ATI – NCLEX Predictor Remediation (16) Study Notes.ATI - Predictor >> RASMUSSEN

>ATI – NCLEX Predictor Remediation Study Notes Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder) Performing Ear Irrigation: Sterile techn ique, warm meds, pull up & back, tilt toward affected ear Thrombolytic Therapy (Stroke): Reteplase recombinant (rTPA – clot buster) w/ in 4.5 hours of initial symptoms Trach care: Dressing ∆, inner cannula ½ hydrogen peroxide, & stoma □ knot Head injury (changes in LOC): Length of time unconscious & GCS General anesthesia (post-op): ABC’s – full body assessment, Vitals every 15 minutes, Lateral position (if unresponsive or unconscious - monitor LOC), Fluids/Electrolytes Superficial Burns: Painful, pink, red, mild edema (3-6 day healing), damage to epidermis Dialysis (reporting unexpected findings): Temp of 100 degrees, ↓ BP, bleeding, 1 L of fluid = 1Kg, clotting, H/A, Nausea, Disequilibrium syndrome (rapid ↓ BUN & Fluid volume), anemia, peritonitis, ↑ BG, ↑ cholesterol Pacemaker (complications): Infection, hematoma, pneumothorax, hemo-thorax, arrhythmias, pacer spikes before P or QRS, hiccups / muscle twitching Magnesium (Mg) Sulfate → Increase Mg+ > 1.3 Mg/dL ↑ Mg foods = (Dairy, dark leafy greens veges) ↓ Mg causes → Hyperactive deep tendon reflexes * Paresthesia’s, muscle tetany, positive chvostek’s & Trousseau’s sign, hypoactive bowels, constipation, abdominal distention, paralytic Ileus. TPN Admin: (Total parenteral nutrition) -feeding that bypasses the GI tract. Fluids are given into a vein to provide most of the nutrients the body needs. Given when person cannot/ should not receive feedings or fluids by mouth. Hypertonic (20-50% dextrose), Used in chronic pain, peritonitis, burns, Infection, etc No more than 10% hourly, ↑ in rate for body adjustment, check BG Hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism (clamp, place in Trendelenburg pos., O2) Fluid imbalance → Fluid volume excess Wound Culture specimen: Sterile field, press / rotate over wound surface inside the wound (center) in drainage Diabetes Mellitus (Nephropathy): Kidney damage d/t prolonged ↑ BG & dehydration Monitor I & O, Creatinine, BP Avoid Soda, alcohol, acetaminophen/NSAIDS / 2 – 3 L fluid from food / beverages Kidney Biopsy (Post op): Monitor VS → Client receives sedation Assess dressings & urinary output (hematuria-blood in urine) Labs: HgB & Hct values, Admin PRN pain meds, Complications hemorrhage / infection Thyroidectomy (Post Op): Needs Thyroid hormone replacement Client in high fowler’s position, Respiratory (trach supplies) present, Check for laryngeal nerve damage Pain management, Hypocalcemia / Tetany can occur Prioritization: Apply knowledge to Standards to determine priority action Systemic before Local – “Life before Limb” Acute before Chronic Actual Problems before Potential Future Listen carefully to clients & Don’t Assume Recognize & Respond - Trends vs. Transient findings Recognize indications - Emergencies vs. Expected Delegate to LPN: Monitoring Findings, Reinforcing teaching, performing trach care, suctioning, checking NG tube patency, administer tube feedings, inserting urinary catheter, administering meds (No IV) Delegate to AP: ADLs, Bathing, Grooming, Dressing, toileting, Ambulating, feeding w/out swallowing precautions, positioning, routine tasks, bed making, specimen collection, I & O, VS for stable clients, monitoring clinical manifestations after initial RN assess/eval. Paracentesis (prep) - take out fluid from belly (peritoneal fluid) Have client VOID Bariatric Surgery: (weight loss surgery) – Semi fowlers, 6 small meals/day, liquid/pureed food for first 6 weeks (not to exceed 1cup), Vitamin / mineral supplements, & 2 servings of protein daily. Ostomy (in small intestine) Avoid odorous & gas foods (dark green veges, dairy, fish, eggs, beans, corn), yogurt ↓ gas Avoid ↑ fiber foods for first 2 months, ↑ fluid intake Dumping Syndrome: Happens within 15mins of eating. Sx: cramps, diarrhea, tachycardia, dizziness, fatigue, hypoglycemia Interventions: small frequent meals, drink liquids 1hr b4/after Parkinson’s disease: Tremor, muscle rigidity, bradykinesia (slowness in movement), postural instability Stages: 1. Unilateral shaking / tremor of one limb 2. Bilateral limb involvement, difficulty walking/balance 3. Slowed physical movements 4. Akinesia & Rigidity make ADL’s difficult 5. Unable to stand/walk, dependent of cares, dementia Assault: threat Battery: touching Hypoglycemia Sx: Shakiness, confusion, sweating, tachycardia, diaphoresis, palpitations, H/A, lack of coordination, blurred vision, seizures, coma Oral Hypoglycemic Agents: promote insulin release from pancreas (Type2 DM) Glipizide (Glucotrol), Chlorpropamide (Diabines), Glyburide (Diabinese), Metformin (Glucophage). * Med for insulin overdose = Glucagon Radiation Adverse Effects: Skin changes, hair loss, debilitating fatigue, 30 minute visits / stays 6ft away / private room Infection control in clients home: good hygiene, avoid crowded areas, avoid raw foods (veges/meats), avoid cleaning litter boxes, clean home and avoid sick family. Client evacuation in response to fire: greatest good for the greatest amount of people Client in seclusion: 18 yo+ → 4 hours, 9 – 17 yo →2 hours, 8 yo & younger →1 hour Conduct Disorders: lack of remorse, bullies, threatens, low self-esteem, tempers, physical cruelty, destroys property, truant, and shoplifts Manic Phase: ↑ mood, irritable, lasts at least a week, euphoria, agitation, restless, ↑ in talking, flight of ideas, grandiose view of self, impulsive, manipulative, poor judgement, attention seeking. Paranoid: distrust / suspiciousness Schizoid: emotional detachment, disinterest in relationships, indifferent to praise/criticism, uncooperative Schizotypal: odd beliefs, eccentric appearance, magical thinking, perceptual distortions Antisocial: disregard for others, lack of empathy, unlawful, failure to accept responsibility, manipulative, impulsive, seductive Borderline: instability of affect, identity & relationships, splitting behaviors, fear of abandonment, self-injurious, impulsive Histrionic: attention seeking, seductive, flirtatious Narcissist: arrogant, constant admiration, lack of empathy Avoidant: anxious, wants close relationships, fear of rejection Dependent: dependency on another individual OCD: perfectionist, orderly, and control Clozapine (Anti-psychotic Atypical ) Adverse effects: metabolic syndrome, orthostatic hypotension, anti-cholinergic effects, agitation, dizziness, sedation, mild EPS, ↑ prolactin levels(galactorrhea, amenorrhea, gynecomastia), & sexual dysfunction Anti-lipemic Agents: (Statins) – treats high levels of fats/cholesterol in blood -called lipid-lowering drugs Monitor liver enzyme levels (hepatotoxicity) and muscles – monitor CK levels (myopathy & peripheral neuropathy) Med interactions: Fibrates (Genfibrozil) - ↑ myopathy risk, Erythroycin & Ketoconazole, Amiodarone, & Cyclosprine = Grapefruit juice can ↑ statin levels Gentamicin (effects urine output) -causes ototoxicity w/ diuretics, digoxin, lithium, ototoxic meds, NSAIDs, & anti-hypertensives Long term therapy for RA: DMARDs (methotrexate, etanercept, infliximab, adalimubrab, Azathioprine, Cyclosporine) ** Slow joint degradation Glucocorticoids (Prednisone) & NSAIDs provide symptom relief from inflammation & pain Bulb Syringe (for babies): Mouth first, then nose, depress. Then insert into mouth, avoid center of mouth- may stim. gag reflex. Priority action to an allergic response: Mild rashes/hives – Benadryl Anaphylaxis - treat with epi, bronchodilators, and anti-histamines Provide respiratory support & notify HCP Losartan (ARBs -Anti-Hypertensive (HTN) & kidney disease) - Cough & hyperkalemia are for ace inhibitors. Side Effects: Angioedema, hypotension, dizziness Tracheostomy Care: 2 xtra tubes, adequate humidification, oral care every 2 hours, trach care every 8 hours, sterile suctioning, surgical asepsis to remove / clean inner cannula, secure trach ties before removing old, square knot, clean from stoma outward Appropriate Doc.: Subjective/objective data, Accurate/concise, Complete/current, Organized/ date/ time/ blk ink Crutch safety: Support bodyweight at hand grips with elbows at 30 degrees, Position crutches on unaffected side when sitting or rising from a chair Varicella (chicken pox) Transmission: Direct contact, droplet, from person with shingles, 10-21 days, 1-2 days before lesions appear and all lesions have sabs Scoliosis: Lateral curvature of spine & spinal/truncal rotation that causes ribs asymmetry. Curve needs to be at least 10 degrees One leg shorter than the other. Asymmetry in scapula, ribs, flanks, shoulders, hips. Screening for Idiopathic Scoliosis: During pre-adolescence - Observe child from back Bend at waist with arms handing down & observe for asymmetry of ribs and flank Measure truncal rotation with a scolio-meter Use Cobb technique to determine degree of curvature Use riser scale to determine skeletal maturity ↓ Cardiac output (interventions): Maintain bedrest, Semi fowler’s/ fowler’s position while awake, Sleep w/ pillows Cardiac output positioning for optimal output: Left lateral side, Semi fowlers, Supine with wedge under one hip Infant car seat: Position infant in car seat at 45 degree angle, Safety restraints loose and low on abdomen Correct use of Condoms: On erect penis, empty space at tip for sperm reservoir (May be used with spermicidal gel to ↑ effectiveness), Protects against STI’s, only water soluble lube with latex condoms Amnio-infusion for Oligohydramnios: (not enough amniotic fluid around fetus) Infusion or NS or LR into amniotic cavity to reduce severity of variable decelerations caused by cord compression Scant amount or absence of amniotic fluid, Membranes must have ruptured to perform - Warm fluid Rhogam for Clients who are RH-Negative: (Antibodies from human plasma injected into RH+ mother to protect fetus) Chadwick’s sign – violet/blue color or cervix & vaginal mucosa Goodell’s sign – softening of cervical tip HSV (Herpes simplex virus): direct contact transmission to fetus is greatest during vaginal birth if woman has active lesions, Lesions & tender lymph nodes, Obtain cultures from women who have HSV or are at or near term Urinary frequency Interventions: ↓ fluid intake b-4 bed, Use perineal pads, and Kegel exercises ↓ stress incontinence Buddhist Dietary practices: vegetarian, nuts, legumes (dried peas/cooked beans), No eggs, no milk products Notifiable Communicable diseases: anthrax, botulism, cholera, diphtheria, gonorrhea, hep A/B/C, HIV, legionaries, lymes, malaria, mumps, pertussis, polio, syphilis, tetanus, TSS, TB, Typhoid fever, VRSA, At risk populations, transmissions routes Anterior Pituitary Hormones: Stimulate growth - Caution in DM patients – can cause hyperglycemia (Somatropin) Anti-Convulsants: Tx- seizures (caphe) Petit Mal (Valet) Carbamazepine, valproic acid, ethosuximide, Phenytoin/phenobarbital – adverse effects = yellowing of skin, nystagmus, teratogenicity, osteomalacia, H/A, vertigo, ataxia Ophthalmic Agents: Beta Blockers: ↓ aqueous humor production (betotopic, betaxon, betagan, betimol) Prostaglandin Analogs: ↑ aqueous humor outflow (xalantan, travatan) Alpha Adrenergic Agonists: ↓ aqueous humor & ↑ outflow (Alphagan) Direct Acting Cholinergic Agonist: ↓IOP & ↑ outflow of AH (Pilocarpine) Side effects for Ophthalmic Agents: Blurred vision, angle closure glaucoma, dry eyes, photophobia, ocular pressure, can cause systemic effects, ciliary muscle constriction Mixing Insulin: (Clear before Cloudy) Air into NPH (Cloudy), Air into Regular (Clear), Draw up Regular (Clear), Draw up NPH (Cloudy) * Hypoglycemia is most likely to occur during peak. Obstetric History: (GTPAL) Gravida, Term, Preterm, Abortions, Living Children Pre-Term Infant: Anticipated Problems (TRIES) Temperature regulation (poor), Resistance to infections (poor), Immature Liver, Elimination problems (Necrotizing Enterocolitis), Sensory-Perceptual Functions (Retinopathy) Fetal Heart Rate: (VEAL CHOP) Variable Decels Cord Compression Early Decels Head Compression Accelerations O2 (Baby is well-oxygenated) Late Decels Placental Utero Insufficiency Pregnant Client - Med. Surg Floor: (FETUS) Fetal heart tones (document every shift) Emotional Support Temperature (Measure maternal) Uterine Activity/Contractions (early-low back pain) Sensations of fetal movement Placenta Previa: low implantation of the placenta / Bright red bleeding present that is painless. Place mother on bedrest in side lying position / Weigh perineal pads Abuptio Placenta: Premature separation of the placenta - Dark red bleeding may or may not be present with sharp stabbing pain Start fluid replacement, oxygen by mask, monitor FHR, keep in lateral position, pregnancy must be terminated - birth or C-Section Endocrine Agents: Thyroid Hormones (Hypothyroidism) Synthetic form of thyroxine (T4), ↑ metabolic rate, body temp, oxygen use, renal perfusion, blood volume, & growth processes. (Levothyroxine, Thyroid, Liothronien, Anti-thyroid meds (hyperthyroidism), graves, thyrotoxicosis, propythiouracil (PTU) Cholecystitis: (Inflammation of Gall Bladder) ↓ fat intake, NO - coffee, broccoli, cauliflower, cabbage, onions/ legumes Compartment Syndrome: Sx: (5 Ps) Pain, Pallor, Pulse ↓ or absent, ↑ BP, Paresthesia (tingling hands, feet) Acute Renal Failure: Can cause HypoNatremia, HyperKalemia, HypoCalcemia, & HyperPhosphatemia Shock Sx: (Chord Item) Anti-Platelets: Aspirin, Plavix (clopidogrel) Cold, clammy skin, Hypotension, Oliguria, Drowsiness, ↑bleeding risk, prevent MI/stroke, taken PO Rapid/shallow breathing, Irritability, Tachycardia Watch for hemorrhagic stroke (weakness, Dizziness, H/A) Elevated or reduced CVP, Multi-Organ damage Avoid NSAIDs, Heparin, warfarin, corticosteroids Anti-Platelets: Aspirin, Plavix (clopidogrel) ↑bleeding risk, prevent MI/stroke, taken PO Herb/Botanical Therapy Watch for hemorrhagic stroke (weakness, Dizziness, H/A) Echinacea (common cold), Ginger root (↓ nausea, RA) Avoid NSAIDs, Heparin, warfarin, corticosteroids Ginko Biloba (↑ vasodialation, dementia, alzheimers) HypoCalcemia Sx: (CATS) Valarian (↑ GABA to prevent insomnia) – don’t use in MH, Convulsions, Arrhythmias, Tetany, Stridor / Spasms Or pregnancy. Black cohosh (estrogen sub)-↑ anti HTN Nephrotic Syndrome meds& hypoglycemia Serum Proteins in urine, Diet with sufficient protein Peptic Ulcer Disease Diet low in sodium Avoid frequent meals/snacks, alcohol, smoking, NSAIDs, Nephrolithiasis (kidney stones) Coffee, spicy foods, & caffeine ↑ Fluid Consumption is primary intervention Lactose Intolerance HypoKalemia Sx: (6 L’s) Distention, Cramps, Flatus, Diarrhea Lethargy, Leg Cramps, Limp Muscles HypoGlycemia Sx: (TIRED) Low Shallow Respirations Tachycardia, Irritability, Restlessness, Excessive Hunger Lethal Cardiac Dysrhythmias Depression / Diaphoresis Lots of urine (polyuria) End Stage Renal Disease: GFR <25mL/min Pre-End Stage Renal Disease Serum creatinine rises, dialysis or transplant required ↑ in serum creatinine ↑ protein, ↓phosphorus, ↓potassium, ↓sodium Limit protein & phosphorous (meat, dairy, pb, dried peas, Fluid restricted diet Beans, cola, chocolate beer) Protein needs ↑ once dialysis begins Restrict sodium to maintain BP Vitamin D deficiency occurs Arterial occlusion (4 P’s) HTN Care: (Diuretic) Pain, Pulselessness, Pallor, Paresthesia Daily weight, I&O’s, urine output, response of BP, CHF Treatment: (MADD DOG) Electrolytes, take pulse, Ischemic Episodes (TIA’s) Morphine, Aminophylline, Digoxin, Diuretics, Oxygen Complications (CVA, CAD, CHR, CRF) Gases (ABG’s) Labs: Normal Values: Normal Values: Creatinine 0.6-1.2 Males 0.5-1.1 Females RBC 4.7-6.1 Males 4.2-5.4 Females Hematocrit 42-52 Males 37-47 Females Urine Specific Gravity 1.0-1.030 APTT 40 Sec. Digoxin 0.5-2.0 Lithium 0.8-1.4 Anti-Emetics (-tron, -zine): Can cause sedation. Metoclopramide (Reglan)- monitor for EPS PPI’s (-zole): can cause Vit. B12 deficiency Erectile Dysfunction agents (-fil): Can cause H/A, flushing, back pain, muscle aches, & temporary vision changes. * Don’t take if have heart problems, BP issues, or stroke. Anti-Enemics: Liquid iron can cause teeth staining, dilute w/ water or juice. Iron – given IM (Z-track method) Oral Iron – avoid Vit. C. (antacids by 2 hours, empty stomach 1 hr before meals) * Black stools are common. Encourage intake of high iron foods. Anti-Coagulants: prevents of blood coagulation/clotting Heparin Sodium – admin = IV or SQ (Antidote=Protamine Sulfate) - Normal APTT = 60-80 seconds Enoxaparin (Lovenox) – admin = SQ, longer ½ life * Administer with MI or DVT * ↑ bleeding risk Avoid: Corticosteriods, NSAIDs, Vit. K, PO Hypoglycemics. Coumadin – admin = PO (Antidote = Vit. K) Avoid: using with low platelets, foods high in Vit. K, Tylenol, glucocorticoids, aspirin, use while pregnant Monitor: INR & patient HypoNatremia: ↓ Sodium - Sx: confusion, restlessness, lethargy, seizures, coma - Treat: fluid restriction HypoKalemia: ↓ Potassium - Sx: poor muscle strength, slow reflexes, flat T waves (cardiac dysrhythmias) - Treat: PO or IV Potassium supplement HyperNatremia: ↑ Sodium - Sx: Postural hypotension - Treat: Fluids (drink/IV) HyperKalemia: ↑Potassium - Sx: Twitching, contraction, paralysis, peaked T waves (cardiac dysrhythmias) - Treat: Kayexalate, Loop diuretic, Insulin HypoCalcemia: ↓ Calcium - Sx: twitching, muscle cramps, Trousseau/Chvostaks - Treat: dietary supplement, antacids, and vitamins HyperCalcemia: ↑ Calcium - Sx: muscle weakness, fatigue, slow GI - Treat: diuretic, 3-4L fluid daily, weight bearing, and calcitonin Antidotes: Bethanechol/Neostigmine = Atropine Atropine = Phyosostigmine Digoxin = Digibind Warfarin = Vitamin K Heparin = Protamine Sulfate Insulin Induced Hypoglycemia = Glucagon Acetaminophen = Acetylcysteine (mucomyst) Ace Inhibitors (-pril): HF, HTN, MI, and Diabetic Neuropathy Side effects: orthostatic hypotension, dry cough, hyperkalemia, NSAIDs ↓ therapeutic effects Alpha Adrenergic Blockers (-zosin): Dilate Veins/Arteries (Prazosin, Doxazosin) ARBS (-sartan): Produce vasodilation by blocking Angiotensin II. (Losartan) CCB’s (-dipine): Vasodilation by blocking calcium channels. (Nifedipine, Amlodipine, verapamil, Diltiazem) Avoid: drinking grapefruit juice – can lead to toxicity Electrolytes: Sodium: Administer Isotonic IV therapy (NS/LR) Potassium: Maintains electrical excitability of muscle conduction of nerve impulses (NEVER given IV PUSH) Calcium: Muscoskeletal, neuro / cardio function, implement seizure precautions Magnesium: Skeletal muscle contraction & blood coagulation. Monitor: BP, Pulse, Respirations Anti-Gout Meds: Gout is a type of arthritis. Buildup of Uric Acid. First line: NSAIDs / Prednisone, Colchicine (GI distress potential – take with food) Allopurinol: prevents uric acid production Drug interactions: salicylates, loop diuretics, alcohol, warfarin Food interactions: anchovies, yeast, organ meat, legumes, mushroom, spinach, asparagus, cauliflower Anti-Reabsorptives : slow bone removal or improve bone mass. (Menopausal women) Bisphosphonates (Alendronate – Fosamax). Can cause severe esophagitis. Take on empty stomach w/8oz of water & sit upright for 30 minutes. Anti-Neoplastics: Cancer meds Side effects: soreness, difficulty swallowing, diarrhea, stomach pain, low platelets, anemia, sensitive skin, excess tear formation Mental Status Exam: LOC, physical appearance, behavior, & cognitive/intellectual abilities Anxious / depressed: open ended supportive statements Suicidal: direct yes/no questions to assess risk Panicked: use gentle reality orientation Confused: Provide reality orientation Delusions/Hallucinations/Paranoia: Acknowledge, don’t reinforce Obsessive Compulsive Behavior: Communicate after behavior Personality/Cognitive Disorder: Be calm and matter of fact Aggressive/Violent: set boundaries, limits, short simple sentences Psychiatric Meds: SSRI’s: Citalopram, Fluoxetine, Sertraline (avoid St John’s Wort) TCA’s: Amitriptyline (anticholinergic effects “cant’s” – orthostatic Hypotension MAOI’s: Phenelzine, Hypertensive Crisis Atypical: bupropion (appetite suppression, H/A, Dry mouth) SNRI’s: Venlafaxine / Duloxetine (nausea, weight gain, sexual dysfunction) RN delegate surgical asepsis responsibilities to UAP's? Only under RN supervision When should traditional hand washing be used instead of using alcohol-based sanitizer? Hands are visibly soiled, touching bodily fluids, Before/after applying sterile gloves, After using sanitizer 10+ times Contradictions of good hand hygiene Nail polish, Long nails, using lotions, Wearing jewelry Potential routes of entry into the body for blood borne pathogens? Mucous membranes, Puncture wounds, Burns on hands, Blood Personal Protective Equipment (PPE) is the single most effective way to prevent the transmission of infection Two potential sites for nosocomial infections: hospital & Homecare Causes of nosocomial infections: suppressed immune system, Failure to follow isolation precautions or aseptic technique, Hospital error A physician is preparing to perform a lumbar puncture. The suspected diagnosis is bacterial meningitis. What type of precaution is needed?Standard precautions A 70 y. male develops new diarrhea and a high WBC while in the hospital recovering from MV Replacement surgery which was complicated by a CVA. He is bed bound and incontinent of stool. What do you suspect is the cause for his diarrhea? A bacterial, nosocomial infection Medical abbreviation: CBR, BR complete bedrest, bedrest Frequent bathing for the older client is necessary to prevent skin breakdown. False A bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation. sitz 3 guidelines for providing patient-centered care when addressing a client's hygiene needs Be respectful to cultural values, Ask the pt in what order they would like to complete their hygiene routine. Provide hygienic care as often as necessary (but not too often) and as gently as necessary. What should be included in documentation of a bath? Date and time, Type of bath, Abnormal findings/pt reaction When might the RN need to collaborate a colleague for personal care? If a patient is not ambulatory and is too heavy to be moved alone What are the components of the Braden scale? Sensory perception, moisture, activity, mobility, nutrition, friction & shear - High score indicates low risk. Trochanter roll -Keeps hips in a neutral position Hemiparesis Weakness on one sign of the body Hemiplegia - Paralysis on one side of the body Prone position - Lying on the abdomen Sim's position - Lying on left side w/ left leg straight and right knee bent Foot drop - Gait w/ drop of the forefoot Fracture pan - A bedpan used for someone w/ a hip fracture Fecal impaction - Dry, hard stool stuck in the rectum Hand roll - Hand placed in the palm to prevent fractures WNL - Within normal limits BRP - bathroom privileges BUS - Bladder ultrasonic scanner Factors to consider when delegating to UAP - Scope of practice, Facility, state regulations, Level of experience, Pt safety Hazards of immobility on CV system & interventions DVT: elastic stockings, SCD's, Orthostatic BP: give pt time between position changes Hazards of immobility on pulmonary system & interventions PE: TED host, Inadequate expansion of the chest: place pt in orthopneic position Pneumonia: clean/sterile technique, pneumovax Intervention for each: early and frequent ambulation Hazards of immobility on renal system & interventions-UTI, problems with continence, altered BP: monitor I/O's, assist w/ voiding as needed Hazards of immobility on integumentary system & interventions Skin breakdown: repositioning, monitor nutrition status, reduce moisture, and provide hygiene care Hazards of immobility on musculoskeletal system & interventions Stiff joints: ROMs/ambulation Muscle atrophy: ROMs/ambulation Ca2+ imbalance: nutrition measures Risk factors for skin breakdown Poor nutrition, bedrest, obesity, using an SPM machine, increased friction and shear 4 areas prone to skin breakdown-Tailbone, Heels, Elbows, Hips Intervention most effective in preventing flaccidity in a hospitalized patient? Early ambulation after surgery After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? Lower extremity circulatory status Components of Morse Fall Scale- History of falls, secondary diagnosis, ambulatory aid, IV/hep lock, gait/transferring, mental status Scores: 45+ = high risk 25-44 = moderate risk 0-24 = low risk TB Injection - Max amt: 0.1 cc, site: forearm, Angle: 15-20 degrees, Length: 1/4 - 1/2 in, Aspiration? No SQ injections - Max amt: 2 cc, Usual site: Upper arm, stomach, Angle: 45 degrees, Length: 1/2 - 1 in, Aspiration? Yes IM injections - Max amt: 5 cc Usual site: deltoid (1 cc), gluteus med/max or vastus lateralis (5 cc), Angle: 90 degrees, Length: 1 - 1.5 in, Aspiration? Yes What factors affect a BG result? Having fasted or eaten, time of day, level of activity, stress, illness, menstruation client most at risk for hypoglycemia? In the morning before breakfast Considerations for pt's on blood thinners such as warfarin, asprin, heparin, coumadin, etc? Monitor platelet levels (labs) Watch for bleeding/reduce risks of bleeding Monitor vitals (esp. BP) Assess skin Monitor mobility status benzodiazepines to older adults? No, benzo's increase the risk of accidents and mental deficits FUO - fever of unknown origin qhs - at bedtime ac - before meals Contraindications for opening capsules and mixing with food? EC: enteric coated & ER: extended release Rapid acting insulin Generic & brand names: Inslin aspart (NovoLog), insulin glulisine (Apidra), insulin lispro (Humalog) Onset: 15 min Peak: 30 - 90 min Duration: 3-5 hr Short acting insulin - Insulin regular (Humulin R, Novolin R) Onset: 30 - 60 min Peak: 2 - 4 hr Duration: 5 - 8 hr Intermediate-acting insulin- Insulin NPH (Humulin/Novolin N) Onset: 1 - 3 hr Peak: 8 hr Duration: 12 - 16 hr Long-acting insulin- insulin glargine (lantus), insulin detemir (levemir) Onset: 1 hr Peak: no clear peak Duration: 20 - 26 hr Signs of infiltration -Edema, pallor, decreased skin temperature around the site, and pain Signs of phlebitis - Pain, increased skin temperature, and redness along the vein Signs of extravasation (infiltration w/ dislodged IV catheter) - Pain, stinging or burning at the site, swelling, and redness Nursing interventions for infiltration, phlebitis, and extravasation Infiltration: D/C IV, elevate extremity, apply warm compress Phlebitis: D/C IV, apply warm/moist compress Extravasation: D/C IV, apply cool compress, administer antidote if needed, document degree of extravasation INT -intermittent (catheter) The 6 rights of medication administration 1. Right drug 2. Right dose 3. Right route 4. Right pt 5. Right time 6. Right documentation 3 nursing interventions r/t routine care of peripheral IV 1. Check insertion site frequently 2. Change tubing every 96 hr 3. Use good hand hygiene + standard precautions Factors to consider when choosing the best IV location Age, condition of veins, circulation status, length of IV therapy What is the smallest gauge IV catheter used to infuse blood? 20-22: RBS' might get crushed when using a smaller cath. 4 techniques to improve the chances of good IV access 1. Trim hair around the area 2. Gently stroke the area from the distal to proximal end 3. Place a warm blanket over the extremity 4. Palpate gently At what range of rate should you administer maintenance fluids? 75-150 Does the secondary/piggyback IV bag hang above or below the primary bag? Below What gauge catheters should you use for IV access? (smaller the gauge, larger the hole) 24: children 22: older adults (esp women) 20: healthy adult 16-18: trauma pt's What is included in an IV start kit? Tourniquet, alcohol wipes, gauze, tape Will also need: IV catheter, saline flushes, extension tubing Cardiac tamponade - Fluid in the pericardial sac Tunneled catheter - A catheter surgically inserted into a trench Delegation: central lines - Care/dressing changes cannot be delegated to UAP. UAP may observe central lines and report concerns. What are PICC lines (ARM) used for? Used for long-term IV access What are mult i lumen central catheters used for? Monitoring central venous pressure, sampling blood, and simultaneous administration of multiple IV solutions/drugs Hickman catheter - Used for chemotherapy or blood withdrawal Nursing interventions associated w/ routine care of a central IV 1. Clamp the central line when not in use 2. Maintain patency by flushing 3. Avoid excessive force w/ small syringes 4. Never use a syringe smaller than 10 mL List potential central IV complications and nursing interventions associated w/ each 1. Infection: hand hygiene, scrub the hub, and use aseptic technique 2. Pneumothorax: monitor vitals, admin O2 if needed, notify the provider of warning signs 3. Air embolism: check the line frequently, keep catheters clamped, don't inject air; if embolism occurs: clamp catheter, admin O2, and place pt of left side in Trendelenburg (supine w/ feet elevated) Which activity is important to include in the plan of care for a client with a PICC? Use sterile technique when changing the PICC dressing. UA - urinary analysis for culture & sensitivity What are two ways the nurse may obtain a C&S? Sterile collection from Foley - Sterile collection from straight cath Midstream urine collection Clean the peritoneal area Collect a midstream sample after urinating for several seconds What color does a fecal sample containing occult blood turn? Blue A UA that is positive for hemoglobin, WBCs, and nitrites indicates: UTI 3 strategies for preventing UTI in the client after insertion of an indwelling catheter. Provide peritoneal care every 6 hours Change out the catheter every 8 hours Drain the collection bag PRN (when full and before ambulation) Remove the Foley post-op day 2 Maintain adequate fluid intake A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. LIWS - Low intermittent wall suction Contraindications for an NG/OG tube - Obstruction, tube already inserted, recent facial surgery, bleeding contraindications Your pt has a PEG tube that was inserted 2 days ago. As you are preparing your pt's morning medications, you are unable to flush the tube with sterile water. Give 2 examples of nursing interventions to manage this problem. Check to see if the tubing is clamped. Check the tubing for clogs. Push in air. Try to unclog w/ warm water. Get order for enzyme. Your pt is receiving TPN. What are some potential complications related to administration of TPN? Give examples of nursing interventions necessary to prevent complications related to administration of TPN. Skin breakdown/irritation: assess frequently, provide adequate hygiene care Air embolism: be careful about administering solutions in the wrong line You are an RN who is inserting an NG tube for decompression. Your pt begins to gag. Give 3 examples of nursing interventions to manage your pt's response. Stop pushing and slow down insertion. Tilt pt's chin toward chest. Check the mouth for substances to prevent aspiration. Continue advancing the tube btwn breaths. laboratory values to monitor for patients requiring continuous enteral feeding? Electrolyte levels, glucose levels patient discharged home with a PEG tube. dietary education/nutritional planning is important once the pt goes home. Ability to clean the dressing and insert feedings properly, knowledge of what to do if complications arise Hydrocolloid dressing - Opaque, biodegradable, non-breathable, adherent dressing Penrose drain - A surgical fluid drain Calcium alginate - Gel used to entrap enzymes during wound healing Hydrogel dressing - Gel used to regulate fluid exchange and relieve pain during wound healing Bio-occlusive dressing - Transparent, air-tight, and impermeable to fluid Eschar - Slough produced by a burn, corrosion, or gangrene Serosanguinous fluid - Blood + serum - Yellow in color w/ some appearance of blood Debridement - Removing dead or contaminated tissue Purulent - pus-containing Undermining - Surgically separating the skin from the underlying stoma to be used to cover a wound Maceration - Softening of tissue after lengthy fluid exposure Granulation tissue - Red, moist tissue made up of new blood vessels Indicates healing Lavage - Washing out a body cavity w/ water or a medicated solution Primary intention - The process of healing in a surgically-closed, approximated wound Assessing surgical wounds Depth/width/height, Ulcer stage, Presence of undermining/tunneling, any change in wound appearance, Amt, characteristics of exudate, Color (note change) Secondary intention - The process by which chronic wounds heal- the wound's edges do not come together. The would heals by the formation of granulation tissue, wound contraction, and epithelialization. Describe variables included in assessing chronic wounds Shape, Size, Condition of wound bed, Color, Granulation status How does proper wound care promote wound healing? 1. Removes bacteria 2. Promotes or supplies fluids that promote healing 3. Provides conditions needed for epithelialization 4. Insulation protects the wound from further trauma 5. Filling dead space prevents exudate Factors that inhibit wound healing. 1. Low iron 2. Poor perfusion or lack of oxygen 3. Suppressed immune system 4. Certain medications (especially cancer treatments, steroids, and DM meds) The 75-year-old pt has undergone an open cholecystectomy 2 days ago and has a JP drain. Which interventions should the nurse delegate to the(UAP)? Select all that apply. 3. Take and record the client's vital signs. 4. Empty the client's indwelling catheter bag at the end of the shift. 5. Assist the client to ambulate in the hallway three to four times a day. Medical abbreviation: TCDB - turn, cough, & deep breath Can suction be performed by the UAP? No What respiratory care tasks can be delegated to the UAP? Turning a client and having them deep breathe or having client use incentive spirometer *Teaching and assessments for these tasks are responsibilities of the nurse. Young adult who sustained a severe traumatic brain injury, unconscious on a ventilator for several weeks and requires frequent tracheal suctioning of thick tenacious secretions to prevent aspiration. A cuffed tracheostomy tube - to prevent aspirations 3 hazards associated with suctioning and describe how the nurse can minimize the risks. Hypoxia - do not over-suction Injury to the airway - use proper technique Nosocomial infections - only aspirate with the sterile part of the tube Describe situations when the cuff of a tracheostomy tube would be deflated. When the client needs to speak, When the client has become more stable and no longer needs the cuff for ventilation Describe the purpose of a fenestrated tracheostomy tube and the purpose of the Passy Muir valve. Allows patient to breath normally, cough, speak, and swallow. The valve improves communication. Precautions necessary for O2 admin – Keep away from shades/curtains. No open flames, don't use razors or radios. Notify visitors. Handle tanks with caution. Check equipment before initiating use. No use of petroleum. Place "Oxygen in Use" sign by client. Your client has a history of pulmonary emphysema and CO2 retention, would an oxygen order for 4L/min be appropriate? No, the risk of rebreathing carbon dioxide is increased. Steps to teaching a pt how to use an incentive spirometer. 1. Exhale normally 2. Put the mouthpiece in your mouth and close your lips tightly around it. 3. Inhale slowly and deeply. Try to make the indicator rise up to the level of the goal marker. 4. When you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 3 seconds. 5. Exhale normally. 6. Repeat these steps 10 to 12 times every hour when you are awake, or as often as directed. Clean the mouthpiece after use. Administering meds into the eyes Use medical aseptic technique. »»Have the client sit upright or lie supine with the head tilted slightly, looking up. »»Rest the dominant hand on the client's forehead, hold the dropper above the conjunctival sac about 1 to 2 cm, drop the medication into the center of the sac, and have the client close the eye gently. »»Apply gentle pressure with the finger and a clean tissue on the nasolacrimal duct for 30 to 60 seconds to prevent systemic absorption. Administering meds into the ears »»Use medical aseptic technique. »»Have the client sit upright or maintain a side-lying position. »»Straighten the ear canal by pulling the auricle upward and outward for adults or down and back for children. Hold the dropper 1 cm above the ear canal, instill medication, and then gently apply pressure with finger to tragus of ear unless contraindicated due to pain. »»Do not press a cotton ball deep into the ear canal. If needed, gently place it into the outermost part of the ear canal. »»Have the client remain in the side-lying position if possible for 2-3 min. Administering meds into the nose - Use medical aseptic technique. »»Have the client supine with the head positioned to allow the medication to enter the appropriate nasal passage. »»Use the dominant hand to instill drops, supporting the head with the non-dominant hand. »»Instruct the client to breathe through the mouth, stay in a supine position, and not to blow the nose for 5 min after drop insertion. How much fluid can the deltoid accommodate for IM injections? up to 1 mL Disadvantages of oral meds Oral medications have a highly variable absorption. Inactivation can occur by the GI tract or first-pass effect. The client must be cooperative and conscious. Contraindications include nausea and vomiting. IM injection disadvantages IM injections are associated with a higher cost. IM injections are inconvenient. There can be pain with the risk for local tissue and nerve damage. There is a risk for infection at the injection site. IV therapy disadvantages Even higher cost than IM's Inconvenient Immediate absorption, which can be dangerous if the wrong dosage or the wrong medication is given. There is an increased risk for infection or embolism with IV injections. Potential irritation to the vein. Precautions when initiating IVs on older clients, clients taking anticoagulants, or clients with fragile veins Avoid tourniquets. Use a blood pressure (BP) cuff instead. Do not slap the extremity to visualize veins. Avoid rigorous friction while cleaning the site. How to select veins for IV Choose: Distal veins first on the non-dominant hand. A site that is not painful or bruised and will not interfere with activity. A vein that is resilient with a soft, bouncy sensation when palpated. What should be documented after initiating IV therapy? Date & time, insertion site & appearance, catheter size, type of dressing, IV fluid & rate, number/locations/condition of failed attempts, client's response Factors affecting med dosage and response: Weight, Age, Gender, Genetics, Biorhythmic cycles, Tolerance, Accumulation, Psychological factors, Medical conditions (GI issues, vascular insufficiency, liver disease, renal disease) What is a Salem sump tube used for? Decompression or lavage What pH should gastric residuals be? Between 0 and 4 What should you use to flush the NG tube before administering formula? At least 30 mL of tap water What should you do when providing enteral feeding and residuals exceed 250 mL for two consecutive assessments? Withhold the feeding. Notify the provider. Maintain semi-Fowler's position. Recheck residual in 1 hr. What should you do when providing enteral feeding and your pt has diarrhea 3+ times w/in 24 hr? D/C the feeding. Notify the provider. Confer with the dietitian. Provide skin care and protection. What should you do when providing enteral feeding and your pt has N/V? Withhold the feeding. Turn the client to the side. Notify the provider. Check the tube's patency. Aspirate for residual. Auscultate for bowel sounds. Obtain a chest x-ray. Nursing interventions for O2 via nasal cannula Assess the patency of the nares. Ensure that the prongs fit in the nares properly. Use water-soluble gel to prevent dry nares. Provide humidification for flow rates of 4 L/min and above Expected Physiological Changes During Pregnancy: Positioning for Optimal Cardiac Output & contraception 1. Nurse should assess which methods will best fit a client’s lifestyle 2. Natural Family Planning a. Abstinence: Client education focuses on refraining from sex (duh) and can focus on “affectionate touching, communication, holding hands,” etc i. Benefits include it being the most effective birth control method that also cuts down on STD infection b. Coitus Interruptus (withdrawal): Withdrawal of penis from vagina prior to ejaculation i. Benefits: possible choice for monogamous couples who don’t have other methods of birth control ii. Disadvantages: Least effective method of contraception, no STD protection, high risk of pregnancy c. Calendar Method: uses calendar to figure out when fertile time is and avoiding sex during this time, keeping in mind that sperm are viable 48-120 hours i. Advantages: Most useful when combined with basal body temperature and cheap ii. Disadvantages: Not reliable, no STD protection, requires accurate record keeping and risk of pregnancy d. Basal Body Temperature: Temp drops slightly before time of ovulation and can be used as natural contraception. Client measures temp in morning prior to getting out of bed. i. Advantages: Cheap, convenient, and no adverse effects (except a baby) ii. Disadvantages: Temp can be influenced by other variables like stress, fatigue, alcohol, illness, etc and no STD protection e. Symptom-Based Method (Cervical Mucus): Client notes that cervical mucus gets thin and flexible under influence of estrogen and progesterone to allow for sperm viability and motility (spinnbarkeit sign = mucus stretches between fingers is greatest during ovulation) i. Pros: Helps woman become knowledgeable about her own fertile periods and the status of mucus ii. Cons: No STD protection and risk of pregnancy 3. Barrier Methods: a. Male Condom: i. Pros: STD protections, no adverse effects and readily accessible ii. Cons: High rate of noncompliance, reduce spontaneity, possible rupture, etc b. Female Condom: Insert closed end of pouch is inserted into vagina by client prior to sex and anchored around cervix, i. Pros: protects against babies and STDs c. Diaphragm and Spermicide: Fits snugly over cervix with spermicide cream or gel, comes in different sizes (fitted by provider every 2 years or after change in client weight by 20%). Leave in 6-24 hours after sex an wash with mild soap/water after each use. i. Pros: More client control ii. Cons: requires prescription and visit to HCP, no STD protection, must be inserted correctly or hello baby iii. Contraindications: Hx of TSS, frequent UTIs d. Cervical Cap and Spermicide: Fits over cervix and comes in 3 sizes, insert prior to sex and leave in 6-24 hours after sex, wash after each use i. Cons: Risk of TSS, allergic rxn, no STD protection e. Contraceptive Sponge: Fits over cervix and is OSFA, leave in 6-24 hours post sex i. Cons: No STD protection 4. Hormonal Methods: a. Combined Oral Contraceptives: Contains estrogen and progestin and suppresses ovulation, thickening cervical mucus blocking semen, and altering uterine decidua (no implantation). Patient education – take missed dose ASAP, monitor for S/Sx of stroke or DVT i. Pros: Effective, decreased menstrual blood and iron loss, improves acne ii. Cons: No STD protection, increased risk of DVT/stroke b. Progestin- Only Pills (Minipill): Provides same action as combination pills i. Client Education: Take at same time of day, you cannot miss a pill, use back up method during first month of use to prevent pregnancy ii. Pros: Fewer side effects (SE), safe to take while breastfeeding iii. Cons: No STD protection, less effective in suppressing ovulation than combined contraceptives, can’t use if had breast cancer c. Emergency Oral Contraceptive: Morning after pill i. Client education: taken within 72 hours of sex, take antiemetic one hour prior to taking, see HCP if no period in 21 days ii. Pros: No age restriction iii. Cons: Nausea, no long term contraception, no STD protection, risk of pregnancy d. Transdermal Patch: Contains progesterone and ethinyl estradiol delivered at continuous levels i. Education: Apply to dry skin over butt, abdomen, upper arm or torso (not over breast tissue) and apply new patch on same day of the week for 3 weeks ii. Pros: Avoids liver metabolism, decreased risk of forgetting pill iii. Cons: No STD protection, same adverse effects as oral contraceptives, possible skin reaction from patch, less effective for women over 198 lbs e. Injectable Progestins: Medroxyprogesterone is IM or SQ injection every 11-13 weeks (3 months) i. Education: Keep follow up appointments, maintain enough Ca and Vitamin D ii. Pros: Effective, only 4 injections a year, possible absence of periods, decreased risk of uterine cancer is used long term iii. Cons: Decrease bone mineral density, no STD protection, return to fertility can be delayed up to 18 months after stopping injection iv. Contraindications: Breast cancer, abnormal LFTs f. Contraceptive Vaginal Ring: Delivers estonegestrel and ethinyl estradiol continuously i. Education: Ring should be replaced every 3 weeks and inserted on same day of week monthly ii. Pros: Doesn’t have to be fitted, decr chance of forgetting to take pill, absorbed vaginally so lower doses can be used iii. Cons: No STD protection, same adverse effects as pill, some possible discomfort during sex g. Implantable Proegestin: Rod containing estonegestrel is inserted on inner side of arm i. Pros: Lasts for 3 years, reversible ii. Cons: Causes irregular menstrual bleeding, no STD protection, irregular and unpredictable menstrual bleeding, increased acne and weight gain iii. Contraindicated with breast cancer h. IUD: i. Pros: effective 1-10 years, have hormonal and non hormonal options i. Cons: Increased risk of PID, no STD protection, possible infection for IUD ii. Contraindicated in women NOT in monogamous relationship, PID 5. Trans cervical sterilization: small flexible agents (like copper) are inserted in fallopian tubes causing scarring of tissue. Client must be examined after 3 months to check procedure a. Pros: Quick procedure with no anesthesia, 99.8% effective and rapid return to normal ADLs b. Cons: Not reversible, not effective for 3 months (use back up), no STD protection, changes in menstrual patterns, possible perforation can occur along with ectopic pregnancy 6. Surgical Methods: a. Female Sterilization (bilateral tubal ligation): fallopian tubes are cut/burned i. Pros: Permanent contraception, sex is unaffected ii. Cons: No STD protection, carries typical surgical risks of hemorrhage/infection/etc b. Male Sterilization (vasectomy): Cut of vas deferens i. Education: Go easy on activities for several days after surgery ii. Pros: Permanent, procedure is short and safe iii. Cons: Requires surgery, no STD protection, risk of infection 7. Body System Changes a. Cardiac Output (CO) i. Increases 30-50% and blood volume increase 30-45% at term ii. HR reaches a peak at 32 weeks’ gestation b. Respiratory i. Last trimester the chest enlarges to compensate for increased oxygen demands (as uterus pushes upward) ii. RR increases as total lung capacity decreases c. Musculoskeletal i. Body alterations and weight increase, making body adjust in posture and pelvic joints relax d. GI i. N/V occur to hormonal changes ii. Constipation may occur as slowing of transit time 8. BP e. Renal i. Filtration rate increases secondary to the influence of pregnancy hormones and increase in blood volume f. Endocrine i. Placenta becomes endocrine organ that produces large amounts of hCG, estrogen, progesterone, etc a. Supine position makes BP appear lower because of pressure on vena cava from uterus (supine hypotension) b. S/Sx include dizziness, pale/clammy skin, lightheadedness c. Change position to lef t lateral side lying, semi-fowler’s position or if in supine then place wedge under hip to alleviate the pressure on the vena cava 9. Pulse a. Increases 10-15 BPM around 32 weeks’ b. Stays elevated throughout remainder of pregnancy 10. Respirations a. Remain unchanged or slightly increased b. SOB may be noted because of changes in pressure against the diaphragm 11. GTPAL a. Gravidum b. Term births (38 weeks or more) c. Preterm births (viability up to 37 weeks) d. Abortions/miscarriages e. Living Children Prenatal Care: Interventions for Urinary Frequency During Pregnancy 1. Urinary Frequency: Typically occurs during 1st and 3rd trimesters a. Patient should empty bladder entirely and decrease fluid intake before bedtime b. Use perineal pads c. Kegal exercises will help to reduce stress incontinence 2. N/V occurs during the first trimester a. Should eat crackers or dry toast 30 min to 1 hour before getting out of bed b. Avoid having an empty stomach c. Don’t eat spicy foods, greasy foods, or gas forming foods d. Drink fluid between meals 3. Breast Tenderness – first trimester a. Wear a support bra 4. UTIs are more common because of renal changes and vaginal flora becoming more alkaline a. Encourage proper wiping, avoid bubble baths, wear cotton underwear, avoid tight fitting pants, and drink tons of water, the usual suspects 5. Fatigue occurs a lot in 1t and 3rd trimester a. Engage in frequent rest breaks 6. Constipation occurs a lot in 2-3 trimester a. Drink lots of fluid b. Eat high fiber diet c. Exercise regularly 7. Hemorrhoids occur in 2-3 trimesters a. Warm sitz bath b. Witch hazelpads c. Topical ointments 8. Supine Hypotension happens in supine position where the gravid uterus compresses vena cava a. Side lying position or semi-sitting position with knees slightly flexed will help alleviate this feeling 9. Health Promotions a. Avoid OTC Meds, alcohol and tobacco b. Exercise throughout pregnancy can offer great benefits c. Avoid hot tubs or saunas d. Consume at least 2 L of water a day 10. Nurse should educate the client about: a. Flu immunizations b. Stop smoking c. Treat current infections d. Genetic counseling and testing e. Exposure to hazardous materials Infections: 1. TORCH Infections are toxoplasmosis, other infections (like hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus and can all negatively affect a pregnant woman (can cross placenta and be teratogenic) a. Risk Factors: i. Toxoplasmosis is caused by consumption of raw or undercooked meat or cleaning cat litter boxes ii. Other infections like syphilis are related to congenital defects iii. Rubella is spread to infants if the mother has it during preganancy iv. Cytomegalovirus is transmitted through droplets (vaginal secretions, breast milk, etc) v. HSV is spread by direct contact with oral or genital lesions (risk is greatest if woman has active lesions with a vaginal birth) b. Expected findings i. Toxoplasmosis resembles flu like symptoms ii. Rubella symptoms include joint and muscle pain, rash, fever and possible fetal death iii. Cytomegalovirus can be asymptomatic or mono like symptoms iv. HSV has painful blisters, lesions and tender lymph nodes and can be fatal for fetuses c. Nursing Care: Rubella immunizations are contraindicated for pregnant women because the pregnant women can develop an infection (avoid groups of children) d. Medications: antibiotics and for toxoplasmosis treat with pyrimethamine and sulfadiazine (harmful to fetus but essential) e. Education is focused on prevention and hand hygiene, safe cooking practices, safe sex and emotional support Therapeutic Procedures to Assist with Labor and Delivery 1. External Cephalic Version: Uses an ultrasound to externally manipulate the fetus into cephalic lie and is done around 36-37 weeks. High risk of placental abruption, umbilical cord compression and emergency C-section a. Client Prep: Perform NST to evaluate fetus, ensure Rho(D) has was given at 28 weeks, admin IV fluid and tocolytics to relax uterus to permit easier manipulation b. Ongoing Care: Monitor FHR, VS, watch for hypotension 2. Bishop Score: Determines maternal readiness for labor by assessing cervix a. Five factors are assigned value 0-3, cervical dilation/effacement/consistency/position/station of presenting part b. Client readiness should be 8+ for a multiparous client or 10+ for nulliparous client 3. Cervical Ripening: This increases cervical readiness for labor and can eliminate the need for oxytocin to induce labor a. Used for clients who cervix fails to dilate and efface b. Considerations: Assess for urinary retention, PROM, vaginal bleeding, fetal distress c. Interventions: Side lying position, monitor VS and FHR d. Complications: Hyperstimulation requires SQ of terbutaline, Fetal Distress requires O2/position client on left lateral side/increase IV fluid/Notify HCP 4. Induction of Labor: deliberately initiates uterine contractions chemically or mechanical means a. Requirements: Bishop score of 8 for multiparous and 10 in nulliparous for 39 weeks gestation client b. Considerations: Prep client for cervical ripening, possible use of oxytocin, anmiotomy or amniotic membrane stripping i. Monitor VS and FHR/contraction pattern every 15 minutes and with every change in dose ii. Increase oxytocin until contraction frequency are more than 2 minutes or duration is longer than 90 seconds iii. Complications: Nonreassuring FHR (less than 110 or greater than 160 BPM) – must position into side lying, keep IV fluids open, notify HCP, monitor VS and FHR 5. Augmentation of Labor: Stimulation of hypotonic contractions once labor has started spontaneously but progress is inadequate 6. Amniotomy: HCP ruptures amniotic membranes using a hook, but increases client risk of cord prolapse or infection a. Must make sure presenting part of fetus is engaged prior to procedure b. Take temp every 2 hours and provide comfort measures 7. Amniofusion: Normal saline or LR are instilled into the amniotic cavity to help reduce the severity of variable decelerations caused by cord compression a. Indications: Oligohydramnios or fetal cord compression b. Interventions: warm fluid prior to administration, assess and monitor client/fetus frequently 8. Vacuum-Assisted Delivery: Used for maternal exhaustion and ineffective pushing, fetal distress during second stage of labor and only used for 34 week gestation and later a. Position in lithotomy position, monitor VS and FHR b. Can cause swelling of the scalp that disappears within 3-5 days (caput succedaneum) 9. Forceps Assisted Birth is used during prolonged labor and fetal distress labor a. Position in lithotomy and ensure bladder is empty b. Assess FHR during and after intervention, observe neonate for bruising and injuries from forceps as well as mother c. Complications include lacerations of cervix/vagina/perineum, injury to bladder, facial bruising or injury to facial nerve on neonate 10. Episiotomy is an incision to the perineum made to enlarge the vagina (speeds up delivery and minimizes soft tissue damage) a. Indicated to shorten second stage of labor, prevent cerebral hemorrhage of fragile preterm infant or help with a macrosomic infant b. Two types of episiotomy: i. Median (midline) episiotomy – most commonly used and is a cut from the vagina to the rectum ii. Mediolateral episiotomy – extends from the vaginal outlet posterolateral, either to left or right of the midline and is used when posterior extension is likely. 1. Greater blood loss, repair is more difficult, local anesthetic is administered c. Alternate labor positions to reduce pressure on the perineum and promote stretching 11. Cesarean birth is a transabdominal incision made horizontally in the lower segment of the uterus and can be needed for many reasons: placenta previa, dystocia, multiple gestations, umbilical prolapse and more a. Assess vitals, FHR, maintain IV fluids, ensure NPO prior to procedure b. Monitor for infection and excessive bleeding post-op, tender uterus and foul smelling lochia can indicate endometritis, and encourage ambulation c. Complications include aspiration, wound infection, hemorrhage, UTI, fetal injuries, etc 12. VBAC is a vaginal birth after c section previously a. Mother must have no other uterine scars, 1-2 previous low transverse c-section births and adequate pelvis b. Constantly asses vitals and FHR Nursing Care of Newborns 1. APGAR Scoring: Rules out abnormalities through an assessment done just after birth a. HR: Absent 0 – Greater than 100 BPM 2 b. RR: Absent 0 – Good Cry 2 c. Muscle Tone: Flaccid 0 – 2 Well Flexed d. Reflex Irritability: None 0 – 2 Cry e. Color: Blue/Pale 0 – Completely Pink 2 2. Expected Weight Ranges: a. Weight: 2500 – 4000 g b. Length: 45-55 cm c. Head Circumference: 32 – 36.8 cm d. Chest Circumference: 30 to 33 cm 3. Gestational Age Assessment: a. New Ballard Scale: Newborn maturity rating scale that assesses neuromuscular and physical maturity 4. Vital Signs a. RR: 30-60 breaths/min and short periods of apnea are normal (<15 seconds) b. HR: 110-160 BPM c. BP: 60-80 / 40-50 mm Hg d. Temperature: 36.5 – 37.5 C (97.7-99.5 F) 5. Reflexes: a. Sucking and Rooting: Expect to elicit by stroking the cheek or edge of the mouth, newborn will turn towards side that is touched (expected age: disappears around 3-4 months) b. Palmar Grasp: Elicit by placing examiner’s finger in palm of newborn’s hand and fingers will curl around examiners fingers (expected age: lessens by 3-4 months) c. Plantar Grasp: Elicit by placing examiners finger at base of newborn’s toes and newborn will respond by curling toes (age: birth to 8 months) d. Moro Reflex: Elicit by allowing head and trunk of newborn in semi sitting position to fall backwards and newborn will symmetrically extend and then abduct arms at the elbows and fingers spread to form a C (age: birth to 6 month) e. Babinski Reflex: Elicit by stroking outer edge of sole of foot and toes will fan up and outward (Age: birth to 1 year) f. Stepping: Elicit by holding newborn upright with feet touching flat surface and they will respond with stepping movements (Age: birth to 4 weeks) 6. Diagnostic and Therapeutic Procedures Following Birth: Blood tests are done to determine Rh factor, blood type and evaluate for infection. a. Expected Lab Values: i. Hgb: 14 to 24 ii. Platelets: 150,000 to 300,000 iii. Hct: 44-64% iv. Glucose: 40-60 v. RBC Count: 4.8 vi. Bilirubin: 1. 24 hours: 2-6 2. 48 hours: 6-7 3. 3-5 days: 4-6 4. Leukocytes: 9,000 to 30,000 7. Complications a. Airway obstruction R/T Mucus: Use bulb syringe or gentle chest percussion b. Hypothermia: Monitor for temp changes and place in warmer if needed c. Inadequate oxygen supply R/T obstructed airway, poor functioning cardiopulmonary system or hypothermia 8. Bulb Syringe a. Mouth first, then nose b. Depress, then insert into one side c. Avoid center – may stimulate gag reflex d. If unsuccessful, back blows, chest thrusts, or mechanical suctioning may be used CAM (Complementary & Alternative Medicine) a. What is Complementary? i. “In addition to…” modern medicine b. What is Alternative? i. “Instead of…” modern medicine c. Define “Chi” i. Chinese life force that provides warmth and protection from illness and injury. d. Reiki i. Use of hands to correct energy fields/chakras. Energy flows from universe into patient. Can help increase WBC and RBC production. Realignment of energy flow. e. Ayurveda i. Indian medicine. Preventive medicine that teaches health is balanced by nature, body, mind and spirit. Uses oils, diet, senses and behavior. f. Guided Imagery i. Focusing on an image either created by the therapist or by the patient’s mind. Uses all 5 senses. S/E are sleepiness and extreme relaxation. g. Biofeedback i. Uses thoughts to control physiological body responses. Electrodes are placed on patient to monitor body response to stress. Patient then relaxes those areas during times of pain, anxiety, temperature, HTN, TMJ, H/A, etc. Stroke h. What test needs to be done right away when a stroke patient comes to an ER? i. CT SCAN immediately! This will help determine what type of stroke has occurred. ii. CT doesn’t require NPO status or any contrast. Results are immediate. i. A patient started having a headache at 4am and started slurring their speech around 0415. If they do, in fact, have an embolic stroke, how long is their window to be able to get TPA? Hint: First symptom was the headache. i. “Golden 3-Hour window” from the “last time normal” to the time the TPA is administered. ICP j. ICP is… i. Intracranial Pressure (pressure within the skull) k. A normal ICP is… i. 7-15mmHg l. What things increase ICP? i. Anything that makes your face RED increases ICP ii. Blowing nose, sneezing, lowering HOB, swelling (tumors, stroke, meningitis, etc.). iii. Elevating the HOB improves venous drainage and decreases ICP m. What do hypertonic saline and Mannitol do for ICP? i. Mannitol: takes ICP fluid to kidneys for removal ii. Hypertonic Saline: pulls fluid from the tissues into the bloodstream, such as burns, ICP and post-op to reduce swelling. n. Why is clustering a bunch of activities together for a patient with increased ICP a bad idea? i. This can increase ICP. Therefore the nurse must decrease stimuli and maintain a calm, low noise, low light, and stress-free environment. o. Why is giving a stool softener a good idea? i. We don’t want these patients to STRAIN with their bowel movements, as it will increase ICP. p. What are the early indicators of increased ICP? What are the late indicators? Early Indicators Late Indicators H/A (usually BAD and prolonged) N/V Blurry Vision Pupillary changes Cheyne Stokes (from lack of O2 to brain) Widening Pulse Pressure (sys-dys=pp) Bradycardia Bulging Fontanels (in infants) Irritability (in infants) q. What is Cushing’s triad and what does it tell you? i. Indicates LATE increase in ICP ii. BAD NEWS! iii. Symptoms Include: 1. Bradycardia 2. Widening Pulse Pressure 3. Cheyne Stokes (changes in respirations) r. What are the bad posturing poses we talked about and what might they indicate? i. Decerebrate Posturing 1. Pointed toes, arms down, wrists are flexed out ii. Decorticate Posturing 1. Everything is pulled towards the core These indicate severe brain swelling from ICP. Liver s. Know your liver labs i. ALT: 3-35 IU/L or 8-20 units/L ii. AST: 5-40 units/L iii. ALP: 30-120 units/L iv. Bilirubin: 0.1-1.0 mg/dL v. PTT: 11-12.5 sec vi. INR: 0.7 – 1.8 vii. Hemoglobin: 12-18g/dL viii. Platelets: 100,000 – 400,000 ix. Ammonia: 15-45mcg/dL (or 11-32 umol/L) x. Creatinine: 0.5-1.2 mg/dL xi. Albumin: 3.5 – 5.0 g/dL xii. Potassium (K+): 3.5-5.5 meq/L t. What is going on with lab levels in Liver Dysfunction? Levels that are going UP Levels that are going DOWN ALT Hemoglobin AST Platelets ALP K+ (initially) Bilirubin Albumin Creatinine Ammonia PTT/INR (prolonged) u. What do you give to reduce ammonia levels? i. Lactulose v. Initially, potassium can be very low in liver failure, but it gets tricky later on in the disease as kidneys are affected. w. Why are liver failure patients at such great risk for bleeding? What labs reflect this problem? i. Liver is highly vascularized ii. LOTS of blood vessels! x. Hepatitis A, B, and C: What are the symptoms, and how are they spread (vowels versus consonants). Hep A Hep B Hep C Symptoms: Mild, flu-like sx Symptoms: anorexia, N/V, jaundice, fever, rashes, light colored stool, dark Symptoms: Flu-like sx (can be severe) Spread: Fecal – Oral Route Contaminated food/water, Shellfish urine Spread: Blood – Body Fluids Sex, healthcare workers, needles, drug users, hemodialysis pts., babies Spread: Blood – Body Fluids, IV drug users, Mobility y. CMS, CMS, CMS: This is VERY IMPORTANT IN FRACTURES. What does it stand for and how do you measure it? i. CMS stands for: Circulation, Motion, Sensation 1. Circulation: pulses, capillary refill 2. Motion: can they move? 3. Sensation: N/T, feeling z. RICE: What is it? What do we use it for? (almost all injuries, right)? i. RICE stands for: Rest, Ice, Compression, Elevation ii. Helps prevent swelling. Vasoconstriction. aa. Hip Surgery. Knee Surgery. What are the risks? What things do you assess for? Why? i. Circulation, sensation and motion distal to the affected area. ii. PT is at risk for: DVT, wound infection, hematoma, hip dislocation, and neurovascular compromise. ab. What is the difference between an open or closed fracture? What do you place on an open fracture? i. Open Fractures: skin is broken, bone is showing 1. Cover with a sterile saline soaked gauze dressing 2. Stop the bleeding. Analgesia, ABX, Tetanus shot 3. Immobilize & elevate ii