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NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF

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Shahid Hussain
Shahid Hussain

NCLEX REVIEW

Health & Medicine
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T H E N U R S E S C O R N E R
TABLE OF CONTENTS Pharmacology & Need to Know Medications................Page 3-13 Fundamentals & Delegation..........................................Page 14-17 Ethical Principals & Law..................................................Page 18-20 Integumentary.................................................................Page 21-23 Respiratory Disorders & Nursing Considerations.......Page 24-32 Disorders of the Heart & Circulation...........................Page 33- 44 Musculoskeletal Disorders.............................................Page 45-47 Diabetes & Insulin.................................................................Page 48 Contact Precautions & Infectious Disease....................Page 49-53 Renal Disorders & Nursing Considerations..................Page 54-58 GI Disorders......................................................................Page 59-60 Spinal Cord Injuries..........................................................Page 61-62 Neuro & Brain..................................................................Page 63- 68 Visual/Auditory & Nursing Considerations...................Page 69- 71 Psychiatric Nursing..........................................................Page 72- 75 Endocrine Disorders........................................................Page 76- 79 Reproductive & Sexual Health........................................Page 80- 81 Maternal- Antepartum.....................................................Page 82- 88 Labor & Delivery................................................................Page 89- 92 Postpartum & Newborn...................................................Page 93- 95 Pediatric Nursing............................................................Page 96- 100
PHARMACOLOGY Vitamin k is the antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis Intake of vitamin k rich foods can decrease effect ( broccoli, spinach, liver) Monitor INR levels Pregnant women should not take Avoid aspirin, NSAIDS, and alcohol If recovering from a PE, Warfarin is usually taken for 3-6 months Antibiotics can affect INR levels INR level 3.0-3.5 contraindicated in pregnancy First line drug therapy for SVT Administer over 1-2 minutes then flush with saline Find a line closest to the heart End with -il, controls high blood pressure Check blood pressure before administering Check potassium levels before administering because these medications increase potassium levels Can cause a dry cough and reflex tachycardia Can have severe adverse effects of angioedema Do not take while pregnant Can cause orthostatic hypertension If a client cannot tolerate ACE inhibitor then they are prescribed ARBS (-an) drugs CCB are like valium to your heart Help control atrial fibrillation End in -em like diltiazem Also end in -ine (Amlodipine) Most severe adverse effect is dizziness Do not drink grapefruit juice while taking this or statins Measure blood pressure before administering, if systolic is under 100 then you hold CCB Warfarin Adenosine ACE Inhibitors Calcium Channel Blockers
Clients with hypertension should not take over the counter medications for colds, these medications have decongestants and can cause vasoconstriction Calcium channel blocker vasodilator Brings blood pressure down, usually after stroke and patients get extremely hypertensive (systolic over 240) The nurse should bring the blood pressure down but not below 170 (systolic) Priority nursing interventions are to monitor for hypotensive effects of this drug Helps control heart rate and blood pressure (mainly heart rate) Side effects may be bronchospasms Do not give to people with asthma The nurse should assess for any wheezing May mask signs of hypoglycemia End with - an like Losartan (sartans) Should not be taken while pregnant Helps lower blood pressure Can cause hyperkalemia Do not take with salt substitutes Increases cardiac contractility and slows the heart rate and conduction (slows the rate of conduction through the AV node) NOT a vasodilator Decreases workload of the heart It is used in heart failure and atrial fibrillation Excreted exclusively by the kidneys so need to check kidney function (creatinine and BUN) Digoxin toxicity: N/V, GI symptoms are the earliest sign, confusion, weakness, Toxic level above 2 visual symptoms, cardiac arrhythmias Hypokalemia can cause digoxin toxicity Treats A fib and heart failure Increased risk for bleeding Helps prevent platelet aggregation Clients should be assessed for black tarry stools, bleeding gums, hematuria, bruising, monitor platelets Should not be taken with Ginko Inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation Clients can receive this when they do not have signs of bleeding or low platelet levels Nicardipine Beta Blockers ARBS Digoxin Antiplatelet Therapy Drugs
plavix , antiplatelet medication that should be discontinued 5-7 days before surgery Can increase risk of bleeding so the HCP should be notified if low platelet levels (<150000) Helps prevent blood clots Decreases preload Nitrate that causes vasodilation At risk for hypotension Can cause headache The nurse should follow up of the client feels dizzy or lightheaded 1 pill every 5 minutes and up to 3 doses EMS should be called if pain is not alleviated by 5 minutes after the first pill Headache and flushing are common side effects Sit or lie down before taking the pill Store away from heat and light Helps lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease Reduces LDL levels, triglycerides, and total cholesterol levels Taken at night with evening meals Muscle aches are a serious side effect Report muscle pains or weakness, could be a sign of rhabdomyolysis Liver function test should be assessed before giving Lower LDL lipid levels Monitor for muscle pain or weakness All NSAIDS are associated with: GI bleeding, black tarry stools, stomach pain can be reduced if taken with food Kidney injury, long term use is associated with this Hypertension and heart failure Increase risk for bleeding Should be avoided in clients with kidney disease, nephrotoxic, COPD Long term use can cause peptic ulcers and chronic kidney disease, exacerbate hypertension and cardiac problems Ibuprofen NSAID Commonly prescribed to relieve joint pain and inflammation Clopidogrel Nitroglycerin Statin Atorvastatin NSAIDS Naproxen
Toradol Highly potent NSAID Subcutaneous or IV anticoagulation medication Administer at 90 degrees or 45 degrees depending on how much adipose tissue they have Administer 2 inches away from umbilicus Works immediately Cannot be given for longer than 3 weeks (accept for lovenox) Antidote is protamine sulfate Lab test that monitors heparin is PTT PTT time should be 1.5 - 2.0 times the normal clotting time of 25-35 seconds Too long could cause spontaneous bleeding Can be given to pregnant women Risk is HIT (drop in the number of platelets) Heparin should be held when there is a drop in platelet Must be administered in 3-4.5 hours Surgery within 2 weeks is contraindicated Platelet less than 100000 or coagulation disorders should not receive it muscle relaxer Side effects: Fatigue and muscle weakness Teach: don't drink, don't drive, and don't operate heavy machinery for patients Muscle relaxer Flex = muscle Iron supplement, avoid giving with calcium supplements and antacids because that decreases absorption Client should increase intake of fluids because these cause constipation Taking with vitamin c like orange juice enhances absorption Administer 1 hour before meals or 2 hours after meals Keterolac Heparin TPA Baclofen Flexeril Ferrous Sulfate
Medication for hypothyroidism Used to replace thyroid hormone Safe to take during pregnancy Do not take with antacids, calcium or iron (avoid over the counter multivitamins) Take on an empty stomach, in the morning, separately from other medications Lifelong therapy, blood test needed This medication will improve mood, higher energy levels, take up to 8 weeks to work, normal heart rate Takes 3-4 weeks for effect Prednisone Given to combat inflammation in the lungs to COPD patients These medications can cause in increase in sugar If the patient is a diabetic, anticipate giving more insulin Started high dose then tapered slowly Treats diabetes insipidus Mimics ADH Increases renal water absorption and concentrates urine Clients receiving this must have their electrolytes closely monitored for water intoxication/ hyponatremia (headache, mental status, weakness) Severe hyponatremia may cause seizures, neurological damage, or death Treats rheumatoid arthritis and psoriasis Can cause bone marrow suppression, clients are at risk for infection They should avoid large crowds and receive killed immunizations (flu, pneumonia) Avoid alcohol (can cause hepatotoxicity) and pregnancy with these drugs Endocrine Medications Levothyroxine Corticosteroids Desmopressin Methotrexate
Keppra Anticonvulsant prescribed for seizures Depresses the CNS and can cause drowsiness, this improves after a few weeks Associated with suicidal ideations and should be reported to the HCP Can trigger steven johnsons syndrome No driving until approved by HCP Treats migraine headaches Work by constricting cranial blood vessels Contraindicated in clients with coronary artery disease and uncontrolled hypertension For motion sickness Apply 4 hours before Keep on for 72 hours Apply behind ear Dilantin, is an anti seizure medication with a therapeutic index of 10-20 Tube feedings decrease phenytoin absorption which can reduce the drugs effect and produce seizures The nurse should pause tube feedings for 1-2 hours before and after administration of these drug to increase absorption Early signs of toxicity include: horizontal nystagmus and gait unsteadiness Commonly taken at bedtime Antianxiety drug Do not ever stop abruptly Versed Benzodiazepine commonly used to induce conscious sedation Flumazenil ( Romazicon) is the antidote to reverse benzo effects Neurological Medications Levetiracetam Sumatriptan Scopolamine Phenytoin Benzodiazepine Midazolam
Patients are usually prescribed Flagyl ( Metronidazole) For severe C Diff vancomycin may be used For treatment of TB Can experience neurological effects due to the decrease in the body's ability to utilize B6 The patient needs additional doses of B6 Zyvox Should not be taken with SSRI because can cause serotonin syndrome Azithromycin These can cause prolonged QT intervals in patients ECG should be monitored Can also cause hepatotoxicity Draw trough prior to administration, 10-20 is a therapeutic level Infuse medication over at least 60 minutes Monitor blood pressure Assess for hypersensitivity (red man syndrome) Monitor for anaphylaxis Check IV site every 30 minutes CVC catheter is preferred Creatinine levels are the most important value to monitor because vancomycin can cause nephrotoxicityIf creatinine is high this is a complication of nephrotoxicity Helps fight bacterial infections of the skin Take on an empty stomach Avoid taking with dairy products, iron supplements, or antacids Take with a full glass of water Wear sunblock because risk of photosensitivity Use additional contraceptive medications Infectious Disease Medications Medications for CDiff Isoniazid (INH) Linezolid Macrolide Antibiotics IV Vancomycin Tetracycline
Stool softener that reduces straining during bowel movement, puts less stress on heart Straining can also cause bradycardia due to vagal response Most commonly used drug for heart failure Lasix Can increase risk of bleeding COX- 2 I inhibitor Black box warning with increased risk for cardiovascular complications Back pain, nausea, vomiting, would need to be assessed immediately Decreases cardiac workload Pain treatment and terminal dyspnea Decreases cardiac irritability Avoid intake of alcohol and limit use of acetaminophen Take vitamin B6 to prevent leg tingling Avoid aluminum containing antacids Report changes in vision Report jaundice, dark urine Does not change color or urine, that is Rifampin Adverse effects: hepatotoxicity, peripheral neuropathy Rifampin: reduced the efficiency of oral contraceptives, changes the color of the urine, used for TB Codeine Opioid and is smaller doses is a cough suppressant Can cause constipation just like opioids do Take medicine with food Drink lots of water Sit on side of bed before getting up because it can cause hypotension in patients Never shave before placing patch Antihypertensive patch that is reapplied every 7 days Do not remove patch if dizziness occurs Rotate site with each use Miscelleneous Drugs Docusate Sodium Furosemide Ginko Celecoxib Morphine Lidocaine Isoniazid INH Transdermal Patches Clonidine
Available in many forms If a patient has difficulty swallowing, the nurse should consult with the pharmacist to see if there is other forms Maybe liquid Fold when discarding Change every 72 hours Not cutting patches Do not apply heat over the patch (does not aid in absorption) Over 3 years years pull ear up and back Less than 3 pulled down and back Children should be placed prone or supine Warm ear drops to room temperature Drop medication against wall of the canal Age appropriate distraction Toddlers and infants toys Preschool and older children deep breaths or count Infant placed supine with knees and and feet raised Other children side lying with knees bent Use water soluble jelly Insert using 5th finger with children under 3 Hold buttocks together after insertion Y tubing Connected with normal saline to keep vein open Continuous IV fluids used PCA pumps Children can use as long as they understanding of the device 10-20, above 20 is toxic Helps relax bronchioles Seizures in toxicity Do not take vitamin A supplements, can cause toxicity Do not give blood on this medication For severe or cystic acne Most important to use 2 forms of contraception KCL Fentanyl Patch Ear Drops Rectal Suppository PCA PUMP Aminophylline Isotretinoin
May cause ototoxicity, especially in patients with kidney disease High doses should be administered slowly to prevent this ototoxicity in patients Viagra Nitrates and viagra are contraindicated with each other as it can cause life threatening hypotension The use of these should be reported to HCP Glucose should be monitored in those receiving this End in -ide and -one Treats hypertension and edema Major side effects: hypokalemia (muscle cramps and dysrhythmias) hyponatremia (AMS and seizures) Hyperglycemia Used to prevent gout attacks Inhibits uric acid production and improves solubility Should be taken with a full glass of water and increase fluids (most important teaching) Used in the treatment of rheumatoid arthritis Adverse effects: bone marrow suppression, hepatotoxicity, gastrointestinal irritation Can lead to thrombocytopenia (small purple dots) Anticonvulsant for seizures Never stop taking abruptly Exception is the development of a rash that may indicate steven johnsons syndrome (flu like symptoms and a painful rash) Good dental care is a must, can cause gingival hyperplasia Can cause suicidal ideation and depression, this an adverse effect -micine ending (azithromycin, zithrominine, and clarithromycin) Treat serious Think “mice” think ears think ototoxic, tinnitus, vertigo, equilibrium, ringing of the ear, dizziness Another toxic effect is nephrotoxicity (monitor creatinine) IM or IV PO, does not absorb Oral micines will sterilize the bowels before surgery (neomincine and canominice) IV Furosemide Sildenafil Prednisone Thiazide Diuretics Allopurinol Methotrexate Phenytoin Aminoglycosides
IV Fluids Iv should not exceed 10 mEq/ hr Iv should be diluted and never given at a concentrated amount, high risk Can cause hypotension, this side effect is not as noticeable when the client is sitting down but when they stand up they can have orthostatic hypotension Those at highest risk for respiratory depression due to administration: the elderly, those with underlying pulmonary disease, snoring, obesity, smokers Adverse effect is paralytic ileus (absent bowel sounds) also can happen with potassium is low Itching is a normal side effect Hydromorphone, morphine Control moderate to severe pain Side effects: sedation, respiratory depression, hypotension, constipation Client is at risk for falls and should not get out of bed unless with assistance Administer daily stool softeners Administer slowly over 2 to 3 minutes Recheck pain 15-30 minutes after administering the medication Can take up to 72 hours for full effect Not prescribed to patients 1 day post op or for acute pain because of the time it takes to reach full effect KCL Opioids Opioid Analgesics Transdermal Fentanyl Patch
FUNDAMENTALS & DELEGATION Always take it off in alphabetical order Gloves, goggles, gown, mask OFF ON reverse for alphabetical for G but mask comes second Gown, mask, googles, gloves Hold the cane on the strong side Close clients eyes Replace dentures Disconnect all tubes and lines Straighten the body and limbs Place pad under perineum Wash body Allow family members to assist with care Place pillow under the head Fold towel to put under the chin to close mouth Address client directly Speak in short sentences Pre conference with interpreter Use qualified interpreter when possible Avoid translation through family members The nurse should be mindful to choose interpreter with the patients prefered age, gender PPE Canes Postmortem Care Speaking with an Interpreter
Can perform passive range of motion exercises Take and document vital signs No trach care or cleaning Can collect urine specimen Cannot document color and characteristic of it They cannot offer orange juice to a client with hypoglycemia Can assist 1 day post op out of bed to the bathroom Cannot reinforce teaching Can remind client to use incentive spirometer Pick up blood products from the blood bank Can take vital signs before blood transfusion and after the first 15 minutes of the transfusion Can perform oral suctioning (not sterile) Report patient behavior but not monitor Can transport body to morgue Can give topical over the counter barrier creams Can do vitals and accuchecks Can delegate ADL’s Measure output in a drainage collection bag Should be assigned stable clients with expected outcomes Cannot perform initial teaching, assessments, or evaluate a client’s condition Can do teaching reinforcement Can administer anticoagulant medications Can suction Can perform sterile procedures (catheterizations) Can auscultate lung sounds but cannot use that information to evaluate Can monitor RN findings Can monitor for bleeding Cannot start an IV, hang or mix IV meds, push IV meds They can maintain an IV and document the flow They cannot administer blood or mess with central lines Cannot plan care , the LPN can implement it Cannot perform or develop teaching, they can reinforce it Cannot take care of unstable patients They cannot do the very first of anything They can do tube feedings, but not the first They can change dressings, but not the first Cannot do admission, discharge, transfer, or the first assessment after a change Can not administer or monitor blood transfusions/ products UAP LPN
Age is not a criteria for prioritization Gender is not a criteria for prioritization Acute beats chronic (higher priority than) Post op is within 12 hours, beats medical or other surgical Stable patients: indicate they are stable, chronic illness, post op greater than 12 hours, regional anesthesia, experiencing the typical, expected signs and symptoms of the disease with which they were diagnosed Unstable: suspected, acute, post op less than 12 hours, general anesthesia, patient is unstable if they are experiencing unexpected signs and symptoms Always Unstable:Hemorrhage High fevers over 105 Hyperglycemia pulselessness/ breathlessness Prioritizing Organs :Brain, lung, then heart, then liver, kidneys, pancreas Prioritization Assessment is the first step in the nursing process, the nurse should assess and then intervene when in doubt, ASSESS FIRST The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved Complication of this is lymphedema, can prevent by positioning each joint higher than the proximal one Can cause bone marrow suppression and tumor lysis syndrome Filgrastim stimulate neutrophil production Assessment Modified Radical Mastectomy Chemotherapy
Place client in semi fowler's position Affected side’s arm needs to be placed on several pillows to promote drainage Never ignore inappropriate behavior by staff Ask yourself if what they are doing is illegal?If yes, tell supervisor No, then ask if anyone is in any immediate danger, if yes, then confront immediately because you don’t want to delay to put someone at risk If behavior is legal, no harmful, but simply inappropriate, then speak with them later on Client allergies and history are confirmed Assessment Confirming Informed consent has taken place Ensuring the client has been NPO Client voids before surgery Witnessing that the correct surgical site has been marked Occurs when doctor does not sign order Doctor puts wrong amount or unit The handwriting is not legible High fowlers for paracentesis Trendelenburg position and on the left lying side if suspected air embolism Position client with arms raised above head for chest tube placements After a liver biopsy the client should lay on the right side for at least 2 hours and then supine for an additional 12-14 hours Thoracentesis the patient is upright sitting position on the side of the bed leaning over on side table with pillow Teaches activities of daily living (bathing, dressing, cognitive or perception issues) Focuses on mobility, ambulation, ability to walk, use the walker or other assistive devices Physical therapy focuses on “below the waist” rehabilitation Do most good for the most people Start with victims farthest away from the radioactive explosion These victims are the most salvageable Do not accept blood components of any type DO accept normal saline, Lactated Ringer’s etc., DO accept Epoetin alfa Mastectomy Staff Management Nursing Responsibilities Prior to Surgery Error in Transcription Positioning Clients Occupational Therapy Physical Therapy Radioactive Disasters Jehovah witness
ETHICAL PRINCIPALS/ LAW Veracity: being truthful Justice: treating every client equally regardless of background Accountability: accepting responsibility for actions and admitting errors Nonmaleficence: do no harm, it also relates to protecting clients who cannot protect themselves due to mental or physical condition Fidelity: fulfilling commitments and showing loyalty to one's self and others Beneficence: the action of promoting good will “Let’s talk about it” Surgeon explains the diagnosis and procedure (not the nurse) Client indicates understanding The client is competent and gives voluntary signature The nurse is responsible for witnessing the signature If the surgery requires additional procedures after the surgery has already begun and the consent has been signed for specific procedures, then medical power of attorney, next in kin, or legal guardian should be contacted to discuss Nurses role: witness client has signed, voluntarily and competently, document in medical record that client has signed with date and time, Physician is responsible for: explaining procedure, answering questions about procedure, offering alternative options, reinforcing right to refuse Assault and injury Failure of treatment or intervention Hospital equipment fail Falls Never document an incident report was filed Failure to report an important lab value Mislabeled laboratory specimens Ethical Principle Informed Consent Incidence/ Occurrence Report
Prevents civil action when helping individuals off the job Cannot receive payment Essential for the nurse to perform in the same way as on the job (applying pressure if bleeding) Must act competently Universal criteria that are used to determine if appropriate, professional care has been delivered Sources used to define standards of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, the Nurse practice act, and regulatory organizations Does not depend on good intentions Nurse has obligation to report abuse Child abuse is common in all children ages Most child abusers have low self-esteem Abusers have history of growing up in a domestic violence Abusers have substance abuse problems When child is dying and parents don’t want treatment, priority is to assess parents knowledge of situation This helps clients determine treatment plans and decision makers when or if the client is unable to do so Documents include: health care proxy (durable power of attorney or medical power of attorney) and living will (advance directive) Providing oxygen via nasal cannula is not considered resuscitation and can be given Notified for every clinical death per hospital protocol Cardiac and respiratory support continue as organ donation is discussed or performed Consent is not needed by family if patient has signed to be organ donor Organ donation does not leave the body disfigured Good Samaritan Law Standards of Nursing Practice and Care Abuse Advance Care Planning Local Organ Procurement Services
Practicing outside of scope Abandonment (leaving patients) Stealing narcotics Falsifying documentation An act that threatens the client and makes them feel harm but they are not touched Physical contact with a client without consent Assesses process standards (guidelines, systems, and operations) Assesses clinical issues that affect delivery of client care and client outcomes Implements processes to improve performances Unanticipated event in the healthcare setting that results in death serious injury Radiation damages DNA, which causes cell destruction Early manifestations of radiation contamination include: oral mucosa ulcerations, vomiting, diarrhea, and low blood cell count PPE should be put on before decontamination Victims should be decontaminated outside the facility Reportable Instances to the Board of Nursing Assault Battery Quality Improvement Committee Sentinel Event Radiation Contamination Chemical Contamination Emergency
INTEGUMENTARY Avoid antihistamines for 2 weeks before test and corticosteroids Can take albuterol Inflammatory rash caused by an immune response Milk, wheat, and egg whites can trigger Pressure Injuries - Assess risk for pressure injuries using the Braden Scale - To prevent pressure injuries: - Use barrier creams - Foam pads to reduce pressure on bony prominences - Keep skin clean and dry - Reposition client with a turn sheet every 2 hours - Avoid pulling or dragging client - NO MASSAGES on bony prominences Unstageable wounds: Full thickness skin loss with slough or eschar Skin Cancer Skin Cancer Screening - Full medical workup of every mole is unnecessary - Rapid changing mole should be evaluated immediately - Melanomas can be any color - Melanomas don’t always occur as a new mole Risk factor for skin cancer: - immunosuppressant agents, - celtic ancestry traits - aging - high number of moles Tinea Corporis (Ringworm) - Teach about spreading the condition more - Wash hands - Very contagious Allergy Skin Testing Eczema
Exposure to sun can help slow and decrease exacerbations Most important is to wash skin and get off any excess resin Linear appearance Complication when solutions infuse into the surrounding tissues Discontinue the IV Assess the sight for swelling, redness, pain Elevate the affected extremity Apply cool or warm compress depending on the solution infiltrated Difference between infiltration and extravasation is the fluid infusing Infiltration of drug into surrounding tissues Pain, blanching, swelling, redness Stop infusion immediately Elevate the extremity above the level of the heart Remove clothing and jewelry to prevent constriction Do not massage, rub or squeeze the area Immerse affected area in warm water Provide pain relief as the rewarming process is extremely painful Allow wounds to dry and then apply loose, nonadhesive dressings Monitor for signs of compartment syndrome Skin can appear mottled, blue or waxy yellow - Wash clothes/ bedsheets in hot water Burns - Urine output best indicator of fluid replacement therapy - Lactated Ringers given for fluid volume replacement - Administer pain medication IV - Burns result in largest fluid shift first 24-72 hours (hypovolemia) - Hyperkalemia occurs, Muscle weakness, EKG tall peaked T waves, Cardiac arrhythmias hematocrit/ hemoglobin will be elevated because of fluid changes, Sodium is lost due to fluid shift so they will be hyponatremic - Providing proper nutrition through enteral feeding is highest priority when bowel sounds come back and they start peeing Psoriasis Poison Ivy Infiltration Extravasation Treatment of Frostbite
Dependent on a child’s age and muscle mass Vastus lateralis muscle is preferred for newborns less than 1 month old and infants age 1-12 months Vastus lateralis preferred for children less than 7 months Infants require 1 inch needles for IM injections Ventrogluteal not recommended until adult IM injection needle needs to be 22-25 in size Large bore needles for fluid resuscitation are 18 26 gauge is for subQ injections Can develop from repeated exposure (healthcare workers) Food allergies such as avocados, bananas, tomatoes can signal latex allergy IM Injection Sites Latex Allergy CAUTION MNEMONIC Change in bowel or bladder habits movement (blood) A sore that does not heal Unusual bleeding or discharge from body Thickening or lump in breast Indigestion or difficulty swallowing that does not go away Obvious change in wart or mole Nagging cough or hoarseness (persistent cough vs. seasonal) Inflammation from bacterial infection Characterized by redness, edema, fever, and pain Affected extremity should be elevated Flat or dependent position may worsen edema Applying a warm compress will promote circulation to the area Warning signs of Cancer Cellulitis
RESPIRATORY DISORDERS Post op complication Clients may have difficulty breathing, hypoxia, and basal crackles The elderly, post op thoracic and abdominal surgery clients are at increased risk Encourages clients to breath deeply with maximum inspiration Pulse ox does not correctly reflect oxygen saturation because carbon monoxide has a stronger bond to hemoglobin The nurses primary action is to deliver 100% oxygen through a non rebreather mask at 15 mL/hr May have symptoms of headache, dizziness, nausea Inflammation of the upper airway after viral infection Rhonchi are heard (low pitched wheeze) The sound resembles snoring or moaning Primarily heard during expiration but can be heard on inspiration Also heard in cystic fibrosis Encourage clients who are losing weight and having loss of appetite to avoid drinking fluids during meals, eat small frequent meals, perform oral hygiene before meals Chronic air trapping and reduced gas exchange in these patients by decreasing ventilation Avoid codeine because it is a cough suppressant Client education:Get vaccinated for the flu Seek medical attention for increased sputum production Use albuterol if short of breath Characterized by acute or worsening of patients baseline symptoms NIPPV is often prescribed short term to support gas exchange in those who have hypercapnia ( PACO2 >45) and acidosis (pH < 7.3) It is most important for the nurse to monitor mental status changes in these clients Long acting, 24 hour inhaled medication used to control COPD Most commonly inhaled with a capsule inhaler The capsule should not be swallowed, but placed in the inhaler Atelectasis Incentive Spirometer Carbon Monoxide Poisoning Bronchitis COPD Exacerbation of COPD Tiotropium (Spiriva)
Priority for a newly admitted patient with suspected pneumothorax is covering the wound with a 3 sided petroleum gauze tape This prevents inward air flow, while allowing air to escape the space Never place in a client with suspected head trauma Postoperative bleeding is uncommon but can last for up to 2 weeks This can be indicated by continuous swallowing and cough These patients may even develop restlessness Teaching instruction include: avoid coughing, clearing the throat or blowing the nose, limit physical activity, avoid milk products, avoid harsh brushing and gargling and oral mouth rinses Suctioning only should be applied when taking the catheter out, not inserting it Pre oxygenate client for 30 seconds on 100% oxygen before suctioning Limit suction time to 10-15 seconds Paradoxical chest movement At risk for respiratory failure Can be caused by trauma, rib fractures Used to measure peak expiratory flow rate For patients with moderate to severe asthma The client should exhale as quickly and forcefully as possible The client moves the indicator to the lowest number on the scale before using the device Repeat 3 times The peak flow meter is used after a short acting bronchodilator rescue MDI Applies a given amount of pressure at the end of mechanical ventilation PEEP is usually kept at 5 but for ARDS it can be kept at a higher rate A high level of PEEP (10-20) can cause rupture of the alveoli and overdistention and can cause barotrauma, leading to pneumothorax and subcutaneous emphysema Pneumothorax Nasopharyngeal Airway Tonsillectomy Suctioning Flail Chest Peak Flow Meter PEEP
High pressure alarm is triggered by increased resistance to airflow, means the machine has to push too hard to push air into the lungs, so alarm with sound Obstruction may be from obstructions: kinks in the tubing, water condensing in the tube, mucus secretions in the airway If mucus is the cause, then you would change position, if that doesn't work then you would suction Low level alarm: decreased resistance, could be caused by disconnection of main tubing, and oxygen sensing tubing Disconnection Could signal hypotension Nurse should assess lung sounds to check for proper endotracheal tube placement (best way to check for tube placement) Characteristics: activity intolerance, barrel chest, hyperresonance on percussion, purse lipped breathing, tripod position (progressed) Fourth intercostal space at the midaxillary line, midway of the AP diameter Anatomical point at the level of the chest and the heart Used for correct placement of transducer when measuring BP, CVP, and/or cardiopulmonary pressure invasively Abnormal collection of fluid >15 mL in the pleural space that prevents the lungs from expanding Diagnosed by a chest x-ray or CT scan Clinical manifestations: dyspnea, non productive cough, pleural chest pain with respirations, on assessment clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over affected lung, chest pain during inhalation No wheezing Dislodgement of tracheostomy tube is a medical emergency If a mature stoma is dislodged (>7 days) then the nurse should attempt to open the airway with a curved hemostat If the stoma cannot be opened then cover with sterile dressing and begin ventilation with a bag valve mask Ventilators Emphysema Phlebostatic Axis Pleural Effusion Tracheostomy
The priority care for a new tracheostomy is to prevent accidental dislodgement of the tube, ties should be checked for appropriate tightness, 1 finger should be able to fit between the ties Do not change inner cannula until 24 hours after insertion A cuff is deflated when the patient is awake and alert, determined not to be at risk for aspiration Before the cuff is deflated the client is asked to cough then suction is applied to remove any secretions Suctioning, the catheter should be advanced even if coughing and once resistance is met, pull back 1 cm before applying suction Use strict sterile technique while suctioning Humidifier should not be removed, helps facilitate secretions, even if there is more secretions, it should not be removed Always carry 2 tracheostomy tubes, a big and small one Wait at least 1 minute between suction passes Provides positive pressure oxygen and help expel CO2 COPD patients Hypercapnic respiratory failure Increase salt intake during hot weather Give pancreatic enzymes with meals or snacks Aerobic exercise is recommended Encourage sports (pleural friction rub) characterized by stabbing chest pain that increases with inspiration or cough Complication of pneumonia Visualization of the larynx, trachea, and bronchi while under sedation This patient should be immediately assessed upon returning from surgery The client must be kept NPO until positive gag reflex returns Blood tinged sputum is common but bright red blood mixed with sputum could indicate hemoptysis and needs to be reported to HCP Client is under mild sedation BIPAP Cystic Fibrosis Pleurisy Bronchoscopy
Signs and symptoms usually present within 2-3 days of starting mechanical ventilation Characteristic clinical manifestations include: purulent sputum, positive sputum culture leukocytosis, elevated temperature, or new or progressive pulmonary infiltrates suggestive of pneumonia on a chest X ray Best indicator would be positive sputum culture Lung infection where lungs fill with thick debris and mucus which may cause impaired oxygenation and ventilation Interventions to facilitate secretions removal include: Chest physiotherapy Huff coughing Increase oral fluid intake and IV fluids to thin secretions Fowler's position If patient has difficulty breathing and has left lobar pneumonia then place them on the unaffected side to help with oxygenation (right lateral) People that are over the age of 65, younger than 2, central nervous system depression, ALOC, immunosuppressant, chronic disease, inadequate nutrition, immobility, smoking, upper airway infections, tracheal intubation are at increased risk Upper airway obstruction with multiple events of apnea and shallow breathing CPAP is an effective treatment for OSA It involves using a nasal or full face mask that delivers positive pressure to the upper airways Findings with OSA include: loud snoring, waking up gasping, sleepiness during the day, witnessed sleep apnea, morning headaches Can develop following a pulmonary insult (aspiration, pneumonia) or non pulmonary insult (trauma, sepsis, blood transfusion) to the lungs Fluid leaks into the alveoli causing a noncardiogenic pulmonary edema Lungs become stiff and non compliant which makes ventilation and oxygenation difficult Ventilator Acquired Pneumonia Pneumonia Obstructive Sleep Apnea ARDS
Profound hypoxia despite oxygenation, high concentrations of oxygen is a key sign of ARDS and most important (refractory hypoxemia) Priority nursing diagnosis is: impaired gas exchange Can be put in the prone position: this helps to mobilize secretions, decrease pleural pressure, decrease atelectasis Exhale for 4 seconds through pursed lips Inhale for 2 seconds through the nose with mouth closed Removal of excess fluid in the lungs After this the nurse assesses for pain and difficulty breathing, monitors vital signs and oxygenation, looks for symmetrical chest expansion If any abnormalities are reported then client will undergo a chest x ray Complications from this include: pneumothorax, hemothorax, infection Chest tube reestablishes negative pressure in pleural space The collection chamber is where drainage from client will accumulate, the nurse will assess amount and color Suction control chamber it is expected to find gentle bubbling that is continuous, this means the suction is working properly, should not be intermittent Air bubbles in the water seal chamber would be abnormal and would indicate a leak and require immediate intervention (continuous) Water seal chamber you will see tidling (up and down movement) when the client breathes (intermittent bubbling) this is normal Drainage should be 50-500ml first day, it is expected to be sanguineous (bright red) then change to serosanguineous (pink) then serous (yellow) over a few days Bright red drainage would be of concern after 24 hours or more than 100ml/hr of drainage after the first 24 hours When removing the patient is asked to hold breath and bear down Post procedure chest x ray is done to ensure no fluid or air in pleural space If drainage stops abruptly the nurse should assess for breath sounds to determine if the lung has re expanded, have the patient cough and deep breath, change position Pursed Lip Breathing Thoracentesis Chest Tube Drainage System
Covered with sterile, airtight petroleum jelly gauze If drainage tube becomes disconnected from the plastic chamber, place distal part of tube in sterile saline water Do not clamp chest tube unless checking for air leaks or told so by the HCP Removed when chest tube drainage is less than 200 ml/24hrs, air leak resolved, lung expanded, absent drainage Apical- remove air Basilar- remove blood Pneumonectomy - no chest tubes, trick question If knock over collection chamber, have them take deep breaths What if the water seal breaks? CLAMP FIRST, cut tube, put in sterile water, unclamp it Ambulate within 8 hours of surgery Pain management Coughing and splinting every hour Deep breathing and the use of an incentive spirometer Place in fowler's position Turn client every 2 hours Mouth care 100-120 per minute allowing complete chest recoil after each Defibrillation pads are placed on the right upper chest just below the clavicle and on the left lateral chest below nipple line During CPR, compressions are paused every 2 minutes to check pulse for 10 seconds Manual breaths are delivered at a rate of 2 breaths for every 30 chest compressions Stand clear with each shock of the defibrillator Correct placement of hands is on the lower half of the sternum in the center of the chest Begin CPR before calling 911 if a home health nurse Strategies to prevent post op pneumonia CPR
Evaluates oxygenation and ventilation ABG If the ph and bicarb are in the same direction it is metabolic(up or down) If they are in different directions it is respiratory Bicarb normal: 22-26 pH: 7.35-7.45 If bicarb is normal then respiratory When ph goes up the patient gets irritable, hyperexcitable (K GOES DOWN) When ph goes down the patient does too (K GOES UP) Borborygmi = increased bowel sounds Hyperventilating: alkalosis Hypoventilating: acidosis Caused by NG tube, vomiting, prolonged suctioning Everything that isn’t lung or vomiting or suctioning is metabolic acidosis Metabolic Acidosis Increase in the production or retention of acid and the depletion of bicarb via kidneys or GI tract Common causes: diarrhea, diabetes, alcoholism, starvation, sepsis, hypoperfusion, renal failure pH less than 7.35, Bicarb less than 22 Hyperkalemic Acid/ Base Imbalances Metabolic alkalosis
NSAIDS sensitivity Beta blockers are contraindicated Severe asthma exacerbation: tachycardia (>120), tachypnea (>30), saturation <90%, use of accessory muscles to breathe, and peak expiratory flow of <40 the nurse should give oxygen, SABA inhaler(Albuterol) , and nebulizer treatment anticholinergic (ipratropium) every 20 minutes, systemic corticosteroids Albuterol side effects: palpitations, tremors, difficulty sleeping, N/V Do not give NSAIDS or beta blockers to people with asthma Asthma
DISORDERS OF THE HEART Inflammation of the membranous sac surrounding the heart Can cause pericardial effusion, this is excess fluid in the pericardium and it places pressure on the heart This can lead to cardiac tamponade- signs of this include; muffled or distant heart tones, jugular vein distention, hypotension, narrowing pulse pressure This requires emergency pericardiocentesis Pericardial friction rub is an expected finding with pericarditis invasive diagnostic study of the coronary arteries, heart, and chambers, and function of the heart, patient is awake but mildly sedated Do not eat or drink anything for 6-12 hours Lie flat for several hours following procedure Client may feel warm or flushed when contrast dye is injected Femoral or radial artery are used Produced by turbulent blood flow across diseased or malformed cardiac valves, sound like musical, blowing, swooshing sounds IV iodine contrast No Metformin before surgery Creatinine should be in normal range, or risk of contrast dye not being excreted by kidneys (normal is less than 1.3) after procedure, lay flat in low fowler's position with affected extremity straight for 4-6 hours Assess pulses hourly Keep leg straight, not elevated Encourage client to cough and deep breathe Refrain from lifting the affected arm until healthcare provider approves it Enlarged spleen needs immediate intervention If having sickle cell crisis and vasoocclusion, adequate oxygenation and hydration can reverse, the priority intervention is high flow IV fluids Bleeding disorder , Joint destruction is a long term complication Monitor for bleeding Pericarditis Coronary Arteriogram Murmurs Cardiac Catheterization Femoral Popliteal Bypass Implantable Cardioverter Defibrillator (ICD) Sickle Cell Disease Hemophilia
Wash incisions daily with soap and water No baths Tingling, itching, and numbness around site is NORMAL No powders or lotions Report any redness, swelling, increase in drainage Wear elastic compression socks when, and elevate the legs when sitting Symptoms include: tachycardia to maintain cardiac output, dyspnea, shortness of breath, pallor Cardiac and respiratory drive maintained during severe anemia to maintain CO and respirations Inflammation of the membranous sac surrounding the heart Can cause pericardial effusion, this is excess fluid in the pericardium and it places pressure on the heart This can lead to cardiac tamponade- signs of this include; muffled or distant heart tones, jugular vein distention, hypotension, narrowing pulse pressure) This requires emergency pericardiocentesis Pericardial friction rub is an expected finding with pericarditis Teach clients to relieve pain by sitting up and leaning forward, this reduces pressure on inflamed pericardium invasive diagnostic study of the coronary arteries, heart, and chambers, and function of the heart Awake but mildly sedated Do not eat or drink anything for 6-12 hours before procedure Lie flat for several hours following procedure Client may feel warm or flushed when contrast dye is injected Femoral or radial artery are used IV iodine contrast No metformin before surgery Creatinine should be in normal range, check this lab and BUN Nursing priority after is check distal pulses CABG Care Severe Anemia Pericarditis Coronary Arteriogram Cardiac Catheterization
Large anterior wall: affects pumping ability of ventricle This patient at risk for heart failure and shock so monitor for pulmonary congestion Clinical Manifestations: S3 heart sound, crackles, JVD Meds you see post MI: Aspirin (antiplatelet), -statin(lipid lowering), docusate sodium (stool softener reduce straining), ACE inhibitor (Prevent ventricular remodeling and HF), beta blocker (reduce reinfarction and HF) Nitro can worsen hypotension and cause headache These patients are at huge risk for life threatening dysrhythmias ALWAYS have them on cardiac monitoring If they become hypokalemic, potassium replacement becomes priority Complication: Pulmonary Edema: S&S: Acute onset dyspnea and productive cough with frothy, pink sputum You would hear bilateral crackles at lung bases If they ask about sexual activity: they need to be able to climb 2 flights of stairs without symptoms, and HCP needs to approve Chest pain brought on by myocardial ischemia (decreased blood flow to heart muscle) Can be caused by exercise, sexual activity, anxiety, fear, hypothermia, stimulants (amphetamine) usage, tobacco usage Teaching:Report fever or any signs of redness, swelling, or drainage at incision site Carry pacemaker identification card and wear medical alert bracelet Take the pulse daily and report to HCP if below rate Avoid carrying a cell phone in the pocket over the pacemaker, and when talking on cell phone hold it in ear opposite pacemaker Notify airport security of pacemaker Avoid MRI scans Clients need to be assessed for electrical capture (ECG) of heart rhythm and mechanical capture of heart rate (apical pulse) Radial artery is preferred site for ABG blood draws Allen's test needs to be performed to determine the patency of the artery and ulnar artery and sufficient circulation in the hand Apical pulse - 5th intercostal space, midclavicular line (mitral) Pulmonic - 2nd intercostal space at the left sternal border Mitral valve - 5th intercostal space, midclavicular line Erb's point - 3rd intercostal space at Myocardial Infarction Angina Pectoris Pacemaker Placement Allen’s Test Heart sounds and Locations
Inability of the leg veins to efficiently pump blood back to the heart Can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers on inside of ankle S&S: Edema, thick skin with brown pigmentation, varicose veins, and large ulcers are expected findings COMPRESSION stockings are crucial treatment for healing ulcers These patients have decreased sensations from nerve ischemia or coexisting diabetes S&S: intermittent claudication, hair loss, decreased peripheral pulses, cool, dry, clammy skin, gangrene, thick, brittle nails, ulcers Teaching: Smoking cessation, no heating pads, regular exercise, ideal body weight, low-sodium, glucose control, antiplatelet meds, limb and foot care (lotion) Leg will be cold and mottled Leg pain not relieved by rest Chronic Venous insufficiency Peripheral Arterial Disease
Blood clot formed in large veins of lower extremities S&S: unilateral edema, localized pain/calf pain, tenderness to touch, warmth, erythema, and sometimes a fever Risk factors: Trauma, major surgery, immobilization, pregnancy, oral contraceptives, smoking, old age, malignancies, obesity and varicose veins, myeloproliferative disorders At risk for pulmonary embolism (cesarean birth) Patients should NEVER massage the site- could trigger pulmonary embolism Virchow’s Triad: Flow/stasis, endothelial damage, hypercoagulable state Teaching: If sitting for a long time, >4 hours, use preventative measures (compression stockings, exercise), plenty of fluids and limit alcohol, elevate legs when sitting and flex foot often, resume normal exercise pattern, avoid restrictive clothing, consult with dietitian if overweight Preventing Thrombophlebitis Administer LMH (heparin) Instruct client to flex and point toes every 2 hours Encourage the client to drink fluids while on bedrest Can see redness, warmth NSAIDs contraindicated, no ibuprofen or naproxen or celecoxib They increase the risk of thrombotic events Aortic Valve Replacement Post-Op Chest drainage >100mL/hr should be reported to hCP immediately Teach this client they need prophylactic antibiotics prior to dental procedures to prevent infective endocarditis IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur Sudden onset of painful, pale, cold foot/leg could indicate embolism and should be reported to HCP immediately Which step is most important in a patient with SVT? Synchronize button This delivers a shock during the R-wave of the QRS complex If the client were to become pulseless, the synchronize button should be turned off Deep Venous Thrombosis Coronary Artery Disease Infective Endocarditis Cardioversion
Clients should lay supine for 5-10 minutes and then measure BP and HR The nurse should have the client stand for 1 minute, measure BP and HR, and repeat measurements at 3 minutes Findings are significant if systolic BP drops greater than 20mmHg or diastolic drops greater than 10mmHg Usually caused by air embolism Client will be in respiratory distress: diaphoretic, cyanotic, tachypnea Apply occlusive dressing over the site to prevent entry of additional air into bloodstream Administer 100% oxygen via non-rebreather mask to improve oxygenation Position patient in left lateral trendelenburg position to promote venous air pooling in heart apex Continuously monitor vitals and respiratory effort Notify HCP immediately Client should be at semi-fowler’s: 30-45 degrees Nurse observes for distension and prominent pulsation of neck veins If present in client with heart failure, may indicate exacerbation and possible fluid overload Back flow of blood through left ventricle through mitral valve into left atrium Leads to reduced cardiac output and pulmonary edema Often asymptomatic, but many clients develop heart failure Teach to report any new symptoms of heart failure: dyspnea, orthopnea, weight gain, cough, fatigue Clients will have palpitations, be dizzy, and lightheaded Beta blockers commonly prescribed for palpitations Teaching: Healthy eating habits, stay hydrated, avoid caffeine, reduce stress, avoid alcohol, exercise regularly Nitrates are not effective for chest pain in people with MVP Orthostatic Hypotension Central Venous Catheter Dislodgment Assessing for JVD Mitral Valve Regurgitation Mitral Valve Prolapse
Narrowing of aortic valve, which obstructs blood flow from left ventricle to aorta this worsens, the heart can’t overcome worsening obstruction, and ejects a smaller fraction of blood volume each systole Decreased ejection fraction, narrowed pulse pressure Blood being pumped out insufficient to meet metabolic demands Patients will have exertional dyspnea, chest pain, and syncope Tear in the inner lining of the aorta that allows blood to surge between layers of arterial wall Before surgical repair, the priority is maintaining pressure in the aorta Administer IV beta blocker Always assess BNP in these patients Elevated BNP indicates increased ventricular stretch and correlates with severity of heart failure and fluid volume overload. (increased HR, Hypertension, edema, crackles) Elevated BNP is an expected finding in HF patients These patients will have DECREASED urine output Patient teaching: Daily weight, sodium restriction, take own pulse if taking digoxin or beta blockers, take BP and keep record of it, increase activity gradually, plan rest periods, consider cardiac rehab program, avoid extreme hot/cold Report these symptoms: weight gain of 3 lb in 2 days, or 3-5lbs in a week, difficulty breathing when lying flat/exertion, waking up breathless at night, dry, hacky cough, fatigue, dizziness, swelling of feet, ankles, abdomen, face To assess for presence of this, nurse would listen with bell of stethoscope in epigastric area slightly left of midline Renal perfusion status monitored closely Monitor for hypotension, dehydration, blood loss, embolism Check BUN and creatinine, and urine output (at least 30mL/hr) Manifestations of graft leakage: ecchymosis of the groin, penis, scrotum, or perineum, increased abdominal girth, tachycardia, weak pulses, decreasing hct and hgb, pain in pelvis, back, or groin, and decreased urinary output Aortic Stenosis Aortic Dissection Heart Failure Abdominal Aortic Aneurysm
After AAA repair, pulses can be absent for 4-12 hours after surgery due to vasospasms But a decrease from baseline after this time could mean an occlusion Light palpation TeachingThis filter will trap blood clots from lower extremity vessels Promote physical exercise, report symptoms of pulmonary embolism (chest pain, SOB), and impaired lower extremity circulation (pain, numbness), and notify the health care team prior to having MRI’s Beck’s Triad: hypotension, muffled heart sounds, distended neck veins, narrowing pulse pressure Often caused by a clot in a chest tube that causes excess fluid buildup in pericardium Warning sign: decrease in chest tube drainage Normal MAP is between 70-105 If MAP falls below 60, vital organs can be underperfused and become ischemic Systolic blood pressure + (diastolic blood pressure x 2)/ 3 Life-threatening emergency due to the possibility of severe organ damage If not promptly treated, can lead to intracranial hemorrhage, heart failure, myocardial infarction, renal failure IV Vasodilators: nitroprusside sodium Lower BP slowly Initial goal: decrease MAP by no more than 25% or maintain MAP at 110-115mmHg Prioritize neurological assessment because decreased LOC can signal a hemorrhagic stroke Associated with hypomagnesemia It causes prolonged QT interval Magnesium sulfate is treatment Inferior Vena Cava Filter Cardiac Tamponade MAP Hypertensive Crisis Torsades de pointes
Surgical connection from an artery to a vein to provide vascular access for hemodialysis Client should perform hand exercises to mature the fistula Thrill (vibration) needs to be palpable and an auscultated bruit Aseptic technique Sterile dressing changes every 48 hours with gauze or every 7 days with as transparent dressing Line should be flushed before and after medication administration Blood pressure and venipunctures on opposite arm of PICC All medications should be paused when blood draw occurs (except vasopressors) Scrub the hub for 10-15 seconds Femoral access sites should be removed first because they have the highest risk of infection Preferred access sites for adults are subclavian vein or jugular veins because less chance of infection Priority after placing subclavian cvc is to check placement in the superior vena cava with a chest x ray A filter should also be used when administering TPN through this site Increased respirations (dyspnea), increased pulse, increased blood pressure May be a normal finding in young adults In older adults, it could indicate fluid volume overload or heart failure so this is a significant finding Arteriovenous Fistula PICC Care Central Venous Access Subclavian Central Venous Catheter Fluid Volume Overload S3 Heart Sound
Blood should not be left out for more than 30 minutes, if the start of the transfusion is delayed, then the blood should be returned to the blood bank- hemolytic reaction: destruction of red blood cells, can see hematuria in the urine, cyanotic, pale, back pain, hypotension Dyspnea can indicate circulatory overload Blood must run slowly for the first 15 minutes, no more than 2-5 ml/min Never warm the blood and blood should be transfused within 4 hours first 15 minutes run slow, watch for reaction, nurse should stay with patient Do not discard blood products, keep to investigate what occurred administer with filter tubing and normal saline If a suspected transfusion reaction is occurring, the first thing to do is to stop the transfusion Normal saline infusion is typically started and it is important that it is transfused through a different port Notify HCP Assess the client Automated external defibrillator should be used as soon as possible AED pads for children up to 8 years, place one on chest and one on back if only have adult AED pads (sandwich the heart) Pads should never touchIf client is wet, dry them, remove anything on them that may be in the way and apply the pads Most common type of shock when blood volume decreases because of hemorrhaging or third spacing from burns Treatment: restoring fluid and preventing further fluid loss, improving hemodynamic stability through vasoactive medications (norepinephrine, dopamine) Norepinephrine causes vasoconstriction and improves heart contractility and cardiac output but the effects end quickly, this should be tapered slowly and never stopped abruptly Isotonic solutions are used to restore fluid (0.9% NS, Lactated Ringers) Blood Transfusion Transfusion Reactions AED Hypovolemic Shock Ventricular Tachycardia
Can be pulseless or with a pulse Stable client with a pulse: treat with medication (Amiodorone) Unstable client without a pulse: CPR and synchronized cardioversion Positive pressure ventilation delivers positive pressure to the lungs using a mechanical ventilator Adverse effect of this is hypotension because it causes decreased cardiac output and decreased venous return to the heart Twisting pattern dysrhythmia First line treatment is IV Magnesium Short, frequent attacks are first treated with vagal maneuvers They can bear down like having a bowel movement Regular tachycardia with a rate of 150-220 Best treatment is vagal maneuvers and Adenosine IV push (Intropin) Used to improve hemodynamic status in those with shock and heart failure Enhances cardiac output by increasing myocardial contraction, increasing heart rate, and elevating blood pressure through vasoconstriction Increases renal perfusion which increases urinary output Adverse effects: tachycardia, dysrhythmias, myocardial ischemia Given to people with hypotension Needs adequate fluid volume replacement Ventricular trigeminy Occur every third heartbeat MI predisposes to PVC PVC are caused or exacerbated by hypoxia, electrolyte imbalances, stress, stimulants, fever, and exercise Potassium replacement if low Cannot shock this rhythm If a patient has this rhythm, the first thing the nurse should do is verify the monitor reading by palpating the pulse (ASSESS!) PPV Torsades De Pointes Paroxysmal Supraventricular Tachycardia Dopamine PVC Asystole
Priority is to provide continuous CPR and epinephrine Phentolamine is the antidote Used to increase rate of heart and CNS Should be given through a central line Avoid IM injections to reduce client injury Monitor neurological changes Takes longer for these clients to clot so at risk for bleeding Check BUN and Creatinine to make sure they don't become elevated with use of diuretics, also check Potassium and blood pressure Produced by turbulent blood flow across diseased or malformed cardiac valves, sound like musical, blowing, swooshing sounds Plasma protein with normal range: 3.5-5.0 Ontonic pressure component that helps PULL water back into the circulatory system Plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels Liver makes albumin Hypoalbuminemia is common in people with liver disease, can lead to pitting edema if albumin levels are low because can not pull fluid back into circulatory space If a patient has protein in the urine, could indicate kidney dysfunction Protein in the urine could be an early sign of kidney disease in patients Can occur 24-72 hours after trauma or surgery and it is where fluid shifts from the intravascular space to the space between cells (interstitial space) Leads to decreased circulating volume (hypovolemia) and decreased cardiac output, weight gain, decreased urinary output, tachycardia, hypotension If this is suspected the FIRST thing the nurse should do is assess vital signs Epinephrine Thrombocytopenia Administering diuretics Murmurs Albumin Third Spacing
MUSKULOSKELETAL DISORDERS Clean limb by washing it daily with soap and water Assess skin for redness or skin breakdown Clean and dry socks and wraps Perform daily range of motion exercises Lie on stomach for 30 minutes several times each day and avoid sitting in Do not apply lotion/ powder Should not be elevated, use ace wrap bandage instead to help with edema Reversible bone disorder caused by lack of vitamin D Characterized by weak, soft, and bones that hurt These bones can easily fracture or become deformed Nurse should clean pin sites with sterile solution to prevent infections Keep the vest cool and dry and using low cool blow dryer to dry Place foam inserts at pressure points Placing a small pillow under clients head when supine Only health care provider can adjust loose pins, keep wrench at bedside though and contact HCP if pins are loose Do not hold frame of device when moving the client Pain and paresthesia in the hand caused by the compression of the medial nerve IMMOBILIZE THE WRIST with a splint Do not do repetitive wrists movements Happens when muscle fibers are released in the blood after trauma or injury This can cause acute renal failure The nurse’s priority action is to prevent kidney failure by filtering the kidneys so the nurse should provide a bolus of NS Residual Limb Care chair for more than 1 hour to avoid hip flexion contractures Osteomalacia Halo Device Fracture Carpal Tunnel Syndrome Rhabdomyolysis
Clinical features: leg abducted, shortening of the affected limb, ecchymosis and pain over groin and hip area and pain when weight bearing, muscle spasms, externally rotated Report foul odors or hot areas in the cast because this may indicate infection Avoid getting the cast wet Elevate the affected extremity above heart level for first 48 hours Perform isometric and ROM exercises regularly Never put anything inside of cast to itch, use air dryer Cane length should be from greater trochanter to the floor Hold cane on strong side to provide maximum support Put can several inches in front of and to the side of unaffected foot Move cane first then affected leg These patients will expect to have confusion, restlessness, petechiae over chest, hypoxic, mental status, respiratory distress, fever NOT EXPECTED would be pain in affected limb and numbness and tingling To help prevent this from happening it is important to stabilize and immobilize the fracture immediately , minimize movement of the fractured extremity to help reduce the risk of FES Client should be supine or in semi fowler's position Do not elevate the head of the bed more than 30 degrees Weights should be free hanging at all times and should never be placed on the bed or floor Never remove the weights, could be life threatening Monitor neurovascular and skin integrity Body should be aligned at all times Immobilize knee, keep in straight position Do not place anything under the knee, can put pillow on foot/heelJoint flexion with increase the risk of fractures Hip Fractures Cast Care Cane Use FES Bucks Traction Knee Replacement Surgery
Weight should be placed on the upper arms and hand grips, not axilla of crutches Hand grip is right when elbow flexion is 30 degrees Swing through - non weight bearing, amputation 2 point and 4 point gates bilateral weakness (2 legs affected) Odd number gate when one leg is affected Up with the good, down with the bad Upstairs- lead with good foot, then crutches Downstairs- lead with the bad Positive orthostatic vital signs Osteoarthritis IV therapy Gait abnormality Medications Ambulatory aid Over age 65 Exercise programs Wearing needed glasses Well lit rooms No rugs Handrails Non skid shoes and socks Staff hourly rounding Rare but life threatening inherited muscle abnormality that is triggered by inhaled anesthetic agents Leads to sustained muscle contraction and rigidity (early sign) then can lead to a dangerously high temperature due to increase metabolic demands and oxygen demands (late sign) If the patient has never had anesthesia before, you can ask if any of their family members have had a bad reaction to general anesthesia Crutches Increased Risk for falls Prevent Falls Malignant Hyperthermia
Can administer insulin through a continuous dose or or bolus administered at meal time The client will experience fewer swings in blood glucose levels and hypoglycemic episodes Still need to check blood sugar 4-8 times a day Assess mental status to see if clients with insulin pumps can manage it safely The diabetic client with hypokalemia is at risk for severe cardiac dysrhythmias Before administering insulin to a client with hypokalemia, the nurse should contact the HCP Insulin can worsen effects of hypokalemia, they may need supplemental potassium Only insulin that can be administered IV Push Regular insulin injection peaks 2-5 hours Clients that receive IV contrast dye for a CT procedure and receive Metformin are at increased risk for lactic acidosis, therefore the HCP may discontinue metformin for 24-48 before the CT Long acting insulin has no peak and may last 24 hours or longer Should not be mixed in same syringe with any other insulin, use seperate site Insulin Pump Hypokalemia Regular Insulin Metformin Glargine DIABETES & INSULIN
CONTACT PRECAUTIONS Airborne Precautions TB Measles Varicella Chickenpox (incubation 2-3 weeks) Confirm with chest x ray before placing client in isolation room >15 is positive TB test in a healthy client Latent TB infection are not contagious Active TB are infectious and can transmit through air TB treatment can be anywhere from 6-9 months long, crucial for patient to finish medications Clinical manifestations: Night sweats, weight loss, purulent or blood tinged sputum, fatigue, low grade fever Airborne precaution Negative pressure room Shingles lesions that are open may be transmitted airborne and contact The client with disseminated lesions that are not crusted over well should be put in a private room with negative airflow pressure, contact precautions and airborne precautions Localized shingles requires only contact precaution Airborne TB Shingles
When client has open active lesions they should be on airborne precaution Negative pressure room N95If in contact with body fluid then contact precautions Varicella Droplet Precaution Meningitis H flu B - can cause epiglottitis Private room, mask, gloves, no gown, no eyeshield, no negative airflow Highly contagious and requires droplet precautions Rapid coughing and vomiting whooping cough monitor for signs of airway obstruction Droplet precaution Care for this client includes: Droplet precaution Seizure precaution Reduced stimulus environment Bed rest, head of the bed elevated 10-30 degrees Does not need a negative pressure room Droplet Pertussis Meningitis
Private room preferred, gloves, gown RSV C diff Hep A Staph infections Herpes Infections Clients with this infection should be bathed with pre moistened cloths or warm clothes with chlorhexidine This can reduce spread of infection Place MRSA client in a private room or semi private with a client that has the same infection Dedicate equipment for client Wear gloves when entering the room Hand hygiene when exiting the room, can be soap and water or alcohol based Wear gown with client contact Post notification on door Ensure client only leaves room for essential test etc. No need to wear a mask Clients should be put on contact precautions (gowns and gloves) in private rooms to eliminate spread of infection Hand hygiene using soap and water (not alcohol based) Diluted bleach solution must be used to clean surfaces Manifestations: watery diarrhea ,fever/nausea , abdominal pain C-Dif can lead to hypovolemia (hyponatremia, hypokalemia, elevated BUN) Steps to prevent UTI in clients with urinary catheters include: Wash hands Wash perineal area with soap and water each shift and after bowel movement Catheter bag below the level of the heart Use sterile technique when collecting urine sample To reduce the risk of infections, the best IV sites would be in the forearm or hands Overwhelming response to infection that causes impaired organ function Septic shock occurs when sepsis causes cardiovascular collapse and/ or the body cannot maintain normal metabolic function Fever or hypothermia, Hypotension , Prolonged cap refill , Tachycardia Contact Precaution MRSA CDiff Preventing HCAUTI Peripheral IV Sites Sepsis Septic shock manifestations: Increased WBC count (over 11000) , Decreased urine output
Infection of the CD4 Helper T cell Low counts can increase chance of infection To reduce the risk of infection patients should: Get influenza vaccine Avoid eating undercooked meals Drink bottled water Use condoms Avoid cat litter Avoid large crowds Develops after bit from infected tick Bulls eye rash Flu like symptoms migraines Usually bacterial in origin Classified as upper or lower depending on where the infection is Inflammation and infection in the kidneys and ureters (pyelonephritis) Become very ill nausea/ vomiting fever/ chills Flank pain Inflammation and infection of bladder (cystitis) Most common type of UTI Burning with urination urgency/ frequency Hematuria , Suprapubic discomfort Infection of the mucous membranes caused by yeast like fungus The fungus causes pearly milk curled lesions orally Clients who are immunocompromised are at increased risk for developing thrush, especially those taking corticosteroids orally Transmitted through fecal- oral route Priority is hand hygiene to prevent transmission HIV Infection Lyme Disease UTI Upper UTI Manifestations: Lower UTI Manifestations: Thrush Hep A
Sputum culture and sensitivity test nursing considerations: teach client to rinse mouth out with water before collecting, morning is best time to collect, inhale deeply several times then cough forcefully, assume a sitting or upright position Always clean wound first before taking a wound culture Clean gloves and hand hygiene to remove old dressing Sterile gloves and hand hygiene to swab from wound center to outer margin Intradermal injection 1 mL tuberculin syringe with a 27 gauge ¼ inch needle Pull skin downward so that it is taut Insert needle at a 10 degree angle Outline of bevel should be visible under the skin Inject the medication slowly and form a small bleb under the skin Circle border Avoid rubbing site after injection Done in forearm Life threatening complication of cancer treatment, considered an oncological emergency When cancer treatment kills cells, it releases different intracellular components causing a life threatening imbalance Clinical manifestations: hyperkalemia, large amounts of nucleic acids can cause acute kidney disease, hyperphosphatemia, hypocalcemia Sputum Culture Collection Wound Culture TB Testing Tumor Lysis Syndrome
RENAL / URINARY Measure of glomerular function and indicator of renal disease process 24 hour urine collection is needed for this test First urine sample is discarded and time is noted All other urine samples for the next 24 hours are collected and kept cool At the end of the 24 hours the client should attempt to void one last time and add to collection container Blood is also drawn to collect creatinine level Obtaining tissue sample to determine the cause of certain kidney diseases Bleeding is the major complication for this procedure Before the procedure the client must give informed consent and discontinue all anticoagulants and antiplatelet medications for at least one week The client should have well controlled blood pressure and be crossed matched just in case of infusion After the procedure the nurse should monitor the vital signs for the first hour every 15 minutes and assess puncture site for bleeding Position the client on the affected side for 30-60 minutes and bed rest for the first 24 hours Inserted through the urethra to directly visualize the bladder wall and urethra Burning sensation upon urination is normal after procedure Complications associated include: urinary retention, hemorrhaging, infection Notify the HCP immediately if blood clots, blood tinged urine, inability to urinate, chills, abdominal pain or fever are present Radiologic test to visualize renal blood vessels Contrast medium is injected into the femoral artery Teach client to increase fluid intake after the exam to flush dye from the body Increased urination after exam is expected outcome because want to flush fluids Creatinine Clearance Kidney Disease Cystoscope Renal Arteriogram
Abnormal prostate enlargement most commonly affecting males over the age of 50 The prostate gradually enlarges and compresses the urethra Clinical manifestations include: urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency, and urinary retention, intermittent or weak stream, incomplete emptying sensation, straining or difficulty starting stream The nurse should teach about ways to control and manage these: medications, lifestyle changes, voiding schedule, avoidance of caffeine and antihistamine These patients have an increased risk of UTI If the patient is experiencing burning while urination, it could mean a UTI is present and further assessment is required Nursing care plan for this includes: teaching kegel exercises, bladder training, incontinence products, and lifestyle changes, avoid smoking, drinking, caffeine, use of pessary The highest priority with a client newly diagnosed with stress incontinence is preventing skin breakdown, and UTI through bladder training, the nurse should teach the patient to void every 2 hours Pessary can remain in place while sexually active Happens when there is increased abdominal pressure, from coughing, sneezing etc The peritoneum is used as a semipermeable membrane to dialysis clients The tubing is clamped to let the fluid work for a specific period Clients are closely monitored for respiratory distress while the fluid is inside Crackles in the lungs require immediate intervention Essential to use sterile technique when spiking the bag Bacterial peritonitis is a potential complication and can lead to sepsis Place the catheter bag below the client (below abdomen) and the client should be in fowlers or semi fowler's position Cloudy outflow, tachycardia, low grade fever are signs of peritonitis Bloody fluid could indicate intestinal perforation Benign Prostatic Hyperplasia Stress Incontinence Peritoneal Dialysis
Brown fluid could indicate fecal contamination insufficient outflow may result from constipation, if outflow becomes sluggish, the nurse should reposition the client (side lying), check for distention, and check for kinks in the tubing or assist with ambulation Never flush the tubing or pull on it Can gently rotate the check for kinks Hallmark finding is painless hematuria Primary cause is cigarette smoking Opioids may cause urinary retention because they relax the bladder muscle The nurse should assess the clients subprubic area for retention Often occurs in older men with BPH If a man is having trouble urinating after surgery, the initial action is to get them out of bed and see if that helps, second intervention would be to bladder scan At risk for uncontrolled hypertension and hypertensive emergencies Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache Immediate assessment and intervention required within one hour Are at risk for hyperkalemia and fluid overload Clients should avoid salt substitutes which typically contain potassium chloride Fluid restriction, potassium restriction, sodium restriction, low protein diet, low phosphorus diet Upper urinary tract infection Clinical manifestations: chills, fever, vomiting, flank pain, costovertebral tenderness Blood and urine cultures should be obtained prior to antibiotic administration Bladder Cancer Urinary Retention Chronic Kidney Disease Acute Pyelonephritis
Rapid, complete, bladder decompression is done This can be associated with hematuria, hypotension and postoperative diuresis Complications the nurse should assess for: hypotension and bradycardia Some medications should be held prior to receiving dialysis including: antihypertensives because it could lead to hypotension also vitamins B and C, digoxin and antibiotics No need to give heparin before dialysis because it is given during rare but life threatening complication that occurs during the initial stage of dialysis creating increased intracranial pressure, slowing the rate can prevent Symptoms include: nausea, vomiting, seizures, headache, restlessness, change in mentation If this is suspected the HCP should be called immediately and dialysis should be slowed or stopped Check weight from previous dialysis and current weight/ VS 3 way catheter usedInfusion rate should be sufficient to eliminate obstruction of flowThe nurse should assess tubing and make sure there are not clots blocking the flow Best indicator of of productive flow rate is the output urine color (light pink) Never pull foreskin back can cause swelling and paraphimosis Can use elastic adhesive to spiral around to secure Leave 1-2 inch space in catheter Take all antibiotics Increase fluid intake Wipe from front to back Cotton underwear Void after intercourse Avoid douching and using feminine perineal products Avoid spermicidal contraceptive jelly Acute urinary Retention Dialysis Dialysis equilibrium syndrome: Continuous Bladder Irrigation Condom Catheters Preventing UTIs
Occurs due to compression of the urethra or impairment of the bladder muscles this can lead to incomplete bladder emptying and urinary retention this can lead to urine dribbling Nursing care includes: scheduling a voiding pattern (every 2 hours) to prevent distention instruct client to bear down and applying gentle pressure to the lower abdomen to facilitate bladder emptying assess skin for breakdown encourage client to void 30 seconds after voiding, and check residual volume If there is leakage then the nurses first action is to assess the catheter tubing Dislodge visible obstruction by milking the tubing Irrigation is usually avoided because puss or sediment can flow back into the bladder Fill balloon with 5mL of saline For males it is recommended that the catheter be inserted 7-9 inches then an additional 1 inch after urine is seen in the collection bag Reversible neurological complication of cirrhosis caused by primarily increased levels of ammonia in the blood Lactulose is the most common treatment for hepatic encephalopathy, it is a laxative but it helps excrete ammonia It can be given on an empty stomach and it can be given with juice, milk or water Low serum Albumin, high ammonia levels, elevated INR/ PT, increased bilirubin levels, low platelets May take Lactulose to excrete ammonia Given dark jug to preserve urine Uncontrolled hypertension is contraindicated in these patients Elevated creatinine is an expected finding in someone with kidney disease Decrease hemoglobin level is expected in someone with kidney disease At risk for hyperkalemia Overflow Urinary Incontinence Bladder Catheterization Hepatic Encephalopathy Liver Failure Urine Collection Kidney Biopsy Acute Kidney Injury
GI DISORDERS At least 3000 ml of fluid a day Avoid eating foods that cause gas (broccoli, cauliflower, brussel sprouts, beans) Empty the pouch when it becomes one-third full Acute inflammation of the pancreas that results in autodigestion Most common causes are cholethiasis and alcoholism Signs include severe epigastric pain radiating to the back, amylase and lipase are ELEVATED Complications: hypovolemia, hyperglycemia, hypocalcemia, latent hypoxia, ARDS, cardiac arrhythmias Barium Enema Uses fluoroscopy to visualize colon with dye Contraindicated in patients with diverticulitis Preprocedure instructions include: take cathartic (magnesium citrate etc.) to empty stool from colon, Follow a clear liquid diet the day before the procedure to aide in bowel preparation and to prevent dehydration, Do not eat or drink anything 8 hours before the test, May experience abdominal cramping and urge to defecate during the procedure Expect passage of chalky white stool after procedure Take a laxative to get rid of excess barium Drink fluids Keep daily record of symptoms Exercise Limit gas producing foods Reduce daily caffeine intake Do not fast, do not go on clear liquid diet when symptoms are bad Care of Stoma Pancreatitis IBS Peptic Ulcer Risk factors: H. pylori infection, stress, smoking, diet, alcohol use, NSAID use, genetic predisposition, avoid eating meals before bedtime
When administering bolus enteral feedings, the nurse should raise the head of the bed and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk Feeding tubes should be flushed before and after feedings to keep the tubes patent Gastric residual volumes are checked every 4 hours with continuous feeding and before each bolus feeding Gastric pH should be acidic (less than 5) A pH over 6 requires chest x ray placement check of the NG tube Newly placed tubes also require placement check Do not remove stylet before x ray is performed These patients can develop respiratory complications due to the release of cytokines and pancreatic enzymes that cause systemic inflammation ARDS is most serious complication If crackles are heard in these patients, immediate action needs to be taken Healthy stoma should be pink to bright red and moist If the stoma is dusk or any color blue the HCP should be informed Medical emergency GI absorption of neurotoxin Organism found in soil and can grow in any food contaminated with the spores Clinical manifestations: muscle paralysis, descending flaccid paralysis (starting with the face), dysphagia, and constipation Main source is improperly canned food or stored foods LOOK FOR CANNED FOODS WITH SWOLLEN ENDS No raw honey for children under age 1 Inflammation of the gallbladder Highest priority for a vomiting/ nauseous patient with this is NPO status so the gallbladder is not stimulated more Also maintain low suction for NG tube, semi-fowler position, IV fluids Tube movement of 0.5 cm when the client coughs Should rest loosely above the skin Resistance shouldn’t be felt when moving around Performed through an orogastric tube to remove ingested toxins and irritants to the stomach Done if the ingested toxins are considered lethal and if it can be initiated within 1 hour Nasogastric Feeding Tubes Acute Pancreatitis Stoma Botulism Cholelithiasis PEG Tube Gastric Lavage
SPINAL CORD INJURIES Vasodilation will occur due to loss of innervation from the spine This will decrease venous return to the heart , signs of neurogenic shock include: hypotension, bradycardia, and pink and dry skin from the vasodilation Usually occurs in cervical or T6 or higher spinal injuries Priority nursing care is administering normal saline to increase blood pressure and perfusion to vital organs Removing the posterior of spinous process Relieves compression of nerve root Pain, paresthesia, paresis(muscle weakness) these are signs that the nerve root is being pressed on so then would get a laminectomy The location will determine the symptoms, prognosis and symptoms 3 locations: cervical, thoracic, lumbar LOG ROLL AFTER SURGERY Anterior thoracic will have chest tubes Laminectomy with fusion- take bone from hip Do not dangle, no sitting Do not sit for longer than 30 minutes They may walk, stand, or lay without restrictions Discharge teaching: 6 weeks no sitting for more than 30 minutes, lie flat and log roll for 6 weeks, no driving for 6 weeks, do not lift anything over 5 lbs for 6 weeks, cervical lams cannot lift anything over the head Trauma should follow ABC Especially true with suspected head and neck injuries Until the spin is appropriately addressed, the patient should be placed on a backboard The nurse should use the jaw thrust maneuver NSAIDS N, neurological damage Neurogenic Shock Laminectomy Jaw Thrust Maneuver Acronym to help determine spine immobilization
S, significant traumatic injury A, alertness I, intoxication D, distracting injury S, spinal examination Treatment: want stomach to empty slower, so lay down after eating, meals should be small, low fluids, low carbohydrate, get fluids before or after meals, NEVER with meals, high protein, high fiber Kalemias do the same as the prefix accept for heart rate and urine output This is a helpful sentence to remember the symptoms of hyper and hypokalemia Calcemias and magnesiums do the opposite of the prefix ( everything goes down when calcium goes up) Earliest sign of any electrolyte disorder is numbness and tingling (paresthesia) Circumoral paresthesia (numb and tingling lips) Fastest way to lower high potassium (give D5W with regular insulin) tpn and parenteral are IV feedings Indicated for malabsorption Enteral are tube feedings like NG Stomach is pushing through the diaphragm GERD Heartburn, indigestion Treatment: sit up after eating, want stomach to empty faster Keep head of the bed in high position, high carb diet, fluids high and carbs because we want things to go fast Low protein Brace should be worn 23 hours a day Lateral deviation Wear shirt under Dumping Syndrome Electrolytes TPN VS ENTERAL VS PARENTERAL Hiatal Hernia Scoliosis
NEURO & BRAIN normal things that happen when clients age are decreased sphincter reflexes, increased frequency, decreased peristalsis Incontinence is not normal in the aging process, GI neurological changes are NOT normal Rupture of blood vessel in brain causing bleeding into brain tissue or subarachnoid space Nursing considerations: Patient is on seizure precautions because risk of IICP They may develop dysphagia so NPO for these patients until swallow function test is performed Frequent neuro checks The nurse should prevent activities that increase ICP How to decrease ICP: reduce stimulation maintain quiet and dim environment limit visitors stool softeners to reduce straining strict bed rest, assist with ADLs maintain head in midline position to improve jugular venous return to the heart NO anticoagulants Inflammation of the meninges covering the brain and spinal cord Clinical manifestations: N/V Fever Severe headache Nuchal rigidity Photophobia AMS (altered mental status) IICP Stiff neck Pain with flexion Patient should be put on droplet precautions No negative pressure room Client aging: Hemorrhagic Stroke Meningitis
Peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (CN7) in the absence of a stroke or other diseases Flaccidity of affected side Clinical manifestations: Inability to close eyes of affected side Cannot smile symmetrically Lacrimation of the eye is decreased on affected side Flattening of the nasal labial fold Facial drop Cannot close eye correctly Expressive , Impaired speech and writing May be able to speak short phrases but has difficulty with word choice The nurse should listen and give time for patient to speak Easily frustrated when attempting to speak Clients speech is limited to short phrases that require effort Receptive Impaired comprehension of speech and writing May speak full sentences but the words do not make sense Ask simple yes or no questions Loss of the ability to perform a movement due to neurological impairment Neurodegenerative disease with no cure Degeneration of motor neurons in the brain and spinal cord Clinical manifestations: Fatigue Muscle weakness that is progressive Twitching and muscle spasms Difficulty swallowing, difficulty speaking Respiratory failure Clients usually survive 3-5 years and there is no cure Part of a focused neurological exam assessing vestibular function and body in space Used to determine the reason for loss of coordination Clients are asked to stand with the feet together and eyes closed If loss of balance occurs then ataxia is considered to be sensory These patients will have loss of balance and need assistance with ambulation Bell Palsy Aphasia Syndrome Broca Wernicke Apraxia ALS Romberg Test
Induced in clients who suffer neurological injury due to cardiac arrest or in comatose or clients who do not follow commands after ressecutation Induce 6 hours after arrest up to 24 hours Improves neurological outcomes and decreases mortality rates Look for signs with Cushing’s Triad as it is related to IICP Change in LOC Bradycardia Widening pulse pressure Cheyenne stokes respirations Cushing's triad is a late sign and signals that the brain stem is compressed Keep head of the bed at 30 degrees Usually occurs in children Daydreaming like episodes, usually 10 seconds and staring No memory of the seizure During seizure activity, priority is client safety Assist to lie down from a chair or whatever they are doing Loosen restrictive clothing Administer oxygen as needed Never restrain and never insert anything into the mouth During seizure activity need to stop, administer IV or rectal benzos (diazepam, lorazepam) Loss of half of the visual field on the same side May lose left side of visual field in both eyes High risk for self neglect Change in LOC Amnesia Headache Rest and light diet are encouraged No strenuous activities for 1-2 days Autoimmune disease involving a decreased number of acetylcholine receptors and leads to skeletal muscle weakness Clinical Manifestations: ptosis/ diplopia Therapeutic Hypothermia IICP Absence Seizures Seizures Homonymous Hemianopsia Concussion Myasthenia Gravis
Bulbar signs (difficulty speaking or swallowing) Difficulty breathing Muscles are stronger in the morning and weaker in the evening Treatment: anticholinesterase drugs before meals Semi solid foods Need to teach about the importance of the flu vaccine (anyone with an autoimmune disease) Involved in coordinating voluntary movement and balance and posture Assessed with gate testing (heel to toe) Finger tapping, touching nose with finger Immediate CT or MRI Thrombolytic therapy within 4.5 hours (contraindicated in bleeding, hypertensive, aneurysm) Neuro assessment Highest score 15 Lowest score 3 Best indicator of decline is score decreasing in small amount of time vs. individual component or answer chronic , progressive, neurodegenerative disease of the dopamine producing neurons Characterized by: Slow movement (bradykinesia) Increase muscle tone (rigidity) Resting tremor Shuffling gait Short steps Stooped posture, Masked facial expression Caused by low levels of dopamine in the brain Levodopa Carbidopa (Sinemet) is a medication that can help in treating bradykinesia Once this medication is started, it should never be stopped because it can lead to complete loss of movement This medication takes several weeks to reach effect The client’s urine and saliva may turn a reddish-brown color but this is not harmful Testing Cerebellar Function Ischemic Stroke GCS Parkinson Disease
Engaging in regular exercise decreases the risk of AD Genetic, lifestyle, and environmental factors Family history is a risk factor Trauma to head is a risk factor Usually over 65 Healthy lifestyle to reduce the risk of AD Caring for clients with AD Use distraction and redirecting to manage agitation (go for a walk) Speak slowly, simple words, yes or no questions No open ended questions Break down complex activities into steps with simple instructions Decrease client’s anxiety by limiting number of choices Sharp pain along trigeminal nerve Primary prevention is consistent pain control Carbamazepine is the drug of choice This is a seizure medication and is highly effective in controlling neurological pain This medication is associated with infection risk and leukopenia so the patient should report any fever or sore throat Evaluate brain electrical activity Hair needs to be washed before procedure Avoid caffeine, stimulants, and CNS depressants The test is not painful and no analgesia is required No chocolate before Foods and liquids are not restricted before test Not painful and not sedated Increased ICP Increased head circumference, sunset eyes, bulging fontanelles Open spina bifida Open area in lumbar spine Risk for infection Priority intervention it to cover with a sterile, moist dressing Alzheimer’s Disease Trigeminal Neuralgia EEG Hydrocephalus Myelomeningocele
The patient with be in the lateral recumbent position or sitting upright, these positions allow for widening of the space inbetween the spinal vertebrae Before the Procedure: Client will be asked to empty the bladder Needle will be inserted between L3/L4 or L4/L5 Pain may be felt radiating down the leg, temporary After the Procedure: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resulting headache Increase fluid intake for the next 24 hour to reduce dehydration Chronic seizure activity Seizure triggers include:Avoid alcohol in excess, sleep deprivation and stress Practice relaxation techniques Medical alert bracelet Phytenin may decrease oral contraceptive effectiveness so use non hormonal birth control Phytenin may cause fetal abnormalities Do not stop medication abruptly Sign of severe brain injury Arms and legs will be straight out, toes pointed down, and head and neck arched back These assessment findings indicate that severe injury has occured CSF fluid leak from nose and ears, racoon eyes, Battle’s sign (bruising around the ears) Dextrose testing can be done on the fluid to confirm it is CSF This CSF leak puts the client at risk for infection No NG or oral tubes should be placed unless with fluoroscopic guidance Coagulated blood surrounded by halo ring of CSF can be a positive sign (halo ring sign) Hyperventilate before suctioning Maintain dark, quiet environment Maintain the head of the bed in a neutral, midline position Elevate head of the bed to 30 degrees Administer stool softeners to decrease straining Manage pain Manage fever Lumbar Puncture Epilepsy Decerebrate Posturing Basilar Skull Fracture What can the nurse do to decrease IICP Administer stool softeners to decrease straining Manage pain Manage fever
VISUAL/ AUDITORY Speak directly to client, facing client, Use facial expressions and gestures Post a hearing impaired sign on clients door The nurse should ensure hearing aids are functionable and in place Speak at a normal volume (no yelling) Encourage client to repeat back teaching Require emergency care to prevent permanent vision loss Copious eye irrigation for all types of ocular chemical burns Sterile saline or water irrigation should begin immediately IV tubing used or a morgans lens, continues until the pH of eye is normal (6.5-7.5) Activities that may increase intraocular pressure should be avoided to decrease risk of damage to suture site These included: bending over, lifting more than 5lbs, sneezing, coughing, constipationIf constipated, the nurse should encourage fluids, fiber intake, and over the counter stool softeners After cataract surgery it is common for the person to feel itching in the affected eye and blurred vision Sleeping on 2 pillows will decrease intraocular pressure Eye Injuries If a person gets something stuck in eye (splinter, or injury) they should first COVER BOTH EYES (since the eyes work in synchrony) Do not flush eye is there is splinter lodged in it, may cause further injury When a foreign body becomes lodged in the eye, both should be shielded Separation of the sensory retina from the underlying pigment epithelium Clients experiencing retinal detachment may experience a gradual, curtain like, loss of visual field Retinal detachment is a medical emergency and interventions should happen immediately to reduce the chance of vision loss The injured person could have the perception of lights flashing, floaters, gnats/hairnet, cobweb vision Traumatic retinal detachment may result in sudden vision loss Retinal detachment requires emergency surgery Post Op teaching: Avoid activities that increase intraocular pressure No rubbing eyes (this increases intraocular pressure) Speaking with the Hearing Impaired Ocular chemical burns Cataract Surgery Retinal Detachment
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF
NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF

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NCLEX RN REVIEW EXAM CONTENT BLUE BOOK PDF

  • 1. T H E N U R S E S C O R N E R
  • 2. TABLE OF CONTENTS Pharmacology & Need to Know Medications................Page 3-13 Fundamentals & Delegation..........................................Page 14-17 Ethical Principals & Law..................................................Page 18-20 Integumentary.................................................................Page 21-23 Respiratory Disorders & Nursing Considerations.......Page 24-32 Disorders of the Heart & Circulation...........................Page 33- 44 Musculoskeletal Disorders.............................................Page 45-47 Diabetes & Insulin.................................................................Page 48 Contact Precautions & Infectious Disease....................Page 49-53 Renal Disorders & Nursing Considerations..................Page 54-58 GI Disorders......................................................................Page 59-60 Spinal Cord Injuries..........................................................Page 61-62 Neuro & Brain..................................................................Page 63- 68 Visual/Auditory & Nursing Considerations...................Page 69- 71 Psychiatric Nursing..........................................................Page 72- 75 Endocrine Disorders........................................................Page 76- 79 Reproductive & Sexual Health........................................Page 80- 81 Maternal- Antepartum.....................................................Page 82- 88 Labor & Delivery................................................................Page 89- 92 Postpartum & Newborn...................................................Page 93- 95 Pediatric Nursing............................................................Page 96- 100
  • 3. PHARMACOLOGY Vitamin k is the antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis Intake of vitamin k rich foods can decrease effect ( broccoli, spinach, liver) Monitor INR levels Pregnant women should not take Avoid aspirin, NSAIDS, and alcohol If recovering from a PE, Warfarin is usually taken for 3-6 months Antibiotics can affect INR levels INR level 3.0-3.5 contraindicated in pregnancy First line drug therapy for SVT Administer over 1-2 minutes then flush with saline Find a line closest to the heart End with -il, controls high blood pressure Check blood pressure before administering Check potassium levels before administering because these medications increase potassium levels Can cause a dry cough and reflex tachycardia Can have severe adverse effects of angioedema Do not take while pregnant Can cause orthostatic hypertension If a client cannot tolerate ACE inhibitor then they are prescribed ARBS (-an) drugs CCB are like valium to your heart Help control atrial fibrillation End in -em like diltiazem Also end in -ine (Amlodipine) Most severe adverse effect is dizziness Do not drink grapefruit juice while taking this or statins Measure blood pressure before administering, if systolic is under 100 then you hold CCB Warfarin Adenosine ACE Inhibitors Calcium Channel Blockers
  • 4. Clients with hypertension should not take over the counter medications for colds, these medications have decongestants and can cause vasoconstriction Calcium channel blocker vasodilator Brings blood pressure down, usually after stroke and patients get extremely hypertensive (systolic over 240) The nurse should bring the blood pressure down but not below 170 (systolic) Priority nursing interventions are to monitor for hypotensive effects of this drug Helps control heart rate and blood pressure (mainly heart rate) Side effects may be bronchospasms Do not give to people with asthma The nurse should assess for any wheezing May mask signs of hypoglycemia End with - an like Losartan (sartans) Should not be taken while pregnant Helps lower blood pressure Can cause hyperkalemia Do not take with salt substitutes Increases cardiac contractility and slows the heart rate and conduction (slows the rate of conduction through the AV node) NOT a vasodilator Decreases workload of the heart It is used in heart failure and atrial fibrillation Excreted exclusively by the kidneys so need to check kidney function (creatinine and BUN) Digoxin toxicity: N/V, GI symptoms are the earliest sign, confusion, weakness, Toxic level above 2 visual symptoms, cardiac arrhythmias Hypokalemia can cause digoxin toxicity Treats A fib and heart failure Increased risk for bleeding Helps prevent platelet aggregation Clients should be assessed for black tarry stools, bleeding gums, hematuria, bruising, monitor platelets Should not be taken with Ginko Inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation Clients can receive this when they do not have signs of bleeding or low platelet levels Nicardipine Beta Blockers ARBS Digoxin Antiplatelet Therapy Drugs
  • 5. plavix , antiplatelet medication that should be discontinued 5-7 days before surgery Can increase risk of bleeding so the HCP should be notified if low platelet levels (<150000) Helps prevent blood clots Decreases preload Nitrate that causes vasodilation At risk for hypotension Can cause headache The nurse should follow up of the client feels dizzy or lightheaded 1 pill every 5 minutes and up to 3 doses EMS should be called if pain is not alleviated by 5 minutes after the first pill Headache and flushing are common side effects Sit or lie down before taking the pill Store away from heat and light Helps lower cholesterol and reduce the risk of atherosclerosis and coronary artery disease Reduces LDL levels, triglycerides, and total cholesterol levels Taken at night with evening meals Muscle aches are a serious side effect Report muscle pains or weakness, could be a sign of rhabdomyolysis Liver function test should be assessed before giving Lower LDL lipid levels Monitor for muscle pain or weakness All NSAIDS are associated with: GI bleeding, black tarry stools, stomach pain can be reduced if taken with food Kidney injury, long term use is associated with this Hypertension and heart failure Increase risk for bleeding Should be avoided in clients with kidney disease, nephrotoxic, COPD Long term use can cause peptic ulcers and chronic kidney disease, exacerbate hypertension and cardiac problems Ibuprofen NSAID Commonly prescribed to relieve joint pain and inflammation Clopidogrel Nitroglycerin Statin Atorvastatin NSAIDS Naproxen
  • 6. Toradol Highly potent NSAID Subcutaneous or IV anticoagulation medication Administer at 90 degrees or 45 degrees depending on how much adipose tissue they have Administer 2 inches away from umbilicus Works immediately Cannot be given for longer than 3 weeks (accept for lovenox) Antidote is protamine sulfate Lab test that monitors heparin is PTT PTT time should be 1.5 - 2.0 times the normal clotting time of 25-35 seconds Too long could cause spontaneous bleeding Can be given to pregnant women Risk is HIT (drop in the number of platelets) Heparin should be held when there is a drop in platelet Must be administered in 3-4.5 hours Surgery within 2 weeks is contraindicated Platelet less than 100000 or coagulation disorders should not receive it muscle relaxer Side effects: Fatigue and muscle weakness Teach: don't drink, don't drive, and don't operate heavy machinery for patients Muscle relaxer Flex = muscle Iron supplement, avoid giving with calcium supplements and antacids because that decreases absorption Client should increase intake of fluids because these cause constipation Taking with vitamin c like orange juice enhances absorption Administer 1 hour before meals or 2 hours after meals Keterolac Heparin TPA Baclofen Flexeril Ferrous Sulfate
  • 7. Medication for hypothyroidism Used to replace thyroid hormone Safe to take during pregnancy Do not take with antacids, calcium or iron (avoid over the counter multivitamins) Take on an empty stomach, in the morning, separately from other medications Lifelong therapy, blood test needed This medication will improve mood, higher energy levels, take up to 8 weeks to work, normal heart rate Takes 3-4 weeks for effect Prednisone Given to combat inflammation in the lungs to COPD patients These medications can cause in increase in sugar If the patient is a diabetic, anticipate giving more insulin Started high dose then tapered slowly Treats diabetes insipidus Mimics ADH Increases renal water absorption and concentrates urine Clients receiving this must have their electrolytes closely monitored for water intoxication/ hyponatremia (headache, mental status, weakness) Severe hyponatremia may cause seizures, neurological damage, or death Treats rheumatoid arthritis and psoriasis Can cause bone marrow suppression, clients are at risk for infection They should avoid large crowds and receive killed immunizations (flu, pneumonia) Avoid alcohol (can cause hepatotoxicity) and pregnancy with these drugs Endocrine Medications Levothyroxine Corticosteroids Desmopressin Methotrexate
  • 8. Keppra Anticonvulsant prescribed for seizures Depresses the CNS and can cause drowsiness, this improves after a few weeks Associated with suicidal ideations and should be reported to the HCP Can trigger steven johnsons syndrome No driving until approved by HCP Treats migraine headaches Work by constricting cranial blood vessels Contraindicated in clients with coronary artery disease and uncontrolled hypertension For motion sickness Apply 4 hours before Keep on for 72 hours Apply behind ear Dilantin, is an anti seizure medication with a therapeutic index of 10-20 Tube feedings decrease phenytoin absorption which can reduce the drugs effect and produce seizures The nurse should pause tube feedings for 1-2 hours before and after administration of these drug to increase absorption Early signs of toxicity include: horizontal nystagmus and gait unsteadiness Commonly taken at bedtime Antianxiety drug Do not ever stop abruptly Versed Benzodiazepine commonly used to induce conscious sedation Flumazenil ( Romazicon) is the antidote to reverse benzo effects Neurological Medications Levetiracetam Sumatriptan Scopolamine Phenytoin Benzodiazepine Midazolam
  • 9. Patients are usually prescribed Flagyl ( Metronidazole) For severe C Diff vancomycin may be used For treatment of TB Can experience neurological effects due to the decrease in the body's ability to utilize B6 The patient needs additional doses of B6 Zyvox Should not be taken with SSRI because can cause serotonin syndrome Azithromycin These can cause prolonged QT intervals in patients ECG should be monitored Can also cause hepatotoxicity Draw trough prior to administration, 10-20 is a therapeutic level Infuse medication over at least 60 minutes Monitor blood pressure Assess for hypersensitivity (red man syndrome) Monitor for anaphylaxis Check IV site every 30 minutes CVC catheter is preferred Creatinine levels are the most important value to monitor because vancomycin can cause nephrotoxicityIf creatinine is high this is a complication of nephrotoxicity Helps fight bacterial infections of the skin Take on an empty stomach Avoid taking with dairy products, iron supplements, or antacids Take with a full glass of water Wear sunblock because risk of photosensitivity Use additional contraceptive medications Infectious Disease Medications Medications for CDiff Isoniazid (INH) Linezolid Macrolide Antibiotics IV Vancomycin Tetracycline
  • 10. Stool softener that reduces straining during bowel movement, puts less stress on heart Straining can also cause bradycardia due to vagal response Most commonly used drug for heart failure Lasix Can increase risk of bleeding COX- 2 I inhibitor Black box warning with increased risk for cardiovascular complications Back pain, nausea, vomiting, would need to be assessed immediately Decreases cardiac workload Pain treatment and terminal dyspnea Decreases cardiac irritability Avoid intake of alcohol and limit use of acetaminophen Take vitamin B6 to prevent leg tingling Avoid aluminum containing antacids Report changes in vision Report jaundice, dark urine Does not change color or urine, that is Rifampin Adverse effects: hepatotoxicity, peripheral neuropathy Rifampin: reduced the efficiency of oral contraceptives, changes the color of the urine, used for TB Codeine Opioid and is smaller doses is a cough suppressant Can cause constipation just like opioids do Take medicine with food Drink lots of water Sit on side of bed before getting up because it can cause hypotension in patients Never shave before placing patch Antihypertensive patch that is reapplied every 7 days Do not remove patch if dizziness occurs Rotate site with each use Miscelleneous Drugs Docusate Sodium Furosemide Ginko Celecoxib Morphine Lidocaine Isoniazid INH Transdermal Patches Clonidine
  • 11. Available in many forms If a patient has difficulty swallowing, the nurse should consult with the pharmacist to see if there is other forms Maybe liquid Fold when discarding Change every 72 hours Not cutting patches Do not apply heat over the patch (does not aid in absorption) Over 3 years years pull ear up and back Less than 3 pulled down and back Children should be placed prone or supine Warm ear drops to room temperature Drop medication against wall of the canal Age appropriate distraction Toddlers and infants toys Preschool and older children deep breaths or count Infant placed supine with knees and and feet raised Other children side lying with knees bent Use water soluble jelly Insert using 5th finger with children under 3 Hold buttocks together after insertion Y tubing Connected with normal saline to keep vein open Continuous IV fluids used PCA pumps Children can use as long as they understanding of the device 10-20, above 20 is toxic Helps relax bronchioles Seizures in toxicity Do not take vitamin A supplements, can cause toxicity Do not give blood on this medication For severe or cystic acne Most important to use 2 forms of contraception KCL Fentanyl Patch Ear Drops Rectal Suppository PCA PUMP Aminophylline Isotretinoin
  • 12. May cause ototoxicity, especially in patients with kidney disease High doses should be administered slowly to prevent this ototoxicity in patients Viagra Nitrates and viagra are contraindicated with each other as it can cause life threatening hypotension The use of these should be reported to HCP Glucose should be monitored in those receiving this End in -ide and -one Treats hypertension and edema Major side effects: hypokalemia (muscle cramps and dysrhythmias) hyponatremia (AMS and seizures) Hyperglycemia Used to prevent gout attacks Inhibits uric acid production and improves solubility Should be taken with a full glass of water and increase fluids (most important teaching) Used in the treatment of rheumatoid arthritis Adverse effects: bone marrow suppression, hepatotoxicity, gastrointestinal irritation Can lead to thrombocytopenia (small purple dots) Anticonvulsant for seizures Never stop taking abruptly Exception is the development of a rash that may indicate steven johnsons syndrome (flu like symptoms and a painful rash) Good dental care is a must, can cause gingival hyperplasia Can cause suicidal ideation and depression, this an adverse effect -micine ending (azithromycin, zithrominine, and clarithromycin) Treat serious Think “mice” think ears think ototoxic, tinnitus, vertigo, equilibrium, ringing of the ear, dizziness Another toxic effect is nephrotoxicity (monitor creatinine) IM or IV PO, does not absorb Oral micines will sterilize the bowels before surgery (neomincine and canominice) IV Furosemide Sildenafil Prednisone Thiazide Diuretics Allopurinol Methotrexate Phenytoin Aminoglycosides
  • 13. IV Fluids Iv should not exceed 10 mEq/ hr Iv should be diluted and never given at a concentrated amount, high risk Can cause hypotension, this side effect is not as noticeable when the client is sitting down but when they stand up they can have orthostatic hypotension Those at highest risk for respiratory depression due to administration: the elderly, those with underlying pulmonary disease, snoring, obesity, smokers Adverse effect is paralytic ileus (absent bowel sounds) also can happen with potassium is low Itching is a normal side effect Hydromorphone, morphine Control moderate to severe pain Side effects: sedation, respiratory depression, hypotension, constipation Client is at risk for falls and should not get out of bed unless with assistance Administer daily stool softeners Administer slowly over 2 to 3 minutes Recheck pain 15-30 minutes after administering the medication Can take up to 72 hours for full effect Not prescribed to patients 1 day post op or for acute pain because of the time it takes to reach full effect KCL Opioids Opioid Analgesics Transdermal Fentanyl Patch
  • 14. FUNDAMENTALS & DELEGATION Always take it off in alphabetical order Gloves, goggles, gown, mask OFF ON reverse for alphabetical for G but mask comes second Gown, mask, googles, gloves Hold the cane on the strong side Close clients eyes Replace dentures Disconnect all tubes and lines Straighten the body and limbs Place pad under perineum Wash body Allow family members to assist with care Place pillow under the head Fold towel to put under the chin to close mouth Address client directly Speak in short sentences Pre conference with interpreter Use qualified interpreter when possible Avoid translation through family members The nurse should be mindful to choose interpreter with the patients prefered age, gender PPE Canes Postmortem Care Speaking with an Interpreter
  • 15. Can perform passive range of motion exercises Take and document vital signs No trach care or cleaning Can collect urine specimen Cannot document color and characteristic of it They cannot offer orange juice to a client with hypoglycemia Can assist 1 day post op out of bed to the bathroom Cannot reinforce teaching Can remind client to use incentive spirometer Pick up blood products from the blood bank Can take vital signs before blood transfusion and after the first 15 minutes of the transfusion Can perform oral suctioning (not sterile) Report patient behavior but not monitor Can transport body to morgue Can give topical over the counter barrier creams Can do vitals and accuchecks Can delegate ADL’s Measure output in a drainage collection bag Should be assigned stable clients with expected outcomes Cannot perform initial teaching, assessments, or evaluate a client’s condition Can do teaching reinforcement Can administer anticoagulant medications Can suction Can perform sterile procedures (catheterizations) Can auscultate lung sounds but cannot use that information to evaluate Can monitor RN findings Can monitor for bleeding Cannot start an IV, hang or mix IV meds, push IV meds They can maintain an IV and document the flow They cannot administer blood or mess with central lines Cannot plan care , the LPN can implement it Cannot perform or develop teaching, they can reinforce it Cannot take care of unstable patients They cannot do the very first of anything They can do tube feedings, but not the first They can change dressings, but not the first Cannot do admission, discharge, transfer, or the first assessment after a change Can not administer or monitor blood transfusions/ products UAP LPN
  • 16. Age is not a criteria for prioritization Gender is not a criteria for prioritization Acute beats chronic (higher priority than) Post op is within 12 hours, beats medical or other surgical Stable patients: indicate they are stable, chronic illness, post op greater than 12 hours, regional anesthesia, experiencing the typical, expected signs and symptoms of the disease with which they were diagnosed Unstable: suspected, acute, post op less than 12 hours, general anesthesia, patient is unstable if they are experiencing unexpected signs and symptoms Always Unstable:Hemorrhage High fevers over 105 Hyperglycemia pulselessness/ breathlessness Prioritizing Organs :Brain, lung, then heart, then liver, kidneys, pancreas Prioritization Assessment is the first step in the nursing process, the nurse should assess and then intervene when in doubt, ASSESS FIRST The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved Complication of this is lymphedema, can prevent by positioning each joint higher than the proximal one Can cause bone marrow suppression and tumor lysis syndrome Filgrastim stimulate neutrophil production Assessment Modified Radical Mastectomy Chemotherapy
  • 17. Place client in semi fowler's position Affected side’s arm needs to be placed on several pillows to promote drainage Never ignore inappropriate behavior by staff Ask yourself if what they are doing is illegal?If yes, tell supervisor No, then ask if anyone is in any immediate danger, if yes, then confront immediately because you don’t want to delay to put someone at risk If behavior is legal, no harmful, but simply inappropriate, then speak with them later on Client allergies and history are confirmed Assessment Confirming Informed consent has taken place Ensuring the client has been NPO Client voids before surgery Witnessing that the correct surgical site has been marked Occurs when doctor does not sign order Doctor puts wrong amount or unit The handwriting is not legible High fowlers for paracentesis Trendelenburg position and on the left lying side if suspected air embolism Position client with arms raised above head for chest tube placements After a liver biopsy the client should lay on the right side for at least 2 hours and then supine for an additional 12-14 hours Thoracentesis the patient is upright sitting position on the side of the bed leaning over on side table with pillow Teaches activities of daily living (bathing, dressing, cognitive or perception issues) Focuses on mobility, ambulation, ability to walk, use the walker or other assistive devices Physical therapy focuses on “below the waist” rehabilitation Do most good for the most people Start with victims farthest away from the radioactive explosion These victims are the most salvageable Do not accept blood components of any type DO accept normal saline, Lactated Ringer’s etc., DO accept Epoetin alfa Mastectomy Staff Management Nursing Responsibilities Prior to Surgery Error in Transcription Positioning Clients Occupational Therapy Physical Therapy Radioactive Disasters Jehovah witness
  • 18. ETHICAL PRINCIPALS/ LAW Veracity: being truthful Justice: treating every client equally regardless of background Accountability: accepting responsibility for actions and admitting errors Nonmaleficence: do no harm, it also relates to protecting clients who cannot protect themselves due to mental or physical condition Fidelity: fulfilling commitments and showing loyalty to one's self and others Beneficence: the action of promoting good will “Let’s talk about it” Surgeon explains the diagnosis and procedure (not the nurse) Client indicates understanding The client is competent and gives voluntary signature The nurse is responsible for witnessing the signature If the surgery requires additional procedures after the surgery has already begun and the consent has been signed for specific procedures, then medical power of attorney, next in kin, or legal guardian should be contacted to discuss Nurses role: witness client has signed, voluntarily and competently, document in medical record that client has signed with date and time, Physician is responsible for: explaining procedure, answering questions about procedure, offering alternative options, reinforcing right to refuse Assault and injury Failure of treatment or intervention Hospital equipment fail Falls Never document an incident report was filed Failure to report an important lab value Mislabeled laboratory specimens Ethical Principle Informed Consent Incidence/ Occurrence Report
  • 19. Prevents civil action when helping individuals off the job Cannot receive payment Essential for the nurse to perform in the same way as on the job (applying pressure if bleeding) Must act competently Universal criteria that are used to determine if appropriate, professional care has been delivered Sources used to define standards of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, the Nurse practice act, and regulatory organizations Does not depend on good intentions Nurse has obligation to report abuse Child abuse is common in all children ages Most child abusers have low self-esteem Abusers have history of growing up in a domestic violence Abusers have substance abuse problems When child is dying and parents don’t want treatment, priority is to assess parents knowledge of situation This helps clients determine treatment plans and decision makers when or if the client is unable to do so Documents include: health care proxy (durable power of attorney or medical power of attorney) and living will (advance directive) Providing oxygen via nasal cannula is not considered resuscitation and can be given Notified for every clinical death per hospital protocol Cardiac and respiratory support continue as organ donation is discussed or performed Consent is not needed by family if patient has signed to be organ donor Organ donation does not leave the body disfigured Good Samaritan Law Standards of Nursing Practice and Care Abuse Advance Care Planning Local Organ Procurement Services
  • 20. Practicing outside of scope Abandonment (leaving patients) Stealing narcotics Falsifying documentation An act that threatens the client and makes them feel harm but they are not touched Physical contact with a client without consent Assesses process standards (guidelines, systems, and operations) Assesses clinical issues that affect delivery of client care and client outcomes Implements processes to improve performances Unanticipated event in the healthcare setting that results in death serious injury Radiation damages DNA, which causes cell destruction Early manifestations of radiation contamination include: oral mucosa ulcerations, vomiting, diarrhea, and low blood cell count PPE should be put on before decontamination Victims should be decontaminated outside the facility Reportable Instances to the Board of Nursing Assault Battery Quality Improvement Committee Sentinel Event Radiation Contamination Chemical Contamination Emergency
  • 21. INTEGUMENTARY Avoid antihistamines for 2 weeks before test and corticosteroids Can take albuterol Inflammatory rash caused by an immune response Milk, wheat, and egg whites can trigger Pressure Injuries - Assess risk for pressure injuries using the Braden Scale - To prevent pressure injuries: - Use barrier creams - Foam pads to reduce pressure on bony prominences - Keep skin clean and dry - Reposition client with a turn sheet every 2 hours - Avoid pulling or dragging client - NO MASSAGES on bony prominences Unstageable wounds: Full thickness skin loss with slough or eschar Skin Cancer Skin Cancer Screening - Full medical workup of every mole is unnecessary - Rapid changing mole should be evaluated immediately - Melanomas can be any color - Melanomas don’t always occur as a new mole Risk factor for skin cancer: - immunosuppressant agents, - celtic ancestry traits - aging - high number of moles Tinea Corporis (Ringworm) - Teach about spreading the condition more - Wash hands - Very contagious Allergy Skin Testing Eczema
  • 22. Exposure to sun can help slow and decrease exacerbations Most important is to wash skin and get off any excess resin Linear appearance Complication when solutions infuse into the surrounding tissues Discontinue the IV Assess the sight for swelling, redness, pain Elevate the affected extremity Apply cool or warm compress depending on the solution infiltrated Difference between infiltration and extravasation is the fluid infusing Infiltration of drug into surrounding tissues Pain, blanching, swelling, redness Stop infusion immediately Elevate the extremity above the level of the heart Remove clothing and jewelry to prevent constriction Do not massage, rub or squeeze the area Immerse affected area in warm water Provide pain relief as the rewarming process is extremely painful Allow wounds to dry and then apply loose, nonadhesive dressings Monitor for signs of compartment syndrome Skin can appear mottled, blue or waxy yellow - Wash clothes/ bedsheets in hot water Burns - Urine output best indicator of fluid replacement therapy - Lactated Ringers given for fluid volume replacement - Administer pain medication IV - Burns result in largest fluid shift first 24-72 hours (hypovolemia) - Hyperkalemia occurs, Muscle weakness, EKG tall peaked T waves, Cardiac arrhythmias hematocrit/ hemoglobin will be elevated because of fluid changes, Sodium is lost due to fluid shift so they will be hyponatremic - Providing proper nutrition through enteral feeding is highest priority when bowel sounds come back and they start peeing Psoriasis Poison Ivy Infiltration Extravasation Treatment of Frostbite
  • 23. Dependent on a child’s age and muscle mass Vastus lateralis muscle is preferred for newborns less than 1 month old and infants age 1-12 months Vastus lateralis preferred for children less than 7 months Infants require 1 inch needles for IM injections Ventrogluteal not recommended until adult IM injection needle needs to be 22-25 in size Large bore needles for fluid resuscitation are 18 26 gauge is for subQ injections Can develop from repeated exposure (healthcare workers) Food allergies such as avocados, bananas, tomatoes can signal latex allergy IM Injection Sites Latex Allergy CAUTION MNEMONIC Change in bowel or bladder habits movement (blood) A sore that does not heal Unusual bleeding or discharge from body Thickening or lump in breast Indigestion or difficulty swallowing that does not go away Obvious change in wart or mole Nagging cough or hoarseness (persistent cough vs. seasonal) Inflammation from bacterial infection Characterized by redness, edema, fever, and pain Affected extremity should be elevated Flat or dependent position may worsen edema Applying a warm compress will promote circulation to the area Warning signs of Cancer Cellulitis
  • 24. RESPIRATORY DISORDERS Post op complication Clients may have difficulty breathing, hypoxia, and basal crackles The elderly, post op thoracic and abdominal surgery clients are at increased risk Encourages clients to breath deeply with maximum inspiration Pulse ox does not correctly reflect oxygen saturation because carbon monoxide has a stronger bond to hemoglobin The nurses primary action is to deliver 100% oxygen through a non rebreather mask at 15 mL/hr May have symptoms of headache, dizziness, nausea Inflammation of the upper airway after viral infection Rhonchi are heard (low pitched wheeze) The sound resembles snoring or moaning Primarily heard during expiration but can be heard on inspiration Also heard in cystic fibrosis Encourage clients who are losing weight and having loss of appetite to avoid drinking fluids during meals, eat small frequent meals, perform oral hygiene before meals Chronic air trapping and reduced gas exchange in these patients by decreasing ventilation Avoid codeine because it is a cough suppressant Client education:Get vaccinated for the flu Seek medical attention for increased sputum production Use albuterol if short of breath Characterized by acute or worsening of patients baseline symptoms NIPPV is often prescribed short term to support gas exchange in those who have hypercapnia ( PACO2 >45) and acidosis (pH < 7.3) It is most important for the nurse to monitor mental status changes in these clients Long acting, 24 hour inhaled medication used to control COPD Most commonly inhaled with a capsule inhaler The capsule should not be swallowed, but placed in the inhaler Atelectasis Incentive Spirometer Carbon Monoxide Poisoning Bronchitis COPD Exacerbation of COPD Tiotropium (Spiriva)
  • 25. Priority for a newly admitted patient with suspected pneumothorax is covering the wound with a 3 sided petroleum gauze tape This prevents inward air flow, while allowing air to escape the space Never place in a client with suspected head trauma Postoperative bleeding is uncommon but can last for up to 2 weeks This can be indicated by continuous swallowing and cough These patients may even develop restlessness Teaching instruction include: avoid coughing, clearing the throat or blowing the nose, limit physical activity, avoid milk products, avoid harsh brushing and gargling and oral mouth rinses Suctioning only should be applied when taking the catheter out, not inserting it Pre oxygenate client for 30 seconds on 100% oxygen before suctioning Limit suction time to 10-15 seconds Paradoxical chest movement At risk for respiratory failure Can be caused by trauma, rib fractures Used to measure peak expiratory flow rate For patients with moderate to severe asthma The client should exhale as quickly and forcefully as possible The client moves the indicator to the lowest number on the scale before using the device Repeat 3 times The peak flow meter is used after a short acting bronchodilator rescue MDI Applies a given amount of pressure at the end of mechanical ventilation PEEP is usually kept at 5 but for ARDS it can be kept at a higher rate A high level of PEEP (10-20) can cause rupture of the alveoli and overdistention and can cause barotrauma, leading to pneumothorax and subcutaneous emphysema Pneumothorax Nasopharyngeal Airway Tonsillectomy Suctioning Flail Chest Peak Flow Meter PEEP
  • 26. High pressure alarm is triggered by increased resistance to airflow, means the machine has to push too hard to push air into the lungs, so alarm with sound Obstruction may be from obstructions: kinks in the tubing, water condensing in the tube, mucus secretions in the airway If mucus is the cause, then you would change position, if that doesn't work then you would suction Low level alarm: decreased resistance, could be caused by disconnection of main tubing, and oxygen sensing tubing Disconnection Could signal hypotension Nurse should assess lung sounds to check for proper endotracheal tube placement (best way to check for tube placement) Characteristics: activity intolerance, barrel chest, hyperresonance on percussion, purse lipped breathing, tripod position (progressed) Fourth intercostal space at the midaxillary line, midway of the AP diameter Anatomical point at the level of the chest and the heart Used for correct placement of transducer when measuring BP, CVP, and/or cardiopulmonary pressure invasively Abnormal collection of fluid >15 mL in the pleural space that prevents the lungs from expanding Diagnosed by a chest x-ray or CT scan Clinical manifestations: dyspnea, non productive cough, pleural chest pain with respirations, on assessment clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over affected lung, chest pain during inhalation No wheezing Dislodgement of tracheostomy tube is a medical emergency If a mature stoma is dislodged (>7 days) then the nurse should attempt to open the airway with a curved hemostat If the stoma cannot be opened then cover with sterile dressing and begin ventilation with a bag valve mask Ventilators Emphysema Phlebostatic Axis Pleural Effusion Tracheostomy
  • 27. The priority care for a new tracheostomy is to prevent accidental dislodgement of the tube, ties should be checked for appropriate tightness, 1 finger should be able to fit between the ties Do not change inner cannula until 24 hours after insertion A cuff is deflated when the patient is awake and alert, determined not to be at risk for aspiration Before the cuff is deflated the client is asked to cough then suction is applied to remove any secretions Suctioning, the catheter should be advanced even if coughing and once resistance is met, pull back 1 cm before applying suction Use strict sterile technique while suctioning Humidifier should not be removed, helps facilitate secretions, even if there is more secretions, it should not be removed Always carry 2 tracheostomy tubes, a big and small one Wait at least 1 minute between suction passes Provides positive pressure oxygen and help expel CO2 COPD patients Hypercapnic respiratory failure Increase salt intake during hot weather Give pancreatic enzymes with meals or snacks Aerobic exercise is recommended Encourage sports (pleural friction rub) characterized by stabbing chest pain that increases with inspiration or cough Complication of pneumonia Visualization of the larynx, trachea, and bronchi while under sedation This patient should be immediately assessed upon returning from surgery The client must be kept NPO until positive gag reflex returns Blood tinged sputum is common but bright red blood mixed with sputum could indicate hemoptysis and needs to be reported to HCP Client is under mild sedation BIPAP Cystic Fibrosis Pleurisy Bronchoscopy
  • 28. Signs and symptoms usually present within 2-3 days of starting mechanical ventilation Characteristic clinical manifestations include: purulent sputum, positive sputum culture leukocytosis, elevated temperature, or new or progressive pulmonary infiltrates suggestive of pneumonia on a chest X ray Best indicator would be positive sputum culture Lung infection where lungs fill with thick debris and mucus which may cause impaired oxygenation and ventilation Interventions to facilitate secretions removal include: Chest physiotherapy Huff coughing Increase oral fluid intake and IV fluids to thin secretions Fowler's position If patient has difficulty breathing and has left lobar pneumonia then place them on the unaffected side to help with oxygenation (right lateral) People that are over the age of 65, younger than 2, central nervous system depression, ALOC, immunosuppressant, chronic disease, inadequate nutrition, immobility, smoking, upper airway infections, tracheal intubation are at increased risk Upper airway obstruction with multiple events of apnea and shallow breathing CPAP is an effective treatment for OSA It involves using a nasal or full face mask that delivers positive pressure to the upper airways Findings with OSA include: loud snoring, waking up gasping, sleepiness during the day, witnessed sleep apnea, morning headaches Can develop following a pulmonary insult (aspiration, pneumonia) or non pulmonary insult (trauma, sepsis, blood transfusion) to the lungs Fluid leaks into the alveoli causing a noncardiogenic pulmonary edema Lungs become stiff and non compliant which makes ventilation and oxygenation difficult Ventilator Acquired Pneumonia Pneumonia Obstructive Sleep Apnea ARDS
  • 29. Profound hypoxia despite oxygenation, high concentrations of oxygen is a key sign of ARDS and most important (refractory hypoxemia) Priority nursing diagnosis is: impaired gas exchange Can be put in the prone position: this helps to mobilize secretions, decrease pleural pressure, decrease atelectasis Exhale for 4 seconds through pursed lips Inhale for 2 seconds through the nose with mouth closed Removal of excess fluid in the lungs After this the nurse assesses for pain and difficulty breathing, monitors vital signs and oxygenation, looks for symmetrical chest expansion If any abnormalities are reported then client will undergo a chest x ray Complications from this include: pneumothorax, hemothorax, infection Chest tube reestablishes negative pressure in pleural space The collection chamber is where drainage from client will accumulate, the nurse will assess amount and color Suction control chamber it is expected to find gentle bubbling that is continuous, this means the suction is working properly, should not be intermittent Air bubbles in the water seal chamber would be abnormal and would indicate a leak and require immediate intervention (continuous) Water seal chamber you will see tidling (up and down movement) when the client breathes (intermittent bubbling) this is normal Drainage should be 50-500ml first day, it is expected to be sanguineous (bright red) then change to serosanguineous (pink) then serous (yellow) over a few days Bright red drainage would be of concern after 24 hours or more than 100ml/hr of drainage after the first 24 hours When removing the patient is asked to hold breath and bear down Post procedure chest x ray is done to ensure no fluid or air in pleural space If drainage stops abruptly the nurse should assess for breath sounds to determine if the lung has re expanded, have the patient cough and deep breath, change position Pursed Lip Breathing Thoracentesis Chest Tube Drainage System
  • 30. Covered with sterile, airtight petroleum jelly gauze If drainage tube becomes disconnected from the plastic chamber, place distal part of tube in sterile saline water Do not clamp chest tube unless checking for air leaks or told so by the HCP Removed when chest tube drainage is less than 200 ml/24hrs, air leak resolved, lung expanded, absent drainage Apical- remove air Basilar- remove blood Pneumonectomy - no chest tubes, trick question If knock over collection chamber, have them take deep breaths What if the water seal breaks? CLAMP FIRST, cut tube, put in sterile water, unclamp it Ambulate within 8 hours of surgery Pain management Coughing and splinting every hour Deep breathing and the use of an incentive spirometer Place in fowler's position Turn client every 2 hours Mouth care 100-120 per minute allowing complete chest recoil after each Defibrillation pads are placed on the right upper chest just below the clavicle and on the left lateral chest below nipple line During CPR, compressions are paused every 2 minutes to check pulse for 10 seconds Manual breaths are delivered at a rate of 2 breaths for every 30 chest compressions Stand clear with each shock of the defibrillator Correct placement of hands is on the lower half of the sternum in the center of the chest Begin CPR before calling 911 if a home health nurse Strategies to prevent post op pneumonia CPR
  • 31. Evaluates oxygenation and ventilation ABG If the ph and bicarb are in the same direction it is metabolic(up or down) If they are in different directions it is respiratory Bicarb normal: 22-26 pH: 7.35-7.45 If bicarb is normal then respiratory When ph goes up the patient gets irritable, hyperexcitable (K GOES DOWN) When ph goes down the patient does too (K GOES UP) Borborygmi = increased bowel sounds Hyperventilating: alkalosis Hypoventilating: acidosis Caused by NG tube, vomiting, prolonged suctioning Everything that isn’t lung or vomiting or suctioning is metabolic acidosis Metabolic Acidosis Increase in the production or retention of acid and the depletion of bicarb via kidneys or GI tract Common causes: diarrhea, diabetes, alcoholism, starvation, sepsis, hypoperfusion, renal failure pH less than 7.35, Bicarb less than 22 Hyperkalemic Acid/ Base Imbalances Metabolic alkalosis
  • 32. NSAIDS sensitivity Beta blockers are contraindicated Severe asthma exacerbation: tachycardia (>120), tachypnea (>30), saturation <90%, use of accessory muscles to breathe, and peak expiratory flow of <40 the nurse should give oxygen, SABA inhaler(Albuterol) , and nebulizer treatment anticholinergic (ipratropium) every 20 minutes, systemic corticosteroids Albuterol side effects: palpitations, tremors, difficulty sleeping, N/V Do not give NSAIDS or beta blockers to people with asthma Asthma
  • 33. DISORDERS OF THE HEART Inflammation of the membranous sac surrounding the heart Can cause pericardial effusion, this is excess fluid in the pericardium and it places pressure on the heart This can lead to cardiac tamponade- signs of this include; muffled or distant heart tones, jugular vein distention, hypotension, narrowing pulse pressure This requires emergency pericardiocentesis Pericardial friction rub is an expected finding with pericarditis invasive diagnostic study of the coronary arteries, heart, and chambers, and function of the heart, patient is awake but mildly sedated Do not eat or drink anything for 6-12 hours Lie flat for several hours following procedure Client may feel warm or flushed when contrast dye is injected Femoral or radial artery are used Produced by turbulent blood flow across diseased or malformed cardiac valves, sound like musical, blowing, swooshing sounds IV iodine contrast No Metformin before surgery Creatinine should be in normal range, or risk of contrast dye not being excreted by kidneys (normal is less than 1.3) after procedure, lay flat in low fowler's position with affected extremity straight for 4-6 hours Assess pulses hourly Keep leg straight, not elevated Encourage client to cough and deep breathe Refrain from lifting the affected arm until healthcare provider approves it Enlarged spleen needs immediate intervention If having sickle cell crisis and vasoocclusion, adequate oxygenation and hydration can reverse, the priority intervention is high flow IV fluids Bleeding disorder , Joint destruction is a long term complication Monitor for bleeding Pericarditis Coronary Arteriogram Murmurs Cardiac Catheterization Femoral Popliteal Bypass Implantable Cardioverter Defibrillator (ICD) Sickle Cell Disease Hemophilia
  • 34. Wash incisions daily with soap and water No baths Tingling, itching, and numbness around site is NORMAL No powders or lotions Report any redness, swelling, increase in drainage Wear elastic compression socks when, and elevate the legs when sitting Symptoms include: tachycardia to maintain cardiac output, dyspnea, shortness of breath, pallor Cardiac and respiratory drive maintained during severe anemia to maintain CO and respirations Inflammation of the membranous sac surrounding the heart Can cause pericardial effusion, this is excess fluid in the pericardium and it places pressure on the heart This can lead to cardiac tamponade- signs of this include; muffled or distant heart tones, jugular vein distention, hypotension, narrowing pulse pressure) This requires emergency pericardiocentesis Pericardial friction rub is an expected finding with pericarditis Teach clients to relieve pain by sitting up and leaning forward, this reduces pressure on inflamed pericardium invasive diagnostic study of the coronary arteries, heart, and chambers, and function of the heart Awake but mildly sedated Do not eat or drink anything for 6-12 hours before procedure Lie flat for several hours following procedure Client may feel warm or flushed when contrast dye is injected Femoral or radial artery are used IV iodine contrast No metformin before surgery Creatinine should be in normal range, check this lab and BUN Nursing priority after is check distal pulses CABG Care Severe Anemia Pericarditis Coronary Arteriogram Cardiac Catheterization
  • 35. Large anterior wall: affects pumping ability of ventricle This patient at risk for heart failure and shock so monitor for pulmonary congestion Clinical Manifestations: S3 heart sound, crackles, JVD Meds you see post MI: Aspirin (antiplatelet), -statin(lipid lowering), docusate sodium (stool softener reduce straining), ACE inhibitor (Prevent ventricular remodeling and HF), beta blocker (reduce reinfarction and HF) Nitro can worsen hypotension and cause headache These patients are at huge risk for life threatening dysrhythmias ALWAYS have them on cardiac monitoring If they become hypokalemic, potassium replacement becomes priority Complication: Pulmonary Edema: S&S: Acute onset dyspnea and productive cough with frothy, pink sputum You would hear bilateral crackles at lung bases If they ask about sexual activity: they need to be able to climb 2 flights of stairs without symptoms, and HCP needs to approve Chest pain brought on by myocardial ischemia (decreased blood flow to heart muscle) Can be caused by exercise, sexual activity, anxiety, fear, hypothermia, stimulants (amphetamine) usage, tobacco usage Teaching:Report fever or any signs of redness, swelling, or drainage at incision site Carry pacemaker identification card and wear medical alert bracelet Take the pulse daily and report to HCP if below rate Avoid carrying a cell phone in the pocket over the pacemaker, and when talking on cell phone hold it in ear opposite pacemaker Notify airport security of pacemaker Avoid MRI scans Clients need to be assessed for electrical capture (ECG) of heart rhythm and mechanical capture of heart rate (apical pulse) Radial artery is preferred site for ABG blood draws Allen's test needs to be performed to determine the patency of the artery and ulnar artery and sufficient circulation in the hand Apical pulse - 5th intercostal space, midclavicular line (mitral) Pulmonic - 2nd intercostal space at the left sternal border Mitral valve - 5th intercostal space, midclavicular line Erb's point - 3rd intercostal space at Myocardial Infarction Angina Pectoris Pacemaker Placement Allen’s Test Heart sounds and Locations
  • 36. Inability of the leg veins to efficiently pump blood back to the heart Can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers on inside of ankle S&S: Edema, thick skin with brown pigmentation, varicose veins, and large ulcers are expected findings COMPRESSION stockings are crucial treatment for healing ulcers These patients have decreased sensations from nerve ischemia or coexisting diabetes S&S: intermittent claudication, hair loss, decreased peripheral pulses, cool, dry, clammy skin, gangrene, thick, brittle nails, ulcers Teaching: Smoking cessation, no heating pads, regular exercise, ideal body weight, low-sodium, glucose control, antiplatelet meds, limb and foot care (lotion) Leg will be cold and mottled Leg pain not relieved by rest Chronic Venous insufficiency Peripheral Arterial Disease
  • 37. Blood clot formed in large veins of lower extremities S&S: unilateral edema, localized pain/calf pain, tenderness to touch, warmth, erythema, and sometimes a fever Risk factors: Trauma, major surgery, immobilization, pregnancy, oral contraceptives, smoking, old age, malignancies, obesity and varicose veins, myeloproliferative disorders At risk for pulmonary embolism (cesarean birth) Patients should NEVER massage the site- could trigger pulmonary embolism Virchow’s Triad: Flow/stasis, endothelial damage, hypercoagulable state Teaching: If sitting for a long time, >4 hours, use preventative measures (compression stockings, exercise), plenty of fluids and limit alcohol, elevate legs when sitting and flex foot often, resume normal exercise pattern, avoid restrictive clothing, consult with dietitian if overweight Preventing Thrombophlebitis Administer LMH (heparin) Instruct client to flex and point toes every 2 hours Encourage the client to drink fluids while on bedrest Can see redness, warmth NSAIDs contraindicated, no ibuprofen or naproxen or celecoxib They increase the risk of thrombotic events Aortic Valve Replacement Post-Op Chest drainage >100mL/hr should be reported to hCP immediately Teach this client they need prophylactic antibiotics prior to dental procedures to prevent infective endocarditis IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur Sudden onset of painful, pale, cold foot/leg could indicate embolism and should be reported to HCP immediately Which step is most important in a patient with SVT? Synchronize button This delivers a shock during the R-wave of the QRS complex If the client were to become pulseless, the synchronize button should be turned off Deep Venous Thrombosis Coronary Artery Disease Infective Endocarditis Cardioversion
  • 38. Clients should lay supine for 5-10 minutes and then measure BP and HR The nurse should have the client stand for 1 minute, measure BP and HR, and repeat measurements at 3 minutes Findings are significant if systolic BP drops greater than 20mmHg or diastolic drops greater than 10mmHg Usually caused by air embolism Client will be in respiratory distress: diaphoretic, cyanotic, tachypnea Apply occlusive dressing over the site to prevent entry of additional air into bloodstream Administer 100% oxygen via non-rebreather mask to improve oxygenation Position patient in left lateral trendelenburg position to promote venous air pooling in heart apex Continuously monitor vitals and respiratory effort Notify HCP immediately Client should be at semi-fowler’s: 30-45 degrees Nurse observes for distension and prominent pulsation of neck veins If present in client with heart failure, may indicate exacerbation and possible fluid overload Back flow of blood through left ventricle through mitral valve into left atrium Leads to reduced cardiac output and pulmonary edema Often asymptomatic, but many clients develop heart failure Teach to report any new symptoms of heart failure: dyspnea, orthopnea, weight gain, cough, fatigue Clients will have palpitations, be dizzy, and lightheaded Beta blockers commonly prescribed for palpitations Teaching: Healthy eating habits, stay hydrated, avoid caffeine, reduce stress, avoid alcohol, exercise regularly Nitrates are not effective for chest pain in people with MVP Orthostatic Hypotension Central Venous Catheter Dislodgment Assessing for JVD Mitral Valve Regurgitation Mitral Valve Prolapse
  • 39. Narrowing of aortic valve, which obstructs blood flow from left ventricle to aorta this worsens, the heart can’t overcome worsening obstruction, and ejects a smaller fraction of blood volume each systole Decreased ejection fraction, narrowed pulse pressure Blood being pumped out insufficient to meet metabolic demands Patients will have exertional dyspnea, chest pain, and syncope Tear in the inner lining of the aorta that allows blood to surge between layers of arterial wall Before surgical repair, the priority is maintaining pressure in the aorta Administer IV beta blocker Always assess BNP in these patients Elevated BNP indicates increased ventricular stretch and correlates with severity of heart failure and fluid volume overload. (increased HR, Hypertension, edema, crackles) Elevated BNP is an expected finding in HF patients These patients will have DECREASED urine output Patient teaching: Daily weight, sodium restriction, take own pulse if taking digoxin or beta blockers, take BP and keep record of it, increase activity gradually, plan rest periods, consider cardiac rehab program, avoid extreme hot/cold Report these symptoms: weight gain of 3 lb in 2 days, or 3-5lbs in a week, difficulty breathing when lying flat/exertion, waking up breathless at night, dry, hacky cough, fatigue, dizziness, swelling of feet, ankles, abdomen, face To assess for presence of this, nurse would listen with bell of stethoscope in epigastric area slightly left of midline Renal perfusion status monitored closely Monitor for hypotension, dehydration, blood loss, embolism Check BUN and creatinine, and urine output (at least 30mL/hr) Manifestations of graft leakage: ecchymosis of the groin, penis, scrotum, or perineum, increased abdominal girth, tachycardia, weak pulses, decreasing hct and hgb, pain in pelvis, back, or groin, and decreased urinary output Aortic Stenosis Aortic Dissection Heart Failure Abdominal Aortic Aneurysm
  • 40. After AAA repair, pulses can be absent for 4-12 hours after surgery due to vasospasms But a decrease from baseline after this time could mean an occlusion Light palpation TeachingThis filter will trap blood clots from lower extremity vessels Promote physical exercise, report symptoms of pulmonary embolism (chest pain, SOB), and impaired lower extremity circulation (pain, numbness), and notify the health care team prior to having MRI’s Beck’s Triad: hypotension, muffled heart sounds, distended neck veins, narrowing pulse pressure Often caused by a clot in a chest tube that causes excess fluid buildup in pericardium Warning sign: decrease in chest tube drainage Normal MAP is between 70-105 If MAP falls below 60, vital organs can be underperfused and become ischemic Systolic blood pressure + (diastolic blood pressure x 2)/ 3 Life-threatening emergency due to the possibility of severe organ damage If not promptly treated, can lead to intracranial hemorrhage, heart failure, myocardial infarction, renal failure IV Vasodilators: nitroprusside sodium Lower BP slowly Initial goal: decrease MAP by no more than 25% or maintain MAP at 110-115mmHg Prioritize neurological assessment because decreased LOC can signal a hemorrhagic stroke Associated with hypomagnesemia It causes prolonged QT interval Magnesium sulfate is treatment Inferior Vena Cava Filter Cardiac Tamponade MAP Hypertensive Crisis Torsades de pointes
  • 41. Surgical connection from an artery to a vein to provide vascular access for hemodialysis Client should perform hand exercises to mature the fistula Thrill (vibration) needs to be palpable and an auscultated bruit Aseptic technique Sterile dressing changes every 48 hours with gauze or every 7 days with as transparent dressing Line should be flushed before and after medication administration Blood pressure and venipunctures on opposite arm of PICC All medications should be paused when blood draw occurs (except vasopressors) Scrub the hub for 10-15 seconds Femoral access sites should be removed first because they have the highest risk of infection Preferred access sites for adults are subclavian vein or jugular veins because less chance of infection Priority after placing subclavian cvc is to check placement in the superior vena cava with a chest x ray A filter should also be used when administering TPN through this site Increased respirations (dyspnea), increased pulse, increased blood pressure May be a normal finding in young adults In older adults, it could indicate fluid volume overload or heart failure so this is a significant finding Arteriovenous Fistula PICC Care Central Venous Access Subclavian Central Venous Catheter Fluid Volume Overload S3 Heart Sound
  • 42. Blood should not be left out for more than 30 minutes, if the start of the transfusion is delayed, then the blood should be returned to the blood bank- hemolytic reaction: destruction of red blood cells, can see hematuria in the urine, cyanotic, pale, back pain, hypotension Dyspnea can indicate circulatory overload Blood must run slowly for the first 15 minutes, no more than 2-5 ml/min Never warm the blood and blood should be transfused within 4 hours first 15 minutes run slow, watch for reaction, nurse should stay with patient Do not discard blood products, keep to investigate what occurred administer with filter tubing and normal saline If a suspected transfusion reaction is occurring, the first thing to do is to stop the transfusion Normal saline infusion is typically started and it is important that it is transfused through a different port Notify HCP Assess the client Automated external defibrillator should be used as soon as possible AED pads for children up to 8 years, place one on chest and one on back if only have adult AED pads (sandwich the heart) Pads should never touchIf client is wet, dry them, remove anything on them that may be in the way and apply the pads Most common type of shock when blood volume decreases because of hemorrhaging or third spacing from burns Treatment: restoring fluid and preventing further fluid loss, improving hemodynamic stability through vasoactive medications (norepinephrine, dopamine) Norepinephrine causes vasoconstriction and improves heart contractility and cardiac output but the effects end quickly, this should be tapered slowly and never stopped abruptly Isotonic solutions are used to restore fluid (0.9% NS, Lactated Ringers) Blood Transfusion Transfusion Reactions AED Hypovolemic Shock Ventricular Tachycardia
  • 43. Can be pulseless or with a pulse Stable client with a pulse: treat with medication (Amiodorone) Unstable client without a pulse: CPR and synchronized cardioversion Positive pressure ventilation delivers positive pressure to the lungs using a mechanical ventilator Adverse effect of this is hypotension because it causes decreased cardiac output and decreased venous return to the heart Twisting pattern dysrhythmia First line treatment is IV Magnesium Short, frequent attacks are first treated with vagal maneuvers They can bear down like having a bowel movement Regular tachycardia with a rate of 150-220 Best treatment is vagal maneuvers and Adenosine IV push (Intropin) Used to improve hemodynamic status in those with shock and heart failure Enhances cardiac output by increasing myocardial contraction, increasing heart rate, and elevating blood pressure through vasoconstriction Increases renal perfusion which increases urinary output Adverse effects: tachycardia, dysrhythmias, myocardial ischemia Given to people with hypotension Needs adequate fluid volume replacement Ventricular trigeminy Occur every third heartbeat MI predisposes to PVC PVC are caused or exacerbated by hypoxia, electrolyte imbalances, stress, stimulants, fever, and exercise Potassium replacement if low Cannot shock this rhythm If a patient has this rhythm, the first thing the nurse should do is verify the monitor reading by palpating the pulse (ASSESS!) PPV Torsades De Pointes Paroxysmal Supraventricular Tachycardia Dopamine PVC Asystole
  • 44. Priority is to provide continuous CPR and epinephrine Phentolamine is the antidote Used to increase rate of heart and CNS Should be given through a central line Avoid IM injections to reduce client injury Monitor neurological changes Takes longer for these clients to clot so at risk for bleeding Check BUN and Creatinine to make sure they don't become elevated with use of diuretics, also check Potassium and blood pressure Produced by turbulent blood flow across diseased or malformed cardiac valves, sound like musical, blowing, swooshing sounds Plasma protein with normal range: 3.5-5.0 Ontonic pressure component that helps PULL water back into the circulatory system Plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels Liver makes albumin Hypoalbuminemia is common in people with liver disease, can lead to pitting edema if albumin levels are low because can not pull fluid back into circulatory space If a patient has protein in the urine, could indicate kidney dysfunction Protein in the urine could be an early sign of kidney disease in patients Can occur 24-72 hours after trauma or surgery and it is where fluid shifts from the intravascular space to the space between cells (interstitial space) Leads to decreased circulating volume (hypovolemia) and decreased cardiac output, weight gain, decreased urinary output, tachycardia, hypotension If this is suspected the FIRST thing the nurse should do is assess vital signs Epinephrine Thrombocytopenia Administering diuretics Murmurs Albumin Third Spacing
  • 45. MUSKULOSKELETAL DISORDERS Clean limb by washing it daily with soap and water Assess skin for redness or skin breakdown Clean and dry socks and wraps Perform daily range of motion exercises Lie on stomach for 30 minutes several times each day and avoid sitting in Do not apply lotion/ powder Should not be elevated, use ace wrap bandage instead to help with edema Reversible bone disorder caused by lack of vitamin D Characterized by weak, soft, and bones that hurt These bones can easily fracture or become deformed Nurse should clean pin sites with sterile solution to prevent infections Keep the vest cool and dry and using low cool blow dryer to dry Place foam inserts at pressure points Placing a small pillow under clients head when supine Only health care provider can adjust loose pins, keep wrench at bedside though and contact HCP if pins are loose Do not hold frame of device when moving the client Pain and paresthesia in the hand caused by the compression of the medial nerve IMMOBILIZE THE WRIST with a splint Do not do repetitive wrists movements Happens when muscle fibers are released in the blood after trauma or injury This can cause acute renal failure The nurse’s priority action is to prevent kidney failure by filtering the kidneys so the nurse should provide a bolus of NS Residual Limb Care chair for more than 1 hour to avoid hip flexion contractures Osteomalacia Halo Device Fracture Carpal Tunnel Syndrome Rhabdomyolysis
  • 46. Clinical features: leg abducted, shortening of the affected limb, ecchymosis and pain over groin and hip area and pain when weight bearing, muscle spasms, externally rotated Report foul odors or hot areas in the cast because this may indicate infection Avoid getting the cast wet Elevate the affected extremity above heart level for first 48 hours Perform isometric and ROM exercises regularly Never put anything inside of cast to itch, use air dryer Cane length should be from greater trochanter to the floor Hold cane on strong side to provide maximum support Put can several inches in front of and to the side of unaffected foot Move cane first then affected leg These patients will expect to have confusion, restlessness, petechiae over chest, hypoxic, mental status, respiratory distress, fever NOT EXPECTED would be pain in affected limb and numbness and tingling To help prevent this from happening it is important to stabilize and immobilize the fracture immediately , minimize movement of the fractured extremity to help reduce the risk of FES Client should be supine or in semi fowler's position Do not elevate the head of the bed more than 30 degrees Weights should be free hanging at all times and should never be placed on the bed or floor Never remove the weights, could be life threatening Monitor neurovascular and skin integrity Body should be aligned at all times Immobilize knee, keep in straight position Do not place anything under the knee, can put pillow on foot/heelJoint flexion with increase the risk of fractures Hip Fractures Cast Care Cane Use FES Bucks Traction Knee Replacement Surgery
  • 47. Weight should be placed on the upper arms and hand grips, not axilla of crutches Hand grip is right when elbow flexion is 30 degrees Swing through - non weight bearing, amputation 2 point and 4 point gates bilateral weakness (2 legs affected) Odd number gate when one leg is affected Up with the good, down with the bad Upstairs- lead with good foot, then crutches Downstairs- lead with the bad Positive orthostatic vital signs Osteoarthritis IV therapy Gait abnormality Medications Ambulatory aid Over age 65 Exercise programs Wearing needed glasses Well lit rooms No rugs Handrails Non skid shoes and socks Staff hourly rounding Rare but life threatening inherited muscle abnormality that is triggered by inhaled anesthetic agents Leads to sustained muscle contraction and rigidity (early sign) then can lead to a dangerously high temperature due to increase metabolic demands and oxygen demands (late sign) If the patient has never had anesthesia before, you can ask if any of their family members have had a bad reaction to general anesthesia Crutches Increased Risk for falls Prevent Falls Malignant Hyperthermia
  • 48. Can administer insulin through a continuous dose or or bolus administered at meal time The client will experience fewer swings in blood glucose levels and hypoglycemic episodes Still need to check blood sugar 4-8 times a day Assess mental status to see if clients with insulin pumps can manage it safely The diabetic client with hypokalemia is at risk for severe cardiac dysrhythmias Before administering insulin to a client with hypokalemia, the nurse should contact the HCP Insulin can worsen effects of hypokalemia, they may need supplemental potassium Only insulin that can be administered IV Push Regular insulin injection peaks 2-5 hours Clients that receive IV contrast dye for a CT procedure and receive Metformin are at increased risk for lactic acidosis, therefore the HCP may discontinue metformin for 24-48 before the CT Long acting insulin has no peak and may last 24 hours or longer Should not be mixed in same syringe with any other insulin, use seperate site Insulin Pump Hypokalemia Regular Insulin Metformin Glargine DIABETES & INSULIN
  • 49. CONTACT PRECAUTIONS Airborne Precautions TB Measles Varicella Chickenpox (incubation 2-3 weeks) Confirm with chest x ray before placing client in isolation room >15 is positive TB test in a healthy client Latent TB infection are not contagious Active TB are infectious and can transmit through air TB treatment can be anywhere from 6-9 months long, crucial for patient to finish medications Clinical manifestations: Night sweats, weight loss, purulent or blood tinged sputum, fatigue, low grade fever Airborne precaution Negative pressure room Shingles lesions that are open may be transmitted airborne and contact The client with disseminated lesions that are not crusted over well should be put in a private room with negative airflow pressure, contact precautions and airborne precautions Localized shingles requires only contact precaution Airborne TB Shingles
  • 50. When client has open active lesions they should be on airborne precaution Negative pressure room N95If in contact with body fluid then contact precautions Varicella Droplet Precaution Meningitis H flu B - can cause epiglottitis Private room, mask, gloves, no gown, no eyeshield, no negative airflow Highly contagious and requires droplet precautions Rapid coughing and vomiting whooping cough monitor for signs of airway obstruction Droplet precaution Care for this client includes: Droplet precaution Seizure precaution Reduced stimulus environment Bed rest, head of the bed elevated 10-30 degrees Does not need a negative pressure room Droplet Pertussis Meningitis
  • 51. Private room preferred, gloves, gown RSV C diff Hep A Staph infections Herpes Infections Clients with this infection should be bathed with pre moistened cloths or warm clothes with chlorhexidine This can reduce spread of infection Place MRSA client in a private room or semi private with a client that has the same infection Dedicate equipment for client Wear gloves when entering the room Hand hygiene when exiting the room, can be soap and water or alcohol based Wear gown with client contact Post notification on door Ensure client only leaves room for essential test etc. No need to wear a mask Clients should be put on contact precautions (gowns and gloves) in private rooms to eliminate spread of infection Hand hygiene using soap and water (not alcohol based) Diluted bleach solution must be used to clean surfaces Manifestations: watery diarrhea ,fever/nausea , abdominal pain C-Dif can lead to hypovolemia (hyponatremia, hypokalemia, elevated BUN) Steps to prevent UTI in clients with urinary catheters include: Wash hands Wash perineal area with soap and water each shift and after bowel movement Catheter bag below the level of the heart Use sterile technique when collecting urine sample To reduce the risk of infections, the best IV sites would be in the forearm or hands Overwhelming response to infection that causes impaired organ function Septic shock occurs when sepsis causes cardiovascular collapse and/ or the body cannot maintain normal metabolic function Fever or hypothermia, Hypotension , Prolonged cap refill , Tachycardia Contact Precaution MRSA CDiff Preventing HCAUTI Peripheral IV Sites Sepsis Septic shock manifestations: Increased WBC count (over 11000) , Decreased urine output
  • 52. Infection of the CD4 Helper T cell Low counts can increase chance of infection To reduce the risk of infection patients should: Get influenza vaccine Avoid eating undercooked meals Drink bottled water Use condoms Avoid cat litter Avoid large crowds Develops after bit from infected tick Bulls eye rash Flu like symptoms migraines Usually bacterial in origin Classified as upper or lower depending on where the infection is Inflammation and infection in the kidneys and ureters (pyelonephritis) Become very ill nausea/ vomiting fever/ chills Flank pain Inflammation and infection of bladder (cystitis) Most common type of UTI Burning with urination urgency/ frequency Hematuria , Suprapubic discomfort Infection of the mucous membranes caused by yeast like fungus The fungus causes pearly milk curled lesions orally Clients who are immunocompromised are at increased risk for developing thrush, especially those taking corticosteroids orally Transmitted through fecal- oral route Priority is hand hygiene to prevent transmission HIV Infection Lyme Disease UTI Upper UTI Manifestations: Lower UTI Manifestations: Thrush Hep A
  • 53. Sputum culture and sensitivity test nursing considerations: teach client to rinse mouth out with water before collecting, morning is best time to collect, inhale deeply several times then cough forcefully, assume a sitting or upright position Always clean wound first before taking a wound culture Clean gloves and hand hygiene to remove old dressing Sterile gloves and hand hygiene to swab from wound center to outer margin Intradermal injection 1 mL tuberculin syringe with a 27 gauge ¼ inch needle Pull skin downward so that it is taut Insert needle at a 10 degree angle Outline of bevel should be visible under the skin Inject the medication slowly and form a small bleb under the skin Circle border Avoid rubbing site after injection Done in forearm Life threatening complication of cancer treatment, considered an oncological emergency When cancer treatment kills cells, it releases different intracellular components causing a life threatening imbalance Clinical manifestations: hyperkalemia, large amounts of nucleic acids can cause acute kidney disease, hyperphosphatemia, hypocalcemia Sputum Culture Collection Wound Culture TB Testing Tumor Lysis Syndrome
  • 54. RENAL / URINARY Measure of glomerular function and indicator of renal disease process 24 hour urine collection is needed for this test First urine sample is discarded and time is noted All other urine samples for the next 24 hours are collected and kept cool At the end of the 24 hours the client should attempt to void one last time and add to collection container Blood is also drawn to collect creatinine level Obtaining tissue sample to determine the cause of certain kidney diseases Bleeding is the major complication for this procedure Before the procedure the client must give informed consent and discontinue all anticoagulants and antiplatelet medications for at least one week The client should have well controlled blood pressure and be crossed matched just in case of infusion After the procedure the nurse should monitor the vital signs for the first hour every 15 minutes and assess puncture site for bleeding Position the client on the affected side for 30-60 minutes and bed rest for the first 24 hours Inserted through the urethra to directly visualize the bladder wall and urethra Burning sensation upon urination is normal after procedure Complications associated include: urinary retention, hemorrhaging, infection Notify the HCP immediately if blood clots, blood tinged urine, inability to urinate, chills, abdominal pain or fever are present Radiologic test to visualize renal blood vessels Contrast medium is injected into the femoral artery Teach client to increase fluid intake after the exam to flush dye from the body Increased urination after exam is expected outcome because want to flush fluids Creatinine Clearance Kidney Disease Cystoscope Renal Arteriogram
  • 55. Abnormal prostate enlargement most commonly affecting males over the age of 50 The prostate gradually enlarges and compresses the urethra Clinical manifestations include: urinary urgency, frequency, and hesitancy, dribbling urine after voiding, nighttime frequency, and urinary retention, intermittent or weak stream, incomplete emptying sensation, straining or difficulty starting stream The nurse should teach about ways to control and manage these: medications, lifestyle changes, voiding schedule, avoidance of caffeine and antihistamine These patients have an increased risk of UTI If the patient is experiencing burning while urination, it could mean a UTI is present and further assessment is required Nursing care plan for this includes: teaching kegel exercises, bladder training, incontinence products, and lifestyle changes, avoid smoking, drinking, caffeine, use of pessary The highest priority with a client newly diagnosed with stress incontinence is preventing skin breakdown, and UTI through bladder training, the nurse should teach the patient to void every 2 hours Pessary can remain in place while sexually active Happens when there is increased abdominal pressure, from coughing, sneezing etc The peritoneum is used as a semipermeable membrane to dialysis clients The tubing is clamped to let the fluid work for a specific period Clients are closely monitored for respiratory distress while the fluid is inside Crackles in the lungs require immediate intervention Essential to use sterile technique when spiking the bag Bacterial peritonitis is a potential complication and can lead to sepsis Place the catheter bag below the client (below abdomen) and the client should be in fowlers or semi fowler's position Cloudy outflow, tachycardia, low grade fever are signs of peritonitis Bloody fluid could indicate intestinal perforation Benign Prostatic Hyperplasia Stress Incontinence Peritoneal Dialysis
  • 56. Brown fluid could indicate fecal contamination insufficient outflow may result from constipation, if outflow becomes sluggish, the nurse should reposition the client (side lying), check for distention, and check for kinks in the tubing or assist with ambulation Never flush the tubing or pull on it Can gently rotate the check for kinks Hallmark finding is painless hematuria Primary cause is cigarette smoking Opioids may cause urinary retention because they relax the bladder muscle The nurse should assess the clients subprubic area for retention Often occurs in older men with BPH If a man is having trouble urinating after surgery, the initial action is to get them out of bed and see if that helps, second intervention would be to bladder scan At risk for uncontrolled hypertension and hypertensive emergencies Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache Immediate assessment and intervention required within one hour Are at risk for hyperkalemia and fluid overload Clients should avoid salt substitutes which typically contain potassium chloride Fluid restriction, potassium restriction, sodium restriction, low protein diet, low phosphorus diet Upper urinary tract infection Clinical manifestations: chills, fever, vomiting, flank pain, costovertebral tenderness Blood and urine cultures should be obtained prior to antibiotic administration Bladder Cancer Urinary Retention Chronic Kidney Disease Acute Pyelonephritis
  • 57. Rapid, complete, bladder decompression is done This can be associated with hematuria, hypotension and postoperative diuresis Complications the nurse should assess for: hypotension and bradycardia Some medications should be held prior to receiving dialysis including: antihypertensives because it could lead to hypotension also vitamins B and C, digoxin and antibiotics No need to give heparin before dialysis because it is given during rare but life threatening complication that occurs during the initial stage of dialysis creating increased intracranial pressure, slowing the rate can prevent Symptoms include: nausea, vomiting, seizures, headache, restlessness, change in mentation If this is suspected the HCP should be called immediately and dialysis should be slowed or stopped Check weight from previous dialysis and current weight/ VS 3 way catheter usedInfusion rate should be sufficient to eliminate obstruction of flowThe nurse should assess tubing and make sure there are not clots blocking the flow Best indicator of of productive flow rate is the output urine color (light pink) Never pull foreskin back can cause swelling and paraphimosis Can use elastic adhesive to spiral around to secure Leave 1-2 inch space in catheter Take all antibiotics Increase fluid intake Wipe from front to back Cotton underwear Void after intercourse Avoid douching and using feminine perineal products Avoid spermicidal contraceptive jelly Acute urinary Retention Dialysis Dialysis equilibrium syndrome: Continuous Bladder Irrigation Condom Catheters Preventing UTIs
  • 58. Occurs due to compression of the urethra or impairment of the bladder muscles this can lead to incomplete bladder emptying and urinary retention this can lead to urine dribbling Nursing care includes: scheduling a voiding pattern (every 2 hours) to prevent distention instruct client to bear down and applying gentle pressure to the lower abdomen to facilitate bladder emptying assess skin for breakdown encourage client to void 30 seconds after voiding, and check residual volume If there is leakage then the nurses first action is to assess the catheter tubing Dislodge visible obstruction by milking the tubing Irrigation is usually avoided because puss or sediment can flow back into the bladder Fill balloon with 5mL of saline For males it is recommended that the catheter be inserted 7-9 inches then an additional 1 inch after urine is seen in the collection bag Reversible neurological complication of cirrhosis caused by primarily increased levels of ammonia in the blood Lactulose is the most common treatment for hepatic encephalopathy, it is a laxative but it helps excrete ammonia It can be given on an empty stomach and it can be given with juice, milk or water Low serum Albumin, high ammonia levels, elevated INR/ PT, increased bilirubin levels, low platelets May take Lactulose to excrete ammonia Given dark jug to preserve urine Uncontrolled hypertension is contraindicated in these patients Elevated creatinine is an expected finding in someone with kidney disease Decrease hemoglobin level is expected in someone with kidney disease At risk for hyperkalemia Overflow Urinary Incontinence Bladder Catheterization Hepatic Encephalopathy Liver Failure Urine Collection Kidney Biopsy Acute Kidney Injury
  • 59. GI DISORDERS At least 3000 ml of fluid a day Avoid eating foods that cause gas (broccoli, cauliflower, brussel sprouts, beans) Empty the pouch when it becomes one-third full Acute inflammation of the pancreas that results in autodigestion Most common causes are cholethiasis and alcoholism Signs include severe epigastric pain radiating to the back, amylase and lipase are ELEVATED Complications: hypovolemia, hyperglycemia, hypocalcemia, latent hypoxia, ARDS, cardiac arrhythmias Barium Enema Uses fluoroscopy to visualize colon with dye Contraindicated in patients with diverticulitis Preprocedure instructions include: take cathartic (magnesium citrate etc.) to empty stool from colon, Follow a clear liquid diet the day before the procedure to aide in bowel preparation and to prevent dehydration, Do not eat or drink anything 8 hours before the test, May experience abdominal cramping and urge to defecate during the procedure Expect passage of chalky white stool after procedure Take a laxative to get rid of excess barium Drink fluids Keep daily record of symptoms Exercise Limit gas producing foods Reduce daily caffeine intake Do not fast, do not go on clear liquid diet when symptoms are bad Care of Stoma Pancreatitis IBS Peptic Ulcer Risk factors: H. pylori infection, stress, smoking, diet, alcohol use, NSAID use, genetic predisposition, avoid eating meals before bedtime
  • 60. When administering bolus enteral feedings, the nurse should raise the head of the bed and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk Feeding tubes should be flushed before and after feedings to keep the tubes patent Gastric residual volumes are checked every 4 hours with continuous feeding and before each bolus feeding Gastric pH should be acidic (less than 5) A pH over 6 requires chest x ray placement check of the NG tube Newly placed tubes also require placement check Do not remove stylet before x ray is performed These patients can develop respiratory complications due to the release of cytokines and pancreatic enzymes that cause systemic inflammation ARDS is most serious complication If crackles are heard in these patients, immediate action needs to be taken Healthy stoma should be pink to bright red and moist If the stoma is dusk or any color blue the HCP should be informed Medical emergency GI absorption of neurotoxin Organism found in soil and can grow in any food contaminated with the spores Clinical manifestations: muscle paralysis, descending flaccid paralysis (starting with the face), dysphagia, and constipation Main source is improperly canned food or stored foods LOOK FOR CANNED FOODS WITH SWOLLEN ENDS No raw honey for children under age 1 Inflammation of the gallbladder Highest priority for a vomiting/ nauseous patient with this is NPO status so the gallbladder is not stimulated more Also maintain low suction for NG tube, semi-fowler position, IV fluids Tube movement of 0.5 cm when the client coughs Should rest loosely above the skin Resistance shouldn’t be felt when moving around Performed through an orogastric tube to remove ingested toxins and irritants to the stomach Done if the ingested toxins are considered lethal and if it can be initiated within 1 hour Nasogastric Feeding Tubes Acute Pancreatitis Stoma Botulism Cholelithiasis PEG Tube Gastric Lavage
  • 61. SPINAL CORD INJURIES Vasodilation will occur due to loss of innervation from the spine This will decrease venous return to the heart , signs of neurogenic shock include: hypotension, bradycardia, and pink and dry skin from the vasodilation Usually occurs in cervical or T6 or higher spinal injuries Priority nursing care is administering normal saline to increase blood pressure and perfusion to vital organs Removing the posterior of spinous process Relieves compression of nerve root Pain, paresthesia, paresis(muscle weakness) these are signs that the nerve root is being pressed on so then would get a laminectomy The location will determine the symptoms, prognosis and symptoms 3 locations: cervical, thoracic, lumbar LOG ROLL AFTER SURGERY Anterior thoracic will have chest tubes Laminectomy with fusion- take bone from hip Do not dangle, no sitting Do not sit for longer than 30 minutes They may walk, stand, or lay without restrictions Discharge teaching: 6 weeks no sitting for more than 30 minutes, lie flat and log roll for 6 weeks, no driving for 6 weeks, do not lift anything over 5 lbs for 6 weeks, cervical lams cannot lift anything over the head Trauma should follow ABC Especially true with suspected head and neck injuries Until the spin is appropriately addressed, the patient should be placed on a backboard The nurse should use the jaw thrust maneuver NSAIDS N, neurological damage Neurogenic Shock Laminectomy Jaw Thrust Maneuver Acronym to help determine spine immobilization
  • 62. S, significant traumatic injury A, alertness I, intoxication D, distracting injury S, spinal examination Treatment: want stomach to empty slower, so lay down after eating, meals should be small, low fluids, low carbohydrate, get fluids before or after meals, NEVER with meals, high protein, high fiber Kalemias do the same as the prefix accept for heart rate and urine output This is a helpful sentence to remember the symptoms of hyper and hypokalemia Calcemias and magnesiums do the opposite of the prefix ( everything goes down when calcium goes up) Earliest sign of any electrolyte disorder is numbness and tingling (paresthesia) Circumoral paresthesia (numb and tingling lips) Fastest way to lower high potassium (give D5W with regular insulin) tpn and parenteral are IV feedings Indicated for malabsorption Enteral are tube feedings like NG Stomach is pushing through the diaphragm GERD Heartburn, indigestion Treatment: sit up after eating, want stomach to empty faster Keep head of the bed in high position, high carb diet, fluids high and carbs because we want things to go fast Low protein Brace should be worn 23 hours a day Lateral deviation Wear shirt under Dumping Syndrome Electrolytes TPN VS ENTERAL VS PARENTERAL Hiatal Hernia Scoliosis
  • 63. NEURO & BRAIN normal things that happen when clients age are decreased sphincter reflexes, increased frequency, decreased peristalsis Incontinence is not normal in the aging process, GI neurological changes are NOT normal Rupture of blood vessel in brain causing bleeding into brain tissue or subarachnoid space Nursing considerations: Patient is on seizure precautions because risk of IICP They may develop dysphagia so NPO for these patients until swallow function test is performed Frequent neuro checks The nurse should prevent activities that increase ICP How to decrease ICP: reduce stimulation maintain quiet and dim environment limit visitors stool softeners to reduce straining strict bed rest, assist with ADLs maintain head in midline position to improve jugular venous return to the heart NO anticoagulants Inflammation of the meninges covering the brain and spinal cord Clinical manifestations: N/V Fever Severe headache Nuchal rigidity Photophobia AMS (altered mental status) IICP Stiff neck Pain with flexion Patient should be put on droplet precautions No negative pressure room Client aging: Hemorrhagic Stroke Meningitis
  • 64. Peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (CN7) in the absence of a stroke or other diseases Flaccidity of affected side Clinical manifestations: Inability to close eyes of affected side Cannot smile symmetrically Lacrimation of the eye is decreased on affected side Flattening of the nasal labial fold Facial drop Cannot close eye correctly Expressive , Impaired speech and writing May be able to speak short phrases but has difficulty with word choice The nurse should listen and give time for patient to speak Easily frustrated when attempting to speak Clients speech is limited to short phrases that require effort Receptive Impaired comprehension of speech and writing May speak full sentences but the words do not make sense Ask simple yes or no questions Loss of the ability to perform a movement due to neurological impairment Neurodegenerative disease with no cure Degeneration of motor neurons in the brain and spinal cord Clinical manifestations: Fatigue Muscle weakness that is progressive Twitching and muscle spasms Difficulty swallowing, difficulty speaking Respiratory failure Clients usually survive 3-5 years and there is no cure Part of a focused neurological exam assessing vestibular function and body in space Used to determine the reason for loss of coordination Clients are asked to stand with the feet together and eyes closed If loss of balance occurs then ataxia is considered to be sensory These patients will have loss of balance and need assistance with ambulation Bell Palsy Aphasia Syndrome Broca Wernicke Apraxia ALS Romberg Test
  • 65. Induced in clients who suffer neurological injury due to cardiac arrest or in comatose or clients who do not follow commands after ressecutation Induce 6 hours after arrest up to 24 hours Improves neurological outcomes and decreases mortality rates Look for signs with Cushing’s Triad as it is related to IICP Change in LOC Bradycardia Widening pulse pressure Cheyenne stokes respirations Cushing's triad is a late sign and signals that the brain stem is compressed Keep head of the bed at 30 degrees Usually occurs in children Daydreaming like episodes, usually 10 seconds and staring No memory of the seizure During seizure activity, priority is client safety Assist to lie down from a chair or whatever they are doing Loosen restrictive clothing Administer oxygen as needed Never restrain and never insert anything into the mouth During seizure activity need to stop, administer IV or rectal benzos (diazepam, lorazepam) Loss of half of the visual field on the same side May lose left side of visual field in both eyes High risk for self neglect Change in LOC Amnesia Headache Rest and light diet are encouraged No strenuous activities for 1-2 days Autoimmune disease involving a decreased number of acetylcholine receptors and leads to skeletal muscle weakness Clinical Manifestations: ptosis/ diplopia Therapeutic Hypothermia IICP Absence Seizures Seizures Homonymous Hemianopsia Concussion Myasthenia Gravis
  • 66. Bulbar signs (difficulty speaking or swallowing) Difficulty breathing Muscles are stronger in the morning and weaker in the evening Treatment: anticholinesterase drugs before meals Semi solid foods Need to teach about the importance of the flu vaccine (anyone with an autoimmune disease) Involved in coordinating voluntary movement and balance and posture Assessed with gate testing (heel to toe) Finger tapping, touching nose with finger Immediate CT or MRI Thrombolytic therapy within 4.5 hours (contraindicated in bleeding, hypertensive, aneurysm) Neuro assessment Highest score 15 Lowest score 3 Best indicator of decline is score decreasing in small amount of time vs. individual component or answer chronic , progressive, neurodegenerative disease of the dopamine producing neurons Characterized by: Slow movement (bradykinesia) Increase muscle tone (rigidity) Resting tremor Shuffling gait Short steps Stooped posture, Masked facial expression Caused by low levels of dopamine in the brain Levodopa Carbidopa (Sinemet) is a medication that can help in treating bradykinesia Once this medication is started, it should never be stopped because it can lead to complete loss of movement This medication takes several weeks to reach effect The client’s urine and saliva may turn a reddish-brown color but this is not harmful Testing Cerebellar Function Ischemic Stroke GCS Parkinson Disease
  • 67. Engaging in regular exercise decreases the risk of AD Genetic, lifestyle, and environmental factors Family history is a risk factor Trauma to head is a risk factor Usually over 65 Healthy lifestyle to reduce the risk of AD Caring for clients with AD Use distraction and redirecting to manage agitation (go for a walk) Speak slowly, simple words, yes or no questions No open ended questions Break down complex activities into steps with simple instructions Decrease client’s anxiety by limiting number of choices Sharp pain along trigeminal nerve Primary prevention is consistent pain control Carbamazepine is the drug of choice This is a seizure medication and is highly effective in controlling neurological pain This medication is associated with infection risk and leukopenia so the patient should report any fever or sore throat Evaluate brain electrical activity Hair needs to be washed before procedure Avoid caffeine, stimulants, and CNS depressants The test is not painful and no analgesia is required No chocolate before Foods and liquids are not restricted before test Not painful and not sedated Increased ICP Increased head circumference, sunset eyes, bulging fontanelles Open spina bifida Open area in lumbar spine Risk for infection Priority intervention it to cover with a sterile, moist dressing Alzheimer’s Disease Trigeminal Neuralgia EEG Hydrocephalus Myelomeningocele
  • 68. The patient with be in the lateral recumbent position or sitting upright, these positions allow for widening of the space inbetween the spinal vertebrae Before the Procedure: Client will be asked to empty the bladder Needle will be inserted between L3/L4 or L4/L5 Pain may be felt radiating down the leg, temporary After the Procedure: Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resulting headache Increase fluid intake for the next 24 hour to reduce dehydration Chronic seizure activity Seizure triggers include:Avoid alcohol in excess, sleep deprivation and stress Practice relaxation techniques Medical alert bracelet Phytenin may decrease oral contraceptive effectiveness so use non hormonal birth control Phytenin may cause fetal abnormalities Do not stop medication abruptly Sign of severe brain injury Arms and legs will be straight out, toes pointed down, and head and neck arched back These assessment findings indicate that severe injury has occured CSF fluid leak from nose and ears, racoon eyes, Battle’s sign (bruising around the ears) Dextrose testing can be done on the fluid to confirm it is CSF This CSF leak puts the client at risk for infection No NG or oral tubes should be placed unless with fluoroscopic guidance Coagulated blood surrounded by halo ring of CSF can be a positive sign (halo ring sign) Hyperventilate before suctioning Maintain dark, quiet environment Maintain the head of the bed in a neutral, midline position Elevate head of the bed to 30 degrees Administer stool softeners to decrease straining Manage pain Manage fever Lumbar Puncture Epilepsy Decerebrate Posturing Basilar Skull Fracture What can the nurse do to decrease IICP Administer stool softeners to decrease straining Manage pain Manage fever
  • 69. VISUAL/ AUDITORY Speak directly to client, facing client, Use facial expressions and gestures Post a hearing impaired sign on clients door The nurse should ensure hearing aids are functionable and in place Speak at a normal volume (no yelling) Encourage client to repeat back teaching Require emergency care to prevent permanent vision loss Copious eye irrigation for all types of ocular chemical burns Sterile saline or water irrigation should begin immediately IV tubing used or a morgans lens, continues until the pH of eye is normal (6.5-7.5) Activities that may increase intraocular pressure should be avoided to decrease risk of damage to suture site These included: bending over, lifting more than 5lbs, sneezing, coughing, constipationIf constipated, the nurse should encourage fluids, fiber intake, and over the counter stool softeners After cataract surgery it is common for the person to feel itching in the affected eye and blurred vision Sleeping on 2 pillows will decrease intraocular pressure Eye Injuries If a person gets something stuck in eye (splinter, or injury) they should first COVER BOTH EYES (since the eyes work in synchrony) Do not flush eye is there is splinter lodged in it, may cause further injury When a foreign body becomes lodged in the eye, both should be shielded Separation of the sensory retina from the underlying pigment epithelium Clients experiencing retinal detachment may experience a gradual, curtain like, loss of visual field Retinal detachment is a medical emergency and interventions should happen immediately to reduce the chance of vision loss The injured person could have the perception of lights flashing, floaters, gnats/hairnet, cobweb vision Traumatic retinal detachment may result in sudden vision loss Retinal detachment requires emergency surgery Post Op teaching: Avoid activities that increase intraocular pressure No rubbing eyes (this increases intraocular pressure) Speaking with the Hearing Impaired Ocular chemical burns Cataract Surgery Retinal Detachment