Summary UWORLD NCLEX STUDY GUIDE

UWORLD NCLEX STUDY GUIDE 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 non- pharmacological 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 MAGNESIUM Ventricular Bigeminy - It’s just PVCs after every other heartbeat - If pt has MI with this they can go into v-tach or v-fib - Take vital signs, assess potassium and magnesium levels - Assess apical-radial pulse - GIVE AMIODARONE* USUALLY PVCS ARE NOT THAT BIG OF A DEAL – IT DEPENDS HOW OFTEN SOMEONE GETS IT OR IF THEY HAVE MI* THAT’S WHEN IT IS SERIOUS!!!! How long can a PICC line stay in for? • Weeks to months Occlusion of one lumen in a PICC • Doesn’t necessitate removal of the catheter CVC • Upper body is preferred access site – low risk of infection • Femoral area – easily contaminated, should be taken out asap if not needed due to high risk of contamination and infection* • If the site shows symptoms of infection, discontinue it – IT SHOULD BE TAKEN OUT o This is serious because CVC goes directly to the heart ▪ In peripheral IV’s we worry about infiltration and all that other shit – but this one gets to the heart super fucking fast so if theres redness, swelling, and you suspect it is infected IT HAS TO BE DISCONTINUED Potassium greater than 7 mEq/L  3.5 – 5 (normal) • Severe hyperkalemia • CALCIUM GLUCONATE ASAP (unless they have no significant ECG changes) – this is suppose to stabilize their heart rhythm o 50mL 50% Dextrose with 10 units of regular insulin IV – the insulin will shift the potassium back into intracellular fluid and the dextrose will prevent hypoglycemia cause by the insulin!!! ▪ This is SECOND priority – give calcium gluconate first if ECG is fucked up and then give this IV* • ONLY REGULAR INSULIN CAN BE GIVEN IV, NPH IS NEVER ADMINISTERED THAT WAY!!!!! Congential defects that cause blood to shunt from higher pressure to lower pressure (LEFT TO RIGHT) • ASD • PDA • VSD o Tachypnea o Tachycardia even at rest o Sweat during feeding or exertion o Heart murmur or extra heart sounds o Signs of CHF o Poor weight gain Why does left side of the heart have higher pressure? - Well it has to pump all your freaking blood to the rest of the body Post-op cardiac catheterization - Check on them every 15 minutes - Back pain, hypotension and tachycardia can indicate possible retroperitoneal bleeding  very important to catch this on time because h&h might not drop and show internal bleeding until it’s TOO LATE!!!!! So we don’t really have reliable labs to make sure person is okay … we have to assess them for these symptoms* Difference in ECG between acute pericarditis and MI Acute pericarditis  ST-segment elevation in ALL ECG LEADS MI  ST-segment elevation only seen in localized leads, depending on which vessel is occluded Meniere disease - Too much fluid in inner ear - “Drop attacks”, vertigo, tinnitus, aural fullness, hearing loss – Don’t let them fall - The vertigo can be so severe it may cause nausea and vomiting - Give sedatives – benzos, antihistamines and anti-emetics - Minimize vertigo by making their room dark and quiet, teach them to avoid sudden head movements - Try not to watch TV or stare at flickering lights - Salt restriction* o They need to stay the fuck away from sodium because remember – water likes to follow salt, they have too much fluid accumulated in the inner ear! The last thing we want is more fluid accumulation* Do not irrigate too quickly because they can freaking THROW UP Can NPH be administered IV push? - No, only regular insulin can be administered via IV push Myxedema Coma - Happens as a result of worsening hypothyroidism – so all the same “slowed down” symptoms but WORST BECAUSE THEY CAN DIE!!!!!! - WATCH OUT FOR RESPIRATORY FAILURE – priority is to make sure they can breathe - NEED EMERGENCY ET INTUBATION AND MV ASAP - Provide bag-valve-mask ventilation until pt can be intubated – THEN you do all the other interventions like giving warming blanket, meds or whatever bla bla bla What is Synthroid? • Levothyroxine • Given for hypothyroidism or post-thyroidectomy • PATIENTS HAVE TO TAKE THIS FOR THE REST OF THEIR LIVES!!!! What meds can impair the absorption of levothyroxine? - Antacids - Take levothyroxine on an empty stomach in the morning, separately from other medications Post-thyroidectomy management - Assess for hypocalcemia – facial or extremity numbness or tingling - Trousseau and Chvostek signs - Assess for stridor - Hoarseness or whispering may indicate laryngeal nerve damage that can result in respiratory arrest - Keep emergency equipment at the bedside - Semi-fowler position TB meds • Know that they’re usually taken 6-12 months • Isoniazid is the ONLY TB MED THAT ISN’T SUPPOSED TO TURN YOUR PEE, SWEAT AND SALIVA ORANGE/RED – the rest of them do cause this • Tell these assholes they cannot fucking DISCONTINUE THEIR ABX TREATMENT WHENEVER THE FUCK THEY WANT o Because this is exactly why we have MDR-TB; their TB becomes resistant and when that happens, no abx under the sun can save them (or maybe just more complicated to treat) and they can give someone else MDR-TB TOO!!!!! • Isoniazid intereferes w/ vitamin b6 (pyroxidine)  can lead to peripheral neuropathy, B6 supplements are needed for high risk groups; older people, malnourished, pregnant or breastfeeding pts, alcoholics, children, people with liver or renal diseases • Isoniazid – AVOID aluminum containing antacids like Maalox within 1 hr of taking this • Rifampin – reduce efficacy of birth control, pt needs alternative non- hormonal birth control Diabetes insipidus – not real diabetes, glucose is normal - Results from low ADH* o ADH tells your kidneys to keep the correct amount of water in the body by “deciding” how much URINE will be made o ADH helps prevent DEHYDRATION – so not enough of this leads to … - Pee a lot of dilute urine (polyuria) - Increase risk for hypernatremia - Increased serum osmolality (osmolality just means how concentrated) - Excessive thirst Cushing syndrome - Too much corticosteroids - Acne, hirsutism, oligomenorrhea  irregular periods, little - Trucal obesity - Hypertension, hyperglycemia - Fat accumulation in the face (moon face) - Buffalo hump - Purple striae on the skin due to collagen loss - Muscle weakness and bone loss due to steroid breaking down muscle and bone Diabetic Ketoacidosis - LOW INSULIN! SERIOUS COMPLICATION WITH DM TYPE 1 - Not enough insulin – blood sugar shoots up: 250-500, bicarb 18 compensate  ketones - Ketosis – because not enough insulin to breakdown glucose and utilize it – so your body starts breaking down FAT to give you energy! o Think about the hippies that go on keto diet to burn fat – this is basically whats happening - Acidosis – ketones make blood acidic - PROFOUND DEHYDRATION – it causes you to pee like crazy - Initially hyperkalemic until ketoacidosis is resolved o Why hyperkalemic? BECAUSE LOW INSULIN!! INSULIN CONTROLS THE WAY POTASSIUM MOVES IN YOUR BODY! - Management o Fluid resuscitation o IV insulin o Monitor blood sugar every hour o When blood sugar is less than 250, give D5W to prevent hypoglycemia (they’re still on IV insulin) o Give potassium anyway even if K+ levels are normal – because theyre peeing it out! Hyperosmolar Hyperglycemia • Serious complication with DM TYPE 2 • Person produces enough insulin to prevent DKA but not enough to prevent EXTREME HYPERGLYCEMIA o Because some insulin is produced, blood sugar rises SLOWLY so they don’t really show symptoms until hyperglycemia has reached extreme levels 600 mg/dL o Bicarb 18 mEq – no ketones so doesn’t elevate to compensate like DKA • Extracellular deficit, osmotic diuresis • Neurological manifestations – blurry vision, lethargy, obtundation – progression to coma • Remember there IS insulin! So some sugar is being utilized so theres no compensatory mechanism  no ketones, no acidosis or kussmaul respirations (hyperventilation) Addison’s disease - Not enough steroid hormones - Mineralcorticoids regulate water & electrolyte balance – low blood pressure and muscle weakness - Glucocorticoids help increase appetite – hypoglycemia and weight loss - High plasma ACTH – low cortisol triggers this feedback trying to tell the body make more steroid hormones o Causes bronze skin, hyperpigmentation in skin folds - Glucocorticoid therapy o Don’t discontinue abruptly because it can lead to Addisonian crisis o Report signs of infection immediately because glucocorticoids are immunosupressants and they can also mask signs of infection (anti- inflammatory) o Watch out for hyperglycemia and osteoporosis o Corticosteroids should not be taken on an empty stomach – causes GI irritation Addisonian crisis • NV abdominal pain • Hypotension, tachycardia • Fever, hyponatremia, hypoglycemia, hyperkalemia due to aldosterone deficiency • FLUID RESUSCITATION – 0.9% NS and 5% Dextrose • Hydrocortisone IV push Cataracts - Not painful - Clouding of the lens - Blurry vision, glares and halos – awful at night - Decreased color perception Open-angular glaucoma - Increased IOP - Tunnel vision – gradual loss of peripheral vision – like Yuchen bc he can never find anything - Not painful - Normal central vision, halos - Can lead to blindness if left untreated Myopia – nearsightedness – Yuchen - Need to squint to see better Hyperopia – farsightedness – My dad GI Why check gastric pH for feeding tubes - Because if the pH is 6 or higher, it means the tube isn’t in the stomach - Need x-ray Balloon Tamponade Tube (Sengstaken-blakemore) - Used to control bleeding esophageal varices - Watch out for airway obstruction because the balloon can become displaced and migrate into the oropharynx - CUT THE TUBE TO DEFLATE THE BALLOON IF THAT HAPPENS – KRUSTY DA CLOWN Clogged NG tube - Don’t touch that shit, tell the surgeon Dicyclomine - Anticholinergic/antispasmodic drug - Decrease hypermotility of intestines in people with IBS - Don’t give it to someone who has paralytic ileus (duh) Colonoscopy - Watch out for shoulder pain at the tip (Kehr’s sign) - Positive rebound tenderness - Tenesmus  feel of constipation - Rigid abdomen o ALL THESE ARE SIGNS OF PERFORATION!! BLEEDING SOMEWHERE IN PERITONEAL CAVITY After liver biopsy - Lay down on right side – minimizes bleeding Albumin – 3.5-5 Ammonia – 15-45 • Elevation – assess for Hepatic Encepalopathy; lethargy, coma, asterixis Bilirubin – 0.2-1.2 • Elevation – assess for jaundice, itching, scleral icterus Metoclopramide (Reglan) - Used to tread GERD - Can have extrapyramidal adverse effects including tardive dyskinesia Inguinal hernia - Can protrude to da ballz - Pain with exercising or straining - Palpable bulge on assessment - See if you can press it back in, if not they need surgery - Why can’t they just stay like that? Bc their bowels can get super compressed causing obstruction and they can die Gastric lavage - Performed through an orogastric tube - Rarely done because too many complications – aspiration, esophageal perforation, dysrhythmia - Only done if person overdosed on something lethal – usually for stuff that doesn’t work with activated charcoal like lithium, iron, alcohol Obese people with hiatal hernia should try to lose weight by walking – don’t do weight lifting because it can increase abdominal pressure Enema infusion - Giving it too fast can cause cramping and pain - If pt complain, stop for 30 min then resume at slower rate After NG tube placement to decompress the stomach - Absence of bowel sounds can be normal up to 72 hours NG tube insertion - If pt is coughing or gagging you have to pull back a little bit and pause - Tell the pt to take a few breaths - When they stop coughing proceed to advance the tube - Ask them to take sips of water (unless they are coughing) - Resistance – rotate tube and keep trying, if doesn’t work try the other naris Acute pancreatitis - NPO status – we don’t want more pancreatic enzymes - NG tube to suction gastric secretions – lessen stimulation of pancreas - Hydromorphone or fentanyl for pain - Aggressive IV fluid treatment – inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing – pt can go into hypovolemic shock - Steatorrhea – yellow foul smelling stool due to decreased lipase production - Elevated blood glucose – treat with insulin Refeeding syndrome (PPM) Rapid decline in Phosphorous, Potassium and/or Magnesium • Fluid overload • Hyperglycemia • Thiamine deficiency • FEED SLOWLY* Acute pancreatitis – where is the pain? • Left upper quadrant midline • Often radiates to the back Dumping syndrome - Gastric contents emptying too quickly into the duodenum - Fluid shifts to small intestine to try to help - Pt becomes hypotensive - Abdominal pain, nausea, tachycardia - EAT LOTSA FAT AND PROTEIN – these take longer to digest - DON’T DRINK FLUID WITH MEALS – WE ARE TRYING TO SLOW DIGESTION! - Small frequent meals - Avoid meals high in carbs Cholecystectomy - Removal of the gallbladder - Monitor for infection - Pt an develop pneumonia or peritonitis – pneumonia is just a post-op complication in general if pt is at risk for atelectasis Asterixis - Flapping of the hands due to elevated blood ammonia levels - Usually due to liver disease Paracentesis - Needle into stomach to reduce ascites - Assess pt for hypotension during this - Might need IV albumin Biggest risk in pancreatitis - Abscess development - High fever, abdominal pain – indicate abscess formation - Treat this asap to prevent sepsis!! Large bowel obstruction - Gradual onset - Absolute constipation - No farting - Cramping pain Small bowel obstruction - Rapid onset - Severe pain - Abdominal distention - Vomiting New ileostomy - Prevent obstruction by following low-residue diet; minimize stool output, helps to rest GI tract after surgery and produce less gas - Stay away from foods that have lots of fiber – fruits and vegetables with pits or edible peels Colostomy irrigation - 500-1000mL warm water - Hang back about 20 in’ above stoma - Use cone-tipped irrigator to slowly infuse the solution - Allow stool to drain through the sleeve into the toilet Iron - Avoid administering calcium with iron at the same time - Calcium decreases iron absorption – pregnant women should still take calcium but they should take it further apart from iron supplement - Vitamin C helps with iron absorption Licorice root - Herbal med used for GI disorders - Can increase potassium loss and cause hypokalemia with hydrochlorothiazide ACE inhibitors - Watch out for angioedema, hyperkalemia (don’t eat salt substitutes) - Teratogenic – contraindicated during all stages of pregnancy Thiazides – watch out for the 4 H’s - Hypokalemia - Hyponatremia - Hyperuricemia - Hyperglycemia IMMUNE PROBLEMS Cyclophosphamide - Cancer drug - Can cause bleeding in the bladder (hemorrhagic cystitis) - Drink lots of fluids CD4 lymphocyte 15% = severely immunocompromised CD4 750/mm3 for 12 months or younger CD4 500/mm3 for kids 1-5 CD4 200/mm3 5-adults Immune thrombocytopenia (ITP) - Acquired disorder in which antibodies cause decreased platelet survival and production - Petechiae, pinpoint lesions on the skin from capillary hemorrhages - Usually resolves on its own - May need IV immunoglobulin – giving antibodies that don’t attack platelets - Check platelets - Corticosteroids IV – suppress immune system from attacking its platelets Marfan syndrome - Autosomal dominant disorder - Affects the heart, muscles, bones and eyes - Very tall, thin, long arms, legs and fingers – SLENDA MANNN - Avoid contact sports because the heart is fucked, cardiac injury can kill them - Advise them NOT TO GET PREGNANT BECAUSE THAT CAN KILL THEM TOO Inc. ICP in babies Carbidopa-levodopa • Reduce parkinsons by increasing dopamine • Can cause orthostatic hypotension • Takes several weeks to reach maximum effectiveness • Pee can be red, brown or black – its okay • Avoid high protein meals – they interfere with the drug absorption Quadriplegia - Usually due to injury of the cervical spinal cord - Edema can occur at site of injury and block the airway - Resp assessment* Phenytoin - Gums get all fucked up - More body hair - Rash - Osteoporosis - Take folic acid to prevent these - Therapeutic levels 10-20mcg/mL – “phen” sounds like ten, pheny sounds like “twenty” - Toxicity – slurred speech, decreased mentation, ataxia, nystagmus o Nystagmus – eye makes uncontrollable movements Broca – cant produce speech Wernicke – can’t comprehend speech – “werttt?” Nasopharyngeal airway - Used in alert or semi-conscious pts - NEVER GIVEN TO ANYONE WITH HEAD TRAUMA Don’t do chin tilt for head/neck/spinal injuries - Do jaw thrust maneuver Head injury • Avoid giving opioids – we have to do neuro assessments and opioid adverse effects can fuck that up – we wouldn’t be able to tell if it’s the opioids or the head injury that is causing decline • No alcohol or any other CNS depressants like benzos for the same reason • Tell them to have someone stay with them • NSAIDs for pain Multiple Sclerosis - Progressive demyelinating disease of CNS, nerve impulses are interrupted - Walk with feet apart to increase base support and gait steadiness - Will eventually need assistive devices (cane/walker) - Do ROM exercises, strength training and stretching to limit muscle spasicity - Pace activity – they get tired - Stay hydrated because dehydration will exacerbate MS Rheumatic fever - Inflammatory disease of the heart - Streptococcal pharyngitis* - Joint pain (migratory arthritis), nodules, erythema marginatum, Sydenham chorea, fever, arthralgias, elevated ESR and C-reactive protein - Give penicillin Levofloxacin - Fluoroquinolone abx - For urinary tract infection Fibromyalgia - Pain disorder - Depression, anxiety, sleep disturbances, forgetfulness, difficulty concentrating - Cyclobenzaprine – muscle relaxer - NSAIDs for pain - Antidepressants Partial Retinal Detachment - Painless - Curtain blocking - Floaters - Sudden flashes of light - Complete retinal detachment can cause blindness Phenytoin (Dilantin) - Therapeutic index is 10-20mcg - Tube feedings decrease phenytoin absorption - Pause tube feeding 1-2 hours before and after phenytoin administration - Toxicity produces nystagmus, dysarthria, ataxia, encephalopathy Metronidazole - Abx that can also treat parasitic infections - No alcohol - Metallic taste and brown urine is harmless Opioid withdrawal - Increase everything – pulse, BP, bowel sounds, sweating - Pupils are dilated (mydriasis) - Nausea, vomiting, insomnia, dysphoric mood - Management o METHADONE, buprenorphine Tardive Dyskinesia - Lip smacking, sucking or puckering - Tongue protrusion or curling - Excessive blinking - Grimace - Foot tap, tremor, shake - Rocking neck/torso Hydromorphone (dilaudid) - 5-10 times stronger than morphine - Max dose is 2mg Why does anorexia cause lanugo? - Lanugo – fine hair, can be seen in extreme cases of anorexia - Body is growing hair attempting to insulate itself and maintain body temp What can cause metabolic acidosis - Diarrhea – shitting out all the bicarbs - Ketoacidosis - Lactic acidosis - Renal failure - Lungs try to compensate by hyperventilating tPA - Dissolves clots - Must be given 3-4.5 hours from onset of symptoms - Surgery within last 2 weeks – contraindication Transsphenoidal hypophysectomy • Surgical removal of the pituitary gland • Watch out for neurogenic diabetes insipidus (low ADH) • Urine specific gravity 1.003 • High serum osmolality • Hypernatremia • Hypovolemia • Polydipsia • Polyuria Postpartum hemorrhage - Fundal massage - Oxytocin bolus o If these don’t work, give second-line uterotonic drugs (misoprostol, carboprost, methylergonovine) o Methylergonovine (methergine) – don’t give if they have high blood pressure because it’ll vasoconstrict further, can cause seizures/stroke Switching from MAOI to SSRI • MAOI should be withdrawn at least 14 days before starting SSRI Beta blockers contraindicated in asthma - Propranolol - Nadolol CVC catheter occlusion - Check for kinked tubing - Could be catheter malposition - Reposition the client’s head and arm - Try to flush again after that – if it doesn’t work, let HCP know Rhabdomyolysis - Muscle wasting - Can lead to acute renal failure – elevated myoglobin levels overwhelm kidney’s ability to filtrate - RAPID IV RESUSCITATION – flush the damaging myoglobin from kidneys - Urine can be dark or bloody - QUESTION SARTANS IF PT HAS THIS AND DOCTOR ORDERS IT Metabolic syndrome 3 or more factors that increase patient’s factor for stroke, DM and heart disease In hypertensive crisis • MAP should be lowered no more than 25% CPR for babies (less than 1 yr old) - Check brachial pulse no longer than 10 seconds - Shout for help - 2 mins of CPR 100 compressions/min before retrieving AED SIADH - Usually caused by cancer or could be a complication of head injury - Low serum sodium, low serum osmolality, low urine output - High urine specific gravity Malignant hyperthermia - Life threatening condition caused by anesthesia - Tachypnea, tachycardia, high fever, rigid jaw, generalized rigidity - Muscle tissue breakdown, hyperkalemia - Need IV dantrolene – reverse this by slowing down metabolism - Give cooling blanket, treat hyperkalemia Acromegaly - Overproduction of GH - Usually occurs age 40-45 - Big hands, feet, face - Skin tags - Enlarged tongue - Hypertension - Galactorrhea – milky nipple discharge related to normal milk production of breast feeding - Additional heart sounds – S3,S4 assess for heart failure Nitrates – contraindicated in pt using erectile agents Normal value of aPTT 30-40 secs Normal PTT 60-80 – anti-coags x 1.5-2.5 Kawasaki Disease - At least 5 days of fever - Non-exudative conjunctivitis - Lymphadenopathy - Hand and foot swelling - Rash - IV immunoglobulin and aspirin to prevent coronary artery aneurysms - Check temp every 6 hours for the first 2 days after discharge - If kid develops a fever again, notify HCP - Live vaccines should be delayed for 11 months after IVIG therapy Parallel play is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Isotretinoin • Accutane for severe acne • Very teratogenic, don’t give to pregnant women – that’s why you have to emphasize they should use 2 forms of contraception and get 2 negative pregnancy test results before giving this • Should not donate blood when on this medication • Derivative of vitamin A – tell them to be careful with their diet because they are at risk for vitamin A toxicity Penicillin allergy - Penicillin desensitization especially if they really need penicillin as treatment (syphilis) Chest drainage 100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include: 1. Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) 2. High serum triglycerides 150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment 3. Low levels of high-density lipoprotein (HDL) cholesterol (40 mg/dL [1.0 mmol/L] in men, 50 mg/dL [1.3 mmol] in women) 4. Hypertension ≥130/85 mm Hg or hypertension drug treatment 5. Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment ABG HCO3 • ^ alkaline • v acidic Normal pH = compensated Amyotropic Lateral Sclerosis (ALS) • Progressive loss of motor neurons in the brain stem & spinal cord • Muscle spasticity, muscle weakness and atrophy • Eventually neurons involved in swallowing and breathing function are impaired • No cure, people usually die 5 years after diagnosis • Priority – maintain respiratory function • Assess for dysarthria – worsening ability to speak – assess for dysphagia and respiratory distress Advance care planning • Health care proxy o Durable power of attorney for health care o Only goes into effect when patient doesn’t have decision- making capacity • Living will o Advance directive describing the type of life-sustaining treatments that will be initiated if the patient can’t make decisions o CPR, intubation, mechanical ventilation, tube feeds Menopause • Decrease in estrogen production leading to reduced osteoblast activity and cardioprotective effect • Increased risk for osteoporosis and CAD • Weight gain, sleep disturbances, vaginal atrophy • Weight bearing exercise, eat more leafy vegetables (high in calcium) • Watch cholesterol levels • Get support for emotional symptoms Pyloric stenosis - Pyloric muscle hypertrophy - Projectile vomiting secondary to an obstruction at the gastric outlit - Olive-shaped mass may be palpated at the right of the umbilicus - Hematocrit and BUN will elevate due to dehydration - Can lead to metabolic alkalosis & hypokalemia Serotonin syndrome - Life-threatening condition - Triggered by drugs; SSRIs, MAOIs, St. John’s Wort and Tramadol (pain reliever) - Assess for mental status changes - Autonomic dysregulation – hyperthermia, diaphoresis, tachycardia, hypertension and neuromuscular hyperactivity; tremors, muscle rigidity, clonus, hyperreflexia Fetal tachycardia is a baseline of 160 beats/min for 10 minutes. Tachycardia needs evaluation and continued surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate. Heimlich maneuver - Used for anyone over age 1 - Upwards abdominal thrust with fist to upper abdomen below rib cage Back blows and chest thrusts - For infants under age 1 Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote lung development. Oligohydramnios • Low amniotic fluid • Fetal outline is easily palpated through the maternal abdomen – lower fundal height than expected due to small uterine size for gestational age • Can be caused by a bunch of things o Fetal kidney anomalies o Undiagnosed ruptured membranes • Major complications o Pulmonary hypoplasia ▪ Lack of alveolar distention by aspirated amniotic fluid, bring an extra person with you to attend birth because baby may need resuscitation o Umbilical cord compression ▪ Apply continuous fetal monitoring for variable decelerations Preterm Labor • Before 34 weeks gestation • Interventions o IM glucocorticoids (betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development o Penicillin to prevent strep B infection in newborn o IV magnesium sulfate for fetal neuroprotection if 32 weeks gestation o Tocolytic meds – nifedipine, indomethacin – slow down labor so glucocorticoids have time to take effect Wound cultures - Remove old dressing with clean gloves - Put on sterile gloves - Check out the wound bed - Cleanse the wound bed and surrounding skin with normal saline - Put on clean gloves - Swab wound from center to outer margin - Put swab in specimen container - Apply bacitracin Atrial septal Defect • Opening between right and left atrium • Left to right shunting • Systolic murmur with a fixed split second heard sound Patent Ductus Arteriosus • Acyanotic congenital defect – more common in premature infants • Most newborns are asymptomatic • Blood shunt from aorta to pulmonary arteries • Machine-like systolic & diastolic murmur • Treated via surgery or IV indomethacin Osteoarthritis • Degenerative disorder of the synovial joints • Joint space gets smaller, cartilage wears away, bones rub against each other – you can hear crepitus • Pain is worst when weight-bearing • Morning stiffness • Decreased joint mobility and ROM • Muscles start to break down due to disuse Oxytocin (Pitocin) • Stimulates uterine contractions • Used to induce labor or prevent PPH • Adverse effects o Abnormal FHR: Late decels, bradycardia – might need emergency c- section due to persistent abnormal FHR o PPH – ironically, prolonged exposure to exogenous oxytocin can cause this too ▪ Increase risk for uterine rupture and placental abruption o Water intoxication – oxytocin has an antidiuretic effect when administered for prolonged periods o Uterine Tachysystole (5 contractions in 10 minutes) Allopuriol • Used to prevent gout • Can take several months to become effective • Report immediately if pt develops a rash – could be SJS During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). Rh-negative mom - Exposed to rh-positive baby - Mom develops antibodies - Future baby is at risk because antibodies will attack it – can result in hemolytic anemia for fetus - Indirect Coombs Test – always done for Rh sensitization any time hemorrhage happens - Give RhoGAM to ALL Rh-negative moms a 28 weeks gestation and then 72 hours post-partum or any maternal trauma (don’t want the blood to mix) - RhoGAM won’t work anymore once sensitization has occurred Buck Traction - Skin traction used to immobilize hip fractures and reduce pain and spasm until patient can undergo surgery - Traction boot is applied - A weight is gently pulling the leg and hip, keeping the limb in place - The limb has to be in a straight neutral position (alignment) - Assess neurovasc status and skin - THEY CAN’T TURN FROM SIDE TO SIDE*** they can move with the overhead trapeze IM injection for infants 1-12 months • Needle has to be at least 1 in • Always inject at vastus lateralis • Anterolateral middle portion of thigh Parkland formula 4 mL × body weight (kg)×TBSA burned (%)=infusion volume (mL) Valsalve maneuver; contraindications • Anyone with increased ICP, stroke or head injury • Heart disease – you don’t want to stimulate vagus nerve, decreases cardiac output • Liver cirrhosis – portal hypertension; risk for variceal bleeding • Anyone who had eye surgery – inc intraocular pressure Bell Palsy • Unilateral face paralysis • Inflammation of facial nerve CN VII • Can’t close eye on affected side with decreased tear production • Flattening of nasolabial fold on the paralyzed side • Can’t smile symmetrically Difference in clinical features between down syndrome & fetal alcohol syndrome Fetal Alcohol syndrome • Microcephaly – small head • Can’t really see the philtrum • Epicanthal folds of eyelids – also seen in trisomy 21 • Short palpebral fissures of eyes – also seen in trisomy 21 Down syndrome • Single transverse palmar crease • Short neck with excess skin • Epicanthal folds & short palpebral fissures – also seen in FAS • Low set small ears • Protruding tongue Codeine • Opioid, treats pain and also suppress cough reflex • Common adverse effects o Constipation, nausea, vomiting, orthostatic hypotension • Teach pt to inc fluid intake or they can take laxatives to help with constipation • Take this with food to prevent GI irritation – nausea & vomiting Dopamine • Sympathomimetic inotropic medication • Used to improve hemodynamic status in pt with shock and HF • Inc HR & BP by vasoconstriction  better perfused kidneys = better urine output • Adverse effects – tachycardia, dysrhythmias and MI • Look at the HR, if pt is tachy the infusion needs to be reduced Bacterial Meningitis • Inflammation of the meninges and spinal cord • For kids under age 2 o Fever, restlessness, HIGH-PITCHED cry o Hydrocephalus due to ICP – can lead to hearing loss, learning disabilities and brain damage in this age group o Assess for bulging tense fontanels and inc head circumference – early indicators of inc ICP • Pts have photophobia – don’t check pupil response too frequently – it’s uncomfortable • Watch out for sunsetting eyes in babies • Late signs of in ICP o Widening pulse pressure (high SBP), bradycardia, resp depression – Cushing’s triad Cognitive behavioral therapy (CBT) • can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking • CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions CBT involves 5 basic components: • Education about the client's specific disorder • Self-observation and monitoring - learn how to monitor anxiety, identify triggers, and assess the severity • Physical control strategies – deep breathing and muscle relaxation exercises • Cognitive restructuring – learning new ways to reframe thinking patterns and challenge negative thoughts • Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events Intradermal – 5-15o SubQ – 45-90 o IM – 90 o • Deltoid muscle, vastus lateralis, ventrogluteal • Ventrogluteal is preferred – less large blood vessels and nerves Involuntary bedwetting at night in a child beyond the age of expected bladder continence is known as nocturnal enuresis. Can be treated with certain meds like desmopressin but use non-pharmacological interventions first. • Limit caffeine and sugar • Pee before bedtime • Don’t punish the kid – it’s not their fault • Encourage child to assist and participate in cleaning soiled bedsheets and clothes – it helps them feel in control of the situation o Reassure them that this isn’t a punishment • Positive reinforcement – calendar of wet and dry nights with rewards • Wake them up nightly like a specified time to pee • Record their schedule • Don’t put the kid in a diaper if they’re already school-aged – this will make them comfortable and they won’t adapt the urge to get up and pee Amniotomy • Artificial rupture of membranes (AROM) • Done to induce labor • Risks associated with this  umbilical cord prolapse if fetal head isn’t applied firmly to the cervix o Assess for fetal bradycardia • Assess FHR before and after the procedure • Note amniotic fluid color, amount and odor o Should be clear/colorless without foul older o Yellow/green fluid with strong odor  fetus poop got into the utero • Monitor pt temp every 2 hours because after AROM pt is at risk for infection • Sit upright to allow for fluid drainage • Procedure is painless Gluten-free diet for celiac disease • BROW o Barley, rye, oats and wheat • Rice, corn and potatoes are gluten-free • Some processed foods have gluten in them (chocolate, hot dogs) • Celiac disease – need to remain gluten free for the rest of their lives • Cheese is okay Infant phototherapy • Use of fluorescent lights to treat jaundice in newborns • The light converts bilirubin into a water-soluble form so it can be excreted in the stool and urine • Newborn needs to be fully exposed, only wearing diaper • No lotions or ointments – can absorb the heat and burn the baby • Watch out for skin breakdown and dehydration • Only removed from light during feeding • Monitor temp – incubator should be in low-heat setting • Cover the baby’s eyes to prevent formation of cataracts Bradycardia • Assess – cardiac monitoring, O2 sat, 12 lead ECG, find out underlying cause • Give ATROPINE if pt is symptomatic – hypotensive, signs of shock, mental status change, chest discomfort, acute HF • IV atropine 0.5mg bolus – repeat every 3-5mins, up to 3.0mg max (0.5-3.0mg every 3-5min) • If that doesn’t work they need other interventions o transcutaneous pacing or dopamine or epinephrine Vancomycin • Abx used to treat gram-positive infections like SA, MRSA, C-diff • Trough level is checked before the 4th dose o 15-20mg is optimal • Excreted by the kidneys, watch out for BUN/Creatinine levels – monitor 2-3 times per week • Risk for nephrotoxicity in older people Child with cleft palate • Risk for aspiration and inadequate nutrition due to feeding difficulties • Has to be surgically repaired • Feeding strategies o Upright position so they don’t aspirate o Tilt the bottle, point DOWN and AWAY from the cleft o There are special bottles and nipples for CP – allows formula to flow more freely because baby can’t suck (squeezable bottle) o Burp more often to avoid regurgitation o Feed slowly over 20-30 mins – any longer than this can exhaust the baby o Feed every 3-4 hours LIVER BIOPSY – lay on right side HYPOTENSION DURING PREGNANCY – lay on left side – alleviate pressure on the vena cava Mannitol • Osmotic diuretic used to treat cerebral edema and acute glaucoma • Shifts fluid into intravascular space that gets excreted by the kidneys to reduce ICP • Adverse effects: fluid overload – if pt has kidney disease and can’t excrete the fluid o Can lead to pulmonary edema o Auscultate the lungs o Monitor input & output, kidney function and serum electrolytes Phenylketonuria (PKU) • Tested at birth • Baby can’t metabolize the amino acid phenylalanine so it accumulates – can cause irreversible neurological damage • Need to be on LOW-PHENYLALANINE DIET FOR LIFE o Safe range phenylalanine level 2-6 mg/dL o May need special formulas o Avoid meats, eggs and milk; eat more fruits and veggies Hemovac • Compress it after emptying drainage to create negative pressure – it’ll function like a suction Sickle cell disease in children • They can have a stroke – sudden onset of weakness & numbness or an extremity • May require exchange blood transfusion Venturi mask • High-flow device • Has adaptor to set oxygen delivery 24-50% • Use this in the presence of tachypnea, shallow breathing with decreased TV, hypercarbia and hypoxemia Nasal cannula • Best for patients with adequate TV and normal vital signs • Don’t give to unstable pt Non-rebreathing reservoir mask • Delivers 60-95% oxygen • Used short therm • Used for pt with low O2 sat usually from asthma, pneumonia, trauma and severe sepsis Sunburns • Give Tylenol for pain • Cold compress to reduce inflammation – NOT CORTICOSTEROID CREAMS Immunosupressive meds can actually convert latent TB into active TB Cystic fibrosis • Viscous respiratory secretions can accumulate and impair airway • Pts usually develop lung disease – they’re prone to resp infections • Impaired pancreatic enzyme secretion – give supplemental enzymes with meals and snacks • Multi-vitamins, diet high in carbs, protein and fats to help meet nutritional requirements – they are underweight even when they eat a lot because body has problem with utilizing fat and calories • Increase salt intake during warm weather or fever because they sweat it all out • Diagnosed with sweat test • Need chest physiotherapy Second trimester (14-27 weeks) • Quickening is expected around 16-20 weeks • Gain 1lb per week • Increase intake of iron-rich foods and continue to prenatal vitamins to prevent anema • Teach them preterm labor warnings and signs of preeclampsia • Ultrasound usually done 18-20 weeks in to look at the baby • Screening for gestational diabetes Bronchial breath sounds in peripheral lung fields • High pitched harsh sounds in lung fields, bronchial breath sounds are normally heard at the trachea • Means lung is consolidated  probably has pneumonia • Pneumonia o Tactile fremitus – because lungs are consolidated so the way air travels in lungs when this happens create palpable vibration o Unequal chest expansion o Fever, chills, cough, pleuritic chest pain o Fine or coarse crackles Thoracentesis • Used to treat pleural effusion – sticking needle through rib-cage to withdraw fluid from pleural cavity of the lungs • Can accidentally puncture lung  pneumothorax o Watch out for respiratory distress, absent breath sounds in punctured lung o Tension pneumothorax can eventually occur because 1 lung isn’t expanding, unaffected lung will push trachea towards affected side** you prevent this by identifying and treating pneumothorax immediately • Infection can occur but usually happens later, priority  RESP DISTRESS, PNEUMOTHORAX, BLEEDING Tracheostomy • You do not want it to dislodge 1 week post-op because it is very difficult to put it back in – site of insertion isn’t fully healed yet • Check tightness around the collar – 1 finger should fit under the ties Dialysis Disequilibrium Syndrome (DDS) • Rare life-threatening complication of hemodialysis • During HD, solutes are removed more quickly from the blood than from the brain cells and CSF – concentration gradient  too much fluid in brain cells  increased ICP • They can get seizures • YOU CAN PREVENT THIS IF YOU JUST SLOW DOWN THE RATE OF DIALYSIS!!! • If you notice this, notify doctor immediately, slow down dialysis and interventions aim to lower ICP Creatinine Clearance • Measure of glomerular function • Sensitive indicator of disease progression • 24-hr urine collection o 1st urine is DISCARDED – record the time o All urine voided after this is recorded within 24 hours o After this void 1 last time and add to container Hemolytic Uremic Syndrome (HUS) • Life threatening complication of E-coli • RBCs get hemolyzed • Low platelets • Acute kidney injury • Petechiae or purapura Pyelonephritis • Inflammation of kidney parenchyma (tree) • Flank pain that can spread toward umbilicus • UTI got up to kidney, you’re fucked – UTI symptoms except with nausea, vomiting and chills – fever PTSD – what to do if pt wakes up from a nightmare • STAY WITH THEM • Provide reassurance • Let them know they are safe and remind them that nightmares are common reactions to traumatic events Electroconvulsive therapy • Induces a seizure by passing electrical currents through the scalp • It is not painful • Seizure last about 15-20 seconds • Very effective in treating depression, bipolar disorder and possibly schizophrenia o Patient has to be NPO 6-8 hrs before getting this o Anesthesia – propofol, methoexital; muscle relaxant – succinycholine o No you can’t drive after this o Temporary memory loss – very common • Post-treatment interventions o Monitor vital signs, monitor resp status and mental status o Re-orient them if they get post-ictal confusion School-aged kids (Sleep) • 6-12 yrs old • Need at least 11 hrs of sleep at age 5 • 9 hrs of sleep at age 12 o Think about why we had nap-time in elementary school Pavlik Harness • Used to treat DDH • Abducts baby’s hips • Worn for about 3-5 months • Teach parents to: o Assess the skin for breakdown under the straps – baby should wear shirt and knee-high socks under the harness to prevent this ▪ No moisturizers o Massage skin under straps to promote adequate circulation o Only apply 1 diaper at a time underneath straps o PARENTS SHOULD NEVER TRY TO ADJUST THE STRAPS ▪ Your baby’s fucking hips are dislocated, do not fuck up the straps because they’re there to correct this!!! Congenital hypothyroidism • In BABIES – need to identify and treat this ASAP or it can cause SEVERE INTELLECTUAL DISABILITY! • Must screen in all newborns in US and Canada • Early treatment can prevent disability • Watch out for hoarse cry in babies – vocal cords are swollen due to fluid retention Transposition of the great arteries • Pulmonary artery is connected to left ventricle and aorta is connected to right ventricle • Oxygenated blood goes back to the lungs instead of traveling to the rest of the body • Low oxygen levels, fatigue from exertion • They stay cyanotic even with supplemental oxygen  because heart can’t really pump oxygenated blood to the rest of the body Inconsolable crying and drawing legs up toward stomach in babies up to 3yrs of age can indicate intussusception or appendicitis* Acute Otitis Externa – infection of outer ear, try to avoid swimming – don’t get ears wet • Severe pain when pulling on the pinna Acute Otitis Media • Tell parents not to smoke around the kid, red and bulging tympanic membrane • Nausea, vomiting, rhinorrhea – baby will PULL ON AFFECTED EAR • HIGH FEVER 104 F • Tympanic membrane can rupture, after rupture there is no more pain • Do otoscope examination LAST – most people who get this are young kids (Toddlers) they will move around too much o Advance speculum into external auditory canal – just don’t shove it in too deep o Teach parents to get their kids vaccinated bc pneumonia/flu can cause this too Ear exam in babies – pull pinna DOWN and BACK Baby w/ green vomit • It’s bile – bile is supposed to aid in digestion; if the baby vomits this, it means there is obstruction in the intestines and stool cannot pass • EMERGENCY* - can lead to bowel rupture, sepsis Preschoolers • DRAMATIC, rich imagination • Imitate adult behaviors • Play dress up, dolls or puppets • Finger paint, clay and puzzles with large pieces – quiet play Nursing interventions for patients with cognitive impairment • They usually get diagnosed as kids • Decreased ability to perform abstract or logical reasoning • Harder for them to learn from experience of adapt complex ideas • Kids like this need SPECIAL ACCOMODATIONS o Consistently assign same staff, maintain familiar environment – they can get very scared o Provide toys that are developmentally appropriate NOT AGE APPROPRIATE!!! o Positive reinforcement for good behavior o Time-outs o Explain things using pictures (visual demonstration) Ventricular Septal Defect (VSD) • Congenital abnormality – opening between left and right ventricle • Blood shunt from left to right – excess blood goes to the lungs – can lead to CHF • Systolic murmur (holosystolic murmur) • Sweating, tachypnea, dyspnea • Babies will grunt • Assess for CHF symptoms* Coarctation of Aorta • Aortic arch is super narrowed • Can’t deliver adequate blood supply to lower extremities • Pulse in lower extremities are weak, pulse is good in upper extremities • Ischemic pain in lower extremities due to lack of circulation • Left ventricle has to work harder – why? o Because the aortic arch is sooooo narrow, the left ventricle has to generate enough force to pump blood through that narrowed opening • More common in boys than girls, more common in girls with Turner Syndrome Turner syndrome • Chromosomal disorder in girls – only 1 X chromosome • Short stature, loss of ovarian function • Very delayed puberty • Infertility, learning disabilities • Heart defects – coarctation of aorta • Need hormone therapy Lead poisoning • Children should always be screened for blood lead levels (BLLs) • Ask parents if they know what year their house/apartment was built o Lead is usually present in the paint of houses built in 1970’s – was banned later on o Screened at ages 1-2 but can be screened up till age 6 if the kid wasn’t tested before • Lead poisoning fucks up the neurological system • Elevated BLLs 5mcg/dL or HIGHER is VERY DANGEROUS • Assess for impulsivity, reading difficulties, visual-motor issues • Extremely elevated BLLs can lead to blindness, seizures, permanent brain damage and death Duchenne Muscular Dystrophy • X-linked recessive disorder = this means females are carriers but males are affected • If mom carries this – 25% chance of having an affected son • Protein for muscle stabilization (dystrophin) is REPLACED with CONNECTIVE TISSUE • Lower extremities are affected first – the calf muscles are big but theyre not really muscle, its just fat and connective tissue o Stand up with Gower Maneuver – placing hand on thighs to PUSH UP o Walk on tip-toes – because they have movement disorder o These kids fall a lot • They usually end up on wheelchair and eventually die from heart/resp problems Always ask how baby sustained injuries – assess if parent/caregiver story makes sense Ex. 3 month old baby comes in with head injury, mom says baby rolled off bed – babies at 3 months CAN’T ROLL* Infant growth • Weight should double at 6 months • Triple by 12 months • Head circumference is slightly greater than chest until 12 months Hodgkin Lymphoma • Malignant Reed-Sternberg Cells • Predictable path of metastasis • At least 1 painless enlarged lymph node usually at the neck, underarm or groin • Fever, unintentional weight loss, drenched in night sweats, fatigue • Fever and night sweats are known as B-symptoms • Epstein-barr virus can cause this* Wilm’s Tumor (nephroblastoma) • Tumor of kidney, usually occur in kids younger than 5 • DO NOT PALPATE!!! IT CAN RUPTURE!!!! – Put do not palpate abdomen sign at bedside • Usually undiagnosed and goes unnoticed until parents see mass at abdomen Mobile lesions are usually …. - Not cancer Hydatidiform mole (Molar Pregnancy) • Rapid growing mass from abnormal fertilization • Brown vaginal discharge • No FHR • Fundal height is HIGHER than expected for gestational age • Early development of preeclampsia • Hyperemesis gravidarum Naegeles rule LMP - 3 months + 7 days FHR can be detected at 10-12 weeks Quickening occurs at 18-20 weeks for primigravidas, 14-16 weeks in multigravidas • Women who already gave birth = muscles are more relaxed and sensitive to baby movement Hep B during pregnancy • Significant risk of infecting baby • NEEDS HEP B VACCINE & HEP B IMMUNE GLOBULIN WITHIN 12 HOURS OF BIRTH • Can still breastfeed as long as theres no bleeding Toxoplasmosis • Cats carry this sometimes – that’s why they are assholes • Can get this from eating undercooked food or soil-contaminated food/vegetables • Teach pregnant women to be careful – some people like to plant their own vegetables and eat them raw • Risk for stillbirth, malformations, blindness, mental stability • Take precaution when gardening Placenta Previa • Placenta implanted over or very near cervix • PAINLESS • Blood vessels get disrupted during cervical dilation – mom can hemorrhage • If contractions cause cervical change – c-section is planned 36 weeks before onset of labor • If mom and fetus are stable they can go home – manage in outpatient setting o Tell them to come to hospital ASAP if any bleeding occurs o Need ultrasound at 36 weeks to see where the placenta is – can sometimes migrate away from cervix NSAIDs during pregnancy • CAN CAUSE PREMATURE CLOSURE OF DUCTUS ARTERIOSUS* we want this to close after birth – NOT BEFORE THAT • AVOID AT THIRD TRIMESTER* • NSAIDs can be taken at 1st and 2nd trimester if benefits outweigh the risk Tylenol and Ibuprofen are okay for breastfeeding Teratogenic meds • Phenytoin • Lithium • Valproate • Isotretinoin • Methotrexate • ACE inhibitors • Warfarin Turtle Sign • Fetal head retracting back toward maternal perineum after birth of head • SHOULDER DYSTOCIA!!!! o Do McRoberts Maneuver ▪ Leg flexed onto abdomen (pick leg up and push toward abdomen) – this opens birth canal more o Suprapubic Pressure ▪ Press down on pubis ▪ Help push baby shoulders out Normal infant pulse 110-160 bpm Progestin Only Pills • Thicken cervical mucus (hindering sperm motility), thinning the endometrium (hindering implantation) • Preventing ovulation • VERY TIME SENSITIVE – if taken 3 hours later or more – use other forms of protection until pill is taken correctly for 2 days Third Trimester symptoms • Leg cramps • Dependent edema in lower extremities – due to decreased venous return • Dyspnea – diaphragm is pushed so far up, prevents lungs from fully expanding Fetal movement • Should NEVER decrease as baby grows in size • Can mean oxygenation to baby is compromised • Do non-stress test – FHR monitoring • Mom’s perception of fetal movement can be altered by obesity, maternal/fetal position, anterior placenta (in front), increase or decrease of amniotic fluid volume HELLP SYNDROME • Hemolysis, Elevated Liver enzymes, Low Platelets • Right upper quadrant pain • SEVERE form of preeclampsia • Can lead to liver failure, stroke, placental abruption – mom/baby can die • ALWAYS ASSESS BP – increase SBP 30, DBP 15 – even if not hypertension needs assessment Vaginal Hematoma • Formed when trauma to tissues of the perineum occurs during delivery • More likely to occur from forceps or vacuum assisted birth or an episiotomy • Severe vaginal pain • “Feeling of fullness” • If patient had epidural they might not feel this until effects wear off • Uterus is FIRM at midline • Assess for labs and change in VS What to do for prolapse cord? • Vaginal exam – manually lift baby head off cord if you can see it to alleviate the compression • Leave the hand in place and call for help Breech presentation • Can palpate baby’s butt or legs • Fetus butt or legs not as firm as head – that’s how you know • Need C-section, vaginal birth isn’t safe Back Labor • Occiput Posterior position • Position mom on HANDS AND KNEES • Help baby rotate – facing the back Distended bladder – fundus above umbilicus deviating to the RIGHT Boggy fundus – uterine atony Pregnancy travel safety • Tell mom to get HCP approval before traveling long distances o Usually its okay when they’re healthy 36 weeks gestation • Carry important documents – prenatal records in case of emergency • Prevent dehydration – prevent DVT • Lap belt UNDER gravid abdomen and across hips • Shoulder belt LATERAL to uterus between the breast to prevent placental abruption from trauma • Wear compression stockings • Wear loose clothing • Don’t travel to places wit