remediation

chest tubes

Overview: Chest tubes are placed in the pleural space to drain air and blood so the lung can re-expand; drainage system consists of one or more chest tubes; collection container placed below the chest and a water seal is used to keep air from entering the chest; nursing responsibilities include observing for constant bubbling in the water-seal chamber (indicates a leak in the drainage system); if chest tube becomes dislodged, apply pressure over the insertion site with a dressing that is tented on one side to allow for the escape of air; if the tube becomes disconnected from the drainage system, cut the contaminated tip off the tubing using sterile scissors and immerse the end of the chest tube in 2 cm sterile water until system can be re-established. Nursing Care: Purpose is to be inserted into the pleural space, chest tubes allow blood, fluid, pus or air to drain and allow the lung to reinflate. They may be required to help treat pneumothorax, hemothorax, empyema, pleural effusion, or chylothorax. Nursing Care: Preparation: Reassure the patient that chest tube insertion will make breathing easier, obtain baseline vital signs and administer a sedative as ordered, collect necessary equipment, including a thoracotomy tray and an underwater-seal drainage system, prepare lidocaine (Xylocaine) as directed for local anesthesia, set up the underwater-seal drainage system according to the manufacturer's instructions and place it at the bedside. Stabilize the unit to avoid knocking it over, monitoring and aftercare: when the patient's chest tube is stabilized, instruct the patient to take several deep breaths to inflate the lungs fully and help flush pleural air out through the tube; obtain vital signs immediately after tube insertion and every 15 minutes thereafter, according to facility policy (usually for 1 hour); routinely assess chest tube function. Describe and record the amount of drainage on the intake and output sheet; after most of the air has been removed, the drainage system should bubble only during forced expiration, unless the patient has a bronchopleural fistula. Constant bubbling may indicate that a connection is loose or that the tube has advanced slightly out of the patient's chest. Promptly correct any loose connections to prevent complications; change the dressing daily (or as facility policy) to clean the site and remove drainage; if the chest tube becomes dislodged, cover the opening immediately with petroleum gauze and apply pressure to prevent negative inspiratory pressure from sucking air into the chest. Call the physician. Reassure the patient and monitor closely for signs of tension pneumothorax. Expected Outcomes includes patient who is discharged with a chest tube in place performs wound care and dressing changes properly and the wound site is clean and no signs of infection are apparent. Background: There are three types of chest tubes and drainage systems, which all have three compartments: traditional water seal (wet suction) systems, dry suction water seal systems, and dry suction (one-way valve) systems. Water seal systems have a collection chamber for drainage, a water seal chamber, and wet suction control chamber. Two-compartment water seal systems (water seal chamber and collection chamber) are available for patients who need only gravity drainage. The water seal chamber, which has a one-way valve or water seal, prevents air from moving back into the chest when the patient inhales. Discontinuous bubbling in the water seal chamber is normal, but continuous bubbling may indicate an air leak. The suction control chamber controls the amount of negative pressure applied to the chest. After the suction is turned on, bubbling can be seen in the suction chamber. Water is needed for suction. Dry suction seal systems have a collection chamber for drainage, a water seal chamber, and a dry suction control chamber, unlike with wet systems, water is not needed for suction. The machine is quieter without the bubbling, an indicator plays the same role as the bubbling in the water seal system; it shows that the vacuum is adequate to maintain the desired suction, dry suction (one way valve) systems have a collection chamber, a one-way valve, and a dry suction control chamber, the valve functions like a water seal, permitting air to leave the chest but preventing it from moving back into the pleural space, because this system lacks a water seal chamber, it has the advantage of operating without water; this means that it can still function even if it is knocked over, an air leak indicator is used to check the system for air leaks. Complications includes pneumothorax, hemo-thorax, cardiopulmonary complications, respiratory distress, infection, pulmonary edema, formation of air leak, atelectasis (alveolar collapse), and tension pneumothorax.

asthma

Overview: Chronic inflammatory disease of the airways caused by increased responsiveness of tracheobronchial tree to various stimuli; indications include cough, dyspnea, wheezing; assess respiratory status, administer as prescribed, instruct about use of peak flow meter, use of metered-dose inhaler (MDI), asthma triggers avoid. Nursing Care: Status astmaticus is severe asthma, a chronic inflammatory airway disorder, in which symptoms persist despite large amounts of medication. Severe asthma affects about 5% of asthma sufferers. Signs and Symptoms: sudden dyspnea, wheezing, cough, or chest tightening, severe bronchospasm, increased mucous secretion, resulting in thick, clear or yellow sputum, & tachypnea. Treatment includes aerosolized bronchodilators, including, sympathomimetics (e.g., albuterol) and anticholinergics (e.g., ipratropium), epinephrine and terbutaline, given subcutaneously (used less often than inhaled beta-adrenergics), corticosteroids, intravenous, oral, or intramuscular, theophylline, orally, and aminophylline, intravenously, instructions on how to avoid triggers, desensitization to specific antigens, &cromolyn and nedocromil, inhaled, for long-term control with no role in an acute episode.Nursing Care :Status asthmaticus that is unrelieved by usual asthma therapy both in and out of the hospital is a medical emergency. Administer humidified oxygen by nasal cannula at 2 L/min, as needed to ease breathing difficulty and increase arterial oxygen saturation. Start intravenous fluids and administer medications, as ordered. Report to the attending physician immediately any sign of respiratory failure, including agitation, confusion, lethargy, and cyanosis. Request blood gas measurements to confirm the diagnosis. Monitor peak expiratory flow rates or other measure of pulmonary function to assess the patient's response to treatment. Instruct patient and their family on peak flow meter use. Assist patient and their physicians in developing a written self-management plan. Educate patient when the crisis is over about the need to identify triggers, prevent upper respiratory infections, use medications properly, and seek help immediately when respiratory distress occurs. Expected Outcomes include patient is compliant with her medications and therefore, needs them less, patient seeks help to quit smoking after contacting the American Lung Association, patient is able to identify triggers and use self-management plan to avoid emergency care and possible hospitalization. -Background: It is not known exactly what causes status asthmaticus. Some patients may be insensitive to the severity of their dyspnea and thus do not seek attention immediately, which may be life-threatening. Pathophysiology: the mucosal lining of the bronchial tubes overacts to various stimuli (bronchial hyper-reactant bronchospasm). In reaction to these stimuli, bronchial smooth muscle contracts to severely narrow the airway. Increased mucus production with plugging and mucosal edema further narrow or obstruct the airways. Expiratory airflow decreases, trapping gas in the lungs and causing alveoli to hyperinflation. Some lung tissues may collapse (atelectasis), and increased airway resistance leads to increased work of breathing. Causes/Risk Factors include genetic predisposition, continuous exposure to allergens, tobacco, or other irritants or sensitizing agents either at home or at work, gastroesophageal reflux disease, chronic sinusitis or other infections (e.g., Mycoplasma, Chlamydia, and respiratory syncytial virus). Noncompliant with medications protocol or peak flow monitoring, underestimation of an asthma attack. Diagnostic Tests include pulmonary function tests, including peak flow measurement and spirometer to detect evidence of obstructive airway disease, arterial blood gas analysis, to measure partial pressures of oxygen and carbon dioxide as well as pH, CXR, to show lung hyperinflation and to rule out other causes of respiratory distress, including pneumonia, congestive heart failure, pneumothorax (collapse lung) and tumors and skin testing, for specific allergens and inhalation bronchial challenge testing (rarely used), to evaluate the significance of identified allergens or irritants. Complications include respiratory failure, requiring mechanical ventilation and death from asphyxia or dysrhythmia -Nursing Care2: Signs and Symptoms include expiratory wheezing, reecurrent nonproductive cough, chest tightness, SOB with activity or at rest, decreased breath sounds, prolonged expiration, tachycardia, tachypnea and accessory muscle use. Treatment includes removal of precipitating causes, airway maintenance and cough enhancement techniques, oxygen, bronchodilators (beta-adrenergics, cholinergic antagonists, theophylline, influenza and pneumococcal vaccinations, corticosteroids, leukotriene modifiers, anti-IgE antibody, and allergen immunotherapy Nursing Care: educate patient about reduction of risk factors, administration and monitoring of oxygen therapy, increased fluid intake to liquefy secretions, educate patient about cough enhancement techniques, educate patient about use of peak flow meter, education patient about used of metered dose inhalers or dry powder inhalers, anxiety reduction and rest during acute attacks, and education about exercise regimen. Expected Outcomes include: patient will experience fewer exacerbations, patient will be able to perform ADLs and maintain previous life style, and patient will maintain stable arterial blood gas values. -Background2 : Pulmonary ventilation takes place across the alveolar-capillary membrane. Oxygen diffuses into the pulmonary capillaries and carbon dioxide diffuses into the alveoli from the capillaries. The alveoli normally have elastic recoil and partially collapse during expiration. The alveoli distend during normal inspiration allowing a greater surface area for gas exchange. Pathophysiology includes hyperresponsiveness in the lower airways due to an inflammatory response, the inflammatory response causes release of chemical mediators histamine, leukotrienes, and prostaglandins, neutrophils, macrophages and lymphocytes infiltrate the lower airway epithelial cells, the inflammatory response promotes bronchoconstriction, vascular congestion, edema, and formation of thick mucus, inflammation and hyperresponsiveness cause airway obstruction and airway remodeling occurs as a result of long term inflammation -Diagnostic Test: Arterial blood gases, Arterial oxygen saturation, Hemoglobin and hematocrit, Chest radiography, Sputum samples, and Peak expiratory flow rate (PEFR) -Causes/Risk Factors : Genetic, Allergen exposure, Environmental pollution &Tobacco smoke -Complications: Respiratory acidosis, Cardiac dysrhythmias, Cardiopulmonary arrest and Chronic obstruction to airflow

Iron Deficiency Anemia

Kaplan Overview Iron deficiency anemia is caused by inadequate intake or excessive loss of iron; indicated in the presence of palpitations, dizziness, sensitivity to cold, dysphagia, stomatitis, and brittle nails; usually affects menstruating women and children; women require 15-18 mg daily, men require 10 mg iron daily; average diet supplies 12 to 15 mg/day of iron; beef, lamb, and liver are good sources of iron, absorbed better when taken with vitamin C; supplements include Feosol PO TID with meals or Imferon IM using Z tract method. Nursing Care . Iron deficiency anemia is a disorder of oxygen transport in which the production of hemoglobin is inadequate. S/S: generalized weakness and fatigue, light-headedness and inability to concentrate, palpitations, dyspnea on exertion, pallor, especially of the conjunctiva, tachycardia, tender, pale, atrophic tongue (glossitis), cracking at the edges of the lips (angular stomatitis) Treatment: Determine the cause of the anemia and restore iron levels: If the cause is inadequate dietary intake, an oral preparation of iron (ferrous sulfate, ferrous gluconate, ferrous fumerate) or a combination of iron and ascorbic acid (which enhances iron absorption) is the treatment of choice. Nursing care: Provide nutritional counseling, and help the patient select a healthy diet, foods that are high in iron include organ meats (liver), other meats, beans (black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Encourage patients to continue iron replacement therapy as long as it is prescribed, even though they no longer feel tired. Advice patients to take iron supplements 1 hour before meals, because iron is best absorbed on an empty stomach. Supply specific guidelines to patients who experiences gastric distress after taking iron supplements. Discourage the frequent use of intramuscular supplementation. Expected outcomes: Patient has adequate dietary intake of iron. Patient does not need parenteral iron injections; Patient takes all of prescribed iron supplements. Outcomes include adequate dietary intake of iron, does not need parenteral iron injections, and takes all of prescribed iron supplement. Parenteral may be necessary if noncompliant or malabsorption issues. Background: -Hemoglobin in red blood cells is responsible for transporting oxygen to the tissues, the rate of hemoglobin synthesis depends on the availability of iron for heme synthesis, iron from dietary sources helps maintain body stores. -Pathophysiology: iron deficiency anemia typically results when the intake of dietary iron is insufficient for hemoglobin synthesis, the body can store about one fourth to one third of its iron, and when these stores are used up, iron deficiency anemia begins to develop, the most common kind of anemia in all age groups, iron deficiency anemia is the most common anemia in the world. -Causes/Risk factors: inadequate intake of iron, especially in adolescence and pregnancy, blood loss (from ulcers, gastritis, inflammatory bowel disease, gastrointestinal tumors, excess menstrual bleeding), iron malabsorption, chronic alcoholism -Diagnostic tests: Complete blood count, with ferritin and hemoglobin values, and bone marrow aspiration -Complications include gastric distress, teeth staining, stool coloring (may occur following use of iron salts)

Chemotherapy

Overview: Alkylating agents, antimetabolites, antitumor antibiotics, hormonal agents, vinca alkaloids; common side effects and nursing considerations include bone marrow suppression (monitor bleeding, avoid IM injections and rectal temperatures, press venipunctures sites); nausea and vomiting (monitor apetite and nutrition, I and O; prophylactic antiemetics; small, frequent meals); altered immunologic response (prevent infection and report early signs); impaired oral mucous membrane; stomatitis (monitor oral hygiene; avoid hot, spicy foods; administer antifungals and anesthetics as ordered); fatigue (rest, energy conservation teaching). Nursing Care: Chemotherapy is used as a treatment for cancer, primarily for systemic disease rather than for localized lesions. Nursing care: Monitor nutritional, fluid, and electrolyte status; it may be necessary to use creative methods to encourage adequate fluid and nutritional intake, control risks for infection, which are increased because of bone marrow and immune system suppression, monitor and treat patient for stomatitis, help patient prepare for and cope with hair loss, take measures to minimize nausea and vomiting, encourage patient to rest and minimize fatigue, assess patient's pain level and assist in minimizing pain, provide emotional support, especially related to possibility of loss, assess patient's family knowledge of therapy and side effects, monitor patient for necrosis at administration site due to extravasation, follow safety precautions to minimize exposure to chemotherapeutic agents. Expected Outcomes: tumor size is reduced, tumor cells remaining after surgery are destroyed, appropriate goal of cure, control, or palliation is achieved, and patient experiences minimal adverse effects Background : Atineoplastic agents interfere with cellular function and reproduction, thereby destroying tumor cells. They are administered in a variety of different routes: topical, oral, intravenous, intramuscular, subcutaneous, arterial, intracavitary, and inrathecal. One dosage of chemotherapeutic agent destroys only a portion of tumor cells because it is most effective on cells in active cell division; doses must be repeated over a prolonged period of time to kill cells as they reach the cell division phase of the cell cycle. Treatment rarely eradicates 100% of the tumor; the goal is to kill enough of the tumor so that the remainder can be killed by the body's immune system. Antineoplastic agents include: Alkylating agents that alter DNA structure, Nitrosureas that act similarly to alkylating agents, Topoisomerase I inhibitors that induce breaks in the DNA strand, Antimetabolites that interfere with DNA and RNA synthesis, Antitumor antibiotics that interfere with DNA synthesis and prevent RNA synthesis, Mitotic spindle poisons that arrest metaphase and inhibit DNA and protein synthesis, Hormonal agents that bind to hormone receptor sites to alter cellular growth, block estrogens from binding to receptor sites, inhibit RNA synthesis, and decrease estrogen level, Miscellaneous agents, with unknown or complex action. Complications: Nausea and vomiting, stomatitis, anorexia, cachexia, malabsorption, myelosuppression, renal damage, hyperkalemia, hypophosphatemia, hypocalcaemia, cardiac toxicity, congestive heart failure, pulmonary fibrosis, altered testicular and ovarian function, possibly including sterility, peripheral neuropathies, loss of deep tendon reflexes, paralytic ileus, hearing loss, fatigue, infection, alopecia, chronic pain, bleeding problems

urinary incontinence

Urinary Incontinence Overview: involuntary loss of urine enough to cause social or hygienic problems; not a normal part of the aging process, but occurs frequently in the elderly; multiple causes and 5 basic types; urge(abrupt strong desire to urinate & inability to suppress it), stress (occurs during activities that increase abdominal pressure such as sneezing, coughing, & laughing), overflow (occurs when bladder is overdistended), functional (problems w/ lower urinary tract and or cognitive environmental factors), or mixed (more than 1 type). Treatment varies with the type of incontinence & may include drug therapy, diet therapy, pelvic muscle exercises, biofeedback, bladder training, habit training, electrical stimulation, or surgery; nursing interventions consist of behavior treatments, administration of any ordered meds, and helping pts with feelings of embarrassment, hopelessness, & stigma. Nursing care: Incontinence is the inability to control urination/defecation. Signs and symptoms are dependent on which kind it is as listed above. Bowel incontinence include constipation, diarrheal stool developing after hx of constipation, minor soiling, involuntary passing of stool, occasional urgency & loss of control, complete incontinence, and poor control of flatus. Treatment depends on the type & causes. Behavioral therapy includes pelvic floor exercises (kegels), voiding dairy, biofeedback, verbal instruction (prompting voiding), and physical therapy. Pharmacologic therapy includes anticholingergic agents, tricyclic antidepressants, pseudoephedrine sulfate, & hormone therapy. Surgical management last resort and other options are unsuccessful. Most common involves lifting and stabilizing the bladder or urethra. Other surgical procedues include anterior vaginal repair, artificial urinary sphincter, and transurethral resection or sling procedures. Bowel incontinence -no known cure; short term treatment of diarrhea, removal of impaction and long term biofeedback therapy, bowel training programs, and surgery. Nursing care includes promote fluid intake, strengthen pelvic floor muscles in women using kegel exercise, help patients use a commode or bedpan; prevent UTIs by drinking 8-10 fluid daily, tell female pts to drink 2 glasses of water before & after sexual intercourse and void immediately after intercourse. Prepare pt for diagnostic procedure. Expected outcomes include : pt urinates in a controlled fashion, defecates in controlled fashion, and experiences relief of constipation. Background: Urinary incontinence may indicate deceased bladder tone, neuromuscular problems, alterations in thought processes, and weakness that may interfere w/ voluntary control and ability to reach a toilet in time. In adults, normal aging may affect urination in various ways: nocturia, increased frequency of urination and UTIs, interference w/ voluntary control and ability to reach a toilet. With bowel incontinence may indicate an organic disease, or sign of mental illness. In older adults, can be caused by decreased muscle tone, alteration in nervous system to rectum and could result in skin breakdown and depression. Diagnostic test include bedside test like residual urine test and stress maneuvers, urodynamaic test, urinalysis, and urine control for urinary incontinence and endoscopic exams like rectal exam and flexible sigmoidoscopy, x-ray studies like barium enema, CT, anorectal manometry and transit studies for bowel incontinence. Causes and risk factors include frequent avoidance of urge to void, weak pelvic muscles and structural supports for stress incontinenece; alcohol consumption, caffeine intake, decreased bladder capacity, increased urine concentration, neurologic dysfunction, and overdistention of bladder for urge continence. Age-related degenerative changes, high intra-abdominal pressure, incompetent bladder outlet, neurological impairment for reflex, altered environment, cognitive impairment, mobility impairment, and sensory deficit for functional; neurological impairment or trauma/ disease for total incontinence. With bowel incontinence local causes include cancer of rectum, inflammation, prolapsed anus, and semisfluid stool; other causes include advancing age, chemo, cognitive impairment, extreme debilitation, fecal impaction, gross constipation w/ impaction, infection, laxative abuse, meds, neurological disorders, organic changes in rectal neural innervation, pelvic floor relaxation, radiation treatment, and trauma. Complication is recurrent bladder infection.

Parkinson's Disease

overview: -chronic disease of the nervous system characterized by fine, slowly spreading tremor, muscular rigidity, and altered gait. Risk factors include men over the age of 60. It is a slowly progresive, degenerative disorder that can appear at any age and affects both sexes but most commonly men. other risk include genetic predisposition, athresclerosis, viral infections, head trauma, antipyschotic meds, and environmental exposure. nursing care: encourage finger exercises like typing, piano playing, range of motion, teaching client ambulation modification, refer to physical therapy, goose-stepping walk, walk with wider base, concentrate on swinging arms while walking and turning around slowly and small steps. teach the family about the disease, sight and hearing are usually intact, the disease is slow but progressive and does not lead to paralysis. Patient may need to be referred to speech therapy. -signs and symptoms include gradual onset of tremors beginning with the pill like roll, muscle rigidity jerky or uniform, abnormal slow movements referred to as bradykinesia, difficulty walking, high-pitched monotone voice, mask-like facies, loss of postural control (body bends forward when walking), slow slurred speech, difficulty swallowing and drooling issue, shrinking slow handwriting, and depression along with hallucinations and sleep disturbances. -treatment is palliative trying to get the patient to maintain a high level of function as possible with the disease. meds that are currently used include levodopa, dopamine agonist, anticholinergics to control tremor, MOI to slow the disease, antihistamines to reduce tremors, antiviral agents to reduce rigidity, tremor, and bradykinesia, antidepressants, and budipine. Surgical therapy include stereotactic neurosurgery to prevent involuntary movements when they have not responded to medical therapy, neural transplantation, and deep brain stimulation. -nursing care: encourage pt to be as independent as possible, remind them that fatigue can exacerbate s/s, establish a schedule for voiding and defecating and encourage pt to drink 2L of liquid and eat high-fiber foods, encourage patient to remain as active as possible, instruct family and patient about disease and treatment, discuss importance of nutritional support and watch closely for urinary and respiratory tract infections. -outcomes: pt is compliant w/ meds, enrolls in exercise class to stay active, family exhibit understanding, and pt sets realistic goals about daily living. background -1% of ppl over age 60 have Parkinsons disease which affects the extrapyramidal system and the part of the CNS that controls all movement. -disease caused by dopamine deficiency results from destruction of pigmented neuronal cells in the nigra, a reduction as a result of destruction upset the normal balance and symptoms occur like tremors, rigidity, slow movements when the affected brain cell can no longer perform their normal fuctions. - complications include respiratory and UTIs, skin breakdowns from immobilization if severe, injury from falls, adverse drug effects , dementia, and depression which increases the suicide risk.

Erectile Dysfunction

Overview: Inability to achieve or maintain an erection sufficient for sexual activity; major medical risk factors include cardiovascular disease, hypertension, diabetes, long-term smoking, renal failure, neurological disorders; psychological and physiological factors can also contribute; nursing care includes sensitive and complete history about ED and contributing factors, instruct about normal physiology, medications.

osteomyelitis

Overview: Infection of the bone caused by Staphylococccus aureus, carried by blood from primary site of infection (upper respiratory infections, otitis media, and tonsillitis). Indications include severe pain, fever, irritability, and tenderness. Child may not want to move extremity and hold in semi-flexion position. Treament include bed rest, analgesics, antibiotics,, support affected extremity with pillo, splint, fluids, monitor I&O, high-protein diet with carbs, vitamins, and minerals Nursing Care: Signs/Symptoms: Fever, chills, and malaise; Septicemia; Pain and swelling over the infected area. Treatment includes intravenous antibiotics (penicillin, cephalosporin) ATC for 3-6 weeks, oral antibiotics for 3 months after IV therapy, immobilization of affected area, warm soaks, to increase circulation, surgery, to expose and remove abscess, irrigate with sterile saline solutioin, and apply antibiotic beads to wounds and amputations. Nursing Care includes strict sterile technique during dressing change and irrigation. Provide good skin care; administer IV fluids and provide diet high in protein and Vitamin C; assess vital signs and wound q4hrs. Check circulation and drainage q4hrs.; support affected limb with pillow; report sudden pain, crepitus,, and malposition of limb; protect pt for pain relief; and instruct pt on how to recognize recurring infection. Outcomes includes experience minimal pain with medication, does not develop new sites of infection or neurovascular deficits, complaint with oral antibiotics after discharge and does not report infection recurrences, and patient returns to normal function after treatment Background : Causes tissue necrosis, breakdown bone structures, and decalcification. Pathophysiology 80% of cases caused by Staphylococccus aureus; Other pathogens: Proteus vulgaris, Pseudomonas aeruginosia, Streptococcus pyogenes, Streptococcus pneumoniae, and E. coli; In children, common sites: lower end of femur, upper ends of tibia, humerus, and radius; In adults, common sites: pelvis and vertebrae; Microorganism reach the bone from infections elsewhere in the body (bloodstream) OR from surgery; Inflammation is the first sign; Thrombosis eventually causes ischemia then necrosis of bone; If untreated, infection in medullary cavity eventually spreads to periosteum and forms abscesses containing dead bone that makes them hard to drain; New bone growth eventually encapsulates the dead bone which seals off antibiotic therapy--chronic osteomyelitis. Cause/ Risk Factors: Malnutrition, old age, immunosuppression, chronic illness. Diagnostic tests: Radiograhic films, Radioisotope bone scans, MRI, Blood studies, wound and blood cultures. Complications: Recurrent infection. Chronic osteomyelitis. Amputation, Death

ENEMA

Overview: Introduction of a solution into the rectum and sigmoid colon for cleansing or therapeutic purposes; include oil retention, soapsuds, and tap water; nursing responsibilities include position on left side; use tepid solution; hold irrigation set no more than 18 inches above rectum; insert tube no more than 4 inches; instruct client as to how long to retain solution; do not administer in presence of abdominal pain, nausea, vomiting, or suspected appendicitis. Nursing care: Enema administration involves instilling a solution into the rectum and colon. Some types of enemas include large-volume cleansing enema, small-volume enema, and retention enema. Purpose: Stimulates peristalsis, lubricates and softens stool, expels flatus, cleans colon, and used for medication administration. Nursing Diagnoses include: Acute pain, Imbalanced nutrition, less than body requirements, Constipation/ risk for, and risk for injury. Implementation: Check doctor's order and assess patient's condition, provide privacy, familiarize patient with equipment, To administer large-volume cleansing enema: warm ordered amount of solution to room temperature; verify temperature with: Bath thermometer, Inner wrist or Faucet, if using tap water. Wash your hands and put on gloves. Put on gown, if necessary. Add enema solution to container. Release clamp; ensure fluid progresses through tube before reclamping. Assist patient into left-lateral Sim's position: Reposition patient on back or right side if Sims' position contraindicated, or if patient reports discomfort . Fold back top linen to expose patient's rectal area. Place linen-saver pads under patient's buttocks. Have a bedpan or commode nearby and toilet tissue within the patient's reach. Apply nonsterile gloves. Elevate solution above the anus. If using a disposable set, rectal tube may already be prelubricated; if not, lubricate end of tube 2" to 3" with generous amount of lubricant. An indwelling urinary catheter or a Verden catheter can also be used as a rectal tube if your facility's policy permits. Insert the lubricated catheter as you would a rectal tube. Gently inflate the catheter's balloon with 20 to 30 ml of water. Gently pull the catheter back against the patient's internal anal sphincter to seal off the rectum. If leakage still occurs with the balloon in place, add more water to the balloon in small amounts. When using either catheter, avoid inflating the balloon above 45 ml. Separate the patient's buttocks and touch the anal sphincter with the rectal tube to stimulate contraction. As the sphincter relaxes, tell the patient to breathe deeply through his mouth as you gently advance the tube; advance tube 3" to 4" for an adult. Angle tube toward the umbilicus, not bladder. Continue to hold tubing until all solution is installed. Allow solution approximately 5 to 10 minutes for installation. Assess patient's tolerance frequently during instillation. If patient feels sensation to defecate, or cramping occurs, clamp tubing or lower container. If the patient feels pain or if the tube meets continued resistance, notify the doctor. If the flow slows or stops, the catheter tip may be clogged with feces or pressed against the rectal wall: Gently turn the catheter slightly to free it without stimulating defecation and If the catheter tip remains clogged, withdraw the catheter, flush it with solution, and reinsert it. Once solution is installed, clamp tubing. Have paper towel ready; remove tube and grasp with paper towel. Ensure patient is in comfortable position with covers drawn and side rails up. Encourage patient to retain solution until experiences strong urge to defecate (approximately 5 to 15 minutes).If an indwelling catheter is in place, deflate the balloon and remove the catheter, if applicable. Discard or restore equipment; wash hands. When patient is ready to defecate: Adjust bed to sitting position, or assist patient to commode or bathroom, Stay with patient, if necessary and remind patient to avoid flushing the toilet if bathroom is being used. Apply gloves and assist patient in cleaning anal area, or supply washcloth, soap and water for capable patient. Observe contents of the toilet or bedpan, Send specimens to laboratory, if ordered, Rinse and wash the bedpan or commode, Properly dispose of the enema equipment and store clean, reusable equipment, Discard gloves and gown, and wash your hands. To administer small- volume cleansing enema. Wash your hands and put on gloves. Put on gown, if necessary < Fold back top linen to expose patient's rectal area, Place linen-saver pads under patient's buttocks, Have a bedpan or commode nearby and toilet tissue within the patient's reach, Apply nonsterile gloves, Remove cap to pre-packaged rectal tube and lubricate end 2" to 3" with generous amount of lubricant, Separate the patient's buttocks an touch the anal sphincter with the rectal tube to stimulate contraction. As the sphincter relaxes, tell the patient to breathe deeply through his mouth as you gently advance the tube; advance tube 3" to 4" for an adult. Angle tube toward umbilicus, not bladder; Compress container with hands; Administer all solution in container, rolling end up on itself toward rectal tip; While keeping container compressed, remove tube; Allow solution approximately 5 to 15 minutes for installation; Expected outcomes Patient retains solution for adequate amount of time and expels feces, Patient verbalizes as increase in comfort and does not show signs of abdominal distention and Patient's rectal mucosa does not experience trauma. Background: Patient teaching include Explain the purpose for administering the enema, Inform patient about the type of enema he'll receive , Instruct patient as to how long the solution needs to be retained in order to achieve effective results and Encourage patient to breathe slowly and deeply through his mouth during installation. Special considerations: General considerations: Do not administer enema if patient is experiencing Abdominal pain, n/v, or Possible appendicitis. Stop enema administration if Patient experiences fullness or pain or fluid escapes around tube. Do not administer more than three enemas at one time. Confirm any order for several enemas ("until clear"). Pediatric consideration: sse caution when administering enemas containing phosphates, ensure appropriate solution temperature (100 F) and volume and ensure appropriate distance for tube insertion. Insert tubing 2" to 3" into the rectum for children. Insert tubing 1" to 11/2" into the rectum for infants. Allow family member to remain with a pediatric patient during procedure. Geriatric considerations: use caution when administering enemas containing phosphates and assist patient having trouble retaining solution adjust pillows and elevate head of his bed to 30 degrees and administer enema while patient is on the bedpan. Unexpected outcomes and associated interventions :Severe cramping or pain is present upon introduction of enema solution (Assess temperature and flow rate, assess amount and length of administration and adjusted as needed) Enema solution is not retained by patient for adequate amount of time (Administer enema while the patient is on bedpan and Adjust pillows and elevate head of bed to 30 degrees). Enema solution does not flow into rectum (Reposition rectal tube and assess tubing for fecal contents)

Buspirone Hydrochloride (Bu Spar)

nonbenzodiazepine antianxiety agent that is contraindicated within 14 days MAO medication. the drug is not controlled substance and has not been shown to be addictive. usually the drug effects will not occur for several weeks and patients need to be taught that alcohol is contraindicated when taking this drug. s/s: dizziness, nausea, headache, nervousness, lightheadedness, and excitement. nursing care: -drug should not exceed 60mg daily, monitor for CNS changes *this drug is not recommended for patients with significant renal or hepatic failure. -

priorities

Kaplan Overview : Establishing priorities enables the nurse to attend to the clients most important needs and helps the nurse organize care; situations that, if left untreated, could cause physical harm to the client having the highest priority; using Maslow's hierarchy of needs enables the nurse to establish priorities. It also enables nurse to attend to patient's most important needs and helps nurse organize care. a. Essential Nursing Care . Implementation: Develop a prioritized list of nursing diagnoses and deal with medical problems (or suspected medical problems) first; consider all health needs and determine relationship between problems. Then, prioritize needs in terms of Maslow's Hierarchy; help patient meet basic physiologic needs (oxygen, food, water, temperature, elimination, sexuality, physical activity, and rest), assist patient with safety and security needs; support patient in meeting love and belonging needs; help patient meet self-esteem needs; help patient meet self-actualization needs, the highest level of hierarchy; consider patient preference and anticipate future problems if a patient chooses to ignore a priority i. Expected outcome: patient's medical problems are addressed and associations drawn between problems, patient's care routine is organized and conducted in the patient's best interest, patient's needs are met according to preference and maslow's hierarchy and patient who refuses necessary care receives care despite reluctance b. Background Nursing Care: Priorities are guidelines for ranking nursing diagnoses, and are established by way of Maslow's hierarchy of human needs, patient preference, and anticipation of future problems.

delegation NAP

NAP/ nurse aides, nursing assistants, technicians, orderlies, nurse extenders, unlicensed nursing assistive personnel; assit with direct client care activities.

Demand Pacemaker

Overview: Functions when HR falls below a set rate; inserted to treat complete heart block and sick sinus syndrome; nursing considerations include monitor HR and rhythm, instruct pt to carry ID, request hand scanning at airport, avoid electromagnetic fields

Croup

Overview: General term for a respiratory system complex affecting children, names of which are given according to main anatomic areas affected (acute epiglottitis, acute spasmodic laryngitis, acute laryngotracheobronchitis, acute tracheitis); LTB is the most common; indications include cough described as barking or seal-like in sound, hoarseness, dyspnea, inspiratory stridor, restlessness, irritability, low-grade fever; may develop hypoxia, cyanosis, respiratory acidosis, eventually respiratory failure; nursing interventions include consistent vigilant observation and accurate assessment of respiratory status, with particular focus on recognizing signs of impending respiratory failure so emergency measures can be taken immediately if needed; keep tracheostomy set at bedside; encourage child to rest as much as possible; use croupette or mist tent; administer IV fluids and medications as ordered (e.g. antipyretics); position in infant seat or propped with pillows; support parents; recommend care at home that includes steamy shower, sudden exposure to cold air, sleep with cool, humidified air Nursing Care: Croup is an obstructive upper airway disease that affects primarily children younger than 5 years of age. Signs and symptoms consist of upper respiratory infection, low-grade fever, barking cough (croupy cough) at night, inspiratory stridor, substernal and suprasternal retractions and agitation or restlessness. Treatment includes a warm, moist environment for the child created by running the shower until the bathroom fills with steam, vaporizers, antipyretics (e.g. acitaminophen), antibiotics, if croup is bacterial in origin, corticosteroids (e.g. dexamethasone [Decadron]), to reduce subglottic edema and inflammation, racemic epinephrine [Isuprel], given by nebulizer, to open the airway by reducing edema and inflammation and intravenous fluids if hospitalized, to keep the child hydrated. Nursing Care includes carefully monitor hospitalized children for respiratory status and airway obstruction, including color, effort of respirations, and evidence of fatigue, assess vital signs for worsening symptoms, administer prescribed medications, as ordered, provide humidified air by vaporizer or mist tent, encourage oral hydration to help loosen secretions, but use intravenous fluids in the child who is at risk for aspiration (i.e. the child with a respiratory rate over 60 breaths/minute), help the child find a comfortable position for the best oxygenation (usually sitting up) and help to alleviate the anxiety of the child and parents by explaining croup and its treatment, especially when at home. Expected Outcomes: parents express an understanding of the disease process and report that they have bought a cool mist vaporizer for home use and pediatric client is well at follow-up, and parents report that there were no additional episodes of respiratory insufficiency as a result of the croup is an obstructive upper airway disease that primarily affects children younger than 5 years of age. Background: Usually results from a viral infection, but it may also be caused by a bacterial infection, self-limiting, involves severe inflammation & obstruction of the larynx, trachea, and major bronchi. Pathophysiology: typically, a common virus causes an upper respiratory infection, which proceeds to laryngitis, which swells and constricts the larynx; the infection descends into the trachea and sometimes the bronchi, causing inflammation of the mucosal lining and subsequent narrowing of the trachea and airways; profound airway edema may result in obstruction and compromised ventilation ; when the airway is significantly narrowed, the child struggles to inhale air past the obstruction, which produces inspiratory stridor, suprasternal retractions, and the classic barking cough. Causes/Risk Factors: viral infection or bacterial infection. Diagnostic Tests history of an upper respiratory infection, physical examination, X-rays, which show a normal epiglottis, distinguishing croup from epiglottitis, and a narrowed subglottic space ("steeple sign"). Complications includes respiratory acidosis and respiratory failure.

Clostridium difficile

Overview: Gram-positive bacterium that causes antibiotic-associtated colitis; antibiotics depress natural intestinal flora

chicken pox

Overview Acute, highly contagious, viral disease. Prodromal s/s: slight fever, malaise, anorexia, prurtic rash (begins as macules, then papule, then vesicles), lymphadeonpathy, elevated temp. Direct & droplet precautions. Spread by contaminated objects also. Incubation 13-17 days. Nursing consideration: isolation until vesicles crusted, communicable from 2 days before appearance of rash, avoid use of aspirin b/c association of Reye's syndrome, use tylenol, topical application of calamine lotion or baking soda baths

K+

Overview Electrolyte solution. Used for electrolyte depletion secondary to diuretic or steroid use or when there has been severe vomiting or diarrhea or other fluid drainage or malabsorption; side effects: nausea, vomiting, diarrhea, abdominal pain, confusion, paresthesia, muscle weakness, flaccid paralysis, oliguria, respiratory distress, dysrhythmias, cardiac arrest; nursing considerations: monitor intake and output and EKG and serum electrolytes; client education: avoid potassium sources in foods, including salt substitutes and licorirce, and OTC medications. Essential Nursing Care: Therapeutic Class: Electrolyte, Action: Replaces lost potassium, Indications: Hypokalemia, Nursing Implications: Do not administer until adequate urine flow is established. Do not administer faster than 20 mEq/h or in concentrations greater than 30-40 mEq/L. Agitate fluid well to prevent bolus doses of potassium at the bottom of the IV container. Decrease rate of administration when using peripheral vein to prevent irritation. Do not administer doses greater than 60 mEq/L in peripheral veins. Monitor patient's ECG when treating extreme hypokalemia. Use an infusion pump to administer. Expected Outcomes: Patient's potassium level is returned to normal levels, Patient maintains normal potassium level through diet. Background Nursing Care: Action: Potassium is the body's primary intracellular electrolyte, It influences skeletal and cardiac muscle activity; imbalances can cause myocardial irritability and rhythm, The kidneys regulate potassium levels by adjusting the amount excreted in urine; however they do not conserve potassium well and may still excrete it in the urine when there is a deficit, Iv potassium replaces lost potassium and allows the body to bring levels back in balance. Adverse Effects: Life- Threatening cardiotoxicity, Hyperkalemia, and pain at infusion site. Interactions: Hyperkalemia may result if taken with salt substances or other supplements containing potassium.

abdominal aortic aneurysm

Overview Localized enlargement of wall of abdominal aorta; may be asymptomatic or pt may complain abdominal pain, low back pain, pulsating mass in periumbilical area, bruit over the aorta, BP may be lower in legs than arms; nursing considerations include monitor BP frequently, monitor renal function, CBC, instruct to avoid bending, lifting constipation

Enoxaparin (Lovenox)

Overview Low-Molecular weight heparin used to prevent DVT and pulmonary emboli; Side effects include hemorrhage, tissue irritation/pain at injection site, anemia, thrombocytopenia, fever; nursing considerations include give deep SQ, never IV or IM, does not require lab test monitoring.

placenta previa

Overview Placenta abnormally implanted near or over the cervical opening; indications include painless bright red vaginal bleeding accompanied by a soft uterus usually in third trimester between 29 to 30 weeks; caused by scarring of uterus from pregnancy, tumor; treatment includes bedrest, ultrasound to locate placenta, no vaginal/rectal exams before fetal viability, amniocentesis for lung maturity, daily Hgb and Hct, 2U cross-matched blood available.

hypernatremia

Overview Serum sodium greater than 145. Normal range 135-145. Sodium is a main extracellular ion, responsible for water balance. Indications of hypernatremia are elevated temperature, weakness, disorientation, delusion, hallucinations, thirst, dry swollen tongue, sticky mucous membranes, hypotension, tachycardia; causes include hypertonic tube feedings without water supplements, diarrhea, hyperventilation, diabetes insipidus; treatment includes IV administration of hypotonic solution 0.3% NaCl or 0.45 NaCl, 5% dextrose in water; offer fluids at regular intervals, decrease sodium in diet, daily weights

age appropriate preparation for surgery

Overview Toddler—fears separation; teach parents to expect regression (in toilet training and difficult separations); Preschooler—fears mutilation; allow child to play with models of equipment, encourage expression of feelings (anger); School age—fears loss of control; explain procedure in simple terms, allow choices when possible; adolescent—fears loss of independence, being different from peers (alterations in body image); involve adolescent in procedure and therapies, expect resistance, express understanding of concerns, point out strengths.

allergies

Overview: Hypersensitivity caused by exposure to an allergen; reaction includes shortness of breath, wheezing, inflamed airways, itching, congestion, erythema; allergic reaction is caused by immense amounts of histamine rapidly dispersed throughout the circulatory system, resulting in extensive vasodilation and severe edema of the bronchial tissue; common allergens include penicillin, radiopaque dyes, aspirin, blood components, toxins such as snake or bee or wasp or hornet food such as berries or chocolate or eggs or shellfish or seafood or nuts. Nursing Care:Obtain a detailed history, establishing airway, administering aqueous epinephrine through EpiPen and/or diphenhydramine (Benadryl) and/or aminophylline for severe bronchospasm and/or vasopressors for severe shock, starting IV with large-bore needle.Client Education: inhaler and EpiPen, how to avoid allergens, paint walls, toys should be wood, plastic or metal, remove rugs, use allergen-proof covers for mattresses and box springs, do not store anything under the bed, keep bed away from forced air vent, decrease exposure to smoke and/or latex and/or chemical and/or animals.

shock

Overview: In any emergency situation, shock should be anticipated e fore it develops; hypovolemia is the most common cause of shock; indications include increased HR, decreased BP, pallor, diaphoresis, moist cold skin, oliguria, hyperpnea, metabolic acidosis, and altered sensorium; treatment includes correct physiologic abnormalities and restore and maintain tissue perfusion; nursing responsibilities include ensuring patent airway, maintaining breathing and circulation, restoring circulating blood volume, inserting indwelling catheter, I&O q 15-30mins, determining cause of shock, lab tests, elevating feet slightly, meds as prescribed, maintaining body temperature, avoiding too much heat. Nursing Care: Shock occurs when systemic blood pressure is too low to carry necessary oxygen and nutrients to vital organs and cells. Types of shock include anaphylactic, cardiogenic, hypovolemic, neurogenic, and septic. Signs and symptoms vary with the stage of shock include compensatory Stage: normal blood pressure, but increased heart rate and increased respiratory rate, mental status changes (confusion, combativeness), cool and clammy skin, & hypoactive bowel sounds, decreased urine output; progressive Stage which includes low mean arterial pressure (MAP), rapid and shallow respirations, crackles in lung fields, rapid heart rate, chest pain, change in mental status; initially agitation and confusion, then loss of consciousness, decrease in urinary output (possible acute renal failure), jaundiced appearance, bloody diarrhea, bruising (ecchymoses) and bleeding (petechiae) in the skin and irreversible Stage which includes BP remains low and patient unresponsive to treatment and cannot survive. Treatment includes compensatory stage :Identify the cause; correct underlying disorder and fluid replacement and medication therapy (to maintain BP and adequate tissue perfusion) then progressive Stage which depends on the type of shock, its cause, and decompensation in organ systems; common treatments include: IV fluids and medications (to restore tissue perfusion and intravascular volume), early enteral nutritional support (for metabolic requirements), vasoactive medications (to restore vasomotor tone and improve cardiac function), IV insulin, (for aggressive hyperglycemic control), and antacids, histamine-2 blockers (h2) blockers, antipeptic agents (reduce risk of GI ulceration and bleeding) and Irreversible Stage which usually comparable to treatment for progressive stage, but patient fails to respond to treatment and experimental options may include investigational medications (to reduce or reverse severity of shock). Nursing Care includes compensatory stage: prepare to recognize and understand significant of even slight changes in patient assessment data, carefully monitor geriatric patients who are at greater risk if any of the following apply: medications such as beta-blocking agents, increasing trend in body temperature, failure of heart to function in hypoxemic states, and sudden change in mentation; provide patient support to reduce anxiety, monitor patient's level of consciousness, vital signs, and urine output, ensure a safe environment; Progressive Stage (often intensive care setting): prepare to recognize and understand significance of even slight changes in patient assessment data, become familiar with patients with any possible risk for shock, and report any and all subtle changes in assessment, including: hemodynamic monitoring, electrocardiographic (ECG) monitoring, arterial blood gases, serum electrolyte levels, physical and mental status changes, administer medications and fluids frequently, as ordered, provide mechanical ventilation, dialysis, and intra-aortic balloon pump, as necessary or as prescribed, carefully document treatments, medications and fluids to promote care from other members of health care team, record time, dosage or volume, and patient responses; coordinate scheduling of bedside diagnostic procedures includes irreversible Stage which includes continue with all previous nursing management, including treatments and monitoring, and preventing complications and injury, explain to patient prognosis and what is occurring, despite patient's level of consciousness, using comfort measures (i.e., touch hand), as necessary, provide comfort to family members as the patient's prognosis becomes worse, explain actions of nursing care team are to provide comfort because they are no longer capable of reversing shock, discuss living wills, advance directives, or other such patient documentation of wishes, if appropriate, discuss use of life-support measures. Expected Outcomes include patient showing signs of shock is treated immediately and symptoms of shock subside. Background: Within cells, nutrients are broken down and stored as adenosine triphosphate (ATP), cells use ATP to perform their necessary functions, ATP can be created aerobically or anaerobically, but aerobic metabolism is far more efficient, anaerobic metabolism of ATP produces lactic acid, which must be sent to the liver to be processed. Patho: compensatory stage include arterial pressure and tissue perfusion falls, compensatory mechanisms activated to maintain cardiac output and perfusion to the heart and brain, as baroreceptors in carotid sinus and aortic arch sense a drop in blood pressure, epi and norepi are secreted, secretion of epi and norepi increases peripheral resistance, blood pressure and myocardial contractility and reduced blood flow to kidney activates renin-angiotensin-aldosterone system, causing vasoconstriction and sodium and water retention; Progressive Stage include compensatory mechanisms can't maintain cardiac output, tissues become hypoxic, cells switch to anaerobic metabolism and lactic acid accumulates, producing metabolic acidosis, tissue hypoxia promotes release of endothelial mediators, leading to venous pooling and increased capillary permeability, sluggish blood flow increases the risk of DIC; and Irreversible Stage includes inadequate perfusion damages cell membranes, Lysosomal enzymes are released, and energy stores are depleted, leading to cell death, Lactic acid continues to accumulate, increasing capillary permeability and the movement of fluid out of the vascular space, further contributing to hypotension, Perfusion to the coronary arteries is reduced, causing myocardial depression and further reduction in cardiac output, circulatory and respiratory failure occur. Causes/Risk Factors includes anaphylactic Shock includes penicillin sensitivity, transfusion reaction, bee sting allergy, latex sensitivity, severe allergy to some foods or medications. Cardiogenic Shock includes coronary cause: MI (especially anterior wall MI) and noncoronary cause (less common): hypoxemia, acidosis, hypoglycemia, hypocalcemia, tension pneumothorax, cardiomyopathies, valvular damage, cardiac tamponade, dysrhythmias. Hypovolemic Shock includes external fluid losses (i.e., traumatic blood loss), trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus, internal fluid shifts, and hemorrhage, burns, ascites, peritonitis, dehydration. Neurogenic Shock includes spinal cord injury, spinal anesthesia, depressant action of medications, glucose deficiency. Septic Shock includes widespread infection due to immunosuppression; extremes of age; malnourishment, chronic illness, invasive procedures. Diagnostic Tests diagnosis is based on symptoms of shock. Complications from fluid administration include cardiovascular overload and pulmonary edema

Labor

Overview: 1st stage is divided into 3 parts- phase 1 (latent): cervix is dilated 0-3 cm, contractions 10-30sec long, 5 to 30 min apart, mild to moderate; phase 2 (active): cervix dilated 4-7 cm, contractions 30-60 sec long, 3 to 5 min apart, moderate to strong; phase 3 (transition): cervix is 8-10 cm, contractions 45-90sec long, 2 to 3 min apart, strong, impending delivery marked by increase in dark red bloody show, increased urge to bear down; second stage: from full dilation of cervix to delivery of baby; third stage: from birth of baby to expulsion of placenta; fourth stage: the first 2 hrs after birth of baby. Nursing care: True labor begins when woman has bloody show, membrane rupture, and painful contractions of uterus that cause effacement and dilation of cervix; labor ends after birth of baby and placenta, and after immediate postpartum period. Preliminary s/s of labor include lightening, increased level of activity, Braxton hicks contractions, and ripening of cervix. Signs of true labor include interine contractions, show, and spontaneous rupture of membranes. 1st stage of labor the cervix effaces and dilates, begins w/ true uterine contractions and ends when cervix is fully dilated, subdivided into 3 phases latent, active, and transition. Second stages starts w/ full dilatation and effacement and ends with delivery of neonate, last about 1-3hrs in primipara and 30-60mins in multipara. Cardinal movements of labor occur during this stage to help fetus move through birth canal. Third stage occurs after neonate has been delivered and ends with delivery of placenta and consist of 2 phases placental separation and expulsion. Fourth stage occurs immediately after delivery of placenta and last for about 4 hours and initiates postpartum period. Outcomes include delivery of neonate w/o complications to mom or baby. Background: complications include dysfunctional labor, contraction rings, precipitate labor, uterine rupture, inversion of uterus, amniotic fluid embolism, prolapse of umbilical cord, multiple gestation, occipitoposterior position of fetus, breech presentation, face presentation, brow presentation, transverse lie, macrosomia, shoulder dystocia, fetal anomalies, inlet contraction and outlet contraction. Interventions includes cervical ripening, induction of labor by oxytocin, augmentation of labor by oxytocin, active management of labor, forceps birth, vaccum extraction, CS birth.

hypoglycemia

Overview: Abnormally low blood glucose level; may occur at any time, but often occurs at the time the insulin is peaking; indications: tremor, perspiration, anxiety, hunger, weakness, tachycardia, confusion, and headache; nursing care: if conscious offer 15 gram load of carbohydrate, if unconscious administer dextrose 50%, follow with additional carbohydrate or dextrose in 15 minutes if blood glucose level not within normal range, determine cause. Nursing Care: Hypoglycemia is an abnormally low level of glucose in the blood, usually occurring suddenly and as a complication of diabetes. S/S: adrenergic: sweating, tremor, tachycardia, palpitations, nervousness, hunger. Central nervous system symptoms: inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of lips and tongue, slurred speech, impaired coordination, emotional changes, irrationally or combative behavior, double vision, drowsiness, seizures, difficulty awakening, loss of consciousness. Treatment: Administration of 15 g of carbohydrates in the form of candy, juice, or sugar, administration of 1 mg of subcutaneous or intramuscular glucagon or 25 to 50 ml of intravenous 50% dextrose in water in unconscious patients. Administration of a snack protein and starch after symptoms resolve. Nursing care: administer glucagon as ordered. Provide education to encourage self-care involving eating patterns, appropriate foods, administration of insulin, and exercise. Expected outcomes: Patient self-manages hypoglycemia and regulates blood glucose levels through diet and exercise and/or pharmacologic therapy Background: The pancreas produces the hormone insulin, which regulates glucose levels in the blood by triggering production or storage, glucose is absorbed in the GI tract formed in the liver from food sources and is necessary for energy, the pancreas releases insulin even during fasting periods to maintain glucose levels. Pathophysiology: blood glucose levels fall, stimulating the sympathetic nervous system to release epinephrine and Norepinephrine; continued hypoglycemia deprives brain cells of fuel and impairs the central nervous system. Causes/ risk factors: Diabetes, excess insulin or oral hypoglycemic agents, not enough food, excessive physical activity. Diagnostic tests: None; Onset is sudden and is diagnosed symptomatically. Complications: Hyperglycemia as a result of treatment.

INH

Overview: Antituberculosis agent, a mainstay medication used for prophylaxis and treatment of tuberculosis; give in combination with other antitubercular agents when treating active TB, administer vitamin B6 to prevent peripheral neuritis; side effects include toxic hepatitis, peripheral neuritis, rash, fever, blood dyscrasias, GI upset, local irritation at injection site; Nursing Considerations include teach signs of hepatitis, check liver function tests, monitor for resolution of TB symptoms (fever, cough, night sweats, weight loss), give before meals on empty stomach, give pyridoxine (vitamin B6) as ordered.

preeclampsia

Overview: Complication of pregnancy; persistent elevation of SBP above 140mmHg and DBP above 90mmHg. May or may not have symptoms: which include HTN, proteinuria, edema; occurs between 20th and 40th week; mild preeclampsia includes BP 140/90mmHg or increase of 30/15mmHg, 2+ or 3+ proteinuria, slight generalized edema. Nursing care includes bedrest in left lateral position, well balanced diet, & daily weights; Severe preeclampsia include BP 150-160/100-110mmHg, 4+ proteinuria, headache, epigastric pain, dizziness, anginal pain; nursing care includes bedrest, monitor I&O, seizure precautions, v/s, fetal heart tones, administer antihypertensives meds as order, education on meds and SE, wt control, increase physical activity, smoking cessation and importance of health care followup. Nursing Care: pregnancy- induced HTN, now known as gestational HTN, develops after 20th wk of pregnancy and has two forms preeclampsia and eclampsia and is potentially life-threatening. Signs/Symptoms include sudden weight gain 3lbs per week in 2nd trimester or more than 1lb per week in 3rd trimester, BP > 140mmHg systolic or >90mmHg diastolic, BP increase, measured in 2 times 6hrs apart of 30mmHg or more systolic or 15mmHg or more diastolic, proteinuria, generalized vasospasm, decrease in circulating blood volume, activation of coagulation systems, manifested as hypertension and decrease perfusion to placenta, kidneys, liver, and brain. Mild includes DBP <100mmHg; Proteinuria 1 or 2+, edema of face and hands, weight gain, can proceed rapidly to severe preeclampsia. Severe includes DBP 110mmHg or higher; Proteinuria 5mg/24hr urine or 2+ or 3+; Raised Hct, Cr, uric acids; Thrombocytopenia, platelet count <100,000mm3; Oliguria; Blurred vision; Epigastric pain; Heartburn; Irritability; Altered LOC. -Treatment includes complete bed rest, left lateral position enhances venous return, antihypertensive drugs (methyldopa and hydralazine). If above 2 fail: Magnesium to promote diuresis. If does not improve or fetus life in danger: Deliver by oxytocin or cesarean section. If seizures begin: immediate IV Magnesium, oxygen, fetal monitoring -Nursing Care: Monitor for changes in BP, HR, RR, fetal heart rate, vision, LOC, deep tendon reflexes, headache unrelieved by medication; if order, administer magnesium: Use piggyback infusion so can be stopped if toxicity occurs. Obtain baseline magnesium (should be between 5-8mg/L. Assess serum levels (>8mg/L is toxic). Assess deep tendon reflexes. Assess ankle clonus; have calcium gluconate ready (Magnesium antidote); monitor edema; Monitor I& O; complete bedrest; well balanced meal (high-protein, limit sodium, high fiber, eight 8 oz glasses of water); Provide emotional support; Teach pt to report: Headache, visual disturbances, gastrointestinal symptoms, worsening edema, decrease in urine output; & maintain seizure precautions Background : occurs in 12-20% of pregnancies; leading cause of maternal death; most common complication of pregnancy -Pathophysiology: Vasospasm and hypoperfusion.; epithilia injury, leading to platelet adherence, fibrin, depositions, schistocytes (fragments of erthrocytes) -Cause/Risk Factors: First pregnancy; Preeclampsia in previous pregnancies; Excess placental tissues; Familial; Lower socioeconomic; hx of diabetes, hypertension, or renal disease, poor nutrition; african-american, young (<17y/o) or older than 35 y/o; Obesity -Diagnostic Test: Blood pressure measurement; Urine protein -Complications: Progression to eclampsia, HELLP syndrome; risk to fetus: poor placental perfusion, intrauterine growth restriction

Delegation

Overview: Delegation is the responsibility and authority for performing a task is transferred to another individual who accepts that responsibility and authority; can delegate only task for which nurse is responsible; steps include defining task to be delegated, determining who should receive the delegated task, identifying what task involves, matching task to individual by assessing individual's skills and abilities, providing clear communication about expectations, and answering any questions. Purpose is to reduce costs of care by delegation of routine task to UAP, results in effective time management, and results in team building which increases production and sense of satisfaction Nursing care: delegate according to 5 rights of delegation: right task, right circumstances, right person, right direction, right supervision/evaluation. Delegate the responsible person in terms of pts needs and delegate's level of competence and understanding. Also plan ahead to prevent problems, communicate expectations, allot sufficient time to ensure clear guidance, provide autonomy for delegates to decide how to accomplish work, and supervise appropriate. Background: common delegation errors include underdelegating (false assumption that may be interpreted as lack of ability, desire to complete whole job personally due to lack of trust, fear that subordinates will resent having work delegated to them, and finds it difficult to assume manager role), overdelegating (manager's poor sense for time and feelings of insecurity), and improperly delegating (wrong time, wrong task and responsibilities, and ineffective communication).

Constipation

Overview: Difficulty in passing stools or incomplete or infrequent passing of hard stools; causes may be intestinal obstruction from tumors or other causes, diverticulitis, medications, inadequate fluid or bulk or exercise, slow peristalsis, decreased muscle tone, anal sphincter dysfunction, poor bowel habits; client may experience feeling of fullness and pressure in rectum, straining at stool, abdominal and/or back pain, headache, poor appetite; nursing interventions may include administering enemas or laxatives as ordered to address current issues; promoting normal elimination is major focus and involves teaching client to respond to urge to defecate; provide facilities, privacy, sufficient time, and proper positioning (ambulatory client should be taught that optimal position for defecation is with feet flat on floor, hips and knees flexed; patient on bed rest should be placed in Fowler's position on bedpan); encourage adequate fluid intake (eight or more glasses of fluid daily), encourage foods high in fiber such as fruits, vegetables, and grains; encourage exercise and ambulation to maintain muscle tone; teach client that stress affects autonomic nervous system, which controls peristalsis. Nursing Care: Constipation is the infrequent, sometimes painful, passage of hard, dry stool. Signs and symptoms: less than 3 bowel movements per week, small dry stools, abdominal distension, abdominal pain or pressure, straining at stool. Treatment (aimed at treating the underlying cause): education about causes of constipation, bowel habit training, increased fiber intake, increased fluid intake, careful use of laxatives, increased exercise. Nursing care: Assess for the presence of signs and symptoms of constipation, Assess diet and fluid intake, Teach about prevention through high-fiber foods (bran, fruits, vegetables, and whole-grain), 8 to 10 glasses of water a day and exercise, Caution patients not to increase fiber intake without increasing water, Encourage patients to pay attention to a defecation stimulus, Remove impacted feces, if necessary. Expected Outcomes include patient demonstrates a normal pattern of bowel elimination, with no constipation, Patient participates in a diet and exercise program designed to maintain acceptable bowel elimination, Patient has adequate fluid intake, Patient remains free of complications from constipation. Background: Constipation is the infrequent, sometimes painful, passage of hard, dry stool; the colon has three major functions: Mucosal transport (mucosal secretions facilitate passage of contents through colon), Myoelectric activity (mixing of contents and propulsive action), Processes of defecation. Pathophysiology: Pathophysiology of constipation is not clear; however, it is thought to be caused by interference with any of the three above functions, Any interference with the urge to defecate may also lead to constipation. Causes/Risk factors: Bed rest, Constipating medications (e.g., opioids, anticholinergics, antidepressants, antihypertensives), Rectal or anal disorders (e.g., hemorrhoids, fissures), Depression, Neuromuscular disease (e.g., Parkinson's disease, multiple sclerosis), Delaying defecation when urge occurs. Complications: Fecal impaction, hemorrhoids, fissures, megacolon, hypertension.

documentation

Overview: Documentation promotes communication, maintains a legal record, meets requirements of regulatory agencies, is required for third-party reimbursement, is legible, accurate, timely, thorough, well organized, and concise, uses proper grammar, spelling, and authorized abbreviations. Description written or typed legal record of all pertinent interactions w/ patient, meet requirements of regulatory agencies, and required for third party reimbursement. Purpose is to promote communication, contains date used to facilitate patient care, serves as financial and legal records, helps in clinical research, supports decision analysis, provides each professional working with the patient access to patients baseline and ongoing data, and includes diagnostic and therapeutic orders. Nursing Care: Formats for documentation include initial nursing assessment, kardex care plan, computerized documentation is increasingly replacing Kardex care plans and benefits provide ready access to large knowledge base, improves record keeping, improves audits, reduces time on paperwork, provides all team members with printouts; plan of nursing care, critical / collaborative pathways, progress notes, flow sheets, discharge & transfer summary, home healthcare documentation, long term care documentation. Background: legal considerations in documentation: legal cases are determined by facts as well as applicable law; guidelines; nurse accountability is demonstrated via nurses signature for each entry in the medical record, and confidentiality must be maintained with any patient information.

enteral tube feeding

Overview: Enteral tube feeding is delivery of liquid food to the stomach, distal duodenum, or proximal jejunum by way of a tube; can be continuous or intermittent; ensure that feeding is at room temperature, elevate the head of the bed at least 30 degrees, verify tube placement, check for gastric residual, return residual to stomach unless greater than 100 mL, flush tubing with 30mL water, initiate feeding, flush tubing with 30mL water. Nursing Care: The purpose is to allow patients who can't or won't eat to receive nourishment and permits administration of supplemental feedings to patients who have high nutritional requirements. Nursing Diagnoses include imbalanced nutrition less than, risk for aspiration, deficient knowledge, impaired swallowing, risk for impaired social interaction, risk for disturbed body image, and feeding self-care deficit. Implementation: Provide privacy, wash hands, inform the patient that nourishment will be received via tube and explain the procedure, cover the chest with a towel or linen-saver pad if the patient has nasal or oral tube, assess patient's abdomen for bowel sounds and distention, elevate bed to semi-fowlers or high fowlers position and check placement of tube. Never give a feeding prior to ensuring tube is properly positioned in the patient's stomach. Use a syringe to aspirate gastric secretions and examine aspirate and place a small amount on the pH test strip; should be pH 5.0 or less. Assess gastric emptying by aspiration and measuring residual gastric contents, hold feedings if residual volume is greater than predetermined amount given by doctor. Connect gavage bag tubing to feeding tube; purge tubing of air and attach to feeding tube. Flush after feedings and if you are administering a continuous feeding flush every four hours. To discontinue gastric feeding, close the clamp on the gavage bag, disconnect the syringe from the feeding tube, or turn off the infusion controller, leave the patient in semi-fowlers or high fowler's position for at least 30 mins. Expected outcomes include: patient successfully receives feeding without experience of nausea and vomiting, free from signs and symptoms of aspiration, and weight increases and nutritional requirements are met. Background: Patient teaching includes explaining to both the patient and the family that the enteral route is the best alternative to oral feeding, inform the patient and family about the procedure to reduce anxiety and promote cooperation by stating a tube is passed into the GI tract where formula containing total or supplemental nutrients is administered which may be short or long term, instruct patient that a feeding schedule will be set up and if they are continued in a home setting the patient and family need to be provided individualized instructions in written form. Instructions should include directive information regarding administration of feedings, instructions related to equipment, care of insertion site and observations that need to be reported, emergency phone numbers, arrangements for follow up care, and oral hygiene to remove tastes and odors following removal. Unexpected outcomes and associated interventions include upon assessment, the tube is not found in the stomach or intestine, patient may be at risk for aspiration if the tube is in the esophagus, tube requires placement. A large amount of residue is aspirated agency policy and physician should be consulted, physician may give instruction to replace half of the residue and continue with follow up assessment. Patient experiences nausea following tube feeding, consult the physician about antiemetics, keep head of patient's bed elevated and suctioning equipment at bedside. Tubing is clogged, ensure that tubing is adequately flushed after each feeding, to unclog tube apply warm water and gentle pressure or replace tubing if necessary.

Intake & Output

Overview: Measuring 24 hour I & O evaluates the patient's fluid status. Intake includes all liquids taken by mouth, through NG or jejunostomy feeding tubes, IV fluids, and blood and its components. Also, intake includes beverages, fluids contained in solid foods, foods that are liquid at room temperature (gelatin, custard, and ice cream). Output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds and chest tubes. Nursing Care: purpose -helps evaluate a patient's fluid and electrolyte balance. Nursing Diagnoses: Deficient fluid volume, Excess fluid volume, and Risk for imbalanced fluid volume. Implementation- document patient's feeding according to facility's policy and record amount in mL. Fluid intake includes all fluid entering pt's body including beverages and GI instillations, bladder irrigations, and IV fluids. Monitor I & O during each shift. Notify the physician if amounts differ significantly over a 24 hour period. Expected outcome: Patient maintains an approximate balance between fluid intake and fluid output. Background: Patient teaching: Tell patient and family that record of all fluid entering and leaving the body ensures proper fluid balance, give instructions for how the patient can help keep measurements of I & O accurate, explain to parents the importance of replacing fluid that is lost when children are ill. Special Considerations: Diuretics can affect I & O measurements and any significant change in UO should be reported. Unexpected outcomes include a pt to increase his fluid intake needs can take fluids orally but is refusing to make sure its proper temp or variety of liquids and when staring an IV infusion to increase intake, fluid does no flow into vein with ease.

bipolar disorder

Overview: Mood disorder ; manic episodes usually begin suddenly, with rapid escalation; Indications include elevated or expansive mood, agitation, accelerated speech, thought, and movement, distractibility, self-confidence, aggression, sarcasm, inappropriate dress, inattention to personal hygiene, anorexia, weight loss, constipation, insomnia; treatment includes lithium or particular anticonvulsant drugs (Tegretol, Valproate); nursing responsibilities include maintaining physical health and safety (nutrition, rest, sleep, elimination), monitoring for lithium or anticonvulsant toxicity, orienting patient to reality, limiting stimuli, setting limits, being consistent. Nursing Care: Bipolar disorder, also called manic-depressive disorder, is a mood disorder marked by severe, pathologic mood swings. Signs and symptoms includes Manic Phase: Expansive, grandiose, or hyperirritable mood, Increased psychomotor activity, Excessive social extroversion, Short attention span, Rapid speech with frequent topic changes, Decreased need for sleep or food, Impulsivity and impaired judgment as well as depressive Phase: Low self-esteem, Overwhelming inertia, Social withdrawal, Feelings of hopelessness, Difficulty concentrating or thinking clearly, Psychomotor retardation, Slowing of speech. Treatment: Drug Treatment- Lithium to prevent and relieve manic episodes. Action: Believed to have multiple effects of neurotransmitters. Adverse effects: Fine hand tremors, dry mouth, increased urination, nausea, weight gain. Antidepressants to treat depressive symptoms. Other treatment: Psychotherapy. Nursing Care: During a manic episode: Maintain a calm environment and protect the patient from overstimulation, Provide emotional support and set realistic goals for behavior. Set firm limits, Watch for early signs of frustration. Tell the patient firmly that threats and hitting are unacceptable; Alert the health care team promptly when acting-out behavior escalates. Make use of available help, and try not to do everything yourself, Administer medications as ordered. Monitor for adverse effects. During a depressive episode: Provide the patient's physical needs, and help with personal hygiene, if necessary. Encourage him to eat, or feed him if necessary. Keep in mind that a depressed patient needs continual positive reinforcement to improve his self-esteem. Provide a structured routine. To prevent self-injury or suicide, remove harmful objects from the environment. Institute suicide precautions per facility policy. Observe the patient closely, and strictly supervise his medications. Expected outcomes: Patient successfully cares for self. Patient exhibits appropriate behavior. Patient experiences minimal adverse drug effects. Patient identifies positive aspects of self. Patient is free from self-harm. Background: There are three major groups of bipolar disorders. Bipolar I disorder: combination of major depressive, manic, or mixed episodes (symptoms of both manic and depression). Bipolar II disorder: combination of major depression and hypomania. Cyclothymic disorder: combination of hypomanic episodes intermixed with depressive episodes that do not fully satisfy the criteria of a major depressive episode. Bipolar disorder is a chronic, cycling condition, Bipolar disorder can result in severe functional impairment as manifested by isolation from family, friends, and coworkers; financial difficulties; and job loss. Causes/Risk factors: Chronic abnormalities of neurotransmission, Anxiety disorders, especially panic disorder and social phobia, Family history, Sleep disturbances. Diagnostic Criteria: At least on manic or mixed episode, with at least one major depressive episode Mania: elevated, grandiose, or restless mood, Exaggerated self-esteem, Inability to sleep, Pressured speech, Flight of ideas, Easy distractibility, Participation in increased number of activities, with more energy, Use of poor judgment in high-risk activities, sometimes with severe consequences. Major depressive disorder: depressed mood, Anhedonism, Unintentional weight change ( 5% or more per month), Change in sleep pattern, Agitation or psychomotor retardation, Fatigue, Worthlessness or excessive guilt, Difficulty thinking, concentrating, or making decisions, Hopelessness, helplessness, or suicidal ideation

normal newborn

Overview: Normal respiratory rate is 30 to 50 breaths/min; normal pulse is 120 to 140 beats/min (may increase to 220 beats/min when crying); normal BP is 60 to 80/40 to 50 mm Hg; axillary temperature less than 97.6 may be caused by prematurity, infection, or low environmental temperature.

cataracts

Overview: Opacity of lens that is usually caused by aging; indications include blurred vision and decreased visual acuity; treatment includes surgical removal of lens and capsule; nursing responsibilities include antibiotic and steroid ointment into eye immediately postop; eye covered w/ patch and protective shield; position on back in semi-fowler's position or on the un-operated side; observe and report any drainage on the eye pad Nursing Care: A cataract is a gradually developing opacity of the lens or lens capsule of the eye. Signs and Symptoms include painless, gradual blurring and loss of vision with progression, whitened pupil; appearance of halos around lights; blinding glare from headlights at night and glare and poor vision in bright sunlight. Treatment: early stages of cataract development aim to improve vision. Treatment includes glasses, contact lenses, strong bifocals, or magnifying lenses. Surgical treatment consists of extraction of the opaque lens and postoperative correction of vision deficits. Removal involves one of two techniques: intracapsular cataract extraction (IOCCE) and extracapsular cataract extraction (ECCE). In ICCE, the entire lens is removed, most commonly with a cryoprobe. However, this technique isn't widely used today. In ECCE, the patient's anterior capsule, cortex, and nucleus are removed, leaving the posterior capsule intact. ECCE represents the primary treatment for congenital and traumatic cataracts. The current trend is to perform the surgery as a 1-day procedure. When both eyes are affected, one eye is treated first, and the other several weeks or months following initial correction. Immediately after removal of the natural lens, many patients receive an intraocular lens implant. Nursing Care: Patient preparation involves telling the patient wear an eye patch after surgery to prevent traumatic injury and infection, have assistance when getting out of bed, sleep on the unaffected side to reduce intraocular pressure. Monitoring and Aftercare; notify the doctor if the patient has severe pain. Also, report if IOP has increased. Because of the change in the patient's depth perception, assist her with ambulation and observe other safety precautions. Make sure the patient wears the eye patch for 24 hours, except when instilling eyedrops as ordered, and have her wear an eye shield, especially when sleeping. Instruct the patient to continue wearing the shield at night or whenever she sleeps for several weeks, as ordered. Expected Outcomes includes patient understands how to administer eyedrops or ointments, patient contacts the doctor immediately in the case of sudden eye pain, red or watery eyes, photophobia, or sudden vision change, patient avoids activities that raise IOP, including heavy lifting, straining during defecation, and vigorous coughing and sneezing, patient avoids strenuous exercise for 6 to 10 weeks, patient wears dark glasses to relieve glare, patient understands that changes in his vision can present safety hazards if she wears eyeglasses and patient uses up-and-down head movements to judge distances in order to compensate for loss of depth perception, patient understands how to insert, remove, and care for contact lenses, if appropriate, or how to arrange to visit a doctor routinely for removal, cleaning, and reinsertion of extended-wear lenses. Patient understands when she should remove the eye patch and when to begin her eyedrops. Background: A cataract is a gradually developing opacity of the lens or lens capsule of the eye. Cataracts interfere with the transmission of light to the retina; light scatters and produces glare or abnormal presence of light in the visual field which decreases visual acuity. Cataracts are not limited to one eye, and are typically progressive in that they develop over a period of time. Pathophysiology: The nucleus and cortex of the lens enlarges with age. New fibers are formed in the cortical zones of the lens and old fibers in the nucleus become more compressed and dehydrated. Lens proteins become more insoluble, and concentrations of calcium, sodium, potassium, and phosphate increase. Extent of impairment depends on the size, density, and location in the lens: Nuclear- involves central opacity; has a substantial genetic component; associated with myopia; may be corrected by varying eyeglass prescriptions. Posterior subcapsular- involves front posterior capsule (small space between the vitreous and the iris); typically develops in younger people; impairs near vision; causes light sensitivity. Cortical- involves anterior (behind the cornea), posterior, or equatorial cortex; vision worse in very bright light. Diagnostic Test: cataract formation, Snellen chart- visual acuity test, Ophthalmoscopy- examines the cornea, lens, and retina into focus sequentially with plus and minus lenses, Slitlamp biomicroscopic examination- examines the ee with magnification of 10 to 40 times, and varying angles of light. Causes/ Risk Factors includes aging, cigarette smoking, high triglyceride levels in men, associated ocular conditions or injuries, or infectious processes, corticosteroids, or calcium and copper related factors that affect the papillary area of the lens, deficient nutrition, diabetes, obesity, sunlight and ionizing radiation. Complications includes retrobulbar Hemorrhage, rupture of the posterior capsule, acute bacterial or chronic endophthalmitis, toxic anterior segment syndrome, suture-related problems, malposition of the intraocular lens (IOL), and opacification of the posterior capsule

oxytocin

Overview: Oxytocin is used to stimulate an active labor pattern; nursing care includes administering with infusion pump, closely monitoring mother and baby; if contractions occur less than 2 min apart, , last longer than 60 to 90s, or if there is significant change in fetal heart rate, stop infusion and turn patient to left side. Nursing Care: Oxytocin is a naturally occurring hormone-released by posterior pituitary; a synthetic form is used to stimulate or augment uterine contractions during labor. Therapeutic Class: oxytocic, synthetic hormone. Action: acts on uterine myofibrils to contract. Indications: to induce or augment labor, in patients with pregnancy-induced hypertension, prolonged gestation, maternal diabetes, Rh sensitization, premature or prolonged rupture of membranes, incomplete or inevitable abortion, to control bleeding and enhance uterine contractions after the placenta is delivered in, in rare cases in nonstress contraction test (after 31 weeks' gestations), if nipple stimulation fails to produce contractions. Nursing Implications/Care: administered intravenously with infusion pump, strat primary IV line, Insert tubing of administration set through infusion pump, set drip rate to prescribed dosage and infusion rate (Infusion rate: 0.5 to 1.0 mL/minute) (Labor-starting dosage: 10 units oxytocin in 100ml isotonic solution) (Maximum dosage: 20 to 40mU); Administer oxytocin by piggyback method in IV line (always given as piggyback, so that if hyperstimulation occurs, the drug can be stopped immediately and IV fluid can continue; also, if necessary, drug can be restarted easily to achieve goals; Using external electronic fetal monitoring methods, monitor for fetal heart rate deceleration or fetal distress and stop infusion immediately if these occur; Be prepared to monitor uterine contractions, as drug acts immediately, regulate infusion rate to achieve contractions that mimic natural labor; Increase oxytocin dose as orders, (do not increase more than 1 to 2mU/minute once every 15 to 60 minutes, before each increase, assess contraction, maternal vital signs, and fetal heart rhythm and rate, verify uterine relaxation between contractions by external or internal fetal monitor.); Monitor maternal heart rate (if hypertension occurs, stop infusion and notify doctor,); Assist with comfort measure, such as repositioning the patient on her other side, as needed; Review infusion rate to prevent uterine hyperstimulation, (if hyperstimulation occurs, discontinue oxytocin and administer oxygen, increase uterine blood flow by changing patient's position and increasing infusion rate of primary IV line, resume oxytocin infusion, per institution policy, after hyperstimulation is resolved); Monitor intake and output and watch for signs of water intoxication; limit IV fluids o 150mL/h. Prepare patient for childbirth; Encourage patient to use breathing techniques as she would in natural labor. Expected Outcomes: Contractions begins and follow pattern of natural labor, patients suffers no adverse effects from drug, fetus suffers no distress, fetus is delivered successfully. Background: Action increases uterine contraction by increasing circulation of free intracellular calcium. Oxytocin receptors increase during pregnancy, especially in third trimester and in latent phase of labor due to influence of estrogen, progesterone, and prostaglandin. With increased number of receptors, amount of oxytocin needed for labor decreases. Continuous infusion of oxytocin raises circulating blood level slowly over 20 to 30 minutes. Half-life is only 1 to 5 minutes, so stopping infusion results in a rapid decrease in effect. Adverse Effects: nausea, vomiting, cardiac arrhythmias, uterine hypertonicity, titanic contractions, uterine rupture, severe water intoxication, and fetal bradycardia.

Colostomy

Overview: Pouch should be measured accurately to fit well; when changing the pouch, the client should assess the color, moistness, presence of edema, tenderness, skin irritation; cleanse around stoma with water and soap; dry well; apply skin barrier and pouch; client education about diet; immediately postoperatively low residue diet for several weeks to allow for healing, then add foods as tolerated, avoid gas forming foods; utilize wound ostomy continence nurse (WOCN) in client care

PreOp Care

Overview: Preoperative checklist includes ensuring that informed consent is signed and attached to chart, all lab tests, chest X-ray, EKG has been completed, performing skin care and bowel prep, NPO, administering preoperative medications (sedation, antibiotics), removing dentures, jewelry, nail polish.

schizophrenia

Overview: Schizophrenia is a chronic illness resulting in psychotic behavior; indications include autism (withdrawal from relationships and the world), inappropriate or no display of feelings; hypochondriasis and depersonalization; hallucinations (false sensory perceptions in the absence of external stimulus), delusions (persistent false beliefs), short attention span, regression, inability to meet basic survival needs; nursing care includes maintaining client safety (protecting from altered thought processes and inappropriate behavior), administering antipsychotic medication as ordered, decreased risk for sensory stimuli, removing from areas of tension, validating reality, do not argue, recognizing that client is experiencing hallucinations, responding to feeling or tone of hallucination or delusion. Nursing Care: Schizophrenia is a severe psychiatric disorder marked by withdrawal from reality, illogical thinking, and delusions and hallucinations. Signs and Symptoms include positive symptoms, delusions, hallucinations, negative symptoms, apathy, lack of motivation, blunted affect, poverty of speech, anhedonia, and asociality. Disorganized symptoms: thought disorders and bizarre behavior (agitation, inappropriate behavior). Treatment includes drug therapy like typical antipsychotic, such as chlorpromazine (Thorazine) and atypical antipsychotics, such as clozapine (Clozaril), olanzapine (Zyprexa), and risperdone (Risperdal). Action: blocking postsynaptic dopamine receptors. Adverse effects (sometimes less with atypical agents): sedation, hypotension, extrapyramidal symptoms, anticholinergic effects, neuroleptic malignant syndrome. Other Treatments includes conjunctive psychotherapy, rehabilitation, & electroconvulsive therapy. Nursing Care includes maintaining a safe environment; If the patient expresses suicidal thoughts, institute suicidal precautions; Establish trust. Do not touch the patient without first informing patient exactly what the nurse is going to do. If necessary, postpone procedures until less suspicious or agitated. Use an accepting, consistent approach, and use clear, unambiguous language. Assess the patient's ability to carry out activities of daily living. Meet needs, but do for patient only what patient cannot do for self. Monitor the patient's nutritional status. Reward positive behavior. Encourage the patient to engage in meaningful interpersonal relationships, and help him learn social skills. Engage the patient in reality-oriented activities. Administer prescribed medications. Monitor for adverse effects and report these promptly. Encourage the patient to comply with the medication regimen to prevent relapse. Encourage family members to participate in support groups that help family members cope with living with a loved one who has schizophrenia. Expected Outcomes includes patient is free from harm, patient cares for self, patient maintains adequate nutritional intake, patient interacts with others, patient establishes contact with reality, patient complies with drug regimen, family participates in support groups Background: Schizophrenia is a severe psychiatric disorder marked by withdrawal from reality, illogical thinking, and delusions and hallucinations. Pathophysiology: There are five types of schizophrenia: Paranoid type: typified by persecutory or grandiose delusions, hallucinations, and sometimes excessive religiosity or hostile and aggressive behavior. Disorganized type: typified by grossly inappropriate or flat affect, incoherence, and disorganized behavior. Catatonic type: typified by psychomotor disturbance, with either motionless or excessive motor activity. Undifferentiated type: typified by schizophrenic symptoms of other types. Residual type: typified by social withdrawal and looseness of associations. Diagnosis is usually made in late adolescence or early adulthood. Generally, two clinical patterns develop: psychosis continues, and patient never completely recovers; however, symptoms may vary in severity over time, episodes of psychotic symptoms alternate with episodes of relatively complete recovery. Causes/Risk Factors: first-degree relatives with schizophrenia, comorbid disorders, substance abuse and depression

sputum specimen

Overview: Sputum obtained to determine pathogenic organisms and to identify malignant cells; early morningspecimen best; encourage client to clear nose and throat and rinse mouth, instruct patient to deep breathe, cough, and expectorate specimen into sterile container; deliver specimen to the lab within 2 hours.

medication administration

Overview: Standards of safe medication administration include the right medication, the right dose, the right route, the right time, and the right documentation. Nursing Care: Purpose is to prevent medication errors. Implementation: Before administering medication, review patient's medical history for known allergies or other problems; Make sure client's chart clearly displays known allergies; Stay with medication cart when delivering drugs to patient's room; never leave without locking cart and returning to medication room or usual storage place; Assess patient's physiological condition before administering drugs; If oral medication is administered: don't open individually prepared doses until at patient's bedside and patient's identity is confirmed, stay with patient until he swallows the medication to verify drugs are taken correctly and never leave medication doses at patient's bedside unless specifically ordered to do so. Administer only medications you've prepared personally or the pharmacist has prepared. After receiving written medication order, transcribe onto working document approved by health care facility, taking follow precautions: Right drug- use 3 check systems when reaching for container or unit dose med. Check immediately before pouring or opening medication container. Check when replacing container to drawer. Check before giving unit dose to patient. Always compare name of ordered drug with name printed on container or label. Take time when comparing drug names (avoid administering drugs with similar-sounding/similar-looking names). For medication wrapped in single doses, check name when removing from drawer; and when unwrapping and giving to patient. Always mention drug name and reason for administration before actually giving it to patient. Check patient's reaction to drug during administration. Follow up on any commentary made regarding the drug (i.e., color, amount) to ensure no mistakes. Right dose-know how and when to perform appropriate dose calculations, think about whether a dose seems right, given patient's diagnosis and drug involved, be especially careful when calculating with decimal points, place zero in front of decimal point without other number in front of it to minimize confusion, never break unscored tablet to prepare calculated dose; instead, ask pharmacist for accurately measured dose, double check any calculation that requires more than one dosage units or a smaller fraction of dosage unit, any calculation you're unsure of, and when dosage calculation involves children's medications, or drugs with narrow safety margins. Never take it upon yourself to alter drug dosage specified in prescriber's order and consult with doctor and obtain a new order. Right patient- never assume patient in labeled bed is patient named on label. Right time- administer at time that appropriately maintains level of drug in patient's bloodstream, space delivery evenly around the clock, and have "set times" for routine medication administration. Right route- make sure ordered form of drug is appropriate for intended route, consider whether amount ordered is appropriate for route, remember that route affects absorption for route, if preparing needle for injection, double check angles of insertion. Perform right documentation- document drugs immediately after administration and record observations of patients positive and negative responses to medication. Expected outcomes include patient receives correct drug and dosage of medication via correct route. Patient receives medication at correct time or within 30 minutes of scheduled dose. Background: Standards of safe medication administration involve 5 rights: right drug, dose, patient, time, and route. Right documentation is an additional right. Patient teaching: teaching patient about her diagnosis and purpose of drug therapy, tell patient for how long she will be taking prescribed med, provide patient with drug information in writing, ask pt to report any known allergies, and confirm allergies on chart, ask pt if she takes herbal remedies and other nutritional support, tell pt what kinds of drug-related problems warrant a call to physician, urge pt to report anything about her drug therapy that concerns or worries her, discuss the importance of taking medication at the correct time as ordered, and stress the importance of taking full range of ABX therapy. Special considerations include when administering an oral drug urge pt to drink a full glass of water it helps moves med out of esophagus and into stomach and dilutes drug reducing chance of gastric irritation. Unexpected outcomes: during administration of 2 yellow pills, pt reports that she usually receives one pink pill, stop administration, recheck order, if order is correct explain differences and if pt vomits shortly after med is administered observe vomit look for pills of fragments and report findings to physician.

Total Hip Arthroplasty

Overview: Surgical replacement of the head of the femur and acetabula w/ artificial joint; used for diseased femoral joint or fracture of the head of the femur or femoral neck; complications following total hip replacement include dislocation of hip prosthesis, excessive wound drainage, thromboembolism, infection; nursing responsibilities: positioning leg in abduction using abduction splints or wedge or 2-3 pillow b/w the legs, hip should not be flexed more than 45-60 degrees, HOB should not be elevated more than 45 degrees, turn from back to unaffected side, use a fracture bedpan by having the client flex the unoperative hip while using a trapeze to lift the pelvis or have the patient ambulate to the bedroom or use a bedside commode, use of over bed trapeze to reposition in bed, incision care, prevent complications of immobility by early ambulation; use semi-reclining or elevated toilet seats and semi-recliner wheelchairs to prevent hip joint flexion. Nursing Care: Purpose: hip replacement is now a common treatment for osteoarthritis or rheumatoid arthritis, congenital malformations, and extensive joint trauma to restore mobility and stability, relieve pain, and increase a patient's independence and self-worth. Nursing Care includes: explain to patient why preop test are necessary. Suggest that patient donate own blood to avoid the risks involved in blood transfusions, discuss postop recover w/ the patient and family. Be sure to mention that they should not expect immediate pain relief. However, reassure patient that analgesics are available. Postop, keep patient on bed rest as prescribed, assess the level of pain, and provide analgesics as ordered. If using narcotics continuously assess patient to toxicity or over sedation. Monitor for complications of hip replacement surgery, particularly hypovolemic shock from blood loss during surgery, fat emboli or venous thromboembolia, all potentially fatal. Report any complications promptly. Inspect the incision for signs of infection and change the dressing as needed, using strict sterile technique. Prevent pressure ulcers, encourage coughing and deep breathing to prevent atelectasis and pneumonia, and stress the need for adequate fluid intake. Begin exercising the affected joint, as ordered, perhaps even on the day of surgery. Instruct patient to keep her hips abducted, not to cross legs, and not to bend at the waist so as not to dislocate the prostheses. Position legs in abduction, using abduction splints. In addition, hips should not be flexed more than 45-60 degrees so the bed should not be elevated more than 45 degrees. A trapeze can be used to lift the pelvis over a special bed pan. Go over homecare instructions w/ patient and family, including proper use of a walker, cane, or crutches. Caution patient to report any signs of infection, even several months after surgery. Expected Outcomes: patient enjoys newfound mobility and pain relief 6wks after hip replacement surgery; patient is compliant w/ instructions on avoiding infections and use of supportive devices (walkers) as no adverse sequel are reported Background: Description: Based on a patient's history and physical status, surgeons pick the best hip prosthesis design. However, common to all prosthesis is a metal component that fits into the femur w/ a ball at the end that, in turn, fits into a plastic acetabular socket that replaces the hip joint on the pelvis; In order for the prosthesis to be properly fitted to the joint, the acetabular socket is formed to accepatient it. After the top of the femur is removed, the center of the femur is drilled so that the metal component of the prosthesis fits inside; While hip replacement surgery is performed under general anesthesia w/ an incision to expose the operative field, dislocation of the prosthesis postop can be corrected w/ closed reduction. However, the hip must be stabilized emergently so that nerve damage does not occur. Complications includes surgery should be scheduled before serious debilitation occurs as a result of contracture or atrophied muscles at the joint following surgery, complications may include: Dislocation of the prosthesis, DVT w/ or w/out Pulmonary embolism, Nerve palsy, Infection of the bone (osteomyelitis) or wound site, heterotrophic ossification.

BPH

Overview: Surgical replacement of the head of the femur and acetabula w/ artificial joint; used for diseased femoral joint or fracture of the head of the femur or femoral neck; complications following total hip replacement include dislocation of hip prosthesis, excessive wound drainage, thromboembolism, infection; nursing responsibilities: positioning leg in abduction using abduction splints or wedge or 2-3 pillow b/w the legs, hip should not be flexed more than 45-60 degrees, HOB should not be elevated more than 45 degrees, turn from back to unaffected side, use a fracture bedpan by having the client flex the unoperative hip while using a trapeze to lift the pelvis or have the pt ambulate to the bedroom or use a bedside commode, use of over bed trapeze to reposition in bed, incision care, prevent complications of immobility by early ambulation; use semi-reclining or elevated toilet seats and semi-recliner wheelchairs to prevent hip joint flexion. Nursing Care: Purpose: hip replacement is now a common treatment for osteoarthritis or rheumatoid arthritis, congenital malformations, and extensive joint trauma to restore mobility and stability, relieve pain, and increase a pt's independence and self-worth. Nursing Care: explain to pt why preop test are necessary. Suggest that pt donate own blood to avoid the risks involved in blood transfusions; discuss postop recover w/ the pt and family. Be sure to mention that they should not expect immediate pain relief. However, reassure pt that analgesics are available. Postop, keep pt on bed rest as prescribed, assess the level of pain, and provide analgesics as ordered. If using narcotics continuously assess pt to toxicity or over sedation. Monitor for complications of hip replacement surgery, particularly hypovolemic shock from blood loss during surgery, fat emboli or venous thromboembolia, all potentially fatal. Report any complications promptly. Inspect the incision for signs of infection and change the dressing as needed, using strict sterile technique. Prevent pressure ulcers, encourage coughing and deep breathing to prevent atelectasis and pneumonia, and stress the need for adequate fluid intake. Begin exercising the affected joint, as ordered, perhaps even on the day of surgery. Instruct pt to keep her hips abducted, not to cross legs, and not to bend at the waist so as not to dislocate the prostheses. Position legs in abduction, using abduction splints. In addition, hips should not be flexed more than 45-60 degrees so the bed should not be elevated more than 45 degrees. A trapeze can be used to lift the pelvis over a special bed pan. Go over homecare instructions w/ pt and family, including proper use of a walker, cane, or crutches. Caution pt to report any signs of infection, even several months after surgery. Expected Outcomes: pt enjoys newfound mobility and pain relief 6wks after hip replacement surgery; pt is compliant w/ instructions on avoiding infections and use of supportive devices (walkers) as no adverse sequelae are reported Background: Description: Based on a pt's history and physical status, surgeons pick the best hip prosthesis design. However, common to all prosthesis is a metal component that fits into the femur w/ a ball at the end that, in turn, fits into a plastic acetabular socket that replaces the hip joint on the pelvis. In order for the prosthesis to be properly fitted to the joint, the acetabular socket is formed to accept it. After the top of the femur is removed, the center of the femur is drilled so that the metal component of the prosthesis fits inside. While hip replacement surgery is performed under general anesthesia w/ an incision to expose the operative field, dislocation of the prosthesis postop can be corrected w/ closed reduction. However, the hip must be stabilized emergently so that nerve damage does not occur. Complications: Surgery should be scheduled before serious debilitation occurs as a result of contracture or atrophied muscles at the joint following surgery, complications may include: Dislocation of the prosthesis, DVT w/ or w/out Pulmonary embolism, Nerve palsy, Infection of the bone (osteomyelitis) or wound site, heterotrophic ossification

AIDs

Overview: Syndrome distinguished by serious deficits in cellular immune function; causes opportunistic infections such as Pneumocystis jiroveci pneumonia, Candida albicans stomatitis and esophagitis, cytomegalovirus (CMV), Kaposi's sarcoma; nursing care includes providing restful environment, assisting w/ personal care, implementing infection control precautions, handwashing when entering and leaving room, monitoring for oral infections, assessing breath sounds, monitoring weight, encouraging nutritional supplements, assessing hydration , encouraging client to express feelings Nursing Care: Marked by progressive weakening of cell-mediated immunity, AIDS increases susceptibility to opportunistic infections and unusual cancers. Signs and Symptoms: After initial exposure, an infected person may have no signs or symptoms- or may have a flulike illness (seroconversion illness) and then remain asymptomatic for years. As syndrome progresses, potential signs and symptoms may include: Neurologic symptoms caused by HIV encephalopathy, symptoms of an opportunistic infection or disease, weakened immune defense is eventual symptom as a result of repeated opportunistic infections. Other manifestations of HIV and AIDS: respiratory symptoms (shortness of breath, dyspnea, cough, chest pain, fever), gastrointestinal symptoms (loss of appetite, nausea, vomiting, oral and esophageal candidiasis, chronic diarrhea) and depression. Treatment: While no cure exists, signs and symptoms are managed with treatment. Primary therapy for HIv infection includes three different types of antiretroviral drugs: protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors. Other drug therapies include: immunomodulatory drugs to boost the weakened immune system and antiinfective and antineoplastic agents to combat opportunistic infections and associated cancers. Nursing Care: Monitor patient for fever, noting patterns, assess for tender, swollen lymph nodes, checking laboratory values regularly, watch for signs and symptoms, encourage daily oral rinsing with normal saline or bicarbonate solution, offer coping support, and evaluate the patient, and educate about the disease. Expected Outcomes (following counseling): Patient states the early signs and symptoms of infection, patient explains how HIV is transmitted, patient describes the limitations AIDS may impose on his lifestyle, and patient maintains an optimal nutritional status. Background: Human immunodeficiency virus (HIV) belongs to a group of viruses known as retroviruses, and is the causative agent of AIDS. The infection integrates intelse into a person's immune system. HIV can be classified as HIV-1 (more predominant) and HIV-2, which is similar in spectrum, but typically characterized as having slower disease progression, requires specific testing, and is most commonly found in western Africa. Pathophysiology: HIV carries genetic material to ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). HIV-1 is made up of a viral core containing RNA, and is encased by an envelope of protruding glycoproteins (GP), which are essential for binding the virus to CD4+ T lymphocyte (necessary for normal immune function), macrophages, and dendritic cells. Replication of HIV occurs in eight steps. Attachment: Virus enters the bloodstream and attaches to the surface of a CD4+ T-cell, but requires attachment to other surface molecules (GP120 and GP41 envelope glycoproteins) to create infection. Virus internalizes once viral envelope peptides fuse to the CD4+ T-cell membrane allowing the strands of RNA and other contents of the viral core to enter the host cell. Reverse transcriptase enzyme influences the change in HIV's single-stranded RNA into a double-stranded DNA. A copy of the viral RNA is made, and then a mirror-image copy. Integration occurs when the DNA enters the nucleus of the CD4+ T-cell, followed by the insertion into the cell's DNA (with help from enzyme integrase). The double-stranded DNA forms a single-stranded messenger RNA (mRNA) by activating the T-cell and including host cell factors (instructions) in a process called transcription. Ribosomal RNA (rRNA) translates the instructions from mRNA to create a chain of proteins and enzymes called a polyprotein, which are necessary for the next stages involving the construction of new viruses. Cleavage occurs, whereby the polyprotein chain is cut by protease enzyme. Resulting individual proteins will make up the new viruses. Proteins and viral RNA are assembled into new HIV viruses and released from the CD4+ T-cell. As a result of HIV replication, the CD4+ T-cell is killed, and the copies of HIV virus are released into the bloodstream where they (virions) invade other CD4+ T-cells for the process to reoccur and permit the infection to progress. CD4+ T-cells are replaced and viral particles are destroyed, and the process of destruction and restorations occurs over several years while the patient remains relatively asymptomatic until the number of CD4+ T-cells gradually decrease, and the number of viruses in the bloodstream increase. Diagnostic Tests: A thorough health history indicates the need for HIV screening. Several screening tests are used for diagnosis, while other tests are used to assess disease stage and disease progression. Some screening tests may include: HIv antibody tests including EIA (enzyme immunoassay [can be blood or saliva test]), and Western blot used to confirm EIA, Viral load, measures HIV RNA in the plasma, and CD4/CD8 ratio, assesses markers found on lymphocytes indicating severity of impaired immune system. Causes/Risk Factors: Transmitted through body fluids contain HIV or infected CD4+ T lymphocytes. HIV is harbored with lymphocytes, a type of white blood cell; exposure to infected blood results in a significant risk of infection (i.e., sharing infected injection drug use equipment; blood transfusions before 1985). Seminal fluid and vaginal fluid secretions are involved in sexual transmission. Inflammation and breaks in the skin and mucosa increases the probability of exposure to the virus. Mother-to-child transmission may occur in utero, or through breast-feeding, but is thought to be most common after exposure during delivery. Health care providers are at risk of nosocomial infection from transmission through bloodborne pathogens, and pathogens from moist body substances. Complications: Opportunistic infections impaired breathing or respiratory failure, wasting syndrome and fluid and electrolyte imbalance, and adverse reaction to medications.

Lithium

Overview: Used to control manic episodes of bipolar psychosis; nursing care includes monitoring blood levels 2 to 3 times a week when started monthywhile on maintenance, need fluid inake to 2,500 to 3,999 mL/day and adequate salt intake, side effects include dizziness, hand tremors, impaired vision. Nursing Care: Lithium is a well-known mood-stabilizing drug. Therapeutic Class Antimanic Drug. Action: Stabilizes bipolar disorder by decreasing degree and frequency of manic episodes or eliminating them altogether. Indication: Prevention and relief of manic episodes of bipolar disorder. Nursing Implications/Care: Administer lithium as or ordered, and encourage the patient to comply with the medication regimen. Advise the patient to take lithium with food or after meals to avoid stomach upset; Because lithium has a narrow therapeutic margin, it is necessary to monitor blood levels closely. Make sure that blood levels are checked 8 to 12 hours after the first dose, two or three times a week for the first month, and then weekly to monthly. Lithium overdose may be fatal. Target blood level 1-1.5 mEq/L; Inform the patient the importance of continuing to take this medication even if he does not think he needs it; Instruct the patient to maintain a fluid intake of 2500 to 3000 mL/day to promote adequate lithium excretion; Tell the patient not to drive until drowsiness, fatigue, or blurred vision has cleared; and Monitor for all adverse effects, document the, and report toxic effects to the prescribing physician. Inform the patient and family about these effects and encourage him to report such problems to the prescribing physician. Expected Outcomes patient takes lithium as prescribed, patient has blood levels checked as ordered, patient maintains an adequate fluid intake, patient verbalized understanding of possible adverse effects and controls them successfully, patient resumes driving when no longer affected by adverse effects such as drowsiness. Background: Lithium is a well-known mood-stabilizing drag. Action: Precise action unknown, enters nerve cells, where it is believed to have effects on several neurotransmitters, onset of action; usually 5 to 7 days; may be as long as 2 weeks. Adverse Effects: excessive thirst, unpleasance metallic-like taste, frequency of urination, fine head tremor, drowsiness, mild diarrhea, weight gain and elevated thyroid-stimulating hormone. Interactions: Dietary Sodium (lithium is a salt); high sodium intake decreased levels; low sodium intake may lead to toxicity; Alcohol: may increase serum lithium; Caffeine: increased lithium, increased tremor; Angiotension-converting enzyme inhibitors; increased serum lithium; Acetazolamide: increased excretion of lithium, decreasing drug levels; Carbamazepine: increased neurotoxicity, despite normal dosage and serum levels.; Fluoxetine: increased serum lithium; Haloperidol: increased neurotoxicity, despite normal dosage and serum levels; Loop diuretics: increased serum lithium; and Osmotic diuretics: increased excretion of lithium, decreasing levels; Thiazide diuretics: promote sodium and potassium excretion; increased lithium levels; may cause cardiotoxicity and neurotoxicity; Methyldopa: increased neurotoxicity without increasing serum levels; Nonsteroidal anti-inflammatory drugs: decrease lithium clearance; Tricyclic antidepressants (TCAs): increased tremor; increased pharmacologic effects of TCAs

TOF

Overview: cyanotic heart defect (poorly oxygenated venous blood enters systemic circulation, four defects include ventricular septal defect, pulmonic stenosis, overriding aorta, right ventricular hypertrophy) acquired due to increased pressure w/I right ventricle; indications include cyanosis at birth, mild cyanosis that progresses during 1st year of life, heart murmur, poor weight gain, poor feeding habits, clubbing of fingers, delayed physical growth & development, child squats or assumes knee-to-chest position; treatment includes surgical repair of defects. Instruct family about how to care for child at home, administer dig, activity restrictions, nutrition, and wound care.

MI

Overview: formation of localized necrotic areas within the myocardium, usually following the sudden occlusion of a coronary artery and the abrupt decrease of blood and oxygen to the heart muscle; s/s include severe crushing chest pain, may radiate to arms, jaw, neck, and back, dyspnea, nausea, vomiting, gastric discomfort, indigestion; apprehension, restlessness, fear of death; nursing care includes providing thrombolytic therapy, relieving family's anxiety, bedrest, monitoring vital signs and intake and output, instructing about modification of lifestyle: stop smoking, reduce stress, regular physical activity Nursing Care: Myocardial infarction (MI) is an occlusion of a artery that leads to oxygen deprivation, myocardial ischemia, and eventual necrosis. Signs and Symptoms includes severe, persistent chest pain, unrelieved by rest or nitroglycerin, may be described as crushing or squeezing, usually substernal, pain may radiate to the left arm, jaw, neck, or shoulder blades, feeling of impending doom; anxiety, fatigue, nausea and vomiting, SOB, cool extremities, perspiration, hypotension or hypertension and palpable precordial pulse. Treatment: Primary Treatment includes thrombolytic therapy, should be started within 3 hours of the onset of symptoms, if possible; involves streptokinase, alteplase, anistreplase, or reteplase; percutaneous transluminal coronary angioplasty (PTCA). Other Treatments includes Oxygen delivery, Nitroglycerin (to relieve chest pain), Morphine (for analgesia), Aspirin (to inhibit platelet aggregation), I.V. heparin (to increase the chances of patency in the affected coronary artery). Nursing Care includes monitoring and recording electrocardiogram (ECG) readings, blood pressure, temperature, and heart and breath sounds. Frequently monitor the ECG to detect heart rate changes or arrhythmias. Assess pain and administer analgesics, as ordered. Record the severity and duration of pain. Avoid giving I.M. injections because absorption from the muscle is unpredictable. Check the patient's blood pressure after giving nitroglycerin, especially after the first dose. Watch for signs and symptoms of fluid retention (crackles, cough, tachypnea, and edema), which may indicate impending heart failure. Carefully monitor daily weight, intake and output, respirations, and serum enzyme levels. Assist with range-of-motion exercises and ambulation, as allowed. Promote comfort, rest, and emotional well-being. Involve patient's family to participate in care as much as possible. Evaluate the patient. Expected Outcomes Patient has no pain related to the myocardial infarction. Patient has normal ECG, heart sounds, and cardiac rhythm. Patient has no signs of fluid retention. Patient and family verbalize understanding of patient's condition. Background: Myocardial Infarction (MI) is an occlusion of a artery that leads to oxygen deprivation, myocardial ischemia, and eventual necrosis. The heart pumps blood to the boy's tissues, delivering oxygen and other nutrients. A critical balance exists between myocardial oxygen supply and demand; if oxygen demand increases, so must the oxygen supply. Rhythmic contraction of the heart's muscular wall pumps the blood through the vessels of the circulatory system. Pathophysiology: In MI, blood supply to the myocardium is interrupted. The scope of infarct depends on the coronary artery affected and the extent of collateral circulation. Gross tissue changes are not seen for hours after onset of an acute myocardial infarction, but the ischemic area stops functioning within minutes, and irreversible cell damage occurs in less than 1 hour. Reperfusion is reestablishment of blood flow through use of thrombolytic therapy or revascularization procedures. Reperfusion within 15 to 20 minutes can halt necrosis. Causes/Risk Factors includes atherosclerosis, vasospasm of a coronary artery, decreased oxygen supply or increased oxygen demand. Diagnostic Tests includes ECG, classic ECG changes: T-wave inversion due to altered repolarization; ST-segment elevation because of muscle injury; later development of Q waves occur due to the absence of depolarization current from the necrotic tissue and opposing currents from other parts of the heart), echocardiogram, serum markers of acute MI: creatinine kinase and its isoenzymes, myoglobin, troponin. Complications include acute pulmonary edema, heart failure, cardiogenic shock, dysrhythmias and cardiac arrest, pericardial effusion and cardiac tamponade and myocardial rupture

TB

Overview: infectious disease of insidious onset that primarily affects the lungs; signs and symptoms include fatigue, lethargy, anorexia, weight loss, low-grade fever, and productive cough of mucopurulent sputum; diagnose with Mantoux test, sputum positive for acid-fast bacilli and CXR; treatment includes chemo, 9 mth regimen of INH combined with streptomycin, ethambutol, rifampin, or pyrazinamide; instruct client to cover mouth and nose with tissue when coughing, sneezing, laughing, and burn tissues, good handwahsing, good nutrition, must take full course of medications, encourage to return to clinic for sputum smears Nursing care: tB is spread through airborne transmission, follow precautions; place patient in a private room with monitored negative air pressure; perform 6-12 air changes per hour; keep door closed and patient in room; transport patient out of room only when necessary and with surgical mask; appropriate discharge of air outside or monitored filtration if air is re-circulated; keep door closed and patient in room; use respiratory protection when entering room; consult the CDC guidelines; become familiar with hospital infection control practices, and assist in helping facilities maintain up to date isolation practices. Instruct patient how to keep airways clear (hydrate, posture), stress importance of adhering to drug regimen, explain multidrug treatment so that patient understands how to follow protocol, teach proper hygiene so opportunities for infections are minimized, address nutritional problems associated with TB like anorexia, malnutrition, and wt loss; watch for SE of meds, monitor VS for indication of drug resistance or spread of TB to other body parts, schedule screening visits with people who have come in contact with the patient, coordinate referral to public health system to ensure uninterrupted treatment. Outcomes expected: pt maintains clear airways, understands disease and dangers of drug resistance and adhere to regimen, survives TB and does not infect others, pts lungs sustain minimal damage as a result of attentive disease management Background: Infect lungs may spread to kidneys, lymph nodes, meninges, and bones. Vaccine results in + skin test, correct technique for needle insertion, bevel upward; skin reaction form of welt; commercially prepared gauge interpreting extent of reaction; TB is caused by the bacterium, a 3rd of world test + for TB, leading cause of death in people who are HIV positive, drug resistant forms of TB now make the disease more difficult to control than in early 20th century. Patho: pt contracts TB infection by inhaling airborne sputum droplets that contain M. tuberculosis, phagocytes and lymphocytes attack and surround bacilli, forming masses; inflammation caused by immune reaction provokes bronchopneumonia; dormant bacilli remain in the interior or granulomas which become necrotic and form scar tissue; if immune system is weaken could cause repetitive process of infection, healing, & scarring. Causes and risk factors include inhalation of infected sputum and living in crowded and poorly ventilated environments (prisons/shelters), compromised immune system (HIV), alcoholism or malnutrition, IV drug use, working with a TB pt, and immigration from a country with a high prevalence of TB; Dx test include comprehensive history, physical exam, TB skin test, CXR, acid-fast bacillus smear of sputum, and sputum culture. Complications include spread of TB, multidrug resistance, adverse SE to meds include upset stomach, diminished effectiveness of other meds, drug-induced hepatitis,hearing loss, rash, visual problems, and kidney damage; massive pulmonary tissue damage, pneumothorax, hemorrhage, pleural effusion, pneumonia, and death

vegetarian diets

Overview: vegan diet includes fruits, vegetables, nuts, beans, and seeds, excludes all sources of animal protein, fortified foods, and nutritional supplements of animal origin; lactovegetarian diet includes all foods on vegan diet along w/ milk, cheese, yogurt, and other milk products as the only sources of animal protein; ovovegetarian diet includes all foods on vegan diet along with milk, cheese, yogurt, other milk products, and eggs as only sources of animal protein.

pain management

Pain management Overview: pain is often referred to as the 5th VS and is defined as "whatever the person says it is, and it exists whenever the person says it does; can be acute / chronic; culture and past experiences w/ pain are major factors influencing pain experiences; indications include increased blood pressure and pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprenhension and irritability, grimacing, guarding, verbalizations of pain; nursing interventions include establish a therapeutic relationship, establish a 24-h pain profile, teach pt about pain and its relief, reduce anxiety and fears, provide comfort measures, administer pain meds, refer for alternative methods of pain relief; with regard to pain meds, use preventive approach, which states that if pain is expected to occur throughout a 24h period a regular schedule is better than as needed, usually takes a smaller dose to alleviate mild pain or prevent occurrence of pain.

Mantoux test

Tubercle bacillus extract, purified protein derivative (PPD) given intradermally in the forearm; read 48- 72hrs; 10 mm induration (hard area under skin) is + reaction; if immunocompromised, greater than 5mm induration is + reaction; indicates exposure to TB or presence of inactive (dormant) disease. The Mantoux test determines whether a person has been infected w/ TB bacillus. Nursing Care: General procedure includes using intermediate-strength PPD in a tuberculin syringe with a half-inch 26 or 27-gauge needle; insert needle (bevel up) into the intradermal layer of the inner aspect of the forearm, 4" below the elbow; inject 0.1 mL of the PPD, creating a wheal or bleb; record site, antigen name, strength, lot number, date and time of the test; wait 48-72hrs to read test results. A reaction occurs when there is both induration and erythema present; inspect area and lightly palpate across injection site from normal area of skin to the margins of the induration; and measure the induration in mm at its widest part. Background: Interpretation of Results: An induration of 0-4mm is considered not significant. An induration of 5 mm or greater may be significant in people who may be at risk, including: Patients who are HIV postive, Pts who have risk HIV risk factors and are of unknown HIV status, Pts who are in close contact with someone with active TB, Pts who have chest x-ray results consistent with TB), An induration of 10 mm or greater is usually considered significant in people that have normal or mildly impaired immunity. A significant reaction indicates past exposure to M. tuberculosis or vaccination with bacilli Calmette-Guerin (BCG) vaccine, A significant reaction does not necessarily mean that active disease is present in the body. More than 90% of pts who are tuberculin-significant reactors do not develop clinical TB; however, all significant reactors are candidates for active TB. A non-significant result does not exclude TB infection or disease; patients who are immunosuppressed cannot develop an immune response that is adequate to produce a positive skin test.

ultrasound

Ultrasound Overview: Transducer rubbed over the pelvic region and abdomen transmits sound waves that show the fetal image on screen; done as early as 5 weeks to confirm pregnancy and gestational age; client must drink fluid prior to test to have a full bladder to assist in clarity of image. Nursing Care: Ultrasonography is a noninvasive, nonradiographic monitoring method. Purpose: confirms pregnancy, verifies due date and correlates it with fetal size, allows visualization of fetus, evaluates condition of fetus through observation of activity, breathing movements, amniotic fluid volume, rules out pregnancy in suspected cases of false-positive pregnancy test, determines cause of spotting or bleeding early in pregnancy, locates intrauterine device (IUD) that was in place at time of conception, locates fetus before amniocentesis and during chorionic villi sampling. Diagnoses presence of multiple gestation, determines if abnormally rapid uterine growth is due to excessive amniotic fluid ,determines condition of placenta, verifies presentation and fetal or cord position before delivery. Nursing Care: Have patient drink 1 quart (1 liter) of fluid 1 hour before test and instruct her not to void; full bladder serves as landmark Background: Description: Performed with transabdominal or transvaginal handheld transducer. Captures real-time moving or still image of fetus within the uterus, technique has no adverse side effects or risks to mother or fetus, most common monitoring technique; allows early assessment. Special Considerations: Ultrasound examination may reveal fetal abnormalities, necessitating further testing, intervention, and patient counseling and Pain management

hyperkalemia

defined as serum Calcium greater than 5.1 mg/dL or total calcium > 10.5mg/dL. signs and symptoms associated with this high ca level include muscle weakness, lack of coordination, constipation, abdominal pain and distention, confusion, depressed or absent tendon reflexes, dysrhythmias. Causes of hyperkalemia typically include malignant neoplastic disease, hyperparathyroidism, and excessive calcium intake. Care includes IV administration, increase fluid intake, maintain acidic urine, restrict dietary calcium, prevent renal calculi, give Lasix and Calcitionin to decease level.

tonsillectomy

overview: -removal of tonsils usually from inflammation performed by ligation or laser surgery. Procedure used to resolve tissue enlargement that obstructs upper airway causing hypoxia or sleep apnea and relieves peritonsillar abscess, chronic tonsilitis and recurrent otitis media. nursing care: -post op position the patient on the side, coughing is discouraged, ice collar in place, administer analgesics, suction set at bedside, offer patient clear liquid diet and check the throat for bleeding, client teaching, after discharge avoid irrirtating or highly seasoned food, gargling, or vigorous tooth-brushing. -Preop monitor child for infection which would cause the surgery to be postponed -after monitor for speech disorders that warrant for speech disorders and monitor vital signs for 24h and watch for signs of hemorrhage such as frequent swallowing, vomiting blood, increased pulse and respiratory rate and throat clearing with s/s of anxiety. -for the child, place them on their stomach w/ a pillow under the chest to encourage drainage from the mouth and not down the throat and if bleeding occurs elevate the child's head and turn on the side to reduce pressure on the surgical wound. use a good light to check for bleeding as it may not be obvious if it is draining in the back of the throat. Give liquids, ice chips, and popsicles but avoid ice cream, acidic juices or red or brown liquids. -progress to soft food after 24hr and child may be released at that time but the danger of bleeding is greatest 7-10days after surgery. outcomes: does not experience bleeding post op and parents keep follow up appointments and report infection have not recurred. background -for obstruction of upper airway by enlarged tonsils risk include post op bleeding, septicemia following procedure: clot will form on operative site, membrane will form -complications include septicemia and hemorrhage.

Hydrocephalus

overview: congenital or acquired condition characterized by increase in the accumulation of CSF within the ventricular system and increase in ventricular pressure; this is suspected when front occipital circumference increase at an abnormally fast rate, split sutures and widened are noticed, tense and distended fontanelles, prominent forehead, dilated scalp veins, irritability, vomiting, ventricular size, increased ICP, irritability, nursing care: post op position these patients on the unoperated side, keep them flat to prevent complication secondary to the reducation of ICF, assess for increased ICP and s/s of infection (flat instead of HOB raised when ICP is a potential complication?) -neuro assessments -ABX treatment, greatest risk infection secondary to shunt infections look for signs and symptoms of fever, lethargy, irritability, redness along shunt. background: defined as disturbance of formation, flow, or absorption of cerebrospinal fluid that leads to an increase in volume occupied by this fluid in the CNS. benign external hydrocephalus is a self-limiting absorption deficiency in early infancy.

Intake and output

overview: The purpose is to help evaluate a patient's fluid and electolyte balance and influence the choice of fluid therapy by measuring I&O for 24hours; intake include all liquids by mouth, via ng tube or jejunostomy feeding tubes, IV fluids, and blood and its components while output conssit of urine, diarrhea, vomit, gastric suction and drainage from postsurgical wounds or other tubes. fluids include beverages, fluids contained in solid foods taken by mouth or liquid at room temperature like gelatin, custard, ice cream, and some beverages as well as GI instillations, bladder irrigations and IV fluids. Output consist of all fluid that leaves the patients body including urine, loose stools, aspirated fluid loss, and drainage from chest tubes. - nursing care: implementation: document patients feeding according to policy of the facility. record amount in milliliters. actually measure, do not estimate if its a small child weigh the diapers, monitor the I&O each shift and notify Dr if the amounts change significantly over a 24h period -patient maintains balance between fluid intake and output which is about 2500mL over 3 days is the outcome. -Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. background: teaching- tell pt/family that record of all fluid entering and leaving the body ensures proper fluid balance, explain and give them rationale for how the patient can keep measurements, and the importance of replacing fluid that is lost when children are ill. -special- diuretics can affect I&O and any dramatic changes need to be reported. with pediatric patients they are at risk for imbalances due to kidney immaturity and increased body surface area in relation to body size, monitor them closely after fluid administration especially if fluid is lost (v/d)

paracentesis

removal of fluid from peritoneal cavity; pre-procedure preparation includes informed consent required, void, take VS, measure abdominal girth, wt patient; during procedure take VS every 15 min; after procedure care includes documenting color, amt, characteristics of drainage; assessing pressure dressing for drainage; positioning in bed until VS stable, 2-3 L may be removed