Autonomic Dysreflexia
Complications:
-severe pounding headache (from onset of HTN)
-Profuse sweating
-Nasal congestion
Iron daily requirements
... [Show More] for women
15 mg/day
Blood transfusion (hemolytic reaction)
S/S:
-chills
-headache
-backache
-dyspnea
-hypotension
-fever
Manic episode (behaviors)
-Grandiose delusions
-difficulty concentrating
-agitation
Meniere's disease/syndrome
Is an inner ear disorder that causes episodes of vertigo/spinning
Boggy uterus deviated to right
-indicates full bladder
-encourage client to void (offer bedpan)
Cystic Fibrosis (diet requirements)
-High protein
-High calorie
Cerebellum
Maintains balance
IVP (intravenous pyelogram)
Is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys ureters and bladder
Nursing management:
-because of the need to visualize the abdominal area, cleansing enemas the evening before and IVP are usually ordered
Rho (D) immune globulin (RhoGam)
Is given to an Rh-negative mother who delivers an Rh positive baby when the baby has a negative Coombs test
Cane use (going downstairs)
-advance cane and weak leg
-then strong leg
Memory trick: the good goes up, the bad goes down
Delegation to remember
LPN/LVN and "pulled" or "re-assigned" RN from another unit
- receive stable patients with expected outcomes
Room assignments
-clients with fracture are considered "clean"
-do. Not place elderly pts with pneumonia pts
IBS (irritable bowel syndrome)
Hx of symptoms:
-pattern of alternating diarrhea and constipation
Immunizations
DPT (diptheria, tetanus, pertussis)
-1st dose: may be given at 2 mos
-2nd dose: given around 4 mos
-3rd dose: given around 6 mos
MMR: given at 12-15 mos
rotavirus: 2, 4, and 6 mos
Varicella: 12 to 15 mos
Cushing's syndrome (too many steroids)
Assessment findings:
-buffalo hump
-weight gain
-moon face
-purple striae
-osteoporosis
-mood swings
-high susceptibility to infections
-hyperglycemia
-hypernatremia
Insulin administration
Insulin should be administered at room temperature; temp extremes should be avoided
Lumbar lesions (ruptured disc)
Cause paresthesia, pain, muscle weakness and atrophy in the lower extremities
Guillain-Barre syndrome (symptoms)
-resp failure
-flaccidity due to paralysis of the muscles
-urinary retention due to loss of sensation
Myelogram
-Test involves a lumbar puncture with infection of contrast medium, allowing x-ray visualization of the vertebral canal
-indentifies tumors, cysts, herniated vertebral disks
Rubella (german measles)
Requires airborne precautions; particulate respirator
ECT (electroconvulsive therapy treatment)
Expected effects:
-headache
-disrupted memory (short and long term)
-general confused state
-backache
EDB (estimated date of birth)
Naegele's rule:
-add 7 days to 1st day of last mentrual period and subtract 3 mos
Continuous tube feeding
-rinse bag and change the formula every 4 hours
-there is an increased growth of organisms after 4 hours
Type 1 diabetes (insulin needs during pregnancy and after delivery)
During pregnancy: Insulin needs increase
After delivery: Insulin needs decrease
Duodenal ulcers
-clients experience pain after meals
2-4 hrs after meals
Hypoglycemia symptoms
-irritability
-tachycardia
-diaphoresis
Autologous blood transfusion
This is blood lost during surgery that is being re-infused into the patient "blood salvage"
Central Venous catheters
Anything having to do with CVAD (central venous access devices) ; it is ALWAYS A STERILE PROCEDURE
-make sure to FLUSH with 10ml syringe to keep patency
RESTLESS=
HYPOXIA
What happens to a pulse when you lower blood pressure?
The HR goes up to compensate.
Impetigo
A highly contagious skin infection that causes red sores on the face.
-Staph infection
-causes fluid-filled vesicles, honey-colored crusts, reddened areas
-can be treated with an antibiotic cream or oral antibiotic
-wash hands before and after applying a topical antibiotic
-child can be in contact with other children 24hrs after starting the antibiotic
Dumping syndrome
Rapid gastric emptying
To avoid rapid emptying:
-include foods that contain fats and protein at every meal
-lie down or sit for 30 to 60 mins after eating
-wait for 1 hour after meals before drinking fluids
Levothyroxine (T4)
Thyroid hormones
-mgmt of hypothyroidism, myxedema coma, thyroid replacement
Side effects:
-weight loss
-arrhythmias
-insomnia, irritability
-nervousness
-heat intolerance
-menstrual irregularities
Nursing:
-take at the same time daily
-avoid OTC meds with Iodine
-Treatment is lifelong
-Take on an empty stomach
Famotidine (Pepcid)
Antiulcer medications
Treatment of duodenal and gastric ulcers, GERD, heartburn
Side effects:
-headache
-blood dyscrasias
-hepatitis
-dizziness
-constipation
Nursing:
-can take at bedtime
-avoid taking with antacids-milk of magnesia
Restless=
Hypoxia
Order on how to instruct a client of the use of an incentive spirometer:
1. Assume a high Fowler's position
2. Seal the lips tightly around the mouthpiece
3. Inhale slowly
4. Hold his breath for at least 3 seconds
5. Exhale slowly through the mouth for 2 to 6 seconds
6. Cough and deep breathe 2 to 3 times
Tetralogy of Fallot
-combination of four heart defects present at birth
-infants get tired really fast
-use a high-flow soft nipple for feeding
Important symptom of sickle cell crisis is...
Severe pain
Atropine
Anticholinergic, antimuscarinics
-Treatment of sinus bradycardia and heart block
Lobes of the brain and function
FRONTAL LOBE:
-largest
-voluntary movement
-speech
-intellectual thoughts
-intelligence
-concentration
-temper
-personality
-emotional control
PARIETAL LOBE:
-sensation
TEMPORAL LOBE:
-language
-hearing
-olfaction (smell)
OCCIPITAL LOBE:
-Vision
-process colors/shapes
Considerations for radiation exposure
-TIME
-DISTANCE
-SHIELDING
Fixed specific gravity
-Values do not change regardless of fluid intake
-if pt has a diagnosis of acute glomerulonephritis and you see that their urine specific gravity is fixed and has not changed, the pt is now in severe renal failure, progressed to chronic
-seen in chronic glomerulonephritis
Foods high in Potassium
Bananas
Orange juice
Beans
Winter squash
Potatoes
Early signs of hypoxia
Increased HR
Late signs of hypoxia
Cyanosis
Airborne precautions
Chicken pox
Measles
TB
ACUTE respiratory distress
No abnormal lung sounds are present on auscultation because the edema occurs first in the interstitial spaces not in the airways
Hep A vaccine
persons traveling to countries with high to medium rates of hepatitis should be vaccinated; countries in Africa, South America, and Asia have high to medium rates of hepatitis A; other candidates for vaccine include clients diagnosed with chronic liver disease and clients with hemophilia receiving clotting factor
Low Albumin
Assess pt for edema
Low serum albumin means that they are not holding volume in their vascular space and its escaping to the interstitial tissues=edema
Projection
attributing to others one's feelings, impulses, thoughts, or wishes (blaming or scapegoating)
Signs of infection in the Elderly
in the elderly, change in mental status, particularly confusion, is very often the presenting symptom of infection; fever may be absent even when bacteremia or pneumonia are present
Normal pulmonary artery wedge pressure (PAWP)
6-12 mm Hg
Neonate normal head circumference
32-37 cm
When should neonate void and pass meconium?
During the first 24 hrs
Desquamation
is also known as peeling skin and is a normal finding in neonates. Moisturizers can be applied to the neonate's skin to resolve desquamation.
Signs of respiratory distress in neonates
Nasal flaring, chest wall retractions, and grunting with respirations are a sign of respiratory distress.
What is the recommended infusion rate for KCL IV?
5-10 mEq/hr
KCL IV (nursing priority action) if pt is complaining of burning and discomfort at the site?
The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort.
Myasthenia gravis
Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.
Management of sickle cell crisis
1. Pain control with narcotics - analgesics are provided around the clock or with patient-controlled analgesia, rather than as needed, to prevent breakthrough pain. Clients with SCD often need large doses of narcotics.
2. Hydration - aggressive intravenous and oral hydration is recommended (to reduce the viscosity of the blood)
3. Oxygenation - to prevent pulmonary complications and provide comfort
4. Infection prevention - age-appropriate vaccination plus pneumococcal, influenza, and meningococcal vaccination
5. Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid and a multivitamin without iron
6. Folic acid - given to help in the creation of the new red blood cells needed due to the hemolysis
Note: cold promotes sickling and should be avoided
Which medications interfere with absorption of Levothyroxine (Synthroid)?
antacids, calcium, and iron preparations.
Heart attack symptoms in women and elderly with a history of diabetes.
nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.
Placenta previa
Placenta previa is suspected in any client with painless vaginal bleeding after 20 weeks gestation. Clients with placenta previa are at high risk for hemorrhage. In the presence of profuse or constant bleeding, the client should be prepared for an emergency cesarean delivery.
Nurse should be prepare for:
-blood draw for hemoglobin
-electronic fetal heart monitoring
-pelvic ultrasound
Abdominal aneurysms
Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm.
s/s of hypoglycemia
shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor, and changes in mental functioning (eg, difficulty speaking, visual disturbances, confusion).
Long acting nitrates for angina
Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates.
Clients at highest risk of MRSA
Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA.
Elevation of which cells indicates ALLERGY response?
eosinophils
Placental abruption
Placental abruption usually presents with abdominal pain and dark red vaginal bleeding. The main concerns are maternal blood loss resulting in hypotension and shock and fetal compromise. Maternal stabilization and expedited birth are indicated.
Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated.
Signing out AMA (against medical advice)
For a client to sign out AMA, the client must be competent and cannot be impaired by drugs or alcohol. Clients cannot be a danger to themselves (suicidal) or others (homicidal). An emancipated minor or a health care provider-determined "mature minor" can give consent.
Good dietary source of both calcium and vitamin D
Sardines
Administering meds through feeding tube
When a feeding tube is used, medications should be crushed, dissolved, and administered separately to prevent interactions. Sterile water should be used to dissolve medications and flush the feeding tube. Liquid medications should be used if possible.
Stress-induced hyperglycemia
Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L].
For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended.
Malignant hyperthermia
Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.
Liver failure lab findings
Laboratory abnormalities common in liver failure include low serum albumin (causes ascites), elevated INR (increases risk for bruising and bleeding), elevated serum ammonia (causes lethargy and confusion), and increased bilirubin (causes jaundice and itching).
Prevention of VAP
Prevention of ventilator-associated pneumonia focuses on minimizing mechanical irritation and bacterial access to the lungs. Specific steps include sealing the endotracheal tube cuffing with ≥20 cm H2O (15 mm Hg), routine oral hygiene with chlorhexidine, elevating the head of the bed, minimizing sedation, and extubating as soon as possible. [Show Less]