Milestone 2 Retake study guide latest updated (Graded A)

Fracture left hip - Answer- - Manifestations: pain in hip/groin, bruising at hip, pain on movement, muscle spasms - Bucks traction (temporary to relieve pain, reduce muscle spasm and immobilize) - use is not routine - Surgery is usually done to reduce and fixate the fracture - Care is similar to that of a patient undergoing other orthopedic surgery or hip replacement surgery Care of Hip fracture - Health history and presence of concomitant problems - Pain - VS, respiratory status, LOC, and signs and symptoms of shock - Affected extremity including frequent neurovascular assessment - Bowel and bladder elimination; bowel sounds, I&O - Skin condition - Anxiety and coping Continuous bladder irrigation - Answer- - A three-way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots—one lumen is for inflating the balloon (30 mL); one lumen is for instillation (inflow); one lumen is for outflow. - Continuous irrigation may be used with TURP (surgery used to treat urinary problems caused by enlarged prostate) - The amount of fluid recovered in the drainage bag must equal the amount of fluid instilled -- secondary hemorrhage may occur from overdistension Urethritis - Answer- - Inflammation of the urethra (tube carry urine from bladder to the outside of the bladder) - Can be bacterial or viral and causes swelling and urination of urethra) - Common in postmenopausal women Low estrogen levels decrease moisture and secretions in the perineal area, predisposing it to the development of infection Renal Calculi (Kidney stones) Risk Factors - Answer- - Men due to dehydration & urinary retention from BPH - Excessive intake of sodium and oxalate - Gout - Hypercalcemia - Metabolic issues - High intake of purine foods or animal protein - Kidney disease - GI issues Calculi pain - Answer- - Requires immediate attention - IV or IM opioids - IV NSAIDs (decrease inflammation) - Around the clock pain meds - Never massage flank pain If pain increases, notify HCP Imitrex (Sumatriptan) contraindications - Answer- - Coronary artery disease - Uncontrolled hypertension - Ischemic heart disease - St. John's wort Seizure - Answer- Assessment: History, factors/precipitating events, alcohol, aura -Maintain patent airway, turn to side, loosen constructive clothing, ease to floor. May require suctioning or oxygen. after, assess level of understanding. -call 911 for seizures lasting more than 5 minutes - maintain bed in low position and keep side rails up. -safety is first. Hyperthyroidism - Answer- - Graves = Gaines "High" High & Hot - High T3 & T4 - Agitation, restlessness & confusion (early sign) - Ophthalmopathy -Exophthalmos (abnormal protrusion of one or both eyeballs), (not always reversible) (grape eye) - Goiter (golf balls in throat) - Hypertension - Tachycardia - Heart palpitations (atrial fibrillation) - Weight loss - Heat intolerance (diaphoresis) - Diarrhea Exophthalmos-POC - Answer- Assessment: - Vision changes, trauma, visual acuity Treatments: - Antibiotic eyedrops if infection is the underlying cause - Antithyroid therapy (propylthiouracil, methimazole), if Graves' disease is the underlying cause - Corticosteroids for optic neuropathy - Eye lubricants (artificial tears) - Surgery if vision is threatened General: - Cold/warm compresses (trauma) - Eye protection (sunglasses) Testing: - CT, MRI, ultrasonography peripheral neuropathy - Answer- A disease affecting peripheral nerves that causes weakness, numbness and pain in feet and hands. The heels are particularly susceptible to breakdown because of loss of sensation of pain and pressure associated with sensory neuropathy. The skin is assessed for dryness, cracks, breakdown, and redness, especially at pressure points and on the lower extremities. The patient is asked about symptoms of neuropathy, such as tingling and pain or numbness of the feet. Deep tendon reflexes are assessed. Teaching: Use a mirror to inspect feet daily. Diabetes foot care - Answer- Feet should be cleaned, dried, lubricated with lotion (but not between the toes), and inspected frequently Supine position - alleviate pressure on the heels by elevating lower legs on a pillow, the heels positioned over the edge of pillow Seated in a chair - position feet so that no pressure on heels If ulcer on one foot - provide preventive care to the unaffected foot and special care to affected foot. Preop labs - Answer- pH 7.35 - 7.45 pCO2 35 - 45 HCO3 22 - 26 Renal Lab Values · BUN 10 - 20 · Creatinine 0.6 - 1.2 · Cholesterol Lab Value 200 CBC Lab Values · HCT F:36 - 46 M:42 - 52 · HgB F:12 - 16 M:14 - 18 · Platelets 200,000 - 450,000, 40,000 be very concerned! · WBC 4.5-11 Calcium 9-11 Sodium 135-145 Chloride 95-105 Magnesium 1.5 - 2.5 Potassium 3.5 - 5.0 Malignant hyperthermia - Answer- - Life threating complications that occurs due to certain drugs used in general anesthesia (succinylcholine) Symptoms Muscle rigidity Fever Tachycardia Tachypnea Dysrhythmias Hypotension Cyanosis Metabolic acidosis - Discontinue surgery if possible - Administer antidote Dantrolene (Muscle relaxant) - Administer 100% oxygen - Implement cooling measures (Cold IV fluids and ice packs) - Administer sodium Bicarb for metabolic acidosis Hydromorphone (Dilaudid) - Answer- Causes Hypotension: Slow position changes Low and slow vitals Assess BP, RR, & pulse before administration Dilute with NS Naloxone for overdose Causes constipation - use stool softener COPD - Answer- Caused by smoking O2 reading 88%-93% is considered normal Low oxygen and high Co2 Low PaO2 = Hypoxemia (below 80) Shows Respiratory acidosis Improve breathing by inspiratory muscle training and breathing retraining: 1. Diaphragmatic breathing 2. Pursed-lip breathing (Inhale 2secs Exhale 4 secs) Hypercapnic (High CO2) Priority= Give BiPap TB diagnostic test - Answer- Mantoux Skin Test - read in 48-72 hours, Over 15 mm induration= positive, Patient has TB infection but additional testing needs to be done to see if it is in active form - Chest xray & sputum culture confirms active TB - Sputum Culture Diagnosis: Early morning sterile sputum specimen for 3 consecutive days - Sputum cultures are taken until 3 negative results - All family members need to be tested - Sputum samples every 2-4 weeks Perforated bowel first sign - Answer- Severe abdominal pain, an elevated white blood cell count (due to infection), fever, nausea, noticeable blood loss, and hemodynamic instability (septic shock) NGT with decreased peristalsis - Answer- Turning side to side in bed Ambulation Bowel sounds Full Fowler's Cholelithiasis n/v - Answer- - severe and will need a NG tube inserted with GI decompression (remove stomach contents with low intermittent suction) so the gallbladder isn't stimulated - Give anti nausea meds - Pt become dehydrated (administer IV fluids to help hydrate them) Diverticulitis WBC - Answer- - Elevated WBC in labs 11,000 (Due to inflammation and bleeding) Stage I: Rest, oral fluids, analgesics, clear liquid diet Stage II: NPO, IV fluids, NG suctioning, antibiotics, oxycodone for pain Anemia labs - Answer- - Decrease in RBC Men 4.0 or Women 3.8 - Decrease in hemoglobin Men 14 or Women 12 Blood administration - Overload - Answer- 1. Slow (to 4 hours max) or STOP the infusion 2. Using new tubing flush area with 0.9% sodium chloride (NS) 3. Report to HCP immediately 4. Assess: vital signs Urine specimen: check for hemolyzed RBC - Can cause hyperkalemia 5 and peaked T waves on ECG Signs - Lung crackles - Restless - Dark urine - SOB & Dyspnea - Jugular vein distention At risk for HF & wait 2 hrs between infusions - HOB elevate - Oxygen - Push diuretics (furosemide) - End all Iv fluids Osteoporosis - Answer- - Treatment is focused on decreasing bone resorption (decrease the amount of calcium that is leaving the bones and going into the blood stream - Primary osteoporosis after menopause Weight-bearing exercise, reduce caffeine, tobacco, alcohol, carbonated drinks Pain : Overweight Sedentary lifestyle Assistive devices - remove stigma Give analgesic before exercise Gout teaching - Answer- - Avoid alochol - Avoid purine rich foods (red meat, organ meat, shellfish, and fructose) - Avoid starvation dieting (can trigger gout) - Increase fluid intake - Reduce stress ABG head injury - Answer- Respiratory acidosis causes hypercapnia (excess CO2) which causes vasodilation of cerebral arteries, increasing intracranial pressure Celiac disease diet - Answer- gluten damages villi gluten-free diet (no BROW: barley, rye, oat, and wheat). Prolapsed cord delivery - Answer- 1.Call for assistance- a medical emergency 2. Sterile gloves, insert 2 fingers into the vagina (one on each side of the cord) & Elevate the fetal presenting part off the cord3. Apply warm sterile saline soaked towel over cord4. Administer O25. Prepare for birth (Modified Sims, Trendelenberg, knee-chest positions) Gestational diabetes lab - Answer- 1 hour oral glucouse tolerance test (drink a 50g solution of glucose and then in 1 hr have blood drawen) 140 mg/dL abnormal (administered at about 24-28 weeks), 3 hour glucose tolerance test is ordered. Blood drawen: Fasting abnormal 95 mg/dL , 1hr abnormal 180 mg/dL , 2hr adnormal 155 mg/dL , 3hr 140 mg/dL Two or more abnormal results is used to diagnose gestational diabetes. GBS positive - Answer- Presence of Group B streptococcus; rarely serious in adults could be life threatening in newborns. Newborns with early-onset (within a week after birth) GBS infections may have pneumonia or sepsis, while late-onset (after the first week) infections often manifest in meningitis. Diagnosis: Using a large cotton swab to collect samples from the vagina and rectum. Treatment: Indicates treatment of the mother with antibiotics (Penicillin G 4 hours prior to delivery) Women who are at 36-37 weeks are screened Nurse Assessment: Review the woman's prenatal history and ask about any previous infection. Nurse Management: Ensure pregnant women are screened for GBS b/w 36- and 37 weeks gestation. If positive, receive appropriate intrapartum antibiotic prophylaxis. Record the results and notify the birth attendant if the woman has tested positive for GBS. During labor, be prepared to administer IV antibiotics to all women who are GBD-positive. Placental abruption - Answer- when the placenta detaches from the uterus - First action: massage the uterus - can deprive baby of oxygen - heavy bleeding can occur - abd/back pain c-section and bedrest (left lateral position) Variable Decelerations - Answer- - A variable deceleration is a very quick decrease in fetal heart rate of 15 bpm or more, that lasts at least 15 seconds (but may last up to two minutes) before the heart rate returns to baseline - place pt knee-chest or reposition from side to side, d/c oxytocin, administer oxygen, notify HCP. amnioinfusion may be indicated. Hemorrhage postpartum care - Answer- - Administration of uterotonic medications (Oxytocin, methylergonovine, misoprostol, and carboprost). - Bimanual massage (one hang in vagina and the other used to massage uterus) - Uterine packing - Surgical intervention (may need a hysterectomy) - Massage fundus - Administer oxygen and IV fluids - Elevating pt legs Post-epidural headache - Answer- - Can be an adverse reaction of spinal anesthesia - Semi-Fowler, IV hydration, O2 Cryptorchidism assessment - Answer- Undescended testes Palpated in inguinal canal Can be unilateral/bilateral If can't palpate, further investigation Acrocyanosis monitor - Answer- Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness May be seen in newborns during the first few weeks of life in response to exposure to cold. Acrocyanosis is normal and intermittent. Vitamin K rationale - Answer- Vitamin K is needed to form blood clots and to stop bleeding. Babies are born with very small amounts of vitamin K stored in their bodies, which can lead to a serious bleeding problem known as vitamin K deficiency bleeding (VKDB). VKDB can lead to brain damage and death. Bleeding from vitamin K deficiency is a risk during the first 6 months of life. VKDB is preventable with a one-time intramuscular shot of vitamin K at birth. Informed Consent Language - Answer- Informed consent is the patient's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed to protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation or battery. Consent is a legal mandate, but it also helps the patient to prepare psychologically because it helps to ensure that the patient understands the surgery to be performed. Sickle cell dehydration - Answer- - Increase fluids Dehydration can trigger sickling Other signs are elevated HR, pain, hyperthermia Promote hydration, give IV fluids Hypoglycemia - milk - Answer- A hypoglycemic patient needs to be treated with sugar (i.e., milk, juice), followed by some form of protein intake Plaquenil (Hydroxychloroquine) teaching - Answer- - Given to treat lupus (decrease inflammation and fatigue) - Retinal damage & vision problems (Optometrist: Regular eve appts every 6-12 months) - No need for regular alert bracelet - No need for osteoporosis vitamins Meningitis assessment - Answer- Nuchal rigidity-stiff neck Kernig's sign- hip flex causes pain in knee extension Brudzinskis- neck flex causes knee and hip flex Congenital hypothyroid (Cretinism) - Answer- Caused by thyroid dysgenesis Aplasia: no thyroid Hypoplasia: small thyroid Ectopic: lost thyroid Screening: 72 hours after birth Heel prick & Check TSH as universal screening but if risk factor then we do thyroid function test Signs Dry hair scaly skin narrow palpebral fissure board nose constipation macroglossia (large tongue) prolonged jaundice constipation protruding and distention of abdomen umbilical hernia xray results shows hypothyroidism Causes diminished physical and mental capacity Measure & record growth Measure thyroid levels Assess for hypo- or hyperfunction L-thyroxine (Synthroid) is treatment RSV: Synagis what is the criteria to receive this vaccine? - Answer- Give IM to child 2 yrs, once/month during RSV season - Prematurity - Chronic lung disease (bronchopulmonary dysplasia) requiring medication or oxygen - Certain congenital heart diseases - Certain neuromuscular disorders Hyperglycemia - Answer- Assess in hospitalized child every 2 hours Child will need immediate access to rapid-acting insulin - Mental status change - Fatigue - Weakness - Dry flushed skin