ATI RN COMPREHENSIVE EXIT EXAM

ATI RN COMPREHENSIVE EXIT EXAM|2022 UPDATED diet for chronic renal failure low protein & potassium DM pt teaching change shoes, wash feet w/soap & water pulse pressure subtract systolic value from diastolic value lantus never mix, long lasting, no peak rhogam given @ 28 weeks & 72 hours post delivery when mom is negative & baby positive indication of baby dehydration improving smooth fontanel pt w/orthostatic hypotension put near nursing station cleaning a wound clean to dirty use bulb syringe peripheral arterial disease cramp in leg while walking intermittent claudication seizure precautions supine position 20 weeks gestation, having urinary frequency u/a & c/s report to new nurse @ shift change pt @ xray s/s of hemolytic blood transfusion flank pain ER rape victim priority acess anxiety nutrition carbs 45%, protein 10-15% latex allergy tape up cords first ingredient on a food label most content thoracentesis, & painful w/breathing put pt on UNAFFECTED side for 1 hour or longer pt w/IV sedation check LOC if not responsive help older brother get used to baby get a gift for big brother early decelerations head compressions methergine contraindication HTN delegate to AP I & O HF monitoring weights location for peripheral line radial prioritizing care for multiple pt's low flank pain ativan for seizures med for diabetes insipidus desmopressin radiation tatoo use mild soap & water uric acid stones eat low fat yogurt antigout med decreases uric acid level allopurinol non-pharm relation technique for pain management in labor hypnosis psychotic disorder assessment finding flat affect newborn withdrawal from heroin (opioids) hypertonicity mitral valve location 5th intercostal amniocentesis go pee before procedure total gastrectomy lack b 12 takes 30-60 meal to eat a meal stoma color pink or red is normal MAOI's diet no pepperoni, no tyramine, COTTAGE CHEESE OKJ give iron w/? OJ statins contraindication Grapefruit juice haldol lip smacking mag sulfate decreased urine output decreased respirations decreased pulmonary edema antidote for mag sulfate calcium gluconate clozaril interventions monitor WBC valproic acid liver function thyroid med effectiveness weight loss diuretics don't skip doses DIG adverse effects N/V & HA prednisone take with milk hemo/peritoneal dialysis pt teaching medical asepsis cranial nerve 11 shoulder peripheral catheter insertion advance catheter when you see flash back of blood return dispose of insulin needles @ home in coffee container confirmation of ng placement x ray swallowing difficulty referral speech therapy acrabose skip a meal, skip dose, give w/1st bite of food sprains & strains RICE pt DNR-CC & family asking questions related to. therapeutic communication: THERAPEUTIC RESPONSE What did the dr tell you? delegating to AP about skeletal traction: NEEDS MORE TEACHING AP places weight on bed daughter feeling guilty about admitting parent into long-term facility: THERAPEUTIC RESPONSE rephrase what daughter is feeling how good nurse plans her day rechecks her priorities half way through her shift good nurse sets these when she works GOALS pt gets bad dx, & asks you not to tell her spouse:YOUR RESPONSE you have a right to privacy delegate to AP CPR baby in contact precautions in a private room, what would you do to save hospital $? bring formula prn how does a nurse properly manage her time mid-shift? reevaluates goals which psych pt would you see first? hallucinations dementia pt @ ER, w/marks on coccyx & wrist, suspected abuse. what do you do? ask pt. INTERVIEW HIM psych pt yelling in front of group. very agitated, what do you do? isolate pt charge nurse scheduling resolution between nurses nurse listens to both sides respite care gives family a break pt in seclusion documentation what happened prior to seclusion that caused for seclusion parkinson's : pt teaching nutrition- thicken liquids pt receiving radiation, what should you wear? lead apron pt suffering from hyperthermia seizure precautions pt refuses last minute for a procedure he already consented for okay to stop procedure s/s of smallpox rash on tongue xerostoma humidifier vagina procedure, cervical cancer place catheter Lyme disease report it lice (pediculodis capitis) can survive on surfaces for up to 48 hours RSV keep stethescope in room (droplet) 16 weeks gestation can get AFP test done bacterial meningitis droplet precautions when can kid return to school for chicken pox when lesions are crusted over kicks a ball: developmental stage 24 months baby w/cleft lip untie arms & perform ROM wrong ostomy care changing everyday may lead to skin irritation after male circumcision apply petroleum jelly w/every diaper change breastfeeding w/hep c don't breast feed if you have cracked nipples contraindication w/oral contraceptives HTN combination contraceptives contraindications pt w/migraines when percussing RUQ, what should we feel dullness dementia pt offer finger foods black males @ great risk for CVA med for alcohol withdrawal disulfiran (antabuse) better nutririon canola oil healthy eating 45 % carbs to prevent neuro tube defects folate prevnting delays of healing protein & o2 pt raped & @ ER assess anxiety pt reports abuse assess pt, check for injuries anorexia 60% refeeding-pre-albumin of 10 telemetry is used for check for dysrythmia do not give mmr to child bearing pt b4 pregnancy test pt w/hx of blood transfusion diet for hf dry spices to flavor food TURP: closed intrermittment irrigation let it drain Cranial nerve XI (hot spot) shoulder Proper lifting technique (picture) bending at knees 24 month old walk up steps Food label greatest weight listed first IV technique advance catheter Refeeding syndrome 60% Low fat diet canola oil instead of vegetable oil Prior to amniocentesis empty bladder Radiation implant limit visitors to 30 minutes Levothyroxine take on empty stomach, in am; increases tsh Metformin contraindication kidney disease, severe infection, shock, hypoxic conditions Mastectomy lay of affected side to promote drainage, support arm on pillow, HOB 30 Circumcision use petroleum jelly with every diaper change Check for NG tube placement in the jejunum X-ray Colostomy care cut the bag Seizure precautions saline lock IV Ethical medical error veracity Early decelerations head compressions Magnesium sulfate interventions (select all) calcium gluconate, stop infusion, UO less than 30, RR less than 12, decreased reflexes Thoracentesis causes pneumothorax expected finding not friction rub; tracheal deviation AP's talking in cafeteria tell them to stop talking Safety for parkinson's clear area Warfarin vitamin k for toxicity; INR 2-3; PT 11-12.5 Contraindication of MMR blood transfusion Diabetic foot care (select all) change shoes frequently, wash feet with soap and water Sprains avoid warm compress Expected finding of small pox rash in mouth 16 weeks pregnant alpha protein Psych med lip smacking Where to start IV first (picture) hand PRBC need further teaching start IV on other arm Delegate to AP CPR compressions Delegate to LPN sterile dressing Postural drainage give albuterol, trendelenberg; 1 hour before meals or 2 hours after Dumping syndrome high protein and fat; avoid milk, sweets, and sugar; small, frequent meals DASH diet increase fruit, vegetables, and low fat dairy; k, mg, ca Baby with reflux small, frequent meals, thicken formula with rice cereal, HOB 30 Cleft palate repair periodic restraints Nephrotic syndrome vitamin K Pernicious anemia schilling's test Peritoneal dialysis report cloudy; monitor glucose; warm solution before Gastric surgery eat 3 meals Gastrectomy small, frequent meals; vitamin B12, D, iron, and folate Statin grapefruit Preventing uric acid stones yogurt RSV have own stethoscope in room Change of shift report orthostatic hypotension by nurses station Confused patient raise 1 side rail Hypoglycemia cool and clammy skin Hyperglycemia thirst Glycosylated blood test HbA1C Priority for patient in seclusion document Buddhist patient vegetarian Positive TB hard raised bump Heart murmur sound blowing or swishing Dehydration oliguria NST PAD pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs Cast with white extremity compartment syndrome Alcohol withdrawal expected finding n&v, tachycardia, diaphoresis, tremors, seizures Varicella scabs okay Hyperthermia not blanket or ice Purpose of ice decrease inflammation Sexual assault assess anxiety THA avoid flexion greater than 90 Beta blocker teaching don't stop abruptly; avoid in asthma; take with food Combination contraceptives increase BP Myelosuppression flu shot Glucocorticoid increase dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped abruptly Extreme focus mild anxiety Good diet 30% carbs Family concern what has the doctor told you Adolescent 1300 mg of calcium Lyme disease report to health department Organize workload goals for the day Intervene pacing around wife Renal failure decrease protein, K, Na, increase carbs, strict I&O Preeclampsia proteinuria Urine frequency in pregnancy urine sensitivity test Lice can live for 48 hours on surfaces Chest tube complications bubbling in water seal Elderly abuse ask privately Informed consent signed willingly Sibling bonding offer gift each time sibling gets one TURP complication hematuria African american over Caucasian heart disease Sickle cell priority hydration Sickle cell complication SOB Respite care give caretaker break Acarbuse take with first bite of each meal Hallucination I understand you are scared Fire extinguisher PASS Advanced directive don't need a lawyer Breastfeeding and hepatitis c as long as you don't have cracked nipples ICP keep HOB midline Long term use of proton pump inhibitors osteoporosis Diabetes insipidus polyuria Difficulty voiding warm water ACE inhibitors cough What do you hear when you palpate abdomen resonance Negotiation strategy understand both sides Dying patient wants to be alone depression or dysfunctional Wife progressing quickly can you tell me more Pregnant non-pharmacological pain management aromatherapy, breathing techniques, imagery, music, use of focal points, subdued lighting Hypnosis purpose alter perception of pain Complication of conscious sedation with RR 6 stop infusion or give something Major depression, OCD give fluoxetine What causes constipation iron Patient can't sleep don't drink caffeine before bed Collecting urine culture on baby straight cath Electrolytes Na - 136-145 K - 3.5-5 Ca - 9-10.5 Mg - 1.3-2.1 P - 3-4.5 Cl - 98-106 Hypervolemia bounding, JVD, edema, confusion, increase everything Anorexia prealbumin 10 Dehydration improving baby flat fontanelle Unsaturated fat coconut oil Priority abdominal pain and went away Opioid agonist naloxone (Narcan) COPD increase calories and protein Needle disposal at home coffee container on top shelf Give RhoGAM in second pregnancy protect future pregnancy Swallow problem refer to speech therapist Nutrition for heart failure Decrease Na, increase fluids, increase fiber; increase K with diuretic Adverse affects of dogoxin Bleeding gums, bloody urine and stools, arrhythmias, petichiae NG nutrition Increase K Methotrexate adverse affect High blood pressure I.M. site for children VASTUS LATERALIS or antelolateral thigh is the site for IM injections in children < 2 yrs. of age Peak Levels show the highest concentration Time for drawing Peak levels: Oral Intake 1 to 2 hour after administration Time for drawing Peak levels: I.M. 1 hour after administration Time for drawing Peak levels: I.V. 30 minutes after administration Trough Levels show the lowest concentration or residual level, usually obtained within 15 minutes before next dose. Do not administer until confirmed. Can meds be administered through blood tubing? NO. Never administer meds through tubing being used for blood administration How long should fluids be infused? Fluids should be infused within 24 hours, discard unused potion, to prevent infection Complications associated with IV infusion infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, venous spasm Preventing Infiltration use smallest catheter for prescribed therapy, stabilize port-access, assess blood return Treatment of Infiltration stop, remove, cold compress, elevate extremity, insert new cath in opposite extremity Preventing Extravasation know vesicant potential before giving medication Treatment of Extravasation stop, discontinue, aspirate med if possible, cold compress, document Preventing Phlebitis & Thrombophlebitis rotate sites every 72 to 96 hrs, secure catheter, aseptic technique for PICC lines, limit activity with extremity Treatment of Phlebitis & Thrombophlebitis stop, remove, heat compress, insert new cath in opposite extremity Preventing Hematoma avoid veins not easily seen or palpated, obtain hemostasis after insertion Treatment of Hematoma remove, apply pressure, monitor for signs of phlebitis and treat Preventing Venous Spasm allow time for vein diameter to return after tourniquet removed, infuse fluids at room temp Treatment of Venous Spasm temporarily slow infusion rate, warm compress TPN hypertonic solution, contains dextrose, proteins, electrolytes, minerals, trace elements, and insulin prescribed, administered via central venous device like PICC line, subclavian, or internal jugular vein Care for TPN verify with another nurse, use infusion pump, monitor daily weights, I & O, fluid balance, serum glucose q4 to 6 hrs, infection, change dressing q48 to 72 hrs, change tubing and fluid q24 hours, if TPN is unavailable, administer dextrose 10% in water to prevent hypoglycemia Complications of central venous catheters pneumothorax during insertion, air embolism, lumen occlusion, bloodstream infection Pneumothorax during insertion use ultrasound to locate veins, avoid subclavian insertion when possible, treat with O2, assist with chest tube insertion Air Embolism have client lie flat when changing administration set or needleless connectors, ask client to perform Valsava maneuver, treat by placing client in left lateral trendelenberg, and O2 Lumen Occlusion flush promptly with NS between, before, and after each med, treat with 10 cc syringe with pulsing motion Bloodstream Infection maintain sterile technique, treat by changing entire infusion system, notify MD, obtain cultures, and administer antibiotics Antidote for Acetaminophen Acetylcysteine, Mucomyst Antidote for Benzodiazepine Flumazenil, romazicon Antidote for Curare edrophonium, tensilon Antidote for Cyanide Poisoning methylene blue Antidote for Digitalis digoxin immune FAB, Digibind Antidote for ethylene poisioning fomepizole, antizol Antidote for Heparin and enoxaparin or Lovenox Protamine Sulfate Antidote for Iron Deferoxamine, desferal Antidote for Magnesium Sulfate calcium gluconate 10%, kalcinate Antidote for Narcotics naloxone, narcan Antidote for Warfarin phytonadione, vitamin K aminophylline 10 to 20 mcg/ml carbamazepine 5 to 12 mcg/ml digoxin 0.8 to 2.0 mcg/ml gentamicin 0.5 to 0.8 mcg/ml lidocaine 1.5 to 5.0 mcg/ml lithium 0.4 to 1.4 mcg/ml magnesium sulfate 4 to 8 mcg/ml phenobarbital 10 to 30 mcg/ml phenytoin 10 to 20 mcg/ml quinidine 2 to 5 mcg/ml salicylate 100 to 250 mcg/ml theophylline 10 to 20 mcg/ml tobramycin 5 to 10 mcg/ml acetaminophen toxicity > 250 aminophylline toxicity > 20 amitriptyline toxicity > 500 digoxin toxicity > 2.4 gentamicin toxicity > 12 lidocaine toxicity > 5 lithium toxicity > 2.0 magnesium sulfate toxicty > 9 methotrexate toxicity > 10 over 24 hours phenobarbital toxicity > 40 phenytoin toxicity > 30 quinidine toxicity > 10 salicylate toxicity > 300 theophylline toxicity > 20 tobramycin toxicity > 12 PRIL ace inhibitors, captopril, enalapril VIR antivirals, acyclovir, valacylovir AZOLE anti fungals, fluconazole, variconazole STATIN antilipidemics, atorvastatin, simvastatin SARTAN angiotensin 2 receptor blockers, ARBS, valsartan, losartan OLOL beta blockers, metoprolol, nadolol DIPINE calcium channel blockers, amlodipine, nifedipine AFIL erectile dysfunction meds, sidenafil, tadalafil DINE histamine 2 receptor blockers, ranitidine, famotidine PRAZOLE proton pump inhibitors, pantoprazole CAINE anesthetics PAM, LAM benzodiazepine ASONE, SOLONE corticosteroid CILLIN penecillin IDE oral hypoglycemic ASE thromolytic AZINE anti emetic PHYLLINE bronchodilator ARIN anticoagulant TIDINE anti ulcer ZINE anti histamine CYCLINE antibiotic MYCIN aminoglycoside FLOXACIN antibiotic TYLINE tryciclic antidepressant PRAM, INE SSRI anti hypertensives assess weight, VS, hydration, ortho BP, renal function, coagulation, educate to take same time each day, avoid hot tubs and saunas, do not discontinue abruptly ACE inhibitors (angiotensin converting enzyme) block the conversion of angiotensin 1 to angiotensin 2 Angiotensin 2 Receptor Blockers selectively block the binding of angiotensin 2 to angiotensin 1 receptors found in tissues ACE Inhibitors captopril or capoten, enalapril or vasotec, enalaripat or vasotec IV, fosinopril or monopril, lisinopril or prinivil ARBs losartan or cozaar, valsartan or diovan, irbesartan or avapro ACE inhibitors and ARBs for HTN, heart failure, MI, and diabetic nephropathy, monitor potassium, use with caution if diuretic therapy is in use ACE inhibitors and ARBs side effects persistent non productive cough with ACE inhibitors, angio edema, hypotension, contra for 2nd and 3rd trimester in pregnancy ACE inhibitors and ARBs nursing interventions captopril should be taken 1 hr before meals, monitor BP, monitor for angio edema and promptly administer epinephrine 0.5 ml of 1:1000 solution sub q Calcium Channel Blockers slows movement of calcium into smooth muscle cells, resulting in arterial dilation and decreased BP, examples are nifedipine/adalat/procardia, verapamil/calan, dilitiazem/cardizem, amlodipine/norvasc Calcium Channel Blockers Use for angina, HTN, veripamil and diltiazem may be used for A Fib, A flutter, or SVT Calcium Channel Blockers Precautions use cautiously in clients taking digoxin and beta blockers, contra for client who have heart failure, heart block, or bradycardia, avoid grapefruit juice (toxic) Calcium Channel Blockers side effects constipation, reflex tachycardia, peripheral edema, toxicity Calcium Channel Blockers nursing interventions do not crush or chew sustained release tablets, administer IV injection over 2 to 3 mins, slowly taper dose if discontinuing, monitor HR and BP Alpha Adrenergic Blockers (symphatholytics) selectively inhibit alpha, adrenergic receptors, resulting in peripheral arterial and venous dilation that lowers BP, esamples are Alpha Adrenergic Blockers (symphatholytics) Use for primary HTN, cardura may be used in treatment of BPH Alpha Adrenergic Blockers (symphatholytics) Precautions increased risk of hypotension and syncope if given with other anti hypertensives, beta blockers, or diuretics, NSAIDs may decrease effect of prazosin Alpha Adrenergic Blockers (symphatholytics) side effects dizziness, fainting Alpha Adrenergic Blockers (symphatholytics) nursing interventions monitor HR and BP, take meds at bed time to minimize effects of hypotension, advise to notify prescriber immediately about adverse reactions, consult prescriber before taking any OTC meds. Lorazepam antidote flumazenil Fluid overload dyspnea s/s, back up of fluid in pulm system Rheumatoid arthritis pain freq rest during the day case mgr arranges for transportation to health care appts w/mental health Total hip install raised toilet seat at home verapamil and grapefruit causes hypotension, g. increases blood levels of v. by inhibiting metabolism vaso occlusive crisis in sickle cell start iv fluids 1st to promote hydration and circulation Do not increase this if pt has COPD exaserbation O2 hemianopsia hemi=half, an=without, opsia=seeing *use scanning tequnique when ambulating narrow QRS complex, irregular 170 bpm, no p waves a fib N/V will cause what lab value to elevate? urine specific gravity-dehydration enoxaparin aka lovenox blowing bubbles to make the "hurt go away" is an example of what? nonpharm visualization for pain mgmt w/kids hypoglycemia irritability hyperglycemia polyuria One or more surgical drains after? masectomy, exercise after 24 hrs TB meds or longer 6 mo If client is disorientated and combative during the night, what should Rn do? move client closer to Rn station Wash clients hand with soap/water prior to? CBG Changing this is final step in trach care trach ties Diazepam (benzo) should be given for? status epileptcus HA is adverse effect of? fluoxetine, hypotension too Use ventrogluteal site with these patients for IM obese Clonidine side affect dry mouth Clozapine side affect wt gain Unstable vs are immediate threat to life? t/f true! TPN pt's need this monitored frequently blood glucose, 24 hr TPN at first then 8-12 hrs per day once stable ECT can cause short term memory loss Nurse should use with transfusion 0.9% sodium chloride to prevent clotting, **not D5W Expected finding in cardiac tamponade pulsus paradoxus-drop in bp during inspiration Nonmaleficence duty to do no harm autonomy informed consent pattern paced breathing during this phase of labor transition position client who is at risk for pressure ulcer at this level 30 degree lateral position in bed Pt with femur fracture highest prioroty upper chest petechiae-risk for fat embolism syndrome Tremors can indicate hyperthyroidism Cloudiness with blurred vision cataracts this med will help reduce icp mannitol-osmotic lung expansion with age decreased precautions with hsv contact Occupational therapy for difficulty performing personal hygeine Have pt lie on this side during gastric levage for NG tube left-prevents aspiration Celiac diet gluten free-chicken and wild rice to decrese icp put in quiet env quick notes during h-t assessment Diaphram should be removed how long after intercourse? 6 hrs or more intervention to prevent heat loss with infant pad scale with paper Pt admitted with dka, first priority? vs If INR is 1.8 and ptt is 98 hold heparin infusion 6-8 wet diapers a day indicates? effective breastfeeding Brat diets are contraindicated with diarrhea Ask this if pt refuses to ambulate after surgery pain Review chest x-ray report prior to initiating infusion in picc LPN can insert NG pt with this needs private room with negative air pressure pulm tb if pt is unconsious and needs er help proceed without consent opioid side effect u. retention Use 1:100 chlorine solution to clean kitchen surfaces with this illness hep A make referral for social services for pt with this terminal illness serum magnesium of 2.5 initiate continuous cardiac monitoring Cold therapy for these patients Rheumatoid arthritis to relieve inflammed joints fluoxetine SSRI antidepressant-watch for tremors since this can cause serotonin syndrome w/in 2-72 stage II pressure ulcer partial thickness skin loss stage III pressure ulcer visible sq tissue stage IV muscle damage, tendon exposure Cyclophosphamide treats cancer, drink 1-1.5x h2o to prevent hemmoragic cystitis and prevent dehydration Valporic acid treats seizures-can cause hepatic toxicity digoxin toxicity sign nausea estradiol (estrace) side effect HA Report findings for pt post ruptured appendix 48 hr ago rigid, board like abdomen absent bowel sounds elevated temp elevated wbc (could be indication of peritonitis) Chlorpromazine antipsychotic to decrease hallucinations Theophylline toxicity bronchodilator-can cause anorexia Check this pulse with an infant during cpr brachial Client is in active labor and receiving oxytocin. FHR shows variability w/accelerations. What is correct response? Document and continue to monitor. This is a reassuring pattern indicating intact fetal CNS and healthy placental/fetal exchange of oxygen. Indication of oxygen toxicity Bradypnea-hypoxic drive is removed Advance Directives 2 components of an advance directive are the living will, and a durable power of attorney. Legal documents that allow people to choose what kind of medical care they wish to have if they cannot make those decisions themselves. Nsg responsibilities are-providing info regaurding advance dir,documenting status of advance dir, ensuring they are current, and reflect pt. status. Recognizing they take prioritiy for the pt. Ensuring that all healthcare team members are aware. living will legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. Ex. cpr, mechanical ventilation, and feeding by artificial means. durable power of attorney enables patient (called the "principal" in the power of attorney document) to appoint an "agent," such as a trusted relative or friend, to handle healthcare decisions on behalf of patient. advocacy supporting pts. by ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care. Nurses must act as advocates even when they disagree with pts. wishes. Nurses are the pts. voice when healthcare system is not acting in pt. best interest. Assigning the process of transferring authority, accountability, responsibility of pt, care to another health care member. delegating The process of transferring authority and responsibility to another team member to complete a task while retaining accountability. supervising Process of directing monitoring and evaluating performance of tasks by another member of the health care team. case management a methodology for moving a patient through the healthcare system while streamlining costs and maintaining quality, Explore resources available to assist with the pt. in achieving or maintaining independence. airway 1st Identify airway concern( obstruction,stridor) Establish a patent airway recognize that 3-5 mins without o2 is irreversible brain damage 2ndary to cerebral anoxia. Breathing 2nd Access effectiveness of pt. breathing(apnea,depressed, respiratory rate, Intervene as appropriate(reposition, administer narcan). circulation 3rd Identify circulation concern (hypotension ,dysrhythmia, inadequate cardiac output, compartment syndrome) identify ways to minimize or reverse circulatory alteration). disability 4th Access for current evolving disability (neurological deficits stroke evolution) Implement actions to slow down disability. Pt. Rights Nurses role Be informed about all aspects of care and take an active role in decision making process. Accept refuse or request a modification to a plan of care. Receive care that is delivered by a competent individual. Prioritize systemic before local. (life before limb) prioritize interventions for a pt. in shock over interventions for a pt. with a localized limb injury. Prioritize acute before chronic Care of pts. with new injuries/illness( confusion, chest pain) over acute exacerbation of a previous illness, over the care over a pt. with a long-term chronic illness. prioritize actual problems before future potential problems. prioritize administration of medication to a pt. experiencing acute pain over a pt. ambulating and at risk for thrombophlebitis. Hypoglycemia risk factors for Newborns, Blood glucose <40 in term newborn, <25 in preterm newborn POST TERM, IUGR, ASPHYXIA, COLD STRESS, Maternal diabetes, Gestational hypertension, Tocolytic therapy, Prematurity, LGA, SGA, Perinatal hypoxia, Infection, Hypothermia Prioritizing care in clients with hyperthyroidism Alternate periods of activity with rest provide calm environment access mental status increased calories and protein monitor intake and output, wt pt. eye protection for pt. with exophthalmos report a degree of 1 or more to MD prepare for thyroidectomy if meds become unresponsive. Pt. education r/t hyperthyroidism medications, methimazole (tapazole) and (PTU) propylthiouracil. These inhibit the production of thyroid hormone. report fever, sore throat, or bruising to md report any jaundice or dark urine follow md instructions about daily intake of iodine. dysphagia Latex allergies must use latex free equipment, gloves and supplies. Risk Factors of Diabetes being African American, Hispanic, or Asian obesity and fat distribution, inactivity, family history, race, age, pre-diabetes, Overweight, family hx, ethnicity, HTN, gestational diabetes, age, viruses, lifestyle, disease of pancreas. Dilantin (phenytoin) Anticonvulsant Seizures, therapeutic levels are determined by blood test. Meds should be taken at the same everyday. Some antieplitic cause overgrowth of the gums, routine oral hygiene. NO ORAL CONTRACEPTIVES OR COUMADIN. Seclusion/ restraints *In emergency situation where there is immediate danger to the pt. or others, the nurse may place the pt. in restraints, nurse must maintain prescription as soon as possible usually within 1 hour. Nsg*assess skin integrity, offer food and fluid, provide hygiene and elimination, vss, rom q2hr. quick release knots to bed frame. Postpartum hemorrhage/ postpartum disorders appropriate assessment. Assess fundus for height firmness and position. If boggy massage fundus to increase muscle contraction. Assess lochia for color, quantity, and clots. Assess for signs of bleeding from lacerations, episiotomy site, or hematomas. Assess for bladder distention, may need to insert urinary catheter to assess kidney function. Pitocin, methergine, IV fluids. X1 (spinal accessory) Cranial nerve 11 Motor turning the head, shrugging shoulders. Head and neck. cultural/spiritual nursing care, use of a interpreter Facility approved interpreter, don't designate the family, or a non designated employee. Inform the interpreter the type of questions that will be answered. Allow time for family and interpreter to be introduced. Direct the questions toward family/pt. not interpreter. Following the interview ask the interpreter if they have any thoughts about pt. verbal or non verbal. Dietary guidelines for celiac disease children-s/s diarrhea, steatorrhea, anemia abdominal distention, impaired growth, lack of appetite and fatigue. Adults- diarrhea, abdominal pain, bloating, anemia, steatorrhea, and osteomalacia. Dietary* Foods that are gluten free-milk, cheese, rice, corn, eggs, potatoes, fruit, veg, fresh poultry, meats, fish, dried beans. * Gravy mixes sauces,cold cuts, and soups, have gluten. Parkinson client safety Encourage exercise (yoga), assistive devices, rom, teach pt. to stop when walking to slow down and reduce speed. pace activities by providing rest periods. assist with adls. Nephrotic Syndrome dietary modifications D/T protein loss, you will need adequate amount of protein and low sodium. Protein-0.7 to 1.0g/kg/day. Soy based proteins, Low sodium g per day. Carbohydrates, trans fat and cholesterol is limited, and total fat should be less than 30% per day, provide multi vitamin supplements. prevention of uric acid stones Increase fluid consumption ml at least preferably h20, at night because that's when urine is most concentrated. Foods high in oxlate such as spinach,rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries., Avoid mega doses of vitamin c, and limit foods high in purine lean meats, organ meats, whole grains and legumes. Pt. teaching about self blood glucose monitoring Check the accuracy of the strips with the solution use the correct code number in the meter to match strip. store strips in closed container adequate amount of blood proper hand hygiene fresh lancets avoid sharing keep record of blood sugars the calories and exercise taken in. food and other events may alter blood glucose metabolism such as activity or illness. Pt. care following a mastectomy Assessment findings for increased intracranial pressure. Severe HA,deteriorating loc, restlessness, irritiability, dilated pinpoint pupils, asymmetric pupils, slow to react or non reactive, alteration with breathing patterns, cheyne stokes respirations, hyperventilation, apnea, deteriation in motor function, abnormal posturing, decerebrate, decorticate, or flaccidity, cushing reflex, htn, widening pulse pressure, and bradycardia, csf leakage, halo sign, seizures,. Deep Vein thrombosis Interventions Encourage pt. to rest Facilitate bed rest and elevation of extremity donot massage extremity thigh high compression stockings monitor APTT, and platelet count. Delegation the 5 rights right task right circumstance right person right communication right evaluation/supervison providing cost effective care using all levels of personnel to fullest when making assignments. providing necessary equipment and charging the pt. Returning uncontaminated or unused equipment to appropriate dept. for credit. Using equipment properly to prevent wastage providing training to staff unfamiliar with equipment, Returning equipment to proper dept. as soon as its no longer needed. Heart failure nutrition recommendations Reduce sodium intake to 2000 mg/day or less monitor fluid intake restrict to 1.5 liters fluid a day. Psychotic disorders assessment findings Hallucinations, deluisons, alterations in speech, bizarre behavior are positive signs of schizophrenia. Negative signs-affect or flat facial expression, alogia-poverty of thought of speech, Anergia-lack of energy, anhedonia- lack of pleasure or joy, avolition-lack of motivation in activities and hygiene 00 Adolescent nutritional needs 2000 cal for female and 4000 cal for male. They need a adequate diet in folate, vit a&e, iron, zinc, mag, cal and fiber. Newborn withdrawl from opioids medications opiate withdrawl, can last 2 to 3 weeks rapid mood changes, hypersensitivity to noise and external stimuli, dehydration, and poor weight gain. Alcohol withdrawl nabdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased heart rate, hallucinations, illusions, anxiety, increased blood pressure, respiratory rate, temp, and tonic clonic seizures. May occur 2-3 days after cessation of alcohol, and may last for 2-3 days, *THIS IS A MEDICAL EMERGENCY. severe disorientation, severe htn, psychotic symptoms, cardiac dysthymias, delirium. Meds- valium, Ativan, carbamazepine (tegretrol) seizures, clonidine (catapres) Librium (chlordiazepoxide) Contraindications to oral contraceptives Hx of blood clots, stroke, cardiac problems, breast or estrogen related cancers, pregnancy or smoking if over 35, are advised not to take oral contraceptives. Oral contraceptives decreases its effectiveness when taking meds that effect liver enzymes, such as ATB's, and anticonvulsants. Antibiotics affecting bacterial cell wall Penicillin, cillians. amoxicillin etc. Magnesium signs of toxicity Access to medical records Clients have a right to read their on records. Nurses may not photocopy any part of mar. Communication should only take place in a private setting. Shred any printed written pt. info after pt. care or use. Discharge teaching regarding circumsion A tub bath should not be given unti healed Notify md of redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying, will heal completely in 2 weeks. Give Tylenol for first 24 to 48 hours. Assess for bleeding every 15 min for the first hour, then every hour for at least 12 hour, then the 1st voiding. Stroke priority assess findings Expressive and receptive aphasia, agnosia, (unable to recognize objects), alexia (difficulty to reading), a graphic (writing difficulty), hemiplegia,(paralysis), or hemiparesis (weakness), slow behavior, depression, anger, visual changes(hemianopsia). Findings of recent cocaine use Rush of euphoria, pleasure, increased energy. Stimulant withdrawl (cocaine) Occurs within1 hour to several days, depression,fatigue,craving,excess sleeping, insomnia, dramatic unpleasant dreams, psychomotor retardation, possible suicide ideation. Withdrawl stimulant (tobacco) Abstinence irritability craving nervousness restlessness anxiety insomnia increased appetite difficulty concentrating anger depressed mood, COPD managing nutrition High calorie foods for energy Encourage rest periods. Drink plenty of fluids to liquidfy mucous, and promote hydration. IV Therapy documenting complications. Require notification of MD, and documentation, all IV infusions should be restarted with new tubing and catheters. Inflitration Infiltration- pallor and local swelling at site, slowed rate of infusion, treatment-stop and remove catheter, elevate extremity, encourage active ROM, apply warm or cold compress. Restart proximal to site or another extremity. Phlebitis Edema, throbbing, or burning at site. Increased skin temp, erythema red line up the arm, with a palpable band at the vein, slowed rate infusion. Treatment- discontinue IV and remove catheter, elevate extremity, warm compresses 3x daily, restart proximal to site, culture the site and catheter if drainage is present. Use surgical aseptic technique. Rotate sites q 72 hours. Ecchymosis Don't apply alcohol apply pressure after IV catheter removal. Use warm compress and elevate after bleeding has subsided. Prevention- minimize tourniquet time, remove tourniquet before starting IV infusion, maintain pressure after removal of catheter. Fluid overload Distended neck veins, increased BP, tachycardia, sob, crackles in lungs, edema. Treatment- stop infusion, raise hob, assess vs & O2 saturation, adjust the rate as prescribed, and administer diuretics as prescribed. Prevention- monitor I&O. Respiration assessing them Observing the rate, depth and rhythm of chest wall movements. Post arthroplasty Use elevated seat, or raised toilet seat. Use straight chairs with arms Use abduction pillow, or pillow if prescribed, b/w the pt. legs while in bed, and with turning, if restless or in a altered mental state. Externally rotate pt. toes. Do not do, cross legs, avoid low chairs, avoid flex ion of hips at 90 degrees, do not internally rotate the toes. Preventing foot drop Cane Keep cane on stronger side of body Support body weight on both legs, move cane forward 6-10 inches, then move weaker leg forward, next advance the stronger leg past the cane. Crutch walking Do not alter after crutches after fitting Support body weight at the hand grips, with elbows flexed at 30 degrees, position the crutches on the unaffected side when sitting or rising from a chair. Insertion of a urinary catheter Usually 8-10 French for kids, 12-14 for women, and 16-18 for men. Use silicon or Teflon if pt. has latex allergies. Explain procedure, a closed intermittent irrigation. if pt. reports fullness in bladder area, check for kinks in tubing or sediment, may need irrigated, make sure bag is below bladder. Ototoxic medications Multiple antibiotics, gentamicin, amikacin, metronidazole(flagyl), lasix, NSAIDs, chemotherapeutic agents. Nursing care of a pt. who is pregnant and has gonorrhea Urethral discharge, yellowish green vaginal discharge, reddened vulva and vaginal walls. Ceftriaxone (rocephin) and azithromycin (Zithromax) pro for gonorrhea, take entire prescription, repeat culture, and educate on safe sex practices. Esophageal prescription for a pt. with esophageal varices No selective beta blockers, propranolol (inderal), are prescribed to decrease heart rate, and reduce hepatic pressure. Vasoconstrictors IV terlipressin and somatostatin increase portal inflow. And vasopressin (desmopressin) and ortreotide ( sandostatin) are avoided d/t multiple adverse reactions. Interventions for prolapse cord Call for assistance ASAP, notify MD, use a sterile gloved hand, insert 2 fingers in vagina, and apply finger pressure on on either side of the cord, to fetal presenting part to elevate it off cord, reposition knee chest position, or trendelenburg, or side lying with a rolled towel under the pt. right or left hip, to relieve pressure on cord. Apply a warm saline soaked sterile towel to cord to prevent from drying. Provide cont electronic monitoring of FHR for variable decels. O2 at 8-10 liters, IV access, prepare for c-section, educate and inform pt. on interventions. Interventions for dementia Provide clocks and memory aids, photographs, memorabilia, seasonal decorations, familiar objects, orient if necessary. Daily routine, allow for safe pacing and wandering. Assign room closets to nurses station, well lit environment. Restraints as a last resort, COver or remove mirrors to reduce anxiety and frustration. Encourage pt. to talk about good times, break instructions and activities into short timeframes. Dumping syndrome S/S Fullness, faintness, diaphoresis, tachycardia, palpitations, hypotension, nausea, abdominal distinction, cramping, diarrhea, weakness, and syncope. Psychotic disorders long term adverse reactions New onset of diabetes, or loss of glucose control in pets. With diabetes, weight gain, increased cholesterol with HTN, orthostatic hypotension, anticholinergic effects such as urinary hesitancy or retention, and dry mouth. agitation, dizziness, sedation, and sleep disruption, mild eps such as tremor. Seizure precautions Suction equipment at bedside, Valium or Ativan. Treating xerostomia following radiation Avoid spicy, salty, acidic foods, hot foods may not be tolerated. Gently wash over irradiated skin with mild soap and water, pat dry. Dips of h20, and candies to prevent dry mouth. Post procedure following a throcentesis Apply dressing and assess for bleeding, or drainage, monitor vs, and resp hourly. Auscultation lungs for reduced breath sounds, encourage deep breathing to assist with lung expansion. CHESTXRAY post procedure. Interventions for icp Hob 30 degrees, avoid extreme flexion, midline neutral position, keep body aligned. Decrease stimuli. Do not delegate What you can EAT E-evaluate A-assess T-teach Addison's & Cushings Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? EleVate Veins, DAngle Arteries APGAR Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) After lumbar puncture and oil based myelogram pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke flat with legs elevated during Continuous Bladder Irrigation (CBI) catheter is taped to the thigh. leg must be kept straight. After Myringotomy position on the side of AFFECTED ear, allows drainage. After Cateract surgery pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida Prone so that sac does not rupture Buck's Traction (skin) elevate foot of bed for counter traction After total hip replacement don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina area of detachment should be in the dependent position administration of enema pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis worsens with exercise and improves with rest Myesthenia Gravis a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) must have lab results for prothrombin time Myxedema/ hypothyroidism slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm increased temp, pulse and HTN Post-Thyroidectomy semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Diabetes insipidus (decreased ADH) excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate irritable, poor sucking brachial pulse pulse area on an infant lead poisoning test at 12 months of age Before starting IV antibiotics obtain cultures! pt with leukemia may have epistaxis due to low platelets when a pt comes in and is in active labor first action of nurse is to listen to fetal heart tones/rate for phobias use systematic desensitization NCLEX answer tips choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC are always secondary to another disease or trauma In an emergency patients with a greater chance to live are treated first Cardinal sign of ARDS hypoxemia Edema is located in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? weight---and skin turgor heat/cold hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress. medication administration is rarely a good choice pneumonia fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2 with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Prednisone toxicity Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts no fresh fruits or flowers Chest tubes are placed in the pleural space Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. Unstable Angina not relieved by nitro PVC's can turn into V fib. 1 tsp 5 mL 1 oz 30 mL 1 cup 8 oz 1 quart 2 pints 1 pint 2 cups 1 g (gram) 1000 mg 1 kg 2.2 lbs I lb 16 oz centigrade to Fahrenheit conversion F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal deferoxamine S3 sound normal in CHF. Not normal in MI After endoscopy check gag reflex TPN given in subclavian line pain with diverticulitis located in LLQ appendicitis pain located in RLQ Trousseau and Chvostek's signs observed in Hypocalcemia never give K+ in IV push DKA is rare in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose peripheral vision. Autonomic dysreflexia patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Spinal shock occurs immediately after injury multiple sclerosis myelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian -Barre syndrome ascending paralysis. watch for respiratory problems. TIA transient ischemic attack. mini stroke, no dead tissue. CVA cerebriovascular accident. brain tissue dies. Hodgkin's disease cancer of the lymph. very curable in early stages burns rule of Nines head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight doubles by 6 months triples by 1 year if HR is <100 (children) Hold Dig early sign of cystic fibrosis meconium in ileus at birth Meningitis--check for Kernig's/ brudinski's signs wilm's tumor encapsulated above kidneys...causes flank pain hemophilia is x linked passed from mother to son when phenylaline increases brain problems occur buck's traction knee immobility; dont adjust weights russell traction femur or lower leg dunlap traction skeletal or skin bryant's traction children <3 y <35 lbs with femur fx eclampsia is a seizure perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam to protect next baby anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks caput succedaneum diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) surfactant. premature babies milieu therapy taking care of pt and environmental therapy cognitive therapy counseling five interventions for psych patients safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's take about 3 weeks to work patients with hallucinations patients with delusions redirect them distract them Thorazine and Haldol can cause EPS Alzheimer's 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw up regular and NHP? Air into NHP, air into Regular. Draw regular, then NHP Cranial nerves S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More Hypernatremia S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) Developmental 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup Hepatitis A Ends in a vowel, comes from the bowel Hepatitis b B= blood and body fluids (hep c is the same) Apgar measures HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Glasgow coma scale eyes, verbal, motor Max- 15 pts, below 8= coma Addison's disease: Cushing's syndrome: "add" hormone have extra "cushion" of hormone Dumping syndrome increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink Disseminated herpes zoster localized herpes zoster Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! Isoniazid causes peripheral neuritis Weighted NI (naso intestinal tubes) Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris Cushings ulcers r/t brain injury Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Thyroid storm HOT (hyperthermia) Myxedema coma COLD (hypothermia) Glaucoma No atropine Non Dairy calcium Rhubarb sardines collard greens Koplick's spots prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth INH can cause peripheral neuritis Take vitamin B6 to prevent. Hepatotoxic pancreatitis pts put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids Murphy's sign Pain with palplation of gall bladder (seen with cholecystitis) Cullen's sign ecchymosis in umbilical area, seen with pancreatitis Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis McBurney's point Pain in RLQ with appendicitis LLQ Diverticulitis RLQ appendicitis watch for peritonitis Guthrie test Tests for PKU. Baby should have eaten protein first shilling test Test for pernicious anemia Peritoneal dialysis Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok Hyper reflexes absent reflexes upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue Latex allergies assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches Tensilon used in myesthenia gravis to confirm diagnosis ALS (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) MMR is given SQ not IM codes for pt care Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival Contraindication for Hep B vaccine anaphylactic reaction to baker's yeast what to ask before flu shot allergy to eggs what to ask before MMR allergy to eggs or neomycin when on nitroprusside monitor: cyanide. normal value should be 1. William's position semi Fowler's with knees flexed to reduce low back pain S/S of hip fx External rotation, shortening adduction Fat embolism blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. complications of mechanical ventilation pneumothorax, ulcers Paget's disease tinnitus, bone pain, elnargement of bone, thick bones with allopurinol no vitamin C or warfarin! IVP requires bowel prep so bladder can be visualized acid ash diet cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread alk ash diet milk, veggies, rhubarb, salmon orange tag in psych is emergent psych thyroid med side effects insomnia. body metabolism increases Tidal volume is 7-10 ml/kg COPD patients and O2 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less Kidney glucose threshold 180 Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood when drawing an ABG put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 Munchausen syndrome vs munchausen by proxy Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child multiple sclerosis motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia hungtington's 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure WBC left shift pt with pyelo. neutrophils kick in to fight infections pancreatic enzymes are taken with each meal! infants IM site Vastus lateralis Toddler 18 months+ IM site Ventrogluteal IM site for children deltoid and gluteus maximus Thoracentesis: position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing Cardiac cath NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr Cerebral angio prep well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. lumbar puncture fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. ECG no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure. Myelogram NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site Liver biopsy administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to h