lOMoAR cPSD| 3015998
Diabetic Ketoacidosis
t assessment: dehydration, ketosis, metabolic acidosis, hyperglycemia
t admin fast acting insulin that can be effective within 10 min, admin IV
t kussmaul resp
Beta blockers (Propanolol)
t monitor: sore throat, vision changes, blurred vision, dry eyes, dry mouth, abd cramping, colitis,
acute pancreatitis
t notify provider: night cough
Factors that affect wound healing
t dehydration (UO)
t infection
t BMI <18.5 or >25
t malnutrition (low protein, vita C)
t age
t decreased hgb, tissue perfusion
t wound stress
HIV/AIDS
t positive response to treatment monitored by viral load
t risk for infection: do not drink fluids left out for longer than 60 min, clean toothbrush in
dishwasher weekly, avoid fresh produce, check temp daily
t dx test: ELISA confirmed by western blot/IFA, viral load
Fluid replacement
t monitor BUN
Cerebrovascular accident
lOMoAR cPSD| 3015998
t right sided: visual, spatial, proprioception; poor impulse control/judgment; unilateral neglect
t left sided: language, math, analytical skills
Preventing UTIs
t wipe from front to back
t void after intercourse
t avoid baths
t drink 2t3 L of fluid daily
t cotton underwear
t urinate Q2t4h
Radiation therapy
t do not remove ink markings
t wash area gently with warm water and mild soap
t avoid sun esposure for 1 year
t dispose body fluids in lead container
t limit visits to 30 min a day
t staff should wear dosimeter badge to monitor exposure
t keep all soiled linens in room until implant is removed
Kidney transplants
t hemodialysis sometimes needed following surgery because kidneys from deceased donors may
not function immediately
t requires lifelong immunosuppressive therapy
t complications: cardiovascular disease
Hemodialysis
t expected: weight loss, decrease BP, increase temp
lOMoAR cPSD| 3015998
t complications: hypocalcemia, bleeding, infection, hypovolemia, anemia
t disequilibrium syndrome: nausea, restlessness, dysrhythmias, seizures, headache
t notify: headache, nausea, dizziness during dialysis
t do not eat during dialysis
Inotropic medications
t dopamine, digoxin, dobutamine, milirinone
t increase contractility and improve CO
t monitor HR (apical), hold if <60 min
Diabetes inspidus
t deficiency in ADH
t inability to concentrate urine, 1.001t1.005
t assessment: hypotension, weak peripheral pulses, polydipsia, polyuria (4t30L/day), nocturia,
dehydration
t DILUTE urine chemistry, CONCENTRATED serum chemestry
t treatments: desmopressin, vasopressin (synthetic ADH)
t complications: CNS damage, serizures
Heart failure
t monitor daily weight and i/o
t prevention/health promotion: exercise regularly, consume diet low in Na, fluid restrictions,
smokin cessation
t left sided HF r/t hypertension, CAD, angina, MI, valvular disease... decreased systemic
perfusion
t right sided HR r/t left sided HF, pulmonary problems, right ventricular MI
t **fluid will be backed up in the system behind the failure (Left in Lungs, right in body)
Esophageal varices
lOMoAR cPSD| 3015998
t do not strain to have BM
t avoid using table salt to season food
Blood transfusion
t prime line with NS
t verify with 2 nurses
t infuse over 2t4 h
t monitor for fluid overload
t hemolytic reaction: back/chest pain, apprehension/impending doom
t allergic reaction: within 24h, bronchospasm, urticaria, anaphylaxis
t graft v host disease: within 14 days, thrombocytopenia, anorexia, nausea, chronic hepatitis,
weight loss
t stop transfusion, change line and run NS
Contact precaution
t leave equipment in room
Fluid volume overload
t assess: distended neck veins, full bounding pulse, hypertension, restlessness, cool clammy skin,
pallor, edema
Gout
t decrease intake of purine; increase foods that elevate urine pH
t avoid aspirin, diuretics
t tx: colchicine, allopurinol
TB
t assessment: anorexia, low grade fever, night sweats, persistent cough, purulent sputum
(possible blood streak)
lOMoAR cPSD| 3015998
t airborne precautions
t have family members tested; intradermal TB test 2t10 weeks of exposure (mantoux)
t no longer contagious after 2t3 cont medication; 3 consequtive sputum cultures (Q2t4wk)
t tx: isoniazid, rifampin, pyrazinamide, ethambutol
Hypokalemia
t assess: hypoactive bowel sounds, shallow resp, orthostatic hypotension, thready weak pulse,
reduce DTR
t monitor EKG: vtach, inverted T waves, ST depression
t do not give potassium IM, subQ, bolus
t increases risk of dig toxicity
t complications: cardiac arrest, resp failure
Shock
t assessment: tachycardia, decrease systolic pressure/increase diastolic, increase resp, hypoactive
bowel sounds
t metabolic acidosis
t treatment priorities airway/breathing, circulation
Lyme Disease
t assessment: joint/muscle pain, memory problems, fatigue, carditis, dysrhythmias
t tx: 30 day abx; penacillin, cephalosporin, tetracycline
Open reduction
t monitor: neuro, decrease circulation, pain
t pin care
t monitor skin breakdown, fat/pulmonary embolism, infection
Cushing's disease
lOMoAR cPSD| 3015998
t assessment: muscle atrophy, bruising, striae, electrolyte imbalances, weight gain, hypertension,
full bounding pulses
t positive outcomes of therapy: decreased Na, urine cortisol, BG; increased Ca
Magnesium sulfate
t use: cardiac dysrhytmias (torsades des pointes, refractory vfib)
t complications: resp paralysis, decreased reflexes, hypotension, decreased cardiac function
(heart block)
Pneumonia
t inflammation of airways leading to hypoxia; maintain SaO2 at (5% to prevent
t use IS Q1h
t drink at least 2L of fluid daily
t increased resp secretions
Myocardial infarction
t troponin T/I elevation
t ckmb most sensitive indicator
t admin morphine to decrease O2 demand of the heart
t tpa within 3t4h
Cirrhosis
t lab: elevated bilirubin, increase PT, increase ammonia, decrease albumin
Potential for hemorrhage
t obtain vital signs
Abd aortic aneurysm
t bruit over middle upper abd, pulsating mass just left to midline; abd/flank/back pain
lOMoAR cPSD| 3015998
t do not palpate abd
t may complain of constant gnawing feeling in abd, flank/back pain
Mannitol
t osmotic diuretic, prevents kidney water reabsorption causing increased UO
t adverse effects: nasal congestion, HF, pulmonary edema, metabolic acidosis, f/e losses,
rebound ICP
Fat embolism
t early: dyspnea, tachypnea, desat
t late: petechiae on chest, fever, fat globules in urine
IM administration
t z track method
t aspirate for blood; start again if flashback occurs
PICC
t indication: admin blood; long term chemo, abx, tpn
t maintenance: flush before and after meds
t change gauze Q48h, transparent dressing Q7days ; remove by pulling toward catheter gently
t admin intermittent IV bolus of heparin saline when not in use; use alteplase if clotted
Digoxin
t toxicity: anorexia, nausea, vomiting, visual disturbances, dysrhythmia
t monitor potassium
t therapeutic range: 0.5t0.8/2.0
t take antacids one hour after
t may take forgotten dose late
lOMoAR cPSD| 3015998
Contrast dye
t assess for shellfish, milk, eggs, chocolate allergy; asthma
t monitor pt with DM, renal impairment, HF; pt taking aminoglycosides, NSAIDs, metformin
t encourage increased fluids
t take laxative and increase fiber
t expect stools to be chalky white for 24t72 h
Diabetes
t assessment: polyuria, polydipsia, polyphagia, neuropathy
t sick day care: take insulin even if unable to eat regular diet, monitor BG Q4h
t notify provider: ketones in urine, BG >250
Oxygen therapy
t nonrebreather: 80t(5% O2
t venturi mask: delivers exact O2 flow, 24t50%
t simple face mask: short term, 40t60%. increased risk for skin breakdown
t partial nonrebreather: for pt who can maintain adequate O2 saturation with mix of RA/O2
Nitroglycerin
t store in original container as it is inactivated by heat, light, moisture
t place under tongue or between cheek/gums and let it dissolve
t take regardless of food intake at onset of angina
t relief should begin 1t3 min after admin; take another if pain persists in 5 min
t lay down after taking, risk for hypotension
Cardiac catheterization
t apply firm pressure to prevent bleeding, hematoma formation
t monitor VS, coagulation studies
lOMoAR cPSD| 3015998
Thoracic aortic aneurysm
t assessment: dysphagia, SOB, hoarseness
Tension pneumothorax
t assessment: deviation of trachea, severe resp distress, reduced lung sounds
Flail chest
t inability of injured side of chest to expand adequately upon inhalation and contract upon
exhalation
t paradoxical chest movement:
t other assessment: SOB, tachycardia, hypotension
t prepare pt for positive pressure ventilation
t admin analgesics
t deep breathing and proper positioning
Meningitis
t nuchal rigidity
Cushing's triad
t bradycardia, hypertension, widening pulse pressure
Gastric hemorrhage
1. admin O2
2. Iv therapy
3. Insert NG tube
4. admin ranitidine
End stage kidney disease
lOMoAR cPSD| 3015998
t risk for anemia; treat with epoetin alfa
t risk for pulmonary edema; treat with furosemide
t hypertension
t hypocalcemic, treat with Ca carbonate
Burns
t change dressing every 12t24h, inspect and monitor for infection
t elevate and immobilize skin graft site for 3t5days
t tak pain med 30 min prior
t wrap fingers individually
t perform ROM Q1h
Chest tube
t expected output: 65 mL/h serosang
Autonomic dysreflexia
t exaggerated response to stimuli in pt who have high level spinal injuries
t assessment: diaphoresis, sudden significant rise in BP, bradycardia, severe headache, flushing,
anxiety, tachypnea
t complications: stroke, organ damage, death
Pressure ulcers
t keep skin clean, dry/properly hydrated
t donut shaped pillows can cause more skin damage
t change position every 1t2h
t limit angle of hips no more than 30 degrees
t do not massage or rub reddened areas
Wound irrigation
lOMoAR cPSD| 3015998
t use proper solution, usually NS
t use 30t60 mL syringe or 18t1( gauge catheter
t deliver 8psi (but can be 4t15 psi)
Morphine
t adverse effects: cough suppression, constipation, urinary retention, pupillary constriction
Celiac disease
t avoid foods with gluten: wheat,
barley, rye (pudding, pasta, crackers)
t suggested food: tapioca, rice/corn flour
Allergy skin tests
t dc meds 2 wk prior: beta blocker, ACE inhibitor, theophylline, nifidipine, glucocorticoids
Warfarin
t expected labs: INR 2t3; aPTT 1.5t2x 30t40 sec
Feverfew
t decrease risk of migraine headache and intensity
t increase risk for bleeding
Seizures
t turn patient to side
t loosen restrictive clothing
t make environment safe
t do not enter anything into mouth
t limit intake of alcohol, caffeine
lOMoAR cPSD| 3015998
t minimize stress, fever, fatigue
t keep side rails with padding up
t ensure pt has patent IV access
Gingko biloba
t increase blood flow and decrease pain r/t PAD
t decrease platelet aggregation
Ginger root
t relieve nausea r/t vertigo
t similar to ondansetron
Glucosamine
t treats joint pain, reduce inflammation
t promote body's ability to make cartilage and synovial fluid
Compartment syndrome
t assess neuro and circulation
t increasing pain esp with passive movement
t loosen dressings
t prepare for fasciotomy
Atherosclerosis
t prevention: smoking cessation, maintain proper weight, eat low high fiber diet, decrease intake
of simple carbs
Mastectomy
t drain will be removed after 1t3 weeks and there is <25mL/24h
t begin exercising 24h after surgery
lOMoAR cPSD| 3015998
t elevate arm to promote lymphatic fluid return
t elevate HOB to at least 30 degree to facilitate breathing and drainage
Leukemia
t decrease platelet/increase aPTT, increased WBC, decreased hgb
Dehiscence/evisceration
t *** call for help
t cover with saline moist dressing
t measure VS
t place in supine position
Hormone replacement
t adverse effects: dvt, cva
Peripheral arterial disease
t impaired circulation
t painful ulcerations on and between toes
t hair loss on lower legs
t pain when resting, relieved when dependent
dependent rubor; intermittent claudication
t bruit
Crutches
t going up stairs: place body weight on crutches, advance unaffected leg, shift body weight to
crutches and affected leg, bring crutches and affected leg up to stair
Anaphylaxis
t patent airway, O2 via face mask
lOMoAR cPSD| 3015998
t high fowler's
t admin epinephrine
t initiate IV infusion NS
Metered dose inhaler
t breathe in slowly and deeply
t rinse case and cap under warm tap water once daily; vinegar soak once a week
t hold breath for 10 sec after inhalation
t wait at least i min between puffs
Ureterostomy
t removal of the bladder and connecting ureters to abd, stoma formation
t no urge to void
t drink 2t3 L of fluid to reduce mucus formation
t cut barrier 1/8
t avoid moisturizers around stoma
Psyllium
t Plantain seed used as laxative/bulking
t drink 240 mL of liquid after admin
t results in 12t24h, regularity in 2t3 days
t take after meal to prevent appetite suppression
t stir and take immediately
Arterial line
t use to obtain abg samples and monitor hemodynamic pressures
t use while pt supine with HOB 60 degrees
t relax; tensing will alter pressure readings
lOMoAR cPSD| 3015998
t place pressure bag around flush NS sol
Plasmapheresis
t adverse effects: citrate induced hypocalcemia
t assess and palpate bruit/thrill Q2t4h, VS Q8h
t report redness and swelling
Suctioning
t limit each pass to 10t15 sec
t hyperoxygenate with 100% for 30s t 3 min
t suction with 80t120 mm Hg
t may suction with up to 3 passes at a time
Organ rejection
t early manifestations: fever, hypertension, pain at transplant site
Heparin
t protamine sulfate to reverse effects
Arteriovenous fistula
t matures over 2t3 months
t encourage hand exercises (squeeze ball)
t assess neuro, circulation
t no IV insertions or BP on arm with fistula
Osteoarthritis
t cartilage destruction with bone spur growth at joint ends
t degeneration
lOMoAR cPSD| 3015998
t pain improves with rest
t localized
t heberden and bouchard node
t exercise, weight loss, orthotic devices
t NSAIDs, COX2 enzyme blocker
Rheumatoid arthritis
t synovial membrane inflammation resulting in cartilage destruction and bone erosion
t inflammatory (increase ESR)
t swelling, redness, warmth
t morning stiffness
t all joints affected, symmetric
t swan neck and bouteonniere deformities
t systemic involvement of heart, lungs, skin
Parkland formula
4 mL x % TBSA x kg = fluid needs for first 24 h
t half the need infused over first 8 h
t second half over 16 h
BMI
t kg/m^2
t lb x 703/ in^2
Hyponatremia
t delay, slow depolarization
t muscle weakness, seizures , increased motility
t PO Na replacement
lOMoAR cPSD| 3015998
Hypernatremia
t s/sx of dehydration, irritability, decreased DTR, seizures
t isotonic/hypotonic solutions
Hyperkalemia
t assessment: weakness, ascending flaccid paralysis, increased motility, slow irregular pulse
t monitor EKG: vfib, peak T waves, wide QRS
t IV glucose and insulin
t furosemide, kayexalate
Hypocalcemia
t pos chvostek and pos trousseau, hyperactive DTR, paresthesias, muscle spasm, bradycardia,
hypotension, hyperactive bowel
t vita D enhances calcium absorption
t minimize overstimulation
Hypomagnesemia
t related to hypocalcemia/hypokalemia
t depressed mood, increase nerve impulse transmission, hypoactive bowel
Respiratory acidosis
t hypoventilation, resp depression
t increased CO2
t anxiety, confusion, pale/cyanosis, fast shallow resp
t COPD, sleep apnea, obesity
Respiratory alkalosis
t hyperventilation r/t anxiety, mechanical vent
lOMoAR cPSD| 3015998
t decreased CO2
t paresthesias, loss of consciousness, dysrhythmias, rapid deep resp
Metabolic acidosis
t DKA, lactic acidosis, kidney/lung problems
t kussmaul resp, bradycardia, hypotension, warm pink dry skin
t admin sodium HCO3
Metabolic alkalosis
t increased HCO3
t atach, tetany, muscle weakness, paresthesias, ineffective breathing, convulsions
t seizure precautions
Increase intracranial pressure
t sleepiness, difficulty arousing from sleep
t widening pulse pressure
t decerebrate posturing
t lower glasgow coma scale
Thyroid storm
t excessive release of thyroid hormone
t dangerously high BP, HR, and temp
Hearing aids
t challenges: background noises
t wear at homes in intervals to adjust to new sounds
t hearing aids amplify sounds but will not enhance sound discrimination