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NCLEX Practice Questions Review

NCLEX Practice Questions Review Leopold maneuvers • Meconium aspiration • Calories • Iron • Maternal PKU • Fundus • Displaced when bladder full • Post-delivery- found firm at midline Magnesium sulfate • Nalbuphine • Opioid pain relief Pre-eclampsia/PIH • Drug Addiction • Active Labor • Check cervix before giving pain meds • Given too close to delivery can cause resp depression in neonate Contraction Stress Test • Ectopic Preg • Betamethasone(Celestone) • PIH • Develop edema, elevated BP, proteinuria • Reflex normally plus 2 Nonstress Test(20 min) • FHR • V C- variable decels cord compression • E H-early decels- head compression • A O-accelerations ok • L P-late decels placenta insufficiency Oxytocin • Weight Gain • ITP • Autoimmune response with decreased platelet count • Increased megakaryocytes 6 weeks gestation 24 weeks • GBS done at 35-37 weeks • Rubella titer done at initial prenatal visit to determine rubella immunity • Glucose tolerance test • 3 hour gtt done in women with elevated glucose levels after 1 hour test is done at 28 weeks LGA(macrosomnic infant) • Breastfeeding and engorgement • apply cold cabbage to relieve pain • breast binders suppress lactation • breast shells for patients with inverted nipples or flat or pts with sore nipples Prolapsed umbilical cord • call for help • apply internal upward pressure to presenting part Abruptio placenta • cocaine use increase risk for vasoconstriction and abrupted placenta Infant safety • set hot water heater no higher than 49 C 120 F • crib slats no more than 6.3 cm 2 3/8 in apart • no comforter in crib hyperemesis gravidarum • eat to taste to avoid nausea • eat healthy snack at bedtime • alternate liquids and solids every 2 hour • eat protein following sweet snack Vaginal hematoma • pressure in vagina • persistent vaginal pain terbutaline • protect from light • relax smooth muscle • primary action- bronchodilation • subqqa 4 hrs no longer than 24 hr • AE- headache, dizzy, arrhythmias, nausea, paradoxical bronchospasms, tachycardia, hyperglycemia, hypoklemia Hydatidiform mole • Placental abnormal • Chorionic villi of placenta develop into grape like mass-clear vesicles • With or w/o fetus present • Avoid preg for 1 year • As cells slough- discharge dark brown vaginal Jaundice • Pathological- 1st 24 hrs, inform HCP- stat bilirubin test • Physiological- breastfed after 24 hours Late decels • Placental insufficiency • Pressure on IVC-decrease O2 to placenta and fetus • Turn on left side, give O2, then give fluids Naloxone • Reverse respiratory depression, hypotension of opiods • AE- seizures, pulmonary edema, tachycardia, HTN, V FIB Diaphragm • Remove after 24 hrs-clean with mild soap water • Replace q 2 years • Insert on empty bladder • Weight gain greater/less 10-15 lbs refitted • Keep in place 6 hours after sex Chadwick sign • Blue discoloration in cervix, vagina Low Back pain • Posterior-face mom back • Rub lower back-help relax muscles in low back and relieve pressure of fetus head Cerclage • Reinforce weak cervix • Use sutures that go around cervix, hold it close • Go to hospital first sign of labor • Can have sex Polyhydramnios • Excessive fluid surrounding fetus • Increased fundal height • Increased weight gain • Increased urination • GI fetal malformations and neuro disorders-anticipate Oligohydraminos • Volume amniotic fluid less than 300 • Fetal renal dysfunction • Obstructive uropathy • Confirmed by US • IUGR Mineral oil • Treat constipation • Take at bedtime on empty stomach • Abruption placentae • Premature separation of placenta from uterine wall • Platelet count decreased • Prolonged partial thromboplastin • Decreased fibrinogen • Normal clotting time • Abdominal pain-sharp painful bleeding Placenta previa • Placenta attach low in uterus • Painless vaginal bleeding • Life threatening-need continued hospitalization and close monitoring • Near or covering cervix opening- partially or totally • Don’t perform vaginal exams • Monitor fetal heart tones- continuous EFM • Take vs q 15 min • Most common in 3rd trimester Abdominal US • Need full bladder • Ask when last voided Rubella • When mom titer neg, give another after delivery • Avoid preg at least one month after vaccine • Mild rash and joint ache 7-10 days after • Get each preg • May have low grade fever Erythromycin ophthalmic • Give within 1st hour • Gonorrhea/chlamydia Hep B vaccine • Given several hours after birth • Parent consent Vitamin K • Used for synthesis of clotting factors in liver • Given to prevent bleeding • Newborns risk of bleeding-lack of intestinal flora needed to make vit K Cephalhematoma • 2-6 weeks for edema and discoloration to disappear • no treatment needed caput succedaneum • resolve 2-3 days Ergotamine • treat migraine • one tab at onset of migraine • max 3 in 24 hr period • Methylergonovine(methergine) • treat PP hemorrhage • monitor VS and vag bleeding • AE- seizures, stroke, headache, nausea, chest pain, palpitations, increased BP • CI- high BP Bethanechol • Cholinergic stimulate muscarinic receptors Phenytoin • Don’t take with mil or calcium • Less than 10mcg subtherapeutic-cause seizures • Levels more than 20 toxic effects • Cause gingival hyperplasia- tell dentist • Report nystagmus Anticholinergic drugs • Worsen urinary retention • Atropine • Scopolamine • Benztropine o Constipation o Tachycardia o Glucose in infants • Normal ranges 40-95 mg/dL • Fasting glucose 60-90 for pregnant Bilirubin • Report greater than 8 Hct • Normal 48-69% LGA • Weight above 90th percent • Increase risk for hypoglycemia Congenital hip dysplasia • Limited abduction indicate head femur slipped out of acetabulum • Limited abduction of hip • Asymmetrical gluteal folds Stepping reflex • Should be gone by 4 weeks Moro reflex aka startle reflex • 8 weeks Babinski reflex • 1 years • Stroke bottom of foot Extrusion • Infant spit out food tonic neck • 3-4 months Jet hydrotherapy • Doppler device, fetoscope, wireless external monitor safe • Don’t use internal electrode Newborn assessment • Posterior fontanel should be larger than anterior • Assess apical pulse for 1 full minute-when baby quiet • Overlapping suture line • Lanugo over shoulders normal • Breast nodules up to 10mm • T 36.5-37.2C • Weight 2.5-4 kg • Length 45-55cm • Chest circumference in term 2 cm less than head circumference-measured at nipples • Head circumference greater than 37cm or less than 33cm investigate for neurologic involvement Neonatal sepsis • Temp instability • Tachypnea • Hypotonia • Lethargy • Nasal flaring • Irritability Vaginal hematoma • Pressure in vagina • Persistent vaginal pain Infant safety • Hot water heater no higher than 49 C 120 F • Crib slats no more than 2 3/8 inch • No loose bedding in crib Amniocentesis • Rhogam given following procedure • Potential of fetal RBC entering maternal circulation • Given at 28 wks Circumcision • Sterile gauze for bleed • Petroleum jelly each change • Don’t wipe off yellow exudate- normal • Document voids after- secondary • Change diaper at least q 4 hours • Avoid soap and water • Rim usually fall off in 1 wk • 1st priority is to monitor for bleeding q 15 min for 1st hour after procedure • DON’T APPLY petroleum jelly after circumcision when plastibell used • Complications-hemorrhage, infection, urethral fistula formation Mastitis • Unilateral breast pain with tenderness Reposition, increase fluids, give oxygen 8L Itp • Decreased platelet • Increased megakaryocytes GBS • 35-37 wks 3 hr glucose • 28 wks Heparin • don’t take aspirin • bedrest • don’t massage • apply warm compress not cold hperbilirubinemia • yellow mucous membranes, bron or gold urine, maculopapular rask normal • irritable complication Uterine Inversion • Don’t remove placenta if still attached- can cause larger SA for bleeding • Large amt blood suddenly gush from vagina • Fundus not palpable in abdomen • Don’t give oxytocics- compounds the inversion • Assess VS and establish IV access and fluids • Discontinue uterotonic drugs-allow uterine relaxation for replacement Pharmacology NCLEX practice questions Acetazolamide • Diuretic • For chronic open angle glaucoma, epilepsy, edema • AE o Paresthesia-tingling fingers o Hyperglycemia Oxybutynin • For urinary incontinence • Anticholinergic effects-dry mouth, photophobia, constipation, blurred vision, tachycardia Dopamine • Increase BP in cardiogenic shock • Cardiac stimulation • No effect on RR • Increase renal circulation- incr UO Doxycycline • Tetracycline antibiotic • CI o Pregnancy o Effects on developing bone and teeth Regular insulin • Manage gestational diabetes Baclofen • Decrease seizure threshold in pt with epilepsy • Decr freq and severity of muscle spasms • No effect on cognition • Inhibits reflexes at spinal level Tamoxifen • Treat breast cancer • AE o Menstrual irregular o Hot flashes-anti estrogen o Bruising Inhibitor overdose • Antidote- atropine sulfate Neuromuscular blocker overdose • Neostigmine- cause nausea, increased salivation, bradycardia Clindamycin • Can cause C dif-watery diarrhea • Topical application cause face swelling • Generalized muscle aches Sedative hypnotic anxiolytics Benzodiazepines • Prototype o Alprazolam • Antidote o Flumazenil • Meds o Diazepam o Lorazepam o Oxazepam o Clonazepam o Clorazepate o Chlordiazepoxide • Complications o CNS depression  Sedation, lighthead o Anterograde amnesia o Resp Depression  Hypotension  Cardiac/resp arrest  Gastric lavage  Activated charcoal  Monitor VS o Paradoxical response  Insomnia  Euphoria  Anxiety  Rage o Withdrawal effects  Taper off over few weeks • Contraindication o Sleep apnea o Glaucoma o Resp depression o Liver disease o Used short term due to dependency • Interactions o CNS depressants  Alcohol  Opioids  Barbituates  Anticonvulsants  Antihistamines o Grapefruit  Reduce metabolism o Fatty meals  Reduce absorption • Considerations o Take at bedtime o Take with meals Atypical anxiolytic/nonbarbituate • Prototype o Buspirone • Action o Bind serotonin and dopamine receptor o Dependency less likely o 2-6 wks full effect o Take on schedule • Complications o Dizzy o Nausea o Lighthead o Agitation o Constipation o Suicide ideation o Take with food • Contraindications o MAOI use- 14 days after use- hypertensive crisis • Interactions o Erythromycin o Ketoconazole o St johns wort o Grapefruit juice  Increase effects of buspirone  Avoid use o Increase risk for serotonin syndrome with SSRI  Monitor for SS • Fever • Tremor • Diarrhea • Delirium • Considerations o Take with meals o A week to notice effects o Take on regular basis o Tolerance, dependence not issue SSRI-antidepressants • Prototype- paroxetine • Other o Sertraline o Citalopram o Escitalopram o Fluoxetine o Fluvoxamine • Action o Inhibit ssri reuptake o Paroxetine  produce CNS stimulation –insomnia, wt loss and decreased appetite  increase risk for birth defects  o Long half life o Up to 4 weeks for therapeutic • Complications o Serotonin syndrome 2-72 hrs after o Nausea o Diaphoresis o Agitation o Confusion o Anxiety o Hallucinations o o Tremor o Headache o Dry mouth o Fatigue o Drowsy o Sex dysfunction  Med holiday  Sildenafil and buspirone use o Wt gain o GI bleed  Report dark stool  Coffee ground emesis o Hyponatremia o Serotonin syndrome  Agitation  Confusion  Difficult concentration  Tachycardia  Abdominal pain- diarrhea  Cardiovascular shock  Hypertension  Seizures  death  Myoclonus-spastic jerky muscle contractions  Hyperreflexia  Fever  Begin 2-72 hrs after  Report manifestations o Bruxism  Grinding of teeth during sleep  Use mouth guard  Treat with low dose buspirone o Postural hypotension o Suicide ideation o Rash o GI bleed • Contraindications o Paroxetine- avoid alcohol o Use cautious pts with liver/renal dysfunction, seizure disorder, GI bleeding o MAOI or TCA use • Interactions o MAOI and TCAs and lithium  Cause SS o Antiplatelet meds/anticoagulants  Increase bleed risk  Warfarin • Monitor PT/INR levels o St john wort- don’t take with o Considerations  Take with food  CNS stimulation • Take¬ in morning  Take on daily basis  4 weeks to be therapeutic  Don’t take with NSAIDS- can take Tylenol  o Digoxin o Normal therapeutic range 0.5-2 ng/mL o Greater than that toxic call HCP o Cause blurred vision AE Depressive disorders SSRI- see above SNRI • Prototype o Venlafaxine • Other meds o Desvenlafaxine o Duloxetine • Action o Block reuptake NE • Complications o Nausea o Anorexia o Wt loss o Headache o Insomnia o Anxiety o HTN o Tachycardia o Dizzy o Blurred vision o Withdrawal syndrome o Suicide risk o Sex dysfunction o SSRIbronchitis o Dyspnea • Contraindications o SSRI o MAOI o TCA o Discontinue 2 weeks before starting MAOI • Interactions o Neuroleptic malignant syndrome if given with MAOIS  Don’t take o NSAIDS/anticoag  Increase bleed risk o Alcohol  Increase risk CNS effects o Kava, Valerian  Increase risk for CNS depression • Avoid Atypical antidepressants • Prototype o Bupropion • Other meds o Vilazodone o Mirtazapine o Reboxetine o Trazadone • Action o Inhibit NE and dopamine uptake o For pts who cant tolerate sex dysfunction o Smoking cessation • Complications-anticholinerggic effects o Headache o Dry mouth o GI distress o Constipation o Tachycardia o Htn o Restlessness o Insomnia o N/V/anorexia, wt loss o Seizures • Contraindication o MAOIs use o Seizure and eating disorders • Interactions o MAOIs-phenelzine  Increase toxicity risk TCAs • Prototype o Amitriptyline o Take with food or immediately after • Other meds o Imipramine o Doxepin o Amoxapine o Trimipramine o Desipramine o Clomipramine o Notriptyline • Action o Block serotonin and NE reuptake o 10-14 days or longer for effects 4-8 wks o Fibromyalgia o Neuropathic pain • Complications o Orthostatic hypotension  Monitor BP and HR before and 1 hr after giving o Anticholinergic effects o Htn o Bluish green urine o Constipation o Tachycardia o Photophobia o Sedation o Toxicity  Cardiac dysrhythmias  Mental confusion  Seizures  Coma  Death o Decreased seizure threshold o Excessive sweating • Contraindications o Seizure disorders with MI o Cautious in diabetics, CAD, BPH, resp disorders o 1 wk supply for suicide risk increase • Interactions o MAOI/st john wort o Antihistamines o Anticholinergics o TCAs o Alcohol MAOI • Prototype o phenylzine • other meds o isocarboxazid o tranylcypromine o selegine-transdermal MAOI • Action o Increase NE, serotonin, dopamine and tyramine o Tyramine can cause hypertensive crisis • Complications o CNS stimulation o Orthostatic hypotension  Monitor BP and HR before and after  Hold less than 60 o HTN crisis  Vasoconstriction and stimulation of heart  Headache/N/increased HR and BP  Give phentolamine IV- rapid acting adrenergic blocker or nifedipine  Continuous cardiac monitoring and resp support o Considerations  Reduce tyraine  MED SURGE REVIEW Respiratory ATI Practice questions Crepitus o Aka subQ emphysema o Coarse crackling sensation palpated over skin surface o Indicate air leak ino subQ tissue o Indicate pneumothorax Friction rub o Scratching/squeaking sound o Don’t clear with coughing o Indicate pericarditis or pleurisy Cheyne stoke respirations o Rhythmic increase and decrease in rate with periods of apnea o Reflect severe brain dysfunction ARDS o Life threatening o Inflammation of lungs and accumulation of fluid in alveoli cause hypoxia o Initial manifestations- increased restlessness, apprehension, anxiety, increased respirations, dyspnea, air hunger, retraction of accessory muscles, cyanosis o Verconium- neuromuscular blocking agent facilitate vent and decrease o2 consumption o Gentamicn- nephrotoxic o PAWP(preload) normal in pt o Fluid in alveoli from increased permeability of the alveolar-cap membrane o o Increased RR indicate decline in condition-earliest sign ARF o Increased CO2 o Decreased pH- resp acidosis o Decrease in O2 sat o Lower pp oxygen Pneumonestomy o Must clear secretions from remaining lung o Pt splint incision while coughing o demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. o Pain with deep breathing is expected and is managed with analgesics. o The client with pneumonectomy most likely will not have a chest tube because the lung has been removed o May cause increased airway pressure because of resistance to lung inflation Pneumothorax o Pt has severe diminished or absent breath sounds on affected side o SOB o Chest pain o Hyperresonance on affected side Emphysema o Purse lipped breathing greatest effect on exhalation not inhalation- breath in through nose and out through lips o Help rid of CO2 COPD o Resp acidosis-hypoventilation dec ph increased co2 o Venturi mask- delivers most oxygen conc. o Delivers precise amt o2 o Manifestations- hypoxemia, hypercapnia, dyspnea on exertion or rest, accessory muscle use, oxygen desat o X-ray reveal hyperinflated chest, diaphragm flattened o PFT- decreased vital capactity o Difficult exhaling CO2-loss elastic recoil in lungs o Vomiting and diarrhea cause metabolic alkalosis o Schedule resp treatments before meals o Give diet high in calories and protein, low in carbs o Schedule short activities o Clubbing expected o Purse lip breathing expected-promote )2 elimination o Low o2 sat expected Chest physiotherapy o Helps mobilize secretions in airway- percussion and vibration performed Thoracentesis o Aspirate fluid or air from pleural space o Upright position sitting and leaning over bedside table o Wear goggles and mask o Cleanse area with antiseptic o Remain completely still o Apply pressure to site after removing needle Chest tube insertion o Continuous bubbling in suction chamber o If CB in water seal- air leak o Gentle constant bubbling in suction control chamber-air being removed o Intermittent bubbling in water seal normal-removing air from pleural space o Drainage less than 100 ML normal o Keep below chest at all time o Tape all connections btw chest tube and drainage system-prevent air leaks o Must change entire system o Have container of sterile water in room(end placed to restore water deal)- in case dislodged, oxygen, occlusive dressing(put over site to prevent reoccurring pneumothorax), enclosed hemostat clamps(check for air leaks) o Removing- Valsalva maneuver-deep breath, exhale, bear down-increase intrathoracic pressure and reduce risk of air embolism o Teach client cough q 2 hrs o Don’t milk/strip tubing-create neg pressure can cause lung tissue damage o X-ray verify placement Asthma o Cromolym sodium- o Anti-inflam agent-maintenance therapy for asthma o Rinse mouth after- prevent thrush o Slow onset-don’t relieve acute attacks o Several weeks for effects o Reduce exercise induced bronchospasm given 3 o o o Prednisone- given following to promote AI effects o Fluticasone, salmeterol- maintenance therapy- combine glucocorticoid and long actin B2 adrenergic agonist o GIVE albuterol first- short acting- act quickly cause bronchodilation o Montelukast o take med once daily, used for maintenance therapy, take on reg schedule, take in evening even if no symptoms o annual flu- risk for infection o use peak flow meter same time each day o play inside during cold weather o encourage to stay active- use inhaler before exercise Bronchoscopy o Report bronchospasms immediately o Expected- blood tinged sputum, hematuria, dry cough Pressure support vent(PSV) o Allows preset pressure delivered during spontaneous vent to decrease work of breathing o No vent breaths delivered o Pt generate force to take spon breath o o AC-assist control o Delivers present vent rate and TV to pt o Takes over breathing o CPAP o Pt generate force to take spontaneous breath o Pt must initiate adequate resp rate to allow adequate gas exchange o SIMV o Pt generate force to take spon breath o PEEP o Maintains pressure in lungs to keep alveoli open o Prevent atelectasis o Improve gas exchange and oxygenation o Normal 5-15 o Greater than 15 cm H20 use close suction tech Albuterol o AE- tachycardia Prednisone inhaler • Wait 20-30 s btw puffs • Exhale with pursed lips • Rinse mouth after • Hold breath for 10 sec Glucocorticoids o Beclomethasone- candidiasis o AE o Osteoporosis- bone density scans Hypoxemia o Manifestations o Early-pale skin, elevated BP o Late- confusion, bradycardia, hypotension Mask Types o Venturi- deliver precise amt o2 Tuberculosis o Airborne precautions and standard precautions- N95 mask o Diagnosed through culture and isolation-MANTOUX TEST, ACID FAST SPUTUM 7 day return o Test read 48-72 hrs o Use 26-27 gauge needle o Insert with bevel up o Presumptive diagnosis- chest xray, tuberculin skin test, granulomatous disease on biopsy o 1st manifestations- slight cough, expectoration of mucoid sputum o late- dyspnea, chest pain, bloody productive cough o Particulate resp, gown, gloves during bed bath o Rifampin- no tinnitus, will always have positive PPD test, urine and other secretions will be orange, take on empty stomach o Med therapy 6-12 mnths o Noncontagious after 2-3 wks o Wear mask around crowds until meds effective o Return to work when 3 sputum cultures neg- 2 wks apart o Resume activities gradually o Sputum culture needed q 2-4 weeks once meds started o No isolation needed- family already exposed o Cover mouth and nose o TB test positive when area induration greater than 5mm in HIV pt o Without HIV larger than 10mm positive o Treatment o Isoniazid-INH(monitor liver function), rifampin, ethambutol(must call hcp if visual probs), py o Active TB nurse wear- N95 mask or HEPA respirator o Neg pressure room o Pt wear mask when transported outside room o Regimen eliminate various combinations of resistant strains o MRSA o Contact precautions AIDS Histoplasmosis o Manifestations- infectious process o Begins as respiratory infection- cause dyspnea Sarcoidosis o Pulmonary problem o Dry cough and dyspnea early symptoms o Later- night sweats, fever, weight loss, skin nodules o Sob and impaired vent occur first o Cause fatigue as secondary prob Silicosis- occupational lung disease o Chronic, excessive inhalation of particles of free crystalline dust o Pt should war masl- can cause restrictive lung disease after years of exposure Types of Precautions Standard • Fecal oral route • Contaminated foods • Rocky mountain fever- bite from tick through blood transfusion • • Hep A Airborne Precautions • Mnemonic- My chicken Hez TB • Found in blood and urine • Private room • HEPA filtration-neg P airflow • Types o Measles o Chicken pox-varicella o Herpes Zoster o TB • Management o Neg pressure room-HEPA filtration o Private room o Mask o N95 for Tb Droplet Precautions o Mnemonic- SPIDERMAn o Found in blood stool and urine o Place in private room or pt with same disease o Use mask/respirator when caring for pt o Adenovirus infxn in infants and children o Types o Sepsis o Scarlet Fever o Strep o Pertussis o Pneumonia o Parvovirus o Influenza o Diptheria o Epiglottitis o Rubella o Mumps o Adenovirus o Influenza-seasonal o HIB o Management o Private room o Mask Contact precautions • Mnemonic: MRS WEE • Types o MRSA o RSV o Skin infections- herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, staph o Wound infections o Enteric infxn C DIF o Eye infection conjunctivitis o Management o Gown o Gloves o Goggles o Private room Blood Transfusion • Bite of infected tick • Rocky mountain fever • Standard Pulmonary Embolism o When substance enter venous circulation and form blockage in pulmonary vasculature o Give heparin via continuous IV infusion to prevent dislodgement o Common initial symptom is chest pain sudden in onset o Dyspnea, with increased RR, apprehension, restlessness, tachycardia, cough, and cyanosis o DVT o Emboli from venous thromboembolism most common o ABG analysis- CO2 levels low from hyperventilation-resp alkalosis o Cbc analysis- monitor hgb and hct o D-dimer elevated- clot formation and fibrin degradation norm 0.4-2.33 mcg/mL o Chest x-ray initially identify PE, CT most commonly used o V/Q- vent/perfusion scan- show circulation of air and blood in lungs-detect PE o Pulmonary angiography- gold standard, most thoroughly to detect PE- invasive costly, catheter inserted into vena cava, visually see PE o Warfarin- monitor foods with Vit K-reduce anticoagulant effects o Avoid aspirin unless HCP prescribe o Complications o BV decreased o Monitor hypotension, tachycardia, cyanosis, JVD, and syncope o S3 and S4 heart sounds o Give IV fluids crystalloids to replace vascular volume o Put pt high fowlers 90 degrees o IV access o Meds o Assess res[ status q 30 min o Compare bp in both arms o Examine neck for distended neck veins o Meds o Anticoagulants- prevent clots from getting larger, additional clots from forming  Monitor Heparin aPTT and warfarin PT/INR, and CBC o Thrombolytic therapy-dissolves blood clots and restore pulmonary BF  Alteplase, reteplase o Tension pneumothorax o Free air fill chest cavity o Are into pleural space during inspiration and cant exit o Cause pressure on heart and lungs o Increase in pressure compresses BV and limits venous return-DECREASED CO o Cause lung to collapse- o Diminished/absent breath sounds o Force trachea to deviate to unaffected side o Characterized by restlessness, tachycardia, dyspnea, pain with resp, asymmetrical chest expansion, diminished/absent breath sounds, o Cause increased airway pressure cause of resistance to lung inflation o Asymmetrical chest wall movement o Hyperresonance on percussion due to trapped air o Chest xray confirm o Productive cough- indicate resp infection Hemothorax o Blood accumulate in pleural space o Dull percussion o Flail chest o paradoxical respirations- chest movement o result from many rib fractures o limit chest expansion Thoracentesis o Aspirate fluid or air from pleural space o Upright position sitting and leaning over bedside table o Wear goggles and mask o Cleanse area with antiseptic o Remain completely still o Apply pressure to site after removing needle o Large bore needle 18 gauge or larger o Informed consent o Tell pt discomfort feeling when local anesthetic solution injected o Pressure but no pain felt o No PFT post procedure Tracheostomy o Dislodged- reinsert immediately o Inspect for infection or skin irritation o Clean with half strength peroxide and rinse with saline o Remove old tie when new tie replaced o Apply suction when withdrawing catheter to prevent tracheal tissue trauma o Limit suctioning to 10-15s o Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube. o Hyperoxygenate the client both before and after suctioning. o This would be the initial nursing action. o The safe suction range for an adult client is 80 to 120 mm Hg o When the nurse advances the catheter into the tracheostomy tube, suction is not applied, because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen. o Provide trach care q 8 hr o Clean from stoma outward o Surgical asepsis to clean an remove inner cannula o Replace ties if wet or soiled o Change nondisposable tubes q 6-8 wks o Reposition q 2 hr prevent pneumonia and atelectasis o Accidental decannulation o Ventilate with BVM o Call for assistance o Keep obturator and 2 spare tubes at bedside o Give oxygen through stoma if cant replace o Hyperextend the neck o Auscult ate for bilateral breath sounds Endotracheal tube o Verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. o After this initial assessment, placement is checked radiographically-XRAY o The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. o Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement. o Removal- The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Endotracheal suctioning o Use sterile tech-surgical asepsis o Rotate suction catheter during withdrawal -reduce risk tissue trauma o Suction endo tube before nonsterile oropharyngeal cavity- prevent cross contamination o Suction as needed o Coughing is expected o Pass catheter no more than 3 times- decrease oxygenation o Withdraw when resistance met=prevent damage to lung tissue o o Emphysema o Overinflation of alveoli o Cause SOB o Digital clubbing expected o Increased T indicate infection o Barrel chest expected o Diminished breath sounds expected Carbon Monoxide Poisoning o 11-20%- flushing, headache decreased visual activity, decreased cerebral functioning, and slight breathlessness o 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia o 41% to 60% result in seizure and coma; and levels higher than 60% result in death Chest physiotherapy o percussion and vibration help loosen secretions in smaller lower airways Chronic kidney disease o The diet for a client with chronic kidney disease who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids, which is indicated in the correct option. Lab values o BUN normal 10-20 o Potassium- 3.5-5 o Serum protein adult- 608 g/dL o Wbc- 4500-11000 o Serum amylase- 25-151 norm- chronic pancreatitis level increase o Platelet 150,000-400,000 Pancreatitis • ULQ pain • Absent bowel sounds-paralytic ileus • N/V • Jaundice • H WBC • Amylase • H lipase • Liver enzymes elevate • MI o Troponin T in striated muscle o Normal 0.1-0.2 consistent with MI o Normal levels lower than 0.6 Thiamine o Foods of plant and animal origin NG tube • High fowlers for insertion-90 • Withdraw slight if gag reflex • Suction when in place • Sip water to move down • Ph 0-4 • Abdominal xray show end of tube above pylorus • Irrigate with 0.9 NS not tap water TPN o Weaned- decrease gradually o Don’t discontinue abruptly may cause hypoglycemia o Before giving solid diet- give clear liquids then full liquids o Normal saline can cause hypoglycemia o indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include those clients with burns, exacerbation of Crohn's disease, and persistent nausea and vomiting due to chemotherapy. o Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery. PN o When removing do Valsalva maneuver during tube change- help avoid air embolism o Turn head to left if tube on right o AIR EMBOLISM- occurs when air enter catheter system- o Opened for IV tubing changes or when IV tubing disconnects o Place lying on left side o Head lower than feet o Minimize effects of air traveling as bolus to lungs by trapping in right side of heart o GOAL in emergency is trap air in right side of heart o Redness at insertion site- indicate infection- assess temp increase o Loose connections cause leakage o Fat emulsions assess for egg allergy, has it in solution o Change solution if fat globules accumulate in top solution o If fever develop, change solution and send to lab for culture o monitor T for infection and weight for hypervolemia o electronic infusion pump before hanging solution o monitor BGL q 4-6 hrs o when bag not ready, hang 10% dextrose in water to prevent hypoglycemia o optimal wt gain- 1-2 lbs per week o greater than that may have fluid retention-monitor crackles in lungs o after adding med to bag of IV soln, agitate or rotate bag gently to mix o Attach complete med label o Prime tubing o Check for discoloration before med added to solution o Then attach tubing to pt o Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume. o Hypervolemia is a critical situation and occurs from excessive fluid administration or administration of fluid too rapidly. Clients with cardiac, renal, or hepatic dysfunction are also at increased risk. The client's signs and symptoms presented in the question are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The increased volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate sepsis, air embolism, or hyperglycemia Fluid volume replacement o Expand intravascular volume quixk as possible o 5% dextrose n LR(hypertonic soln) incr intravascular volume and replace fluid volume loss-incre BP- water rush out cell o 0.33 NS, 0.225 NS, 0.45 NS- all hypotonic solns o Infiltration o IV dislodged from vein o Lying in subq Tissue o Pallor, coolness, swelling from fluid in sub1 tissue Phlebitis o Red, warm, swelling o Discontinue the IV insert new IV o Infection, phlebitis, a thrombosis is warmth at site Hyperglycemia o Manifestations- excessive thirst, weakness, confusion, kussmaul respiration, diuresis, coma o Infection- fever, chils Heparin o Normal aPTT 30-45 sec o Therapeutic for heparin treatment of DVT- 1.5-2.5 times norm o If greater than normal stop the infusion o Antidote protamine sulfate o Therapeutic ptt 60-80 Warfarin o Normal PT 10-12 sec o INR 0.9-1.5 o 2.5 within normal o Antidote vit K o Give same time each day o Red black tarry stools indicate bleed-report to HCP o No NSAID use o Blood tests every day for 1st 5 days o Apt therapeutic 30-40 sec o o Carry med alert bracelet at all times o Avoid aspirin- higher risk for bleed o Exercise regularly-prevent venous stasis o Draw sample for PT and INR to determine anticoagulation status and risk for bleeding Ammonia 10-80 Bilirubin Albumin 3.4-5 PICC o Protect site during bath o Carry medic alert ID o Repair kit in home Central Venous Catheter o Assess that catheter in right place before giving fluid o Fluid overload complication o Signs- rapid breath, dyspnea, moist cough, crackles Hematoma o Ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. o Air embolism o characterized by tachycardia, dyspnea, hypotension, cyanosis, and decreased level of consciousness o Systemic infection o characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia Blood transfusion o T greater than 100F – don’t hang call HCP o Ask about past transfusions o Always check exp date o Use blood warmer o NS 0.9% standard isotonic soln used with blood products o Dextrose can cause clumping don’t use o Don’t use LR o o Septicemia o Signs- chills, fever, vomit, diarrhea, hypotension, shock o In-line filter tubing o Cool blood can increase dysrythmias o Transfusion rxn o Stop transfusion o Remove blood tubing from IV access o o Give NS at keep vein open rate not dextrose using new tubing o Don’t remove IV line o Send back to lab for testing o Get culture of tip of catheter when infection o Check VS before and q 15 min after o Acute Hemolytic o immediate o Incompatible with RH facto or blood type o Can cause DIC or circulatory collapse o Findings  Chills  Fever  Low back pain  Tachycardia  Flushing  Hypotension  Chest pain  Tachypnea  Nausea  Anxiety  Hemoglobinuria  Impending sense of doom o Febrile o Occur within 2 hr of rxn o Findings  Anti WBC antibodies  Chills  Increase T  Hypotension  Tachycardia o Nursing actions  Use wbc filter for admin to prevent rxn  Stop transfusion give antipyretics  Give NS using new tube o Allergic  During or up to 24 hrs after transfusion  Itching  Urticarial  Flushing  Anaphylactic rxn- bronchospasm,, laryngeal edema, shock  Give antihistamine like Benadryl o Anaphylactic  Stop  Give epi  Oxygen  CPR  Remove blood tubing from pt IV access  Give NS using new tubing o Bacterial  Contaminated blood products  Wheezing  Dyspnea  Chest tight  Cyanosis  Hypotension  Shock  Give antibiotics, NS with new tube, send BC to lab for analysis o Circulatory Overload  Occur anytime  Rate too fast  Crackles  Sob  Cough  Anxiety  JVD  Tachycardia  PE  Slow or stop, position pt upright with feet lower than level of heart, give oxygen diuretics and morphine  Platelets o Need for blood clotting Blood return to heart o Leg elevation and giving IV fluids Fresh frozen plasma o Given for fluid volume expansion KCL o Give through infusion pump Anthrax o Bacillus anthracis o Contracted through digestive system, abrasions in skin, inhaled through lungs o Cannot spread person to person Restraints o Remove q 2 hrs to allow circulation-1 at a time o Check skin integrity q 30 min o Tie to part of bed frame that move when raising or lowering bed o 2 fingers should fit underneath o Quick release tie Colostomy o Pink and moist o Red peristomal skin under adhesive Heating pad • Apply no more than 30-45 min at time-prevent vasoconstriction • Don’t raise T • Don’t use pins or sharp needles Heart Transplant o May no longer feel chest pain o Activity tolerance should improve as healing process o Diet low sodium and fat o Immunosuppressants remainder of life to prevent rejection of heart Heart Failure o Report weight gain 1-2 lb in 1 day ECG o SVT o Vagal stimulation help heart turn to normal sinus rhythm temp o No atropine o No defib Pacemaker o Hiccups indicate pacemaker stimulating chest wall or diaphragm-lead wire perforation o Pain stinging at insertion site normal o Headache not complication Stress test o Don’t have to be NPO o Don’t take cardiac med before o Chest pain not CI o Smoking CI Nitroglycerin Patch o Rotate patch site o Apply to skin away from skin folds and joints o Wear 10-12 hrs to prevent tolerance o Prevent chest pain Nitro Tabs • Keep tabs in dark dry place • Dark colored glass bottle with tight lid • Can lose potency in other containers • Don’t buy in bulk amts • Go to ER if pain don’t go away • 3 nitro tabs in 5 minutes • Call 911 if pain not relieved after 2 tabs • Myocardial Infarction o CKMB elevated when muscle injured o Ace inhibitors o For HTN o Decrease BP o AE o Cough –discontinue o Diarrhea o Dizzy o Frequent urination o Hyperkalemia- potassium rention of kidneys Calcium channel blockers o AE o Constipation Integumentary Psoriasis • Scaly white patches Herpes zoster-shingles • Diagnose- viral culture of lesion Melanoma • Pigmented malignant lesions • Metastatic • irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color Multiple myeloma aka kahlers disease • cancer of plasma cells • Increased number of plasma cells in the bone marrow • Anemia • Hypercalcemia caused by the release of calcium from the deteriorating bone tissue • Elevated blood urea nitrogen level Autograft • placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days Hodgkin's disease • A chronic progressive neoplastic disorder of lymphoid tissue • characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver • Weight loss is most likely to be noted. • Fatigue and weakness may occur but are not related significantly to the disease. Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspneaFmao, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer. Cardiovascular Review PAD-Peripheral Artery Disease • Affects arteries(vessels carry blood away from heart) • Atherosclerosis • Lower extremities • Inadequate blood flow to affected tissues • Increase resistance to flow • Plaque formation cause walls to be rough and fragile • Inflow(distal aorta and iliac arteries) • Outflow(femoral, popliteal, tibial arteries) • Tissue damage below arterial obstruction • Ex: Buergers disease, subclavian steal syndrome, thoracic outlet syndrome, raynauds disease • Findings o Intermittent claudication-burning, cramping, pain in the legs o Bruit over femoral and aortic arteries o Decreased cap refill of toes greater than 3 sec o Cold and cyanotic extremities o Rubor-redness of extremity o Muscle atrophy o Ulcers and possible gangrene of toes(tissue death) • Diagnostic procedures o Arteriography- inset contrast to visualize decreased art flow on xray  Observe bleeding  Palpate pedal pulses to identify occlusions o Segmental systolic BP measurements  Doppler probe used  Absence- p in lower extremities higher than upper  Presence- pressure in thigh, calf, and ankle lower o ABI-Ankle Brachial index  Compared to brachial p  0.9-1.3  Less than that indicate PAD • Management o Exercise for collateral circulation o Promote vasodilation and avoid vasoconstriction o Never apply direct heat-burn risk o Avoid exposure to cold-cause vasoconstriction o Avoid stress, caffeine, nicotine o Vasoconstriction from smoking can lasts up to one hour o Don’t cross legs o Use lubricating lotion prevent cracking skin o No restrictive garments o Elevate legs to reduce swelling o Don’t elevate above heart level-slows arterial bf to feet • Medications o Antiplatelet  Aspirin, clopidogrel(Plavix), pentoxifylline  Reduce blood viscosity  Decrease blood fibrinogen levels  Increase bf to extremities  Monitor for bleeding, abdominal pain, coffee ground emesis black tarry stools o Statins  Simvastatin, atorvastatin  Relieve manifestations associated with intermittent claudication  Mild injury causing muscle weakness or aces- may cause myositis  Monitor CK levels- incr when muscle injury • Therapeutic procedures o Percutaneous transluminal angioplasty and laser assisted angioplasty o Insert stent to keep vessel open or vaporize atherosclerotic plaque and open artery o Always observe bleeding at site o Bed rest with limb straight for 2-6 hr before ambulation o Antiplatelet therapy for 1-3 mnths • Arterial revascularization surgery o Severe claudication pts o Bypass grafts used o Limit bending at hip and knee-decrease risk of clot formation • Peripheral venous disease • Affects veins(carry blood to heart) Cardiovascular and Hematology ATI REVIEW Hemosiderosis • Excess storage of iron • Overuse of substances • Many blood transfusions-sickle cell anemia CHF • Heart doesn’t pump effectively • Problems with tissue perfusion • Aortic pressure lower when valve defect • Mitral stenosis- defect in mitral valve • Right Heart Failure o Decreased systemic venous return o Increased abdominal growth o JVD o Dependent edema • Symptoms o Early sign- weight gain, HTN o Late sign- pitting edema (mild 1-severe 3) o SOB o edema • Medications o Diuretics o Cardiac agents to improve heart contractions • Left Heart Failure o Weak peripheral pulse o Percutaneous transluminal coronary angioplasty • Open blocked coronary arteries • Catheter with inflatable balloon tip inserted into the obstructed coronary artery • Balloon inflated CABG • Bypass a blocked coronary artery • Mediastinal drainage up to 150 normal • Increased BP report to provider- inc vascular pressure can cause bleeding at incision site • Don’t take aspirin 5-7 days before surgery • Can take HBP med • Don’t take anticoagulants warfarin 5-7 days before • Can take reduced insulin Aneurysm • A surgical excision treat that cause ventricular dysfunction • Herbal supplements • Flaxseed oil o Has omega 3 fatty acids o Lower risk of heart disease and stroke • Antioxidants o Occur naturally in fruits and veggies, nuts, grains, poultry and fish o Beta carotene, vitamin ace, selenium o Studies say may prevent cancer Carbamazepine • Interact with OCP Heart failure meds Hydralazine • Direct acting vasodilator • AE- SLE o Fluid retention o Edema o Hypertensive crisis-abrupt stopping o Headache o Tremors o • Loop Diuretucs • Ethacrynic acid o Treat pulmonary edema o Can cause hearing loss o Ototoxicity-hearing loss-similar to furosemide o Hypokalemia o Dehydration o Hyponatremia • Furosemide o Increase sodium loss o Reabsorb lithium-toxicity o Take in morning-diuretic o Eat potassium food- may cause hypokalemia o Dizzy o Not seizures o Urinary freq o • Cardiac glycoside o Digoxin o Blurred vision AE Calcium channel blockers • Nifedipine-Procardia o Increase HR o Give propranolol if AE o Lower BP and prevent angina o Suppress uterine contraction by blocking calcium channels o Treat bradycardia o CI  Cardiogenic shock  Unstable angina-reflex tachycardia  Breast feed or preg  o AE  Dizzy  Lighthead  Headache  Flushing  Hypokalemia  Pedal edema • Verapamil o Treat a fib-may cause palpitations o Treat high bp o AE  Bradycardia  Dizziness  Hypotension- change position slow o Avoid grapefruit- cause hypotension o Take with food o V tach • Repetitive firing • Can cause cardiac arrest • No p waves • Wide QRS • Without pulse o Treatment  Defibrillate  CPR V fib • Chronic rapid rhythm • NO CO • Vents quiver • Fatal if not terminated in 3-5 min • No true QRS • Treatment o CPR o Defib o Mono  360J o Biphasic  120-200J PVC • Isolated ectopic beats superimposed on underlying rhythm • Hypokalemia can cause • Give oxygen and amiodarone(MI) • Call HCP for chest pain • Monitor BP and O2 status Potassium sparing • Eplerenone o Avoid salt subs- hyperkalemia o Cause dizzy Simvastatin • Cause cough and rhinitis • Muscle pain AE • Insomnia • Interact with warfarin and erythromycin Aliskiren • Treat HTN • Cause cough • Hyperkalemia • Throat swelling • Diarrhea • Headaches Amiodarone • Potassium channel blocker • Treat A fib • Avoid grapefruit Reserpine • AE o Depression o Suicide risk Procainamide • Sodium channel blocker • SE o Cardiotoxicity o Arterial embolism ARBS • Losartan o Cause angioedema o Insomnia o Treat peripheral edema o Diarrhea o Propranolol • CI in asthma • Don’t take with antacids or Vit C • Can cause vasoconstriction Hydroxyzine • Give in deep muscle • Anticholinergic properties o Constipation o Urinary retention o Dry mouth • AE o Drowsy o Dry mouth o Hypersensitivity • Antihistamine and antianxiety • Relieve nausea vomiting and anxiety, itching • Don’t give IV • Asthma • Albuterol o Treat acute exacerbations o Need fine motor control to use MDI properly Lithium • Therapeutic level 0.8-1.4 • Maintenance levels 0.4-1.3 • Mood stabilizing drug for bipolar disorder • Give with water • Give after meals • AE o Seizures o Arrhythmias o Hypotension o Renal toxic o Leukocytosis • CI o Pregnant o Breastfeed • Considerations o Monitor lithium levels o EC o Urine specific gravity o Increase sodium intake o Lithium toxic  Diarrhea/V/tremors/muscle weakness Cyclosporine-Sandimmune • Immunosuppressive agent-kidney transplant • Take for rest of life • Not used to manage renal function Theophylline • Relieve chronic bronchitis • Xanthine derivative bronchodilator • Toxicity o Early-CNS stimulation o Tremors o Insomnia o Confusion o Irritable o Diarrhea o Hypotension o Albuminuria o Tachycardia o anorexia Dexamethasone • Give with food • Large muscle for IM injection • Never stop abruptly-taper • Never give steroids on empty stomach-ulcer formation • Alternate day dose to prevent SE • Anti-inflamm and glucocorticoid • Can give undiluted over 1 min • Prone to blood dyscrasia-bleed and bruise easily • Inhibit protein synthesis-delayed wound heal • Prone to infection-immunosuppresant • Hyperglycemia • AE o Peptic ulcer o Osteoporosis o Myopathy o Cataracts o PUD o Cushings syndrome o Adrenal insufficiency o Insomnia o Hypokalemia-it pushes potassium into cell • CI o Breastfeed • Indications o Cerebral edema o Shock o Monitor BP and serum electrolytes Clonidine-Catapres • BP med • Don’t stop abrupt-hypertensive crisis • Report rash to HCP • Take in divided doses throughout day • Can cause constipation • Orthostatic hypotension • Minimize diaphoresis during alcohol withdrawal Disulfram • Help maintain abstinence from alcohol Cholesterol meds Simvastatin-Zocor • HMG coA reductase inhibitor • Cause cough and rhinitis not bronchoconstriction • Myopathy- muscle pain –rhabdomyolysis- kidney damage from protein breakdown • Insomnia Amphotericin B Trimethoprim/sulfamethoxazole • AE o Not dry coug o Photosensitive o Vesicular crust rah- sign of SJS-report Neurology Review • Low motor neuron lesion o Cell bodies in spinal cord o Damage to neuron decrease motor activity of affected muscles o Legs will have flaccidity • Upper motor neurons damage o Spasticity o Hyperactive reflexes • Left posterior temporal lobe functions o Integrates visual and auditory input for language comprehension • Anterior front lobe o Reason o Problem solving • SNS inhibition-B blockers o Decreased heart rate-bradycardia • Peripheral nervous system inhibition o dry mouth o constipation o urinary retention • Cranial Nerves o 1-olfactory smell o 2-optic o 3-oculomotor-levator palpebrae muscle o 4-trochlear- superior oblique muscle o 5- trigeminal-corneal reflex-shine light into pt pupil o 6-abducens- lateral rectus of eye o 7-facial-corneal reflex- control taste and eye blink o 8-vestibulocochlear- hearing and balance o 9-glossopharyngeal-innervate pharynx and control gag reflex o 10-vagus nerve--innervate pharynx and control gag reflex, heart lungs and digestive system o 11-accessory- turning head and hand functions o 12-hypoglossal- tongue movement • Head Injury o Cushing Triad  3 primary signs indicate increased ICP  Widened PP  Bradycardia  A change in respirations- irregular and deep- cheyne stokes  hypertension o Xray of skull and spine o CT scan o Neuro checks q 15 min o No lumbar puncture- can cause herniation of brain • Cushing Disease o Increased cortisol o From long term use of glucocorticoids to treat asthma or rheumatoid arthritis o Symptoms  Moon face  Hyperglycemia  Hypernatremia  Wt gain  Hypokalemia  Hypocalcemia  HTN  CNS irritability  Edema- sodium and fluid retention  Osteoporosis  Thin skin  Hirsutism- inc hair growth  Purple striae  Bruises and petechiae  Thin extremities  gyneocomastia  Nursing considerations  24 hr urine collection  Plasma ACTH high  K and Ca levels decreased  Lymphocytes dec • Addisons disease o Need diet high in salt and carbs and protein and low in potassium o Low cortisol and aldosterone o Wt loss o Craving salt o Fatigue and weak o Constipation or diarrhea o Dizzy o Anorexia N/V o Hyperpigmentation o Cardiac insufficiency o Hypotension o Diarrhea o Ab pain o Muscle weak o Hyperkalemia o Hypoglycemia o Hypercalcemia o Serum electrolytes  High k  Decreased Na  Increased Ca o BUN/Creat  Increased o Serum glucose  Norm to decreased o Complication  Polystyrene sulfonate • Resin absorb potassium • Give dextrose and insulin- pull k back into cell  Acidotic • Give sodium bicarb and move k into cells • Don’t abrupt stop meds • • Lumbar puncture o Side laying position-lateral recumbent o No sedative needed o Procedure done in pt room o No risk for aspiration o Postprocedure complication  Difficult voiding  Elevated T  Headache- CSF leakage at puncture site  • Frontal lobe o Brocas area- speech o Intellectual activity- judgement o Weakness on one side • Parietal lobe o speech • Occipital lobe • Temporal lobe o Wernicke’s area- receptive speech o Difficulty hearing • Romberg Test o Positive- Difficulty maintain balance with eyes close • Evoked potential studies o Diagnose probs with visual or auditory systems • Cerebral angiography o Diagnose vascular problems o Catheter inserted into femoral artery o Assess for bleeding after procedure- high priority o Check pulse and BP frequently • CSF analysis o Specific gravity o Glucose o WBC o Protein o Clear nasal drainage- dural tear, will test positive for glucose • Myelogram o Iodine contrast injected in subarachnoid space o Assess for shellfish allergy o Clear liquids safe up to 4 hrs before procedure • Brainstem infarction o Vital centers o Respiration and rhythm Intracranial Problems • Ventriculostomy o Helps show whether BF to brain is adequate o Monitor ICP o Catheter measures pressure in vent o Transducer is external • Cushings Triad o systolic HTN o widened PP o bradycardia o respiratory changes o findings mean increased ICP o brain herniation imminent • Oxygen in brain tissue o Norm 20-40 o Low levels ischemia o CSF norm- 20-30 • Decorticate posture o Internal rotation o Adduction o Flexion of arms • Decerebrate o Extension of arms and legs • Mannitol o Osmotic diuretic o Reduce cerebral edema o Reduce ICP o Initially may reduce hct and inc BP o AE  vomiting  Increase thirst  Muscle cramps  Peripheral edema • Glasgow Coma Scale o Eye opening o Verbal response o Motor response • Increased ICP o No coughing or deep breathing- increase intrathoracic p and ICP o Elevate HOB to 30 degrees o Don’t position with hips and knees flexed- increase abdominal pressure o Early signs  LOC decreased  Restlessness  Irritability  Disorientation  Lethargy o Late signs  Pupil dilation  Ataxia-loss of balance  Bradycardia • Cerebral Perfusion Pressure CPP o CPP=MAP-ICP o MAP=SBP-2DBP/3 o Normal ICP =5-15 o Normal MAP=70-150 o Normal CPP=60-100 • Epidural hematoma o Treatment- remove hematoma o Prevent herniation o Craniotomy o If ICP after surgery use Lasix or high dose barbituate therapy • Meningitis o Immunize adolescents and college freshman against Neusseria meningitides o Meningoccoceal  Spread y resp secretions- wear mask  Resp isolation  Low light to decrease pain  Nutrition impt  Has increased fluid needs o Bacterial  Shock serious complication  Low BP indicate need for vasopressors and fluids  Nuchal rigidity  Kernigs sign  Obtain cultures first o Basilar skull fracture  Battle ssign  Periorbital exxhymoses H2 receptor antagonist • Decrease stomach acid secretion Sucralfate • Mucosal protectant • Gel like coat ulcer • Create barrier to HCl Epoetin alfa • Increase RBC/HCt • If hct rise to fast cause increased BP • Can cause seizures from inc BP • Critical Care SVR • Resistance to vent ejection-afterload • Monitor to determine effectiveness of meds given to reduce left vent afterload • Vasoconstrictors increase SVR-increase work of heart and decrease peripheral perfusion PVR • Contribute to pulm HTN • Decrease indicate improvement CVP • BP in vena cavae • Amt of blood returning to heart • Low- hypovolemia • 8-12 normal • Increase infusion rate • Don’t elevate head of bed- decrease cerebral perfusion PAWP • Left vent preload • Sensitive indicator of cardiac function • Increase- left vent failure, volume excess- don’t give fluids • Increase- give furosemide Low Pressure alarm • Drop in BP • Assess for cardiac dysrhythmias Pulmonary Artery Catheter • Attach cardiac monitor before the procedure • No anesthesia needed • Doesn’t need NPO • No changes in troponin or breath sounds • Measures PAWP • Wedge position- deflate and reinflate PA balloon. BF past catheter obstructed(risk for pulm infarction) Radial Art Line • MAP norm- 70-150 • Flush system change q 96 hrs • Deliver 3-6 mL/hr flush solution IABP • CO- 5L • SV- 60-80 • Monitor U/O q 1 hr-determine CO • Elevate 30 degrees • Use anticoagulants • Limit movt Oral ET insertion • End tidal CO2 monitors recommended for placement- initial-changes color • Chest x-ray confirms placement but done after tube is secured Mechanical Ventilation o Low pressure alarm- artificial airway cuff leak-interfere with oxygenation, pt stop spontaneous breathing, displaced et tube, disconnected ventilator tube o High pressure alarm- kinks or water in tubing, pt biting tube, excess secretions, wheezing, bronchospasm, presence of mucous plug o ARBs determine effectiveness o If cant determine why alarm sounding- ventilate pt manually, disconnect pt o Monitor vent settings hourly o Document tuce placement in cm at pt teeth/lips o Assess breath sounds q 1-2 hrs o HOB- 30-45 to prevent vent associated pneumonia o Decrease risk of aspiration o Complications- o (1) hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; o (2) pneumothorax or subcutaneous emphysema as a result of positive pressure; o (3) gastrointestinal alterations such as stress ulcers; o (4) malnutrition if nutrition is not maintained; o (5) infections; o (6) muscular deconditioning; and o (7) ventilator-dependence or inability to wean o Weaning o Tachypnea sign WOB too high to allow weaning o Cuff Pressure o Inject air into cuff until slight leak heard at peak inflation o Cuff pressure 20-25 maintain o Ventilator Associated Pneumonia o Sedation holiday o Elevate HOB 30 o Give PPI o Provide oral care with chlorhexidine Shock MAP <60 Septic Shock • Infection cause body BV to dilate • Increased temperature for burn patients • SVR decreased- vasodilation BP less perfusion • Increase fluids • Early stages- warm and dry skin • Late stages- cool and clammy skin • Antibiotics given in 1st hour • Usually has normal BV • Don’t use LR- failing liver cant convert lactate to bicarb • Furosemide o Lower filling pressure and renal perfusion o Keep BP high Neurogenic Shock • Spinal shock- vessels vasodilate • Poikilothermia- keep pt warm • Hypotension • Bradycardia Cardiogenic Shock • Heart not pumping enough blood to tissues • CVP increased with increased SVR • Increase SVR- increase work of heart and decrease peripheral perfusion, must decrease SVR o Nitroprusside  Arterial vasodilator  Decrease SVR and afterload  Improve CO • Warm pink, dry skin- tissue perfusion improved • Manifestations o Pulmonary congestion o Dyspnea • Assess breath sounds often • Elevate HOB to decrease SOB o MODS  Creatinine levels increase- renal and heart failure Hypovolemic Shock • Decrease 15-30% • - 2 large IV bore needles 14 or 18-20 gauge- normal saline • Hypotension • Tachycardia • LR used cautiously • Keep pts warm • Need fluid resuscitation with NS • Adequate fluid needed before giving vasopressors • Low CVP- need more fluid volume replacement Anaphylactic Shock • Airway edema • Assess oxygen status • Tachycardia • Hypotension • Angioedema • wheezing Systemic Inflammatory Response Syndrome • PPI o Given to decrease stress ulcer risk o Check for occult blood stools Emergencies • Primary survey o GCS score • Secondary Survey o VS o Assess chronic medical conditions o Attach cardiac ECG monitor • Hematology Review Renal Urinary GI Endocrine Muscoskeletal Integumentary Peds Review • Infant mortality highest of other developed nations • Major cause of death in kids older than 1 is unintentional injuries(motor vehicle fatalities) • Unintentional injuries- more occur in males • Demonstrate on stuffed animal what you will do-atraumatic care Obesity • Type 2 diabetes risk factor Culture • Group of people who share set of values, beliefs, practices, social relationships, law, politics, economics and norms of behavior Ethnocentrism • Ones values superior than the others Native Americans • Health is state of harmony with nature and the universe Asians • Good health is balance between yin and yang Cephalocaudal • Head to tail direction of growth Growth of Child • Weight triples by end of first year • Length doubles by 4 years of age • puberty occurs earlier in girls • determine skeletal age by radiographs of hands and wrists • lymphoid tissue such as lymph nodes are 2x their adult size by age 10-12 • 1-2 years head to chest circumference equal • Satisfactory radial pulses at 2 years • Apical pulse in infants and child less than 2 • Anterior fontanel close at 12-18 mnths • Posterior fontanel close at 6-8 mnths Health history • Review symptoms • Sex history • Nutrition assess • Family medical history Abdominal assessment in kids • Inspection • Auscultation • Percussion • Palpation Breath sounds • Vesicular-heard over entire surface of lungs • Broncial- heard over trachea an • Adventitious- not usually heard • Bronchovesicular- heard over manubrium and in upper intrascapular regions BMR • rate of metabolism when body at rest • slightly higher in boys than girls at all ages • highest in infancy • 9-10%-normal • 85th %and less than 95th –risk for obesity • Greater than 95th-obese Calipers • Measure body fat Stadiometers • Measure height Infant Children • Sit steadily unsupported at 8 mnths • 9 mnths- pull to standing position • 6 mnth on- piaget in secondary circular reactions • Object permanence- search for hidden object • Fear strangers at 6 mnths • Tactile stimulation- allow splash in bath • 2 mnths- smile at pleasurable stimuli • 6 mnth- 2 teeth usually • Solid foods- begin at 4-6 mnths Breastfeeding • Recommended until 1 year old • Less than 1 yeat give iron fortified formula • Don’t give cows milk younger than 1 • Don’t heat formula or breast milk in microwave • Warm in lukewarm water bath • Fluoride supplements recommended at 6 mnths if not drinking water Colic • Change position is beneficial • Gently massage abdomen • Can put in crib and allow periodic crying Failure to thrive • Avoid eye contact • Weight below 5th percentile • Nonstimulating environment • Developmental delays • Establish structured routine and follow consistently Plagiocephaly • Flat head syndrome • Place infant prone 30-60 min a day aka tummy time SIDS • Ask factual questions • Sleep on back aka supine to prevent • No loose fitted sheets • Risk factors- low apgar scores, males, recent viral illness Pacifiers • Easily grasped handle • One piece construction • Sturdy, flexible material Immunizations • RV, DTAP, HIB, IPV- 4 mnths Toddlers • 0-2 years old • Developmental task- withstand delayed gratification • Want autonomy • 6 mnths- birth weight doubled • Birth weight tripled at 1 year checkup • By 2 and a half- birth weight quadrupled • Rapid mood swings • Egocentric- cant see others point of view • Tricycle- age 4 • 2- walk up and down stairs • Temper tantrums- ignore behavior • Ritualism- maintain sameness and reliability • 18 mnths- spoon used mastered • 1 year old- drink from cup • Leading cause of death- injuries • Peanuts cause aspiration • Burn- most common is flame burn from playing with matches • Animism- attribute lifelike quantities to in

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