NCSBN Points to Remember (mandra121705)

Wernicke's aphasia

"fluent" aphasia - inability to understand the meaning of spoken words and reading and writing is impaired; able to speak but sentences do not hang together and speech may consist of mostly jargon.

Broca's aphasia

"non-fluent" aphasia - speech is limited mainly to short utterances of less than four words; the client may understand speech and be able to read but has limited writing ability.

functions of protein

- secondary energy source (4 kcal/gram). - essential for cell growth and wound healing. - the body's only source of nitrogen (negative nitrogen balance can occur with infection, burns, fever, starvation, and injury).

therapeutic lab values for the mood stabilizer, lithium carbonate - Lithane:

0.8 to 1.2 mEq/L; overdose symptoms may include nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of coordination, blurred vision or tinnitus.

Casts:

A cast may be heavy or impair mobility due to its location and type of casting material. Analgesics may be given 20 to 30 minutes before casting to reduce pain. A cast should be snug but not restrict circulation.

Pain:

Allow the client to rate the degree of pain (typically using a 10 point scale) and later to assess (and chart) degree of relief from pain relief measures. Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, and hypnosis.

Glucose:

Although most energy needs could be met by fats and proteins, the brain requires carbohydrates, specifically glucose. Neurons need a constant supply of glucose since they cannot store it.

Tracheostomy: Clients with these issues may need more frequent tracheostomy care: Tracheal stomatitis; Pneumonia; Bronchitis; Short, fat neck; Excessive perspiration.

Always have another staff or family member assist with tracheostomy care in case of accidental dislodgement or extubation. Because upper airway is not functioning, expect more secretions. Yeast infections can form under moist dressings.

chest tube

As the lung heals after surgery, the air leak should resolve. Persistence of the air leak after seven days is abnormal and may require further intervention. A new air leak that was not present on previous assessment would also be a significant finding that would require notification of the provider with possible intervention.

Dehydration in babies:

Babies should have a minimum of 4 to 8 wet diapers a day. Babies can become quickly dehydrated. Other signs of dehydration in infants include sunken fontanels, decrease or absence of tears, dry mouth, and irritability.

Mood disorders:

Bipolar and related disorders are characterized by mood swings; depressive episodes are more common than mania.

Anticonvulsants - adverse effects:

CNS depression, myelosuppression: infection and bleeding. Nursing interventions: assist with activity; protect airway, breathing; minimize invasive procedures.

recommended daily intake:

Carbs: approximately 50 to 60% of total cals; complex recommended. Lipids: total fat intake should not exceed 30% of daily calories with saturated fats not exceeding 10% of total daily caloric intake. Proteins: 0.8 grams per kg of body weight a day. Water: approximately 2 to 3 liters a day.

copd

Clients with COPD are usually on lower doses of oxygen, titrated to maintain an oxygen saturation of 88-91%. Semi-Fowler's position is usually most comfortable for someone with COPD, because this position allows the client's diaphragm to expand.

Tracheostomy:

Clients with new tracheostomy tubes may have bloody secretions for a few days after the procedure or after a tube change. Tracheostomy obturator should be attached to head of bed at all times. Pediatric tracheostomy tubes do not usually have an inner cannula - Children have shorter necks so stoma care may be more difficult.

Chest Tube:

Continuous bubbling in the water seal chamber indicates an air leak. The nurse should first assess the dressing and tubing for an air leak in the system. If there is no leak, then there is an air leak in the lung. In the immediate postoperative period, this is a common finding that should be documented and reassessed periodically.

X-rays and other diagnostic tests:

Correct views to isolate possible fracture: two view minimum. Include joints above & below suspected fracture. Not all fractures show on x-ray; diagnosis relies on clinical evidence. Especially in children, x-rays of unaffected limb may be needed for comparison.

Stereotyping refers to defining people and institutions, mentally or by attitudes, with narrow, fixed traits, rigid patterns, or with inflexible "boxlike" profile characteristics. Discrimination is the unfair treatment of a person or group on the basis of prejudice.

Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways, can be a major barrier to providing culturally conscious care.

Ostomies:

Fecal matter that leaves the body through a stoma is called either a colostomy (large intestine) or ileostomy (small intestine). A stoma has no feeling, so touching it does not hurt client. A colostomy may not function for a number of days after surgery.

laparoscopy

Following a laparoscopy, carbon dioxide trapped in the abdomen may cause discomfort and even shoulder pain. Cardiac output = heart rate x stroke volume.

casts

For proper drying, casts must dry from inside out; covering will delay drying. Cast may smell sour but should never smell foul. Elevation and use of ice reduces swelling. Report signs of neurovascular impairment immediately - compartment syndrome is a medical emergency.

Protein

In a healthy person, a nitrogen balance is achieved when dietary intake is balanced by excretion of urea wastes. A negative nitrogen balance occurs if excretion is greater than the nitrogen content of the diet, as seen in burns, infections, injuries, fever, or starvation.

Elimination:

In constipation, increase fluid to 3000 mL/day (unless contraindicated). Small frequent loose stools or seepage of stool are often indicative of a fecal impaction. Use transparent drainage bag initially for assessment of stoma and drainage. Avoid foods that cause odor, gas, diarrhea, or may block ileostomy. The majority of residents in nursing homes are incontinent but incontinence is not a normal sequela of aging.

Ostomies

Infection, diet or medication may cause spillage between colostomy irrigations. Findings of bowel perforation include rigid, painful abdomen with absence of bowel sounds, no output from colostomy except small amount of blood. There will always be some mucus in urinary diversions that involve segments of bowel, such as ileal loop or continent urinary diversion.

ostomie

Initially ileostomy drainage may be copious and green in color changing to brown after client resumes normal diet. The bowel must be totally healed before attempting irrigation of colostomy.

Minerals

Iron is considered a trace mineral. The seven major minerals are: calcium, magnesium, sodium, potassium, phosphorus, sulfur, and chlorine.

Tracheal deviation:

Likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side.

Traction:

Maintain established line of pull and counter traction continuously. Prevent friction between device and body. Maintain proper body alignment. Effective traction correctly aligns affected body parts. Pain and spasms should be relieved by traction. Client does not have to keep other body parts immobile.

anticonvulsants

Monitor: seizure activity, complete blood count with differential, temperature, regional redness, swelling, or drainage, monitor liver enzyme tests. Client teaching: wear MedicAlert identification, avoid dangerous activity, wash hands, avoid crowds, need for follow-up care and testing, avoid alcohol.

Specimens:

Obtain all specimens using gloves and sterile equipment. Seal all specimen containers tightly. Label all specimens with client's name, content and date obtained.

pain

Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks and valleys of nurse-administered narcotics; clients typically use less pain medication overall than clients receiving nurse-administered narcotics. Be sure to assess and monitor respiratory rate for client on PCA; have Narcan ready to reverse effects of the narcotic.

Nasogastric or Intestinal Intubation:

Placement of tube is confirmed by x-ray when first inserted. Check placement of tube by aspirating stomach contents and testing for pH thereafter; for gastric placement - should be less than 5.

Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities.

Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group, or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation.

Schizophrenia ranks among the top 10 causes of disability in developed countries; it is treatable but cannot be cured.

Programs that train clients with schizophrenia on the primary activities of daily living have been shown to enhance their social skills, motivation, and desire to change while decreasing their lethargic and apathetic state.

COPD:

Pursed-lip breathing should be encouraged during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse and to improve respiratory muscle coordination.

Metabolic acidosis:

Serum carbon dioxide is an indicator of acid-base status. C02 of 20 would indicate metabolic acidosis because the lungs compensate by blowing off CO2 so it will be low. Normal carbon dioxide is 35 to 45 mEq/L.

Lead poisoning:

Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ.

Nutrition & Fluid Intake:

The average adult drinks 2 to 3 liters of water per day. Sodium: 135 - 145 mEq/L Potassium: 3.5 - 5.1 mE1/L Chloride: 96-106 mEq/L Bicarbonate: 22 - 29 mEq/L

Autonomic dysreflexia

The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.

HHNS

The typical client with HHNS will have a plasma glucose level of 600 mg/dL or greater, high serum osmolality, profound dehydration, a serum pH greater than 7.3 and some alteration in consciousness. Unlike diabetic ketoacidosis, however, there is little to no ketosis. HHNS usually presents in older clients with type 2 diabetes mellitus who have some concomitant illness (usually an infection) that leads to reduced fluid intake, or who do not adhere to their diabetic medications and diet. All clients with HHNS require hospitalization and rapid treatment to correct the profound hypovolemia and hyperglycemia characteristic of this condition.

Mobility:

There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus. Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by regularly turning and positioning the client in good alignment. Discontinue ROM exercises at point of pain. Use non-skid, rubber tips on crutches and canes to prevent slipping.

Tracheal deviation

This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure.

autonomic dysreflexia, also called hyperreflexia:

This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations.

Autism

a neurodevelopmental disorder, affects the brain's normal development of social and communication skills; it affects boys more often than girls and is typically diagnosed between the ages of 18 months to 2 years of age.

Attention deficit hyperactivity disorder

a neurodevelopmental disorder, symptoms fall into 3 categories: inattentiveness, hyperactivity, and impulsivity.

Electroconvulsive therapy - ECT:

a very effective and generally safe treatment for severe depression. The procedure uses a small amount of electric current to trigger a seizure. Confusion and temporary memory loss is an expected side effect.

Feeding and eating disorders

can affect every body system. Clients should be monitored for electrolyte imbalance, anemia, malnutrition, dehydration, and bone density.

Complementary and alternative therapies:

can be used to treat many of the mental disorders. Clients should understand that concurrent use of prescribed medications and some complementary and alternative medications may cause adverse or life-threatening effects.

liquid diets

clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple, cranberry, grape, and carbonated beverages. full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt, vegetable juice, creamy peanut butter.

newborns and infants nutrition:

fluid needs - adequate to maintain hydration (approximately 6-8 wet diapers per day). infants - protein needs approximately 2.2 gm/kg/day. breast milk or formula alone is adequate for the first six months of life; whole milk should be introduced around age 1 year.

Potassium: essential for polarization and repolarization of nerve and muscle fibers; regulates neuromuscular excitability and muscle contraction.

high and/or low findings may result in a fast or slow heart rhythm and muscle function with results of cramping in abdomen or legs.

Calcium: needed for cardiac contraction, healthy bones and teeth, functioning of nerves and muscles, clotting of blood.

hypercalcemia: weakness, paralysis, decreased deep tendon reflexes. HYPOcalcemia: muscle tingling, twitching, tetany.

Magnesium: - involved in normal muscle and nerve function, heart rhythm, immune system, blood sugar regulation, blood pressure, energy metabolism, protein synthesis, and bone strength.

hypermagnesemia: lethargy, nausea, vomiting, slurred speech, muscle weakness, paralysis, decreased deep tendon reflexes, slowing of cardiac conduction. hypomagnesemia: mood irritability, cardiac irritability, muscle tingling, twitching, tetany, delirium, convulsions.

Treatment of post-traumatic stress disorder

includes cognitive behavioral therapies, eye movement desensitization and reprocessing (EMDR), hypnotherapy and medications.

Fight or flight response

increased cardiac output increased heart rate increased respiratory rate dilated pupils increased mental alertness

Delirium tremens

is a severe form of alcohol withdrawal, commonly occurring within 72 hours after the last drink; associated findings may include seizures and severe mental status changes, e.g., agitation, confusion, delirium, hallucinations.

Sodium: needed to maintain water balance, transmit nerve impulses, and contract muscles; used to control blood pressure and blood volume.

low levels of 125 mEq/L or less result in mental confusion, hostility, hallucinations. excess levels may result in hypertension or generalized edema, called anasarca. regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney.

Anions

normal lab value for serum chloride is 96-106 mEq/L. normal arterial bicarbonate 22-26 mEq/L, normal venous bicarbonate 24-30 mEq/L. normal serum phosphate level 2.8-4.5 mg/dL.

Cations

normal lab value for serum sodium is 135-145 mEq/L. normal lab value for serum potassium is 3.5-5 mEq/L. normal values - total calcium 8.5-10.5 mg/dL. normal Magnesium values - 1.5-2.5 mEq/L.

Long-acting injectable antipsychotic medications, LAI's:

or "depot formulations" are given once every 1 to 4 weeks, which improves medication compliance.

Diabetic diet

recommended caloric distribution: 50-60% carbohydrates, 20-30% fat, and 10-20% protein.

when calcium is high, phosphorus is likely to be low.

when calcium is low, phosphorus is likely to be high.

Parathyroid

when serum calcium level is low, PTH secretion increases; when serum calcium level rises, PTH secretion falls. high levels of active vitamin D inhibit PTH; low levels or magnesium stimulate PTH secretion.

Leading causes of death: • Ages 0 to 1 year: developmental and genetic conditions that were present at birth, SIDS, all conditions associated with prematurity and low birth weight.

• Ages 1 to 4 years: accidents, developmental and genetic conditions present at birth, cancer. • Ages 5 to 14 years: accidents, cancer, homicide. • Ages 15 to 24 years: accidents, homicide, suicide.

Lungs - Airway

• Anemic patients may never become cyanotic, and are more commonly a dusky-ashen color when hypoxic). • Polycythemic patients may be cyanotic, even when oxygenation is normal. • Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.

Growth and development

• Both growth and development normally proceed in a regular fashion from simple to complex and in a cephalocaudal and proximodistal pattern. • Impacted by genetics, environment, health status, nutrition, culture, and family structures and practices.

Vasculature

• Compare blood pressure in both arms. • Compare blood pressure with client lying, sitting and standing.

Wheezes indicates narrowing/inflammatory process of lower airways.

• Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described as "moist", "dry," "fine," and "coarse."

Stress Management: • Physical and emotional stressors trigger the same stress response; however the magnitude of the response may vary.

• Duration and intensity of physiologic indicators are directly related to the duration and intensity of the stress.

Safety

• Falls are the most frequent cause of injury for elderly clients in acute care. • Know the institution's plan for fire drills and evacuation. • Know the emergency phone number for reporting fire. • Know locations of all fire alarms, exits, and extinguishers.

G & D

• Growth should be measured and evaluated at regular intervals throughout childhood; deviations from normal growth and development should be thoroughly investigated and treated as quickly as possible. • Development occurs through conflict and adaptation.

Before birth: • Pregnancy diet must include increased calcium, protein, iron and folic acid.

• If the client's situation warrants, suggest ways to adapt activity, employment, and travel. • It is helpful if the woman can have the same support person throughout pregnancy and birthing classes. • A doula gives prenatal, labor, birth and postpartum support for mothers and families.

Children G & D:

• In both toddlerhood and adolescence, hallmarks are development of independence and further separation. • Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition and give anticipatory guidance related to nutrition.

Children G & D:

• In the care of children, key concepts are anticipatory guidance and disease prevention. • Major developmental tasks of infancy include increase in mobility, separation, and establishment of trusting relationships.

Therapeutic Communication:

• Make eye contact, without staring - but be aware of cultural differences regarding eye contact- and be aware of your own body language - use an open body posture and appear relaxed.

Abdomen:

• Men breathe abdominally; women breathe costally. • Auscultate all four quadrants for bowel sounds; start in the lower right quadrant. • Auscultate abdomen between meals.

Postpartum

• Mothers are discharged quickly, usually within 48 hours, so you must teach accordingly.

Poisons

• Never induce vomiting unless instructed to do so by a poison center or health care provider. • If you suspect someone has taken poison, take the poisonous substance with you to the emergency room. • Call the local poison control center to determine appropriate treatment for the specific poison.

Labor

• Normal active labor progresses 1.2 centimeters per hour for primiparas and 1.5 centimeters per hour for multiparas. • Maintain safety and medical asepsis through the labor and birth process to reduce risks to mother and fetus/newborn.

Health Risks in Older Adults

• Older adults clear drugs from kidney and liver more slowly; so medications have longer half-lives, and they can bring on side effects and toxicity at lower doses.

Health Risks in Older Adults

• Older adults need the same nutritional needs as other adults, but they need more bulk and fiber, and a more nutrient dense diet containing fewer calories.

Coping and Defense Mechanisms

• People use coping mechanisms and ego-defense mechanisms to relieve anxiety and stress. • They are usually unconscious; that is, the client is not aware of their use. • Depending on the situation and how often these mechanisms are used, they may be healthy or unhealthy.

Postpartum

• Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. - for breasts, uterus, bowels, bladder, lochia and episiotomy or C-section incision.

• Special (N95) respirator masks are necessary to care for clients under airborne precautions who have tuberculosis or other airborne infectious conditions.

• Protective, neutropenic, isolation is used for clients with immunosuppression and low white blood counts. • Disease reporting of "notifiable diseases" is mandated at the state level- through legislation or regulation.

Safety

• R.A.C.E. or P.R.C. - find out which one is the procedure suggested by your institution. • Turn off all oxygen supplies in the area of the fire. • In a fire, never use an elevator - use the stairs. • In a fire, close all doors and windows.

Neurological: • Reflexes are normally less brisk or even absent in older clients.

• Reflex response diminishes in the lower extremities before the upper extremities are affected. • Absent reflexes may indicate neuropathy or lower motor neuron disorder, resulting in flaccidity. • Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity.

Labor, continued:

• Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but be flexible since woman will have shorter attention span, increased discomfort, and experience a fluctuation of emotions during labor. • Pain and anxiety can impede progress of labor.

Labor

• Safest time for the fetus is to administer analgesics is when the woman is dilated between 4 to 7 centimeters. • Be prepared to assist newborn transition to extrauterine environment.

• Only certain electrical outlets access the emergency generators in a power failure; know which ones they are. • Know your agency's policy for cleaning up a biohazardous spill.

• Safety devices, such as restraints, are used only as a last resort. • Use the least restrictive immobilizing device possible for the situation.

Stress Management: • Prolonged stress decreases the adaptive capacity of the body.

• Severity of reaction to a stressor depends on how it is interpreted or perceived by the individual and the meaning or significance given to it.

Standard Precautions

• Standard precautions are used for contact with all body fluids, except sweat. • Standard precautions are used for all clients and transmission precautions are used for all clients with transmittable organisms.

Cyanosis indicates decreased available oxygen; etiology can be either peripheral or central in origin.

• Stridor is a harsh sound produced near the larynx by vibration of structures in upper airway, producing the classic "barky cough."

Infections

• The major sites for health care acquired infections are urinary and respiratory tracts, blood, and wounds. • All HAI's that occur in hospitals must be tracked and recorded by risk management.

Grief

• The stages of grief are not linear; they may come and go. • Grief follows death; but also follows any loss, e.g., divorce, loss of job, loss of financial status, retirement, loss of limb or other physical disability.

Before Birth: • Early and regular antepartal. before-birth, care is critical since first trimester health directly influences the development of embryonic organs.

• To identify risks, nurses need both subjective- client's opinions and statements) and objective- measurable) assessment data. • Prescribed medications, over-the-counter drugs, alcohol and tobacco may lead to problems for the fetus and woman.

Therapeutic Communication: The 3 phases of a therapeutic relationship include the initial phase, the working phase, and the termination phase.

• Use therapeutic techniques such as open-ended questions, unless the client is cognitively impaired; use "yes" or "no" questions with the cognitively impaired, severely depressed clients or clients with respiratory distress.

Postpartum- Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn:

• direct Coombs' test on newborn using neonatal cord blood. • indirect Coombs' test and antibody screen on the mother. • A normal-negative- indirect Coombs' test indicates that no antibodies are detected-there is no clumping of the cells) and the woman is considered to be a candidate for RhoGAM.

administration of enteral feedings:

• may be continuous or intermittent. • prevent bacterial growth by limiting infusions to hang for less than 8 hours and changing tubing every 24 hours. • prevent fluid and electrolyte imbalances by administering at a rate of no more than 300 mL/hour.

Glasgow Coma Score: assesses eye opening, verbal response, motor response; score ranges from 3 to 15 points

• not valid in patients who have used alcohol or other mind-altering drugs. • possibly not valid in patients who are hypoglycemic, in shock, or hypothermic, below 34 degrees-C. • should be compared to total of 10 when client is intubated.

Specific hazards associated with disasters include: • bioterrorism, e.g., anthrax, plague-bacterial agents; smallpox, VHF-viral agents. • chemical emergencies

• radiation emergencies, • mass casualties • natural disasters and severe weather • recent outbreaks and incidents, e.g., salmonella, E. coli, H1N1, Ebola virus.