Continuous bladder irrigation - Answer- -Peri and Foley care will need to be done twice a day
- Will be on this for 24 hrs and then after 24hrs need to
... [Show More] be on a lot of fluids
-Use only sterile saline with bladder irrigation ( prevents fluid and electrolyte imbalance)
- Increase fluids to 3000mL/day
- Sometimes give anti-spasmatic bc they have lots of bladder spasms
- Make sure pt is on stool softener
-Pt needs to urinate q2-3hr
-Will have sensation of full bladder
-Advise the patient to not attempt to void as it will cause bladder spasms
urethritis - Answer- - Urethritis: Inflammation of the urethra (Lower UTI)
- S&S: Burning on urination, urinary frequency (voiding more than every 3 hours), urgency, nocturia, incontinence, suprapubic or pelvic pain
- RISK: Female, diabetes, pregnancy, neurologic disorder, gout, incomplete emptying of bladder
- Prevention: Hand hygiene, careful perineal care, and frequent toileting may decrease UTIs
TX: Antibiotics when bacteriuria present, monitor kidney function, monitor I&O, increase fluid intake if cardiac status does not contraindicate
Renal calculi risk - Answer- Risk factors:
- Family history, dehydration, certain diets (high in protein, sodium, and sugar increase risk), strictures, neoplasms, prostatic hypertrophy, medications/supplements (Vit C, laxatives, calcium-based antacids)
Risks (emergency):
- Can lead to infection with fever and chills à this is an emergency and can be life-threatening
- Calcium and oxalate
-Risk for developing kidney stone pt with gout (middle age)
-Strain all urine
-Avoid supine position
-regularly scheduled pain medication rather then PRN to prevent spasm and promote comfort
Calculi pain - Answer- - Opioid are given to prevent shock and syncope that may result from the excruciating pain
- NSAIDS
- Once stone is passed the pain the relieved
- Hot baths or moist heat to the flank area may also be helpful
- S&S nausea, vomiting, diarrhea, and abdominal distention
Severity and location of pain are determine, along with any radiation of pain
Imitrex contraindications - Answer- Imitrex (Sumatriptan) is used for migraine headaches with or without an aura
(also used to treat cluster headaches)
- Contraindications
1. Older adults should not take
2. Caution when administering to renal impaired patients because elimination takes place in the renal system
3. Caution with hepatic impaired patients because metabolism takes place in liver
4. History of hypersensitivity reactions to the drug
5. Cerebrovascular or peripheral vascular systems
- Important to ask patient about recent administration ergot alkaloids, should not be given within 24 hours of administration (causes cardiac ischemia)
- Administration of MAO inhibitors lead to increased serum levels of sumatriptan and sumatriptan toxicity
- 2 weeks after MAO inhibitor has been discontinued, it is permissible to give sumatriptan in combination with MAO inhibitor
- Administration of St. John's wort with triptans results in triptan toxicity.
Seizures - Answer- -Patient bed in the lowest position with side rails padded
-Suction
-Oxygen equipment must be available at the patient's bedside
-Document
-Airway patency turn patient head to side
Hyperthyroidism signs/symptoms - Answer- - Exophthalmos (bulging eyes)
- Enlarger thyroid gland
- Weight loss
- T3 elevated and T4 elevated
- Diarrhea
- Tachycardic, palpitation, inc BP
- Bruit over thyroid
- Increased appetite
- Heat intolerance
- Diaphoresis
- Nervous, insomnia
- Monitor EKG, heart rate, and blood pressure
Exophthalmos-POC - Answer- - Wear sunglasses or eye patches to protect eyes from light
- Antithyroid drugs (Propylthiouracil (PTU) and methimazole
- Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area
- Use artificial tears
-Tapping pt eyelids shut during sleep
- Natural tears/ eye lubrication
- Sunglasses for light sensitivity
- Corticosteroids
- Smoking cessation
- Antithyroid drugs (propylthiouracil and methimazole)
peripheral neuropathy - Answer- -Regular exercise, such as walking three times a week, can reduce neuropathy pain
-Improve muscle strength
-Help control blood sugar levels
-Quit smoking.
-Protect Skin and Feet
Diabetes foot care - Answer- - Inspect feet daily
- Wash feet daily with warm soap and water and pat dry
- Instruct to wear flat comfortable walking shoes
- Never walk barefoot
- Look for blisters, cut, ingrown toenails, and contact PCP immediately
-If pt supine, put a pillow on the lower legs to elevate to alleviate pressure
- If pt sitting on chair, the feet should be positioned so that pressure is not placed on the heels
-If pt has ulcer on one foot, the nurse provides preventative care to the unaffected foot as well as to the affected foot
Preop lab - Answer- Urinalysis: can determine pregnancy, but also infections so patients can be started on antibiotics
WBC 4,500-11,000: can help detect certain fevers and infections, or if patient is using a medication that could change this
Glucose (70-100): managing glucose before surgery reduces risk of infection and cardiac concerns
Potassium (3.5-5): MUST be within range due to cardiac concerns, especially those undergoing a heart surgery
CBC: M (4.25-5.65) F (3.92-5.13) à measures electrolytes within blood and help regulate heart rhythms also detect for anemia and infection
Coagulation (PTT): blood needs to clot after surgery, so identify this is important beforehand. Identifies those with bleeding disorder who might suffer perioperative bleeding.
Informed consent language - Answer- -Informed consent is the patient's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed
- The signed consent form is placed in a prominent place on the patient's medical record and accompanies the pt to the OR
- If the patient is non-English speaking, it is necessary to provide consent in a language that is understandable to the client (interpreter)
- If consent can not be obtain and emergent treatment is required to save life or limb, the emergency laws can be applied
-14years of age must agree to treatment along with their parent or guardians
malignant hyperthermia - Answer- - Severe muscle rigidity or spasms.
-Rapid, shallow breathing and problems with low oxygen and high carbon dioxide.
-Rapid heart rate.
-Irregular heart rhythm.
-High body temperature.
-Excessive sweating.
-Patchy, irregular skin color (mottled skin)
- Recognize symptoms early and discontinue anesthesia
Tx:
- Cooling blanket
-O2
-IV fluids
-Dantrolene
-ICU after
Post op pain - Answer- Nurse assesses the patient's pain level using a verbal or visual analog scale and assesses the characteristics of the pain.
- Pts; appearance, pulse, respirations, b/p, skin color (adequate or cyanotic), skin temperature (cold and clammy, warm and moist, or warm or dry)
- Relieved by prescribed analgesic medication, changing the position frequently, and assessing and alleviating anxiety
- Opioid are commonly prescribed for pain and immediate postoperative restlessness
- Nonpharm: guided imagery, music, healing touch, changing position, distraction, apply cool washcloth, back massage
- Early ambulation if possible
Hydromorphone & B/P - Answer- -Diladid given to patients who state they have severe pain, given IV and is quick acting
- May suddenly drop blood pressure
Should not be given to patients with hypotension, hypovolemia, or CNS depression
COPD and breathing - Answer- COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs
Ineffective breathing patterns and SOB due to the modified respiratory mechanics of chest wall and lung resulting from air trapping
- Pursed-lip breathing helps slow expiration, prevent collapse of small airways, and control the rate and depth or respiration
- Inspiratory muscle training
Diaphragmatic breathing training reduces respiratory rate
TB diagnostic test - Answer- -Quantiferon TB Gold test (takes 24 hr)
Skin testing
- Positive skin test, blood test, or sputum culture for acid-fast bacilli
- Tuberculin skin test, chest x-ray
- Tuberculin Skin test- the Mantoux method is used to determine whether a person has been infected with TB
-Sputum culture can indicate disease but does not confirm diagnosis
Perforated bowel first sign - Answer- -Sudden and severe abdominal pain.
-Nausea and vomiting.
-Fever is often a sign of infection or disease.
-Chills.
-Swelling and bloating of the abdomen
-Less gas passed
NGT with decreased peristalsis - Answer- -Placement is done to give GI system rest. Lack of use will slow the GI system down.
Cholelithiasis N&V - Answer- - Nurse notes nausea and vomiting could indicate infection or disruption of the GI tract should be reported promptly
- Should also report RUQ pain, bile drainage around any drainage tube, clay-colored stools, and change in VS
- Biliary colic is usually associated with nausea and vomiting, and it is noticeable several hours after a heavy meal
-General peritonitis may result
Diverticulitis WBC - Answer- -Elevated white blood cell (WBC) count and left shift, although patients with early and mild diverticulitis may have a normal WBC count.
-This result may be blunted in the elderly or immunocompromised.
-Normal number of WBCs in the blood is 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 109/L)
Anemia labs - Answer- -Iron deficiency, Sickle cell disease, low HgB and Hct, high creatinine, low erythropoietin level, low B12, low folate
-RCB Male(4.5-5.5) Female(4-4.9)
-Hgb Male(13.5-16.5) Female(12-15)
HCT Male(41-50) Female(36-44)
Plaquenil teach - Answer- Used for Lupus- Hydroxychloroquine
- Effective for managing cutaneous, musculoskeletal, and mild systemic features of SLE
- Patient should undergo a thorough ophthalmologic exam before tx and every 6 months after
- Objects may start to appear blurry or distorted.
-Should be advised to contact the prescriber if any visual disturbance
Blood administration - overload - Answer- S/S overload:
- dyspnea, orthopnea, tachycardia, increase B/P, JVD, crackles, hypoxemia, pulmonary edema, pink, frothy sputum
-More common in people with heart problems
- If mild blood can continue after slowing the rate of infusion and administering diuretics
-Taking diuretic medicine after a blood transfusion may prevent this problem.
- If severe pt is placed upright with feet in a dependent position, transfusion discontinued, primary provider notified
- Oxygen and morphine may be needed to treat dyspnea
Can develop as late as 6 hrs after transfusion
Menopause risk of osteoporosis - Answer- -Estrogen, a hormone in women that protects bones, decreases sharply when women reach menopause, which can cause bone loss.
Primary osteoporosis occurs in women after menopause (51)
- Should consume approximately 1200 mg of daily calcium
- Engage in exercise (weight-bearing): walking, dancing, climbing
- Accelerated bone resorption within the first 5 years after cessation of menses
DEXA testing is recommended
Osteoporosis goal - Answer- -Reduce bone loss
-Prevent fracture
-Control pain
-Prevent disability.
-Eating foods that are rich in calcium and vitamin D
-Regular weight-bearing exercise, such as weight training, walking, hiking, jogging, climbing stairs, tennis, and dancing.
Osteoarthritis pain assessment - Answer- -Physical assessment. Physical assessment of the musculoskeletal system reveals the tender and swollen joints.
-X-ray. OA is characterized by a progressive loss of joint cartilage, which appears on x-ray as a narrowing of the joint space.
-Acute pain related to inflammation of the synovium and irritation of the nerve endings
Gout teach - Answer- Hyperuricemia (increased serum uric acid) most common in the great toe
- Restrict consumption of foods high in purines, organ meats, seafood and limit alcohol intake
- Normal body weight encouraged
- Avoidance of factors that increase pain and inflammation; trauma, stress, and alcohol
Medication adherence
ABG head injury - Answer- -Up to one-third of patients with severe traumatic brain injury develop Acute Respiratory Distress Syndrome
-Tachypnea, tachycardia, and respiratory alkalosis
-Respiratory alkalosis (Some of the causes include the build-up of CO2 in the blood, hypoventilation, and increased dead space.)
Celiac disease - diet - Answer- Celiac disease- immunologic disorder in which gluten, a product most commonly found in grains, causes damage to the small intestine
- Only treatment is a strict gluten-free diet
- Allowed foods: potato, soy, rice, cornmeal, vegetables, fruits, milk (except malted milk, yogurt), meats, butter, margarine, coconut, marshmallows
Prolapsed cord delivery - Answer- -Place sterile dressing soaked with saline on cord to prevent drying
- Positioning mom to modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure.
-Give O2 through non-rebreather mask at 8-10mL
- Prepare women for emergency C-section to save fetus's life if cervix is not fully dilated
-Provide space from compressing cord by placing 2 fingers into vaginal canal
Gestational diabetes lab - Answer- The urine is analyzed for albumin, glucose, ketones, and bacteria >140mg/dL
- 1-hour glucose tolerance at 24-28 weeks
- If positive notify provider who will order the pt to take 3 hour glucose tolerance test
GBS positive - Answer- -Penicillin G is treatment of choice, administered IV at least 4 hours before birth
-Will need antibiotic treatment or neonate can become ill
-Right after birth: low temperature, pyrexia, bradypnea, tachypnea, bradycardia, tachycardia, appear floppy, have the inability to feed, and appear pale or irritable"
-Develop symptoms of rapidly invasive disease including sepsis, pneumonia, and meningitis within the first week after birth
Placenta abruption actions - Answer- -Place the woman in a lateral, not supine position to avoid pressure in the vena cava.
-Monitor fetal heart sounds.
-Monitor maternal vital signs to establish baseline data.
-Avoid performing any vaginal or abdominal examinations to prevent further injury to the placenta.
Hemorrhage postpartum care - Answer- -Manual massage of the uterus (to stimulate contractions)
-Removal of placental pieces that remain in the uterus.
-Empty Bladder
-Start Pitocin
Variable deceleration actions - Answer- -A clinical manifestation of a prolapsed umbilical cord
- Discontinue oxytocin
- Turn the client on her left
-Provide mother with O2
-Bolus IV fluids
Post epidural headache - Answer- - Hypotension and associated FHR changes are managed with maternal positioning (semi-fowler position), IV hydration, and supplemental oxygen
- Bed rest, fluids, caffeine, oral pain relievers
Post spinal headache: lay flat, fluids, blood patch
-Has to do with change in CSF
-Can last 7-10 days
Cryptorchidism assessment - Answer- -Impaired urinary elimination
-Risk for infection
-Visual assessment first
-Palpation of the testis
Acrocyanosis monitor - Answer- -Normal in a newborn, wherein the hands, feet, and lips are bluish in color
-May persist for 24 to 48 hours
Vitamin K rationale - Answer- -Babies need the shot as they do not have enough clotting factor after birth.
-If the baby didn't receive the shot they would hemorrhage
-Newborn bowels are sterile, so vitamin K is not produced in the intestine until after microorganisms have been introduced, such as first feeding
-Takes about a week for the newborn to produce enough vitamin K to prevent vitamin K deficiency bleeding
IEO - pediatrics - Answer-
Sickle cell dehydration - Answer- -Dehydration makes the pain worse
-Lack of fluids causes the blood to clot more furthering the sickle cell crisis
Hypoglycemia - milk - Answer- Dairy provides protein, carbohydrates, vitamins and minerals and also helps control blood sugar for reactive hypoglycemia
Meningitis assess - Answer- -Lumbar puncture
-High pitched cry
-Nuchal Rigidity
-Bulging fontanels
-Projectile vomiting
Congenital hypothyroid - Answer- -Shortage of iodine in the diet of the mother and the affected infant
-Jaundice (yellow skin or eyes)
-Sleeping longer or more often than usual.
-Constipation.
-Large soft spot (fontanel) on the head.
-Large, swollen tongue.
-Weak ("floppy") muscle tone.
-Swelling around the eyes.
-Poor or slow growth.
RSV synagis (Palivizumab) - Answer- If born prematurely (at or before 35 weeks) should receive at 6 months of age or less at the beginning of RSV season
-Its a monthly shot
hyperglycemia - Answer- -Usually Type 1 for pediatrics
-Body is unable to produce insulin
-Only able to take
-1st sign is bed wetting
Biliary atresia - Answer- -Infants in which the bile ducts outside and inside the liver are scarred and blocked
-Bile can't flo [Show Less]