Nursing 101 Complete Hurst Packet

Nursing 101 Complete Hurst Packet TABLE OF CONTENTS Fluids and Electrolytes 3 Acid-Base Balance 13 Burns… 16 Oncology… 22 Endocrine 38 Cardiac 52 Psychiatric Nursing… 71 Gastrointestinal 92 Neuro… 104 Maternity Nursing… 114 Respiratory… 139 Orthopedics… 144 Renal 150 Questions 158 Final Thoughts 178 Evaluations 186 Table of Contents for CD 188 Pediatric… 189 Hurst Review does not condone the discussion of the NCLEX-RN exam post- test. Thank you. NOTICE TO FACULTY All materials used during any Hurst Review Services seminar are copyrighted and are not for use without the sole permission of Marlene Hurst in any form or fashion. This material is not intended for lecture use by any School of Nursing without permission. NOTICE TO STUDENTS If you are a student who has obtained this book from a past participant of my workshops SHAME, SHAME, SHAME!!! Please understand that this book is written to accompany the live or video lectures presented in the class itself or my Internet Tutorials. This book is only an outline of what is needed to pass NCLEX. I hope you will join me in a live or video class or on the Internet to reap the full benefits of my materials. General Class Information - Please turn off ALL cell phones and pagers. -This class MAY NOT be recorded in any manner. (This included tape recording or videoing.) -Class Time: 8AM-4PM * Please note that each class is presented in a particular sequence if your instructor completes the material for that day, you may get out prior to 4 PM. FLUID VOLUME EXCESS: HYPERVOLEMIA Define: too much volume in the l. Causes: a. CHF: heart is , CO , decreased perfusion, UO *the volume stays in the b. RF: Kidneys aren't c. Alkaseltzer Fleets enemas All 3 have a lot of IVF with Na d. Aldosterone (steroid, mineralocorticoid) Where does aldosterone live? -Normal action: when blood volume gets low (vomiting, blood loss, etc.) →aldosterone secretion increases→ retain Na/water→ blood volume ** Diseases with too much aldosterone: -also seen with liver disease and heart disease 1. 2. **Disease with too little aldosterone: 1. e. ADH (anti-diuretic hormone) Normally makes you retain or diurese? Retain? 2 ADH problems Too Much Not enough Retain Lose (diuese) Fluid Volume Fluid Volume SIADH DI Syndrome of Inappropriate ADH Secretion Diabetes Insipidus Urine Urine Blood Blood *Concentrated makes #’s go up specific gravity, Na *Dilute makes #’s go down ADH lives in pituitary; key words to make you think potential ADH problem: craniotomy, head injury, sinus surgery, transphenoidal hypophysectomy *Another name for anti-diuretic hormone (ADH) is Vasopressin. The drug Vasopressin (Pitressin or DDAVP (Desmopressin acetate) may be utilized as an ADH replacement in Diabetes Insipidus. f. S/Sx of FVE: Distended neck veins/peripheral veins: vessels are Peripheral edema, third spacing: vessels can't hold anymore so they start to CVP: measured where? ; number goes More More Lung sounds: Polyuria: kidneys trying to help you Pulse: ; your heart only wants fluid to go If the fluid doesn't go forward it's going to go into the BP: move volume more Weight: any acute gain or loss isn't fat-it’s fluid g. Treatment: Low Na diet Diuretics Loop *Bumex® may be given when Lasix® doesn’t work. Thiazide (HCTZ) * Watch lab work with all diuretics *Dehydration and electrolyte problems K-sparing Bed rest induces *when you are supine you perfuse your kidneys more h. Interventions: Physical Assessment Give IVF’s slowly to elderly FLUID VOLUME DEFICIT: HYPOVOLEMIA Big Time Deficit=Shock l. Causes: Loss of fluids from anywhere Thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage Third spacing (when fluid is in a place that does you no good) *burns *ascites Polyuria- Diseases with polyuria Oliguric- Anuric- 2. Weight Decreased Skin Turgor Dry mucous membranes Decreased Urine Output kidneys either aren't being or they are trying to BP? (less , less ) Pulse? , heart is trying to pump what little is left around CVP? , less volume, less Peripheral Veins/Neck veins Cool Extremities (peripheral in an effort to shunt blood to ) Urine Specific Gravity , if putting out any urine at all it will be 3. Tx and Nursing Interventions: Mild Deficit: Severe Deficit: Quickie IV Fluid Lecture Isotonic: Go in the vascular space and stays there! Examples of Isotonic Solutions: , , Hypotonic: Go in the vascular space, hang out a little while and rehydrate, but they do not stay in the vascular space.....If they stayed in the vascular space they wouldn't be hypotonic they would be These solutions go in and hang out and rehydrate, then they move into the cell and the cell burns the remainder up in cellular metabolism. They are hydrating solutions, but they won't drive your pressure up because they do not stay in the vascular space. Hypertonic Solution: - Volume expander and solution that draws fluids into the vascular space. - Examples: D10W, 3% NaCl, 5% NaCl, D5 LR, D5 ½ NaCl, D5 NaCl, TPN Hypotonic Solution: - Causes a fluid shift from the vascular space into the cells. - Examples: D2.5 W, ½ NaCl, 0.33% NaCl MAGNESIUM AND CALCIUM Fact: Magnesium is excreted by kidneys and it can be lost other ways, too (GI tract) Hypermagnesemia Hypercalcemia Causes: Renal Failure Causes: Hyperparathyroidism: too much Antacids Thiazides (retain ) DTR's Muscle Tone Immobilization (you have to bear weight to keep Ca in ) Flushing Arrhythmias bones Warmth LOC Mg makes you Pulse kidney stones Respirations *majority made of calcium Tx: Ventilator Tx: Move! Dialysis Calcium gluconate Fluids! *Calcium gluconate in the presence of magnesium- they inactivate each other Phospho Soda & Fleets enema -both have phosphorous *Ca has inverse relationship with . *When you drive Phos up, Ca goes . Steroids Add what to diet? Safety Precautions? *Must have Vitamin to use Ca. *Calcitonin serum Ca HINT: If you want to get Mg & Ca questions right, think muscles 1st. HYPOMAGNESEMIA HYPOCALCEMIA Causes: Diarrhea - lots of Mg in intestines Causes: Hypoparathyroidism Alcoholism Radical Neck *alcohol suppresses ADH & it’s Thyroidectomy hypertonic -not eating -drinking HINT: If you want to get Mg & Ca questions right, think muscles 1st. S/Sx: Muscle Tone -Could my patient have a seizure? Stridor/laryngospasm - airway is a +Chvostek's - tap cheek +Trousseau's - pump up BP cuff Arrhythmias - heart is a DTR's Mind Changes Swallowing Probs - esophagus is a Tx: Give some MG Tx: Vit D Check function Amphogel® (before and during IV Mg) Phosphorous binding drug NCLEX scenario answers: IV Ca A. call the doctor Always make sure on a B. decrease the infusion C. Stop the infusion D. Reassess in 15 min. Seizure Precautions What do you do if your patient begins to c/o flushing and sweating when you start IV Mg? SODIUM Your Na level in your blood is totally dependent on how much water you have in your body. Hypernatremia=Dehydration Hyponatremia=Dilution Too much Na; not enough water Too much water; not enough Na Causes: Causes: hyperventilation -vomiting, sweating then drinking H2O *this only replaces the water heat stroke -psychogenic polydypsia DI *loves to drink S/Sx: -D5W (sugar & water) Dry mouth -SIADH Thirsty - already dehydrated by the time you're thirsty Swollen tongue Neuro changes - Brain doesn't like it when Na's messed up Tx: Tx: Restrict . Pt needs Dilute pt with IV Fluids Pt doesn't need . Diluting makes serum Na go If having neuro probs: Needs hypertonic saline Daily weights -means "packed with particles" If you've got a Na problem you've I & O got a problem. 3-5% NS Lab work Feeding tube pts - tend to get POTASSIUM Excreted by kidneys Kidneys not working well, the serum potassium will go Hyperkalemia Hypokalemia Causes: Causes: kidney troubles -vomiting aldactone - makes you retain . -NG suction -diuretics -not eating S/Sx: Begins with muscle twitching Life- S/Sx: Muscle Cramps Then proceeds to weakness, Threatening & weakness Then flaccid paralysis Arrhythmias Tx: Tx: Dialysis - Kidneys aren't working Give K! Calcium gluconate Aldactone -decreases Eat K Glucose and insulin - Insulin carries & into the cell - Any time you give IV insulin worry about & Kaexalate® - given for hyperkalemia - exchanges Na for K in the GI tract Extras! Major problem with PO K? Assess UO before/during IV K. Always put IV K on a . Mix well! Never give IV K ! Burns during infusion? Is it okay to add to a bag that's already up and running? ACID-BASE BALANCE Major chemicals you have to remember = Bicarb, Hydrogen, CO2 Lung chemical→CO2 Kidney chemicals →B and H There's only one way to get rid of CO2. What is it? These chemicals can either make you sick or compensate. It depends on which imbalance you have. In respiratory acidosis/alkalosis, which organs are sick? Who's going to fix everything (compensate)? What are the chemicals the kidneys use to compensate with? In metabolic acidosis/alkalosis which organs are sick? If they are sick, who's going to fix things (compensate)? What is the only chemical the lungs have to compensate with? Do the lungs compensate slowly or quickly? Do the kidneys compensate slowly or quickly? Compensation acidosis metabolic respiratory lungs compensate kidneys compensate RR to blow off C02 retain/secrete B PCO2 alkalosis excrete H Bicarb on ABG’s metabolic respiratory lungs compensate kidneys compensate RR to save C02 excrete B PCO2 Respiratory Acidosis (hypoventilating) Is this a lung problem or a kidney problem? What's the problem chemical? Do we have too much or too little of this chemical in the body? How did this happen? Who's going to compensate? Increased C02→Decreased LOC retain H Bicarb on ABG’s Increased C02→ Decreased 02 early hypoxia late hypoxia Treatment→ Fix the problem!!!! Drug to help correct acidosis? Be aware of drugs that decrease RR. Restless pt? Respiratory Alkalosis (hyperventilating) Think about the name. Who’s sick? Who’s going to compensate? Situation: Hysterical patient. Well, are we going to wait until the kidneys kick in? Breathe into a . Maybe sedate. TX: Treat the problem. Metabolic Acidosis Think about the name. Who’s sick? Who’s going to compensate? Scenario: DKA, Starvation When you're starving you break down , produce , ketones are . TX: Treat the problem Metabolic Alkalosis Think about the name. Who’s sick? Scenario: Vomiting TX: Treat the problem. Who’s going to compensate? What would these cause? Pneumothorax R. acid R. alk M. acid M. alk Pneumonia R. acid R. alk M. acid M. alk Alka Seltzer/Antacids R. acid R. alk M. acid M. alk NG to suction R. acid R. alk M. acid M. alk Contusion to lung parenchyma R. acid R. alk M. acid M. alk Broken ribs R. acid R. alk M. acid M. alk Patient getting lots of IVP bicarb R. acid R. alk M. acid M. alk Factoid: acidosis=hyperkalemia (acidosis makes K leak out of cell) alkalosis=hypokalemia (alkalosis pushes K back into the cell) BURNS -The risk of death increases in the very and the very . -Where do most burns occur? -After a burn many different pathophysiological changes occur. WHY? a. Why does plasma seep out into the tissue? Increased permeability b. When does the majority of this occur? c. Why does the pulse increase? Anytime you're in a FVD, Pulse d. Why does the cardiac output decrease? Less to pump out. e. Why does the urine output decrease? Kidneys are either trying to hold on or they aren't being f. Why is epinephrine secreted? Makes you , shunts blood to vital organs g. Why are ADH and aldosterone secreted? Retain & with aldosterone and Retain with ADH Therefore your blood volume will go -What is the most common airway injury? poisoning -Normally oxygen should bind with hemoglobin. Carbon monoxide can run much faster than oxygen . . . . Therefore, it gets to the hemoglobin first and binds Can oxygen bind now yes/no - Carbon monoxide poisoning cannot be determined with O2 saturations; the sat monitor picks up anything that is bound to hemoglobin so if carbon monoxide is bound to the Hb then the sat may appear normal - Carboxyhemoglobin: blood test to determine carbon monoxide poisoning Now the patient is . Tx: From this information do you think it would be important to determine if the burn occurred in an open or closed space? -When you see a patient with burns to the neck/face/chest you had better think what? -A patient is burned over 40% of their body. How do you think this is determined? *Estimate of Total Body Surface Area Head= Each arm= Each leg= Anterior trunk= Posterior trunk= Genitalia= -One of the most important aspects of burn management is . -It is not uncommon for albumin to be given after a major burn. (Not given during the first 24 hours). You know that albumin holds onto in the vascular space. -This will increase/decrease the vascular volume. -What will it do to kidney perfusion? -What will it do to BP? -What will it do to cardiac output? -Will this help correct a fluid volume deficit? -When you start giving a patient albumin you know that the vascular volume will increase. What will happen to the work load of the heart? -If you stress the heart too much you know that the patient could be thrown into fluid volume . -If this occurs what will happen to CO? -What will the lung sounds be like? -On any patient who is receiving fluids rapidly, what is a measurement (hint: heart) you can take hourly to make sure you’re not overloading them? -Is it important to know that the burn occurred at 11:00 p.m.? Why? Because you know that fluid therapy (for the first 24 hours) is based on the time the injury occurred, not when treatment was started. Common rule: Calculate what is needed for the first 24 hours and give half of it during the first 8 hours. This is the Parkland Formula. 1st 8 hours = ½ of total volume 2nd 8 hours = ¼ of total volume 3rd 8 hours = ¼ of total volume To calculate fluid replacement properly you also need to know the patient’s weight and TBSA affected. If the patient is restless it may mean fluid replacement is inadequate, pain, or hypoxia. *Priority: If you had to pick, which of the following would you choose to determine if a patient’s fluid volume is adequate? Their weight or their urine output? -A patient’s respirations are shallow. You know they are retaining what? Therefore, which acid-base imbalance will they have? -A patient was given only 5 mg of Morphine when the order was for a maximum of 10mg. Why did the nurse do this? -Why are IV pain meds preferred over IM with burns? -Why is the patient given a tetanus toxoid plus the immune globulin? (1) Tetanus Toxoid: (active immunity) *takes 2-4 weeks to get the AB’s (2) Immune globulin: think immediate protection (passive immunity) -Do you think there is more death with upper or lower body burns? -A patient has a circumferential burn on their arm. What does this mean and what should you be checking? -If a patient’s vascular checks in this arm are bad the doctor may do what procedure to relieve pressure? -A patient was wrapped in a blanket to stop the burning process. Since the flames are gone does that mean the burning process had stopped? -What else could have been done to stop the burning process? -How else did the blanket help? Held in and kept out . -Why is it important that jewelry be removed? -What kinds of things do you look for to determine if any airway injury has occurred? -A foley catheter was inserted so you could measure urine output. -How often will this need to be monitored? -Is it possible that when you insert the catheter that no urine will return? Why? Kidneys are either attempting to the fluid or they might not be being perfused adequately. -What would you do if the urine was brown/ red? -If there is no urine output or if it is less than 20cc/hour, what would you start worrying about? -What drugs might be ordered to increase kidney perfusion? -After 48 hours, the patient will begin to diurese. Why? Because fluid is going back into the space. Now we have to worry about fluid volume . What will naturally happen to urine output during this time? -The patient’s serum potassium level is 5.8. You know that potassium likes to live inside or outside of the cell? With a burn, what happens to cells? So, what happens to the number of potassiums in the serum (vascular space)? Therefore, you better monitor your patient for which electrolyte imbalance? hypokalemia or hyperkalemia -Why do you think Mylanta®, Protonix®, Pepcid®, and Reglan® are ordered? -Why do you think the doctor wants the patient to be NPO and have an NGT hooked to suction? -If a patient doesn’t have bowel sounds, what will happen to the abdominal girth? -Do you think the patient will need more or less calories than before? -The NGT will be removed when you hear what? -When you start GI feedings, what could you measure to ensure that the supplement was moving through the GI tract ok? -What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance? -Since the patient has 2nd and 3rd degree burns, is it possible that they could have problems with contractures? -Since they have burns on their hands, what are some specific measures that may be taken? -Neck? -If a patient has a perineal burn, what do you think the number one complication will be? -What is eschar? -Does it have to be removed? -If it’s not removed can new tissue regenerate? -What likes to grow in eschar? -What type of isolation will you use with the patient? -Travase® or Collagenase®: enzymatic drug→ eats dead tissue -Don’t use on face -Don’t use over large nerves -Don’t use if pregnant -Don’t use if area opened to a body cavity -Hydrotherapy is also used to debride. -Why should these drugs be alternated? -Broad spectrum antibiotics are avoided to prevent super-infections. However, they will be used until the wound cultures have returned. -If grafting is done, a pressure dressing will be applied in surgery….Then when the bleeding has stopped the wound will be left open to air. -If the skin graft should become blue or cool what would this mean? -Sometimes the doctor will order for you to roll sterile Q-tips over the graft with steady, gentle pressure from the center of the graft out to the edges. Why? -If a patient has a chemical burn what do you do? -If the patient has an electrical burn there will usually be 2 wounds. What are they? -If a patient comes in with an electrical injury what is the first thing you should do? -What arrhythmia is this patient at high risk for? -With electrical burns toxins can build up and cause damage. -It is not uncommon for this patient to be placed on a spine board with a c-collar. Why? Electrical injuries tend to occur in places. -Are amputations common? Why? -Other complications of electrical wounds: cataracts, gait problems, and just about any type of neurological deficit. ONCOLOGY General Information: - Alcohol + tobacco = co-carcinogenic -Tobacco is the #1 cause of preventable cancer. -Suspected dietary causes of cancer: - Low fiber diet -Nitrites (processed sandwich meat) - Increased red meat - Alcohol - Increased animal fat -Preservative and additives -Increased incidents of cancer in the immunosuppressed *that is why there is a higher incident of cancer age 60 -The most important risk factor for cancer = aging -Cruciferous veggies (broccoli, cauliflower, and cabbage), Vitamin A foods (Colored veggies), and Vitamin C could decrease risk -African Americans have a greater incident than Caucasians. -Primary Prevention: Ways to prevent actual occurrence (sunscreen and no smoking) -Secondary Prevention: Using screenings to pick up on cancer early when there is a greater chance for cure or control -Chronic brings about uncontrolled growth of abnormal cells. -Female: a. Monthly self- breast exam b. Yearly clinical breast exam for women 40 years old - Between ages 20-39 needed every 3 years c. Annual pelvic exam d. Pap smear every 3 years if there's been no problem e. Mammogram-baseline at 35-40, yearly after 40 (2 views of each breast) f. Colonoscopy at age 50 then every 10 years. -Male: a. Monthly self-breast exam b. Monthly testicular exam - testicular tumors grow fast c. Yearly digital rectal exam and yearly PSA (prostate specific antigen) for men over age 50 d. Colonoscopy at age 50 then every 10 years CAUTION: (Change in bowel/bladder habits; A sore that does not heal; Unusual bleeding/discharge; Thickening or lump in breast or elsewhere; Indigestion or difficulty swallowing; Obvious change in wart or mole; Nagging cough or hoarseness) -Cancer can invade bone marrow→ anemia and thrombocytopenia - Cachexia- extreme wasting and malnutrition -Radiation therapy: a. Internal Radiation (brachytherapy)