Uworld NCLEX review

Spinal immobilization (NSAIDS) – THINGS THAT YOU CONSIDER BEFORE IMMOBILIZING SPINE* Neurological examination – check for focal deficits, numbness and decreased strength Significant Traumatic mechanism of injury Alertness Intoxication – if they’re intoxicated they might lack awareness of pain Distracting injury – another significant injury distracting them from spinal pain Spinal examination – tenderness of spine or neck, pain on movement Pathologic vertebral fractures are very common in people with multiple myeloma Joint dislocations - Can be an orthopedic emergency because the articular bone might compress surrounding vasculature causing limb-threatening distal ischemia* - Can cause damage to nerves and blood vessels - Pain, deformity, decreased ROM, extremity paresthesia - Goal is to reduce and immobilize the joint, do frequent neurovasc checks Phalen’s test – assess for carpal tunnel syndrome CSF leakage through nose or ears can indicate skull fracture - If the drainage is clear, dextrose testing can be done to identify the CSF - Presence of blood would make this test unreliable because there is glucose in blood o Use gauze to do halo/ring test in the presence of blood o Blood will clot in the center, CSF will stay surrounding the blood like a “halo” Racoon eyes and ecchymosis behind the ear (mastoid) – battle’s sign; basilar skull fracture Should patient elevate arms when they have arm cast? - Elevating the arm for the first 48 hours after placement is okay, helps reduce edema - If compartment (3rd space shifting  tissue compartment) syndrome develops, keep the arm at torso level Long term PPI (for GERD) meds can lead to - Osteoporosis; because it can decrease the absorption of calcium - Can increase risk for C-diff (can get because antibodies destroy normal flora) too somehow Mandibular fracture - Drooling can occur because they can’t close their mouth due to edema or jaw misalignment - Bleeding can occur and it can pool up in the mouth – PRIORITY IS AIRWAY!! Suction to maintain airway patency - Give O2 via nasal cannula, opioids for pain and ice to reduce edema Ankylosing Spondylitis - Inflammatory disease affecting the spine, no known cause or cure - Axial joints fuse together, person becomes very stiff and mobility is restricted - Low back pain can be improved with activity - If thoracic spine is affected watch out for breathing, they can end up hypoventilating due to limited chest wall expansion - Tell them to fix their posture, stretch, swim, stop smoking - NSAIDs for pain - Sleep on a firm mattress Pelvic fracture – WORRY ABOUT BLEEDING - Abdominal distention - Watch out for hgb and hct, worry about internal hemorrhage - Assess for injury to other structures within the pelvis – bowel or bladder - Assess for hematuria and low urine output - Absent bowel sounds – could be paralytic ileus (no bowel sounds) due to trauma or RETROPERITONEAL HEMATOMA o Retroperitoneal hematoma results from ruptured organs Hip Fracture - Ecchymosis (bruise) over hip - Femur is very vascular – can result in significant blood loss >1000mL - Hip pain with weight bearing - Muscle spasms in the injured area – muscles surrounding the fracture contract to try and protect and stabilize the injured area - Affected extremity can shorten Inferior vena cava filter - Device inserted percutaneously via the femoral vein - Trap blood clots from lower extremity and prevent it from migrating to the lungs causing PE - Usually given to pts that keep getting recurrent emboli and can’t be on anticoags - Report this to HCP before getting MRI - Don’t cross the legs – restricts venous return to legs - REPORT LEG PAIN OR NUMBNESS – can indicate impaired neurovasc status BNP - Used to distinguish cardiac from respiratory causes of dyspnea - Can indicate heart failure if greater than 100 CK-MB - Released when heart muscles are injured - Can indicate myocardial infarction but NOT specific for heart failure Troponin - Highly specific cardiac marker for the detection of MI - Has greater sensitivity than CK-MB - Levels increase 4-6 hrs after onset of MI - Return to baseline in 2 weeks - Troponin I: <0.5ng/mL - Troponin T: <0.1ng/mL Adenosine - First-line drug for SVT (super ventricular tachycardia) - Half life is less than 5 secs, administer quickly in 1-2 seconds – flush with 20mL saline - Start with 6mg Bolus IV, then 12 - Injection site should be as close to the heart as possible – antecubital area o Brief period of asystole is due to adenosine slowing impulse conduction through AV node - Monitor for flushing, dizziness, chest pain or palpitations during and after administration Should patients with peripheral artery disease use heat pads? No because they can burn themselves First degree heart block - Rhythm is regular - P-waves always precedes each QRS People who usually get atypical symptoms for heart attacks - Old people - Diabetics - Women They usually get pain in the jaw or arms, shortness of breath, dizziness, nausea and cold sweats – they need a 12 lead ECG, because we don’t realize they’re experiencing impending heart attack based on their atypical symptoms After cardiac cath via femoral entry - Keep the affected leg straight for up to 6 hours to avoid pressure at the insertion site and prevent hemorrhage Ischemic stroke - Loss of brain tissue perfusion due to blockage - Permissive hypertension – blood pressure is elevated because the body is trying to compensate and perfuse the brain, usually autocorrects within 24-48 hours o You should not treat the permissive hypertension that occurs after stroke because the body is trying to perfuse important organs – WE WANT HYPERTENSION* (permissive BP for 2 days) - Doesn’t require treatment unless its super high like SBP > 220 or DBP >120 OR if they have other problems like HF, aortic dissection … - THIS ONLY APPLIES TO ISCHEMIC STROKE – NOT IN HYPERTENSIVE CRISIS**** Valsalva Maneuver for SVT - Place ice bag to face and hold breath while bearing down - When this doesn’t work and pt becomes unstable – adenosine and synchronized cardioversion - We want to stimulate the vagus nerve to tell the heart to chill out – stop beating so quickly, remember; SVTs are about 150-220 bpm – if nonpharmacological methods don’t work resort to ADENOSINE Acute onset of dyspnea, productive cough with pink frothy sputum – pulmonary edema**  complication of MI  Complication of MI  Crackles at lung bases CVP value: 2-8 mmHg  Right ventricle PAWP value: 6-12  Left ventricle Elevated CVP and PAWP with crackles indicate left-sided failure, give furosemide to decrease both preload SVT heart rate is usually between 150-220  Caused by stimulants like cocaine, nicotine or caffeine  QRS are very narrow  Palpitations, dyspnea, angina  Blood pressure can eventually drop Tetralogy of fallot  septum goes away  Combo of 4 congenital anomalies  VSD, pulmonary stenosis, overriding (misplaced) aorta, right ventricular hypertrophy  Usually diagnosed in babies – this is generally a peds problem  Kids can get cyanotic, tet spells – they turn blue from feeding or crying too long  Teach them knee-to-chest position when they have trouble breathing if they’re CHILDREN but when they’re babies you have to HOLD them in that position (squatting) to help blood flow to the lungs  Usually these type of kids get treatment and surgery – they usually grow up find and can live normal lives After repair of Tetralogy of Fallot - Worry about heart failure post-op - Watch out for cold extremities, periorbital edema, rapid weight gain, reduction in number of wet diapers, decreased appetite and dyspnea* Digoxin (Lanoxin)  important medication - Used for HF and a-fib - Therapeutic range 0.5-0.2 ng/mL - Take apical pulse, don’t give if under 60 - Watch out for digoxin toxicity – seeing color changes, blurry vision, nausea, vomiting, abdominal pain, weakness, confusion - Earliest symptoms of digoxin toxicity is usually nausea, vomiting and abdominal pain* Pulsus paradoxus - More than 10mmhg fall in SBP during inspiration - Have to take BP manually to assess for this Torsades de pointes  can cause death - Polymorphic ventricular tachycardia - GIVE IV MAG