes in mental status and death if not adequately and promptly treated. The lactulose dosing frequency should be adjusted to ensure 2-3 soft stools per day with no confusion or lethargy.

Phenazopyridine hydrochloride (Pyridium)

is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics.

Concrete thinking

literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener

A peripherally inserted central catheter (PICC)

is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access.Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol. Blood pressure and venipuncture should not be performed

Folic acid or folate

is a water-soluble, B-complex vitamin necessary for red blood cell production. Pregnant women and those attempting pregnancy need a minimum of 400 mcg of folic acid per day to decrease the chance of fetal neural tube defects (eg, spina bifida, anencephaly). Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid can come from the diet. Leafy green vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving

Lisinopril

is an ACE inhibitor used to treat hypertension and slow the progression of heart failure. Adverse Effects include angioedema (rapid swelling of lips, tongue, throat, face and larynx) leads to airway obstruction.

A pleural effusion

is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations. On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung

Rheumatic fever

is an acute inflammatory disease of the heart. It is a complication that occurs 2-3 weeks after a streptococcal pharyngitis. RF is caused by a delayed-onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with the antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity.RF affects the heart, skin, joints, and central nervous system. The presence of 2 major criteria or 1 major and 2 minor criteria and evidence of a preceding streptococcal infection indicate a high probability of RF.

Guillain-Barre syndrome (GBS)

is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Neuromuscular respiratory failure is the most life-threatening complication. Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure.

Addison's disease

is an adrenocortical insufficiency. Can cause bronze hyperpigmentation of the skin in sun-exposed areas. May also cause vitiligo or patchy/blotchy skin Corticosteroid therapy (eg, hydrocortisone, dexamethasone, prednisone) is the primary treatment for Addison disease.

Warfarin (Coumadin)

is an anticoagulant given to clients with a mechanical valve replacement. To determine if the client is receiving an appropriate dose, the INR needs to be checked regularly. A therapeutic INR for a client with a mechanical heart valve is 2.5-3.5. The nurse should not administer warfarin without checking the INR first. If the INR is >3.5, the nurse should hold the dose and contact the health care provider for further direction. Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (eg, broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy. Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment. Bananas and oranges are rich in potassium, not vitamin K, and are not known to interact with warfarin. The chemical symbol for potassium (K+) should not be confused with vitamin K because they are two different micronutrients; potassium (K+) is an element involved in muscle contraction, whereas vitamin K is a fat-soluble vitamin involved in blood clotting

Phenytoin

is an anticonvulsant prescribed for the treatment of seizures. Clients should never abruptly stop taking the medication due to the possibility of seizure reoccurrence and status epilepticus. An exception is the development of a rash, which may indicate Stevens-Johnson syndrome (SJS).Gingival hyperplasia (ie, swollen, bleeding gums) is common with cyclosporine and phenytoin. Photosensitivity reactions are common with tetracycline antibiotics and sulfa drugs. Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. In the presence of an elevated phenytoin level (32 mcg/mL [127 mcmol/L]), the nurse anticipates that the health care provider will prescribe a decreased daily dose. The nurse should continue to monitor for signs of toxicity, typically presenting as neurological manifestations (eg, ataxia, nystagmus, slurred speech, decreased mentation).

Clozapine (Clozaril)

is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC.

Cystic fibrosis (CF)

is an inherited disorder (autosomal recessive) characterized by thickened secretions due to impaired chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with CF should primarily address potential complications related to the following body systems: -Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in frequent respiratory infections and sinusitis. Frequent infections and inflammation damage lung tissue and may lead to chronic hypoxemia. -Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies . High-protein, high-calorie foods and supplemental enzymes with meals are necessary. -Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferns contributes to infertit

Isotretinoin

is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception.Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication

A child with a cleft palate (CP)

is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: -Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration. -Tilt the bottle so that the nipple is always filled with formula. -Point down and away from the cleft.Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. -These devices allow formula to flow more freely, decreasing the need for the infant to create suction. -Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing. -These infants swallow large amounts of air during feeding and so need to be burped frequently

Atrial Fibrillation (A-Fib)

is characterized by a disorganization of electrical activity in the atria due to multiple ectopic foci. It results in loss of effective atrial contraction and places the client at risk for embolic stroke due to thrombi formed in the atria from stasis of blood. During atrial fibrillation, the atrial rate may be increased to 350-600/min. The ventricular response (pulse rate) can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased cardiac output (ie, hypotension). Ventricular rate control is a priority in clients with atrial fibrillation. This client has an irregular heart rate of 140/min and is not currently hypotensive. However, if the high ventricular response is allowed to continue, it is likely that the client will begin to show signs and symptoms of decreased cardiac output such as hypotension. Therefore, giving the client diltiazem (a calcium channel blocker) is the priority as its purpose is to decrease the

Obstructive sleep apnea (OSA)

is characterized by partial or complete airway obstruction during sleep that occurs from relaxation of the pharyngeal muscles. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia and hypercarbia. Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions include: -Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward -Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction -Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA. -Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opoids

Angina pectoris

is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: -Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) -Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload -Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) -Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release -Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction -Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

Preterm labor (PTL)

is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: -Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development -Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs -Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation -Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect -Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained

Metabolic acidosis

is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq [22 mmol/L]). Common causes of metabolic acidosis include: -GI bicarbonate losses (eg, diarrhea) -Ketoacidosis (eg, diabetes, alcoholism, starvation) -Lactic acidosis (eg, sepsis, hypoperfusion) -Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) -Salicylate toxicity

The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA)

is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO2 30 mm Hg [4.0 kPa], HCO3 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3).As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH.

C difficile

is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective.

Phenylketonuria (PKU)

is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur.

An indirect Coombs test

is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma)

Syndrome of inappropriate antidiuretic hormone (SIADH)

is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: -Fluid restriction to <1000 mL/day -Oral salt tablets to increase serum sodium -Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations -Vasopressin receptor antagonists (eg, conivaptan) -The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

Incentive spirometry

is recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially in upper abdominal incisions (close to the diaphragm). Adequate pain medication should be administered before using the incentive spirometry. Guidelines recommend 5-10 breaths per session every hour while awake. Volume-oriented or flow-oriented sustained maximal inspiration (SMI) devices can be used. The client instructions for using a volume-oriented SMI device include: -Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally -While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it -Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. -Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation -Exhale slowly

Tinea corporis

is ringworm which is a fungal infection of the skin that is transmitted person to person. Highly contagious

Trigeminal neuralgia

is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: -Oral care - use a small, soft-bristled toothbrush or a warm mouth wash -Use lukewarm water; avoid beverage

Pica

is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

Adenosine

is the first-line drug of choice for the treatment of paroxysmal supraventricular tachycardia (SVT; a rapid rhythm exceeding 150/min). The half-life is <5 seconds, so adenosine should be administered rapidly as a 6-mg bolus IV over 1-2 seconds followed by a 20-mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. The injection site should be as close to the heart as possible (eg, antecubital area). The client's ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the atrioventricular node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during and after administration.

Neurologic injury

is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation.The client is cooled to 89.6-93.2 F (32-34 C) for 24 hours before rewarming. Cooling is accomplished by cooling blankets; ice placed in the groin, axillae, and sides of the neck; and cold IV fluids. The nurse must closely assess the cardiac monitor (bradycardia is common), core body temperature, blood pressure (mean arterial pressure to be kept >80 mm Hg), and skin for thermal injury. The nurse must also apply neuroprotective strategies such as keeping the head of the bed elevated to 30 degrees. After 24 hours, the client is slowly rewarmed

A laparoscopic cholecystectomy

is the safest and most commonly used procedure for gallbladder removal. A laparoscope and grasping forceps are inserted through small punctures made in the abdomen. The procedure is associated with decreased postoperative pain, better cosmetic results, shorter hospital stays, and fewer days for recovery versus the open technique.Postoperative teaching includes: -Diet - a low-fat diet is recommended postoperatively as it is well tolerated. A regular diet can be resumed after a few weeks although weight loss may be recommended. -Activity and work - resume normal activity slowly, as tolerated. Most individuals can return to work within a week. -Incision care and hygiene - dressings can be removed the day after surgery, and showering is permitted at this time. -Signs and symptoms of infection (redness, edema, pus, severe pain, nausea, fever, chills) should be reported immediately

The immediate postoperative priority goal for a client with a new tracheostomy

is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties.

The guaiac fecal occult blood test

is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: -Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. -Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves -Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. -Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood -Close the slide cover and allow the stool specimen to dry for 3-5 minutes. -Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide -Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn blue.

Hawthorn extract

is used to treat heart failure and is approved for this treatment in Germany

Sodium polystyrene sulfonate (Kayexalate)

is used to treat mild to moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. In clients without normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload (water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment.

Postpartum hemorrhage (PPH)

is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes).Risk factors for PPH include: -History of PPH in prior pregnancy -Uterine distension due to: --Multiple gestation --Polyhydramnios (ie, excessive amniotic fluid) --Macrosomic infant (≥8 lb 13 oz [4000 g]) --Uterine fatigue (labor lasting >24 hours) --High parity Use of certain medications: -Magnesium sulfate -Prolonged use of oxytocin during labor -Inhaled anesthesia (ie, general anesthesia)

Tonsillectomy

is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: -Avoid coughing, clearing the throat, or blowing of the nose -Limit physical activity -Milk products are discouraged due to their coating effect, which can prompt clearing of the throat -Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery.

A hemorrhagic stroke

occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits. The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes .Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: -Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors -Administer stool softeners to reduce strain during bowel movements -Reduce exertion, maintain strict bed rest, assist with activities of daily living -Maintain head in midline position to improve jugular venous return to the heart

Gastroesophageal reflux disease (GERD)

occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: -Weight loss, as excessive abdominal fat may increase gastric pressure -Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals -Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages -Chewing gum to promote salivation, which may help neutralize and cle

Myopia

or nearsightedness, is reduced visual acuity when viewing objects at a distance. Myopia occurs when the eye structure causes images to focus before they arrive at the retina. Near vision is usually intact, and many clients with myopia report needing to hold objects near their face or sit near objects to see clearly. Myopia in pediatric clients may first be discovered by the school nurse during routine visual acuity testing. Children often report headaches, dizziness, and the need to squint the eyes to see clearly. School performance may be affected because of impaired ability to see class presentations.

Sleep hygiene

refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep-related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed. The nurse should encourage the following healthy sleep habits: -Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep -Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep -Avoid going to bed hungry or eating a heavy meal just before bed -Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia

Oral cancer

refers to cancers of the lips, tongue, mouth, pharynx (ie, throat), and larynx (ie, vocal cords). The most common type of oral cancer is squamous cell carcinoma, which initially presents as a nonhealing lesion or ulcer. Other symptoms of oral cancer include mucosal thickening, difficulty swallowing, mouth bleeding, sore spots, leukoplakia (ie, white patch), and changes in salivation. Modifiable risk factors include: -Chronic alcohol and/or tobacco use -Poor oral hygiene habits -Chronic irritation to the mucosa (eg, chipped teeth, improperly fitted dental appliances) -Excessive exposure to ultraviolet light -In addition, unprotected sexual activity (eg, oral sex, multiple partners) increases the risk for sexually transmitted infections in the oral cavity (eg, human papillomavirus virus), which can cause oral cancer.

Meniere disease (endolymphatic hydrops)

results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. Vertigo can be severe and associated with nausea and vomiting. Can have "drop attacks"

Oxytocin (Pitocin)

stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: -Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). -Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions. -Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern -Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin. -Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. -Uterine tachysystole (ie, >5 contractions in 10 minutes)

Clients with chronic alcohol abuse

suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.

When an acute asthma exacerbation occurs,

the child has rapid, labored respirations using accessory muscles. The child often appears tired due to the ongoing effort. In the case of severe obstruction (from airway narrowing as a result of bronchial constriction, airway swelling, and copious mucus), wheezing/breath sounds are not heard due to lack of airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs. Bronchiolitis is associated with the respiratory syncytial virus (RSV). Cell debris clumps and clogs the airways. Air can get in but has difficulty getting out. Mild symptoms include low-grade fever, wheezing, tachypnea, and poor feeding; severe infections have more serious distress, including signs of hypoxia. Treatment is supportive. This child should be isolated and will receive supportive care, but the child with no air movement/wh

Naegele's rule

the last menstrual period (use the start of my period) minus 3 months plus 7 days Detection of a fetal heart rate is possible using a Doppler by 10-12 weeks gestation

A 24-hour urine is collected

to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: -Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity. -Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. -All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded

Radioactive iodine (RAI)

treats hyperthyroidism by partially damaging or destroying the thyroid gland. RAI has a delayed response, requiring up to 3 months for maximal effect. After treatment, the client emits radiation, and excreted bodily fluids are radioactive. The nurse teaches home precautions to protect those who come in contact with the client. Depending on the dosage, clients should use the following precautions for up to 1 week: -Limit close contact and time spent with pregnant women and children. -Use a separate toilet, and flush 2 or 3 times after each use to remove urine residue. -Use disposable cups, plates, and utensils, and do not share foods that could transfer saliva. -Isolate personal laundry (eg, clothing, linens) and wash it separately. -Sleep in a separate bed from others.Do not sit near others for a prolonged time (eg, train or flight travel).

Pepto-Bismol (bismuth subsalicylate)

use of bismuth subsalicylate as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome.

Fat Embolism Syndrome (FES)

usually develops 24-72 hours following injury or surgical repair. -No Diagnostic tests to identify FES Characteristics: -Respiratory problems -Neurologic changes -Petechial rash (pin-sixed purplish spots that do not blanch with pressure) This differentiates a FES from a PE -Fever

A pharmacologic nuclear stress test

utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion.Pre-procedure client instructions include the following: -Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). -Small sips of water may be taken with medications. -Avoid caffeine products 24 hours before the test. -Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine. -Do not take theophylline 24-48 hours prior to the test (if tolerated).If i

leukopenia

white blood cell count <4,000/mm3 [4 × 109/L]