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Points to Remember Neurological.
General Points
•
Peripheral nerves can regenerate whereas nerves in the spinal cord do not regenerate.
•
In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend
to be in cognition and bowel control.
•
Tremors associated with Parkinson's disease occur at rest; they disappear when the client
reaches for something.
•
The client with myasthenia gravis will have more severe muscle weakness in the evening due to
the fact that muscles weaken with activity - described as progressive muscle weakness - and
clients usually regain strength with rest.
•
When caring for a comatose client, remember that the hearing is the last sense to be lost.
•
Changes in a client's respirations (rate, rhythm and depth) are more sensitive indicators of
increases in intracranial pressure than blood pressure and pulse.
•
Spinal cord injury and traumatic brain injury causes major life changes. Monitor for depression
and provide support for client and family.
•
Monitor respiratory status of client with amyotrophic lateral sclerosis and discuss end of life
issues/care.
•
Clients with migraines should be taught to avoid triggers and take medication at the onset of
pain.
Alzheimer's Disease
•
Alzheimer's victims should not be concurrently treated with donepezil (Aricept) and the
antidepressant paroxetine (Paxil); donepezil increases acetylcholine in the brain and paroxetine
works by decreasing acetylcholine levels in the brain.
•
Monitor and prevent injury to the client with Alzheimer's disease when wandering; divert
activity if possible.
Stroke
•
Clients with CVAs are at a greater risk for aspiration; a speech language therapist should
evaluate for dysphagia.
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•
After a CVA, clients often have a loss of memory, emotional lability and a decreased attention
span.
•
Communication difficulties of a client with a CVA usually indicate involvement of the
dominant hemisphere (usually the left brain) and is associated with right-sided hemiplegia or
hemiparesis.
•
A major problem often associated with a left-sided brain infarction (CVA) is an alteration in
communication.
Seizures
•
Teach clients with a seizure disorder to routinely take prescribed medication and not abruptly
discontinue the medication.
•
Priority when caring for a client having a seizure is protecting the client from injury - side rails
should be up and padded; oxygen and suction should be at the bedside at all times.
•
During a seizure, do not force anything into the client's mouth or attempt to suction the mouth.
Points to Remember coordinated care
•
Nursing practice is governed by laws and professional standards.
•
What a nurse can do depends on the nurse practice act in the state in which the nurse is
licensed.
•
The LPN/VN cares for physiologically stable clients with predictable conditions.
•
The RN is the manager of care and is responsible for client education; the LPN/VN reinforces
the information provided by the nurse and provider.
•
Standards of nursing practice apply to all nurses in all practice settings.
•
Standards of care are based on facility policy and procedure, nursing education, experience,
and publications of professional nursing associations and accrediting groups.
•
Delegation overview:
•
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The registered nurse must monitor delegated tasks and evaluate the outcomes.
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•
•
•
Final responsibility for any delegated task resides with the RN and the LPN/VN (if allowed
by the state's nurse practice act.)
Good communication skills are essential when interacting with members of the health care
team.
•
S-B-A-R (situation, background, assessment, recommendation) technique
•
I P-A-S-S the B-A-T-O-N (introduction, patient, assessment, situation, safety concerns,
background, actions, timing, ownership, next)
•
C-U-S (concern, uncomfortable, safety)
•
•
An effective leader modifies his/her style according to situational conditions.
•
Each board of nursing defines what constitutes professional misconduct.
•
The board of nursing has the authority to impose a penalty for professional misconduct.
•
Penalties include probation, censure, reprimand, suspension or revocation of the license.
•
•
To avoid negligence:
•
Provide care within the legal scope of practice
•
Know the standard of care
•
Be competent in your practice
•
Deliver care that meets the standard and follows the facility's policies and procedures
•
Document care accurately and in a timely manner
•
•
The only employee of a health care organization who may legally witness the signing of an
advance directive is a clinical social worker.
•
Ethical principles guide a nurse's behavior in establishing a therapeutic client relationship.
•
In most situations, individuals have the right to accept or refuse treatment.
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Points to Remember
Safety
•
Safety is the primary concern when caring for clients.
•
The goal of the Quality and Education for Safety in Nursing (QSEN) project is to meet the
challenge of preparing future nurses who will have the knowledge, skills and attitudes
(KSAs) necessary to continuously improve the quality and safety of the health care systems
within which they work.
•
Falls are the most frequent cause of injury for elderly clients.
•
Know the institution's plan for fire drills and evacuation.
•
At origin of fire, remember R.A.C.E.; away from origin of fire, listen to overhead paging
system.
•
Know locations of all fire alarms, exits, and extinguishers.
•
Turn off all oxygen supplies in the area of the fire.
•
Never use an elevator - use the stairs to evacuate.
•
•
Only certain electrical outlets access the emergency generators in a power failure; know
which ones they are.
•
Know your agency's policy for cleaning up a biohazardous spill.
•
Safety devices, such as restraints, are used only as a last resort; use the least restrictive
immobilizing device possible.
Poisons
•
Call the local poison control center to determine appropriate treatment for the specific
poison; never induce vomiting unless instructed to do so.
•
If you suspect someone has taken poison, take the poisonous substance with you to the
emergency room.
•
Unintentional (or accidental) poisoning is one of the leading causes of death, across almost
every age group.
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Infection
•
Hand washing is the most effective method of preventing infection; friction is the most
important variable.
•
Standard precautions are used for all clients; transmission precautions (contact, droplet and
airborne) are used for clients with transmittable organisms.
•
PPE includes gloves, gowns, masks and/or goggles; N95 respirator masks are required to
protect health care workers from exposure to airborne particles, such as tuberculosis and
measles.
•
Neutropenic protocol is used for immunocompromised clients with low white blood count
(usually when the neutrophil count is less than 1500.)
•
All health care acquired infections (HAI) that occur in hospitals must be tracked and
recorded by risk management.
•
The major sites for health care acquired infections (HAI): urinary and respiratory tracts,
blood, and wounds.
•
Reporting of "notifiable conditions" is mandated through legislation or regulation; notifiable
conditions include infectious and non-infectious conditions as well as outbreaks.
Emergency Preparedness and Response
•
Triage in a health care setting is different from that in a community or field setting.
•
Specific hazards associated with disasters include
•
bioterrorism, e.g., anthrax, plague (bacterial agents): smallpox, viral hemorrhagic fever
(viral agents)
•
chemical emergencies
•
radiation emergencies
•
mass casualties
•
natural disasters and severe weather
•
recent outbreaks and incidents, e.g., salmonella, E. coli, H1N1 (influenza), Ebola
•
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Points to Remember - OB
Before Birth
•
Early and regular antepartal (before-birth) care is critical. First trimester health and nutrition
directly influences the development of organs in embryo and fetus.
•
To identify risks, nurses need both subjective (client's) and objective (the nurse's own) data.
•
Prescribed medications, over-the-counter drugs, alcohol, street drugs, and tobacco may lead
to problems for the fetus and mother.
•
Pregnancy diet must include increased calcium, protein, iron and folic acid, which is most
critical the first trimester.
•
If the mother's situation warrants, suggest ways to adapt activity, employment, and travel.
•
It is helpful if the mother can have the same support person throughout pregnancy, birthing
classes, and the labor and delivery process.
•
A doula gives prenatal, labor, birth and postpartum support for mothers and families.
Labor
•
Normal active labor progresses 1.2 centimeters per hour for primiparas and 1.5 centimeters
per hour for multiparas.
•
Maintain safety and medical asepsis through the labor and birth process to reduce risks to
mother and fetus/newborn.
•
Ideally, the same caregivers should stay through all stages of labor.
•
Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but
be flexible since woman will have shorter attention span, increased discomfort, and
experience a fluctuation of emotions during labor.
•
Respect the cultural and religious beliefs of the woman and partner.
•
Involve the family in the birth process as noted in their birth plan or special requests.
•
Document ongoing assessments, changes in condition and care.
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•
Pain and anxiety can impede progress of labor.
•
Safest time for the fetus is to administer analgesics is when the woman is dilated between 4
to 7 centimeters.
•
Be prepared to assist newborn transition to extrauterine environment.
Points to Remember - OB 2
Postpartum
•
Reinforce teaching (by demonstration and praise) self assessment and care soon after
newborn's birth.
•
Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. (for
breasts, uterus, bowels, bladder, lochia and episiotomy or C-section incision)
•
Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn
•
direct Coombs' test on newborn using neonatal cord blood
•
indirect Coombs' test and antibody screen on the mother
•
•
Share your findings and plans with the parents; welcome their input.
•
Respect culture and religious beliefs of the family.
•
Praise the parents' skills.
•
Media and pamphlets are useful teaching aids if the parents have a chance to discuss them;
be mindful of the level of education.
•
Mothers are discharged within 24 to 48 hours; reinforce teaching accordingly.
•
Home visits and follow-up telephone calls enhance discussions about adaptations, questions
and concerns.
•
Women's health promotion should be emphasized in postpartum period.
•
The adolescent mother benefits from developmentally appropriate teaching and referral to
community resources, including parenting classes.
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•
Receptiveness to teaching peaks about 3 to 7 days after delivery.
Points to Remember - Growth & Development
General Concepts
•
Both growth and development normally proceed in a regular fashion from simple to complex
and in a cephalocaudal and proximodistal pattern.
•
Growth and development are impacted by genetics, environment, health status, nutrition,
culture, and family structures and practices.
•
Growth should be measured and evaluated at regular intervals throughout childhood;
deviations from normal growth and development should be thoroughly investigated and
treated as quickly as possible.
•
Development occurs through conflict and adaptation.
Children
•
In the care of children, key concepts are anticipatory guidance and disease prevention.
•
Major developmental tasks of infancy are: increase in mobility, separation, and establishment
of trusting relationships
•
In both toddlerhood and adolescence, hallmarks are development of independence and
further separation.
•
Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition
and give anticipatory guidance related to nutrition.
•
Leading causes of death
•
Ages 0 to 1 year: developmental and genetic conditions that were present at birth, sudden
infant death syndrome (SIDS), all conditions associated with prematurity and low birth
weight.
•
Ages 1 to 4 years: accidents, developmental and genetic conditions present at birth, cancer
•
Ages 5 to 14 years: accidents, cancer, homicide
•
Ages 15 to 24 years: accidents, homicide, suicide
•
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Points to Remember - Growth & Development 2
Older Adults
•
Older adults must adjust to changing physical and cognitive abilities; a majority of older
adults have at least one chronic disease.
•
When older adults experience cognitive changes, check for possible substance abuse or
polypharmacy.
•
Cognitive impairment can be acute and reversible, or it can be chronic and irreversible.
•
Many older adults have some impairment in performance of activities of daily living.
•
Some physiologic changes are a normal part of the aging process and do not signal disease,
e.g., decreased cardiac and respiratory reserves.
•
Older adults usually need more time to complete psychomotor tasks.
•
Age is a weak predictor of survival in traumatic injury and critical illness.
•
Major health problems typically include cardiovascular, cerebrovascular, and respiratory
diseases; diabetes; and cancer.
•
The older adult will change social roles, and these changes may affect psychological health,
leading to depression.
•
Older adults need the same nutrition as other adults, but need more bulk and fiber, and a
more nutrient dense diet containing fewer calories.
•
Older adults clear drugs from kidney and liver more slowly; medications have longer halflives, causing side effects and toxicity at lower doses (Rule: start low [dose], go slow
[increasing the dose]).
•
Older adults with low protein levels may have increased risks of drug toxicity for drugs that
are protein-binding.
Points to Remember - Health Promotion
Data Collection
•
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Check equipment prior to exam for proper functioning.
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•
Take vital signs after the client is at rest for 5 to 10 minutes..
•
Compare both sides of the body for symmetry.
•
Collect data for the systems related to the client's major complaint first.
•
Offer rest periods if client becomes tired.
•
Note if culture and religious beliefs might play a role in observed differences.
•
Warm hands and equipment such as stethoscope before touching client.
•
Tell client what is going to be done before touching client.
•
Keep in mind that normal variations exist among clients with a range of normalcy for
physical findings.
•
Maintain the client's privacy throughout the process.
•
Control for environmental factors which may distort findings - lights, sounds.
•
Consider growth and developmental needs when working with specific age groups.
•
Integrate health teaching or reinforcement throughout the process.
Cardiovascular
•
Compare blood pressure in both arms.
•
Compare blood pressure with client lying, sitting with feet in a dangling position, and
standing.
Points to Remember - Health Promotion 2
Lungs
•
Anemic patients seldom become cyanotic (and are more commonly a dusky-ashen color
when hypoxic).
•
Polycythemic clients may be cyanotic, even when oxygenation is normal.
•
Cough results from stimulation of irritant receptors, with implications of either acute or
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chronic etiology.
•
Cyanosis, either peripheral (hands, feet) or central (circumoral) in origin, is one of the last
signs of decreased available oxygen.
•
Wheezes indicates narrowing/inflammatory process of lower airways, such as bronchioles.
•
Stridor is a harsh sound produced near the larynx by a vibration of structures in upper airway
with a classic "barky cough."
•
Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described
as "moist," "dry," "fine," and "coarse."
Breasts
•
Breast tissue shrinks with menopause
•
Teach client breast self examination
Abdomen
•
Remember that tightening of abdominal muscles hinders accuracy of palpation and
auscultation; position is dorsal recumbent for abdominal evaluation
•
Warm hands before touching client's abdomen.
•
Note that men breathe abdominally; women breathe costally.
•
Auscultate all four quadrants for bowel sounds, starting in the lower right quadrant.
•
Auscultate abdomen between meals if possible.
•
Auscultate the abdomen before performing percussion or palpation to avoid altering the
pattern of bowel sounds
Points to Remember - Health Promotion 3
Musculoskeletal
•
Older adults walk with smaller steps and need a wider base of support.
•
Adolescents should be screened for scoliosis.
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Neurological
•
Glasgow coma score
•
not valid in clients who have used alcohol or other mind-altering drugs.
•
possibly not valid in clients who are hypoglycemic, in shock, or hypothermic (below 93 F
[33.9]).
•
•
Reflexes are normally less brisk or even absent in some areas in elderly clients.
•
Reflex response diminishes in the lower extremities before the upper extremities are affected.
•
Absent reflexes may indicate a neuropathy or a lower motor neuron disorder, resulting in
flaccidity.
•
Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity.
Reinforcement of Health Care Team Teaching
•
The teaching-learning process mirrors the nursing process.
•
Teaching strategies are to be compatible with the client's learning style, age, culture, level of
education.
•
Client teaching should be multi-sensory - tell (auditory), show (visual), have them
demonstrate (tactile).
•
The client's learning style is determined and teaching methods geared to using that style.
•
The client's understanding is to be validated and documented.
•
Teaching must be geared to the educational level and interest of the learner - most written
materials are written at the sixth to eighth grade level.
•
Repeat key information and summarize main points at intervals.
•
Medical terminology should be stated in lay terms.
•
Information should be sequenced the way the client will use it.
•
Be concrete and use the simplest words and the shortest sentences when teaching low literacy
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clients or any client under stress.
Points to Remember
Coping and Defense Mechanisms
•
People use coping mechanisms and ego-defense mechanisms to relieve anxiety and stress.
•
They are usually unconscious; that is, the client is not aware of their use.
•
Depending on the situation and how often these mechanisms are used, they may be healthy
or unhealthy.
Therapeutic Communication
•
The three phases of a therapeutic relationship include the initial phase, the working phase,
and the termination phase.
•
Make eye contact, without staring (but be aware of cultural differences regarding eye
contact) and be aware of your own body language - use an open body posture and appear
relaxed.
•
Show empathy, genuine caring, and respect.
•
Use therapeutic techniques such as open-ended questions, unless the client is cognitively
impaired; use "yes" or "no" questions with the cognitively impaired, severely depressed
clients or clients with respiratory distress.
Grief
•
Since the distinction between grieving and depression can be a matter of degree, look for
signs of clinical depression.
•
Grieving takes time; the amount of time varies with individuals.
•
The stages of grief are not linear; they may come and go.
•
Grief follows death; but also follows any loss, e.g., divorce, loss of job, loss of financial
status, retirement, loss of limb or other physical disability.
•
Be aware of culturally diverse ways of responding to grief, which are important in collecting
data about grief reaction and in respecting the customs and rituals of a cultural group.
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•
Beware of personal reaction to death and over identification with client; when necessary,
seek assistance to cope with personal issues.
Stress Management
•
Severity of reaction to a stressor depends on how it is interpreted or perceived by the
individual and the meaning or significance given to it.
•
Physical and emotional stressors trigger the same stress response; however the magnitude of
the response may vary.
•
Duration and intensity of physiologic indicators are directly related to the duration and
intensity of the stress.
•
Prolonged stress decreases the adaptive capacity of the body.
Points to Remember 2
Mental Disorders
•
Bipolar and related disorders are characterized by mood swings; depressive episodes are
more common than mania.
•
Know the therapeutic lab values for the mood stabilizer, lithium carbonate (Lithane): 0.8 to
1.2 mEq/L; overdose symptoms may include nausea, vomiting, diarrhea, drowsiness, muscle
weakness, tremor, lack of coordination, blurred vision or tinnitus.
•
Suicide precautions are started when a client verbalizes and/or makes an overt suicidal
attempt, including attempts at self-mutilation.
•
Electroconvulsive therapy (ECT) is a very effective and generally safe treatment for severe
depression. The procedure uses a small amount of electric current to trigger a seizure.
Confusion and temporary memory loss is an expected side effect.
•
Feeding and eating disorders can affect every body system. Clients should be monitored
for electrolyte imbalance, anemia, malnutrition, dehydration, and bone density.
•
Autism (a neurodevelopmental disorder) affects the brain's normal development of social
and communication skills; it affects boys more often than girls and is typically diagnosed
between the ages of 18 months to 2 years of age.
•
Attention deficit hyperactivity disorder (a neurodevelopmental disorder) symptoms fall
into 3 categories: inattentiveness, hyperactivity, and impulsivity.
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•
Health care workers should take care to be sensitive to cultural differences, since personality
disorders are typically based on Western ideas.
•
Schizophrenia ranks among the top 10 causes of disability in developed countries; it is
treatable but cannot be cured.
•
Programs that train clients with schizophrenia on the primary activities of daily living
(ADLs) have been shown to enhance their social skills, motivation, and desire to change
while decreasing their lethargic and apathetic state.
•
Long-acting injectable antipsychotic medications (LAIs) or “depot formulations” are given
once every 1 to 4 weeks, which improves medication compliance.
•
Delirium tremens is a severe form of alcohol withdrawal, commonly occurring within 72
hours after the last drink; associated findings may include seizures and severe mental status
changes, e.g., agitation, confusion, delirium, hallucinations.
•
It's important to treat the symptoms of withdrawal as well as any underlying mental disorders
and infectious processes.
•
Complementary and alternative therapies can be used to treat many of the mental disorders.
Clients should understand that concurrent use of prescribed medications and some
complementary and alternative medications may cause adverse or life-threatening effects.
•
Treatment of post-traumatic stress disorder includes cognitive behavioral therapies, eye
movement desensitization and reprocessing (EMDR), hypnotherapy and medications.
Points to Remember
Nutrition & Fluid Intake
•
All individuals require the same nutrients, but the amounts vary according to factors such as
age, weight, activity level, and health state.
•
The energy value of foods is defined in calories; only proteins, fats and carbohydrates
provide calories.
•
Essential amino acids cannot be synthesized; they must be ingested daily.
•
Weight is maintained when daily food intake equals energy expenditure.
•
Weight loss is a long-term process and patients need long-term support.
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•
Increased fiber in the diet may cause flatulence.
•
The normal thirst mechanism in the elderly may be diminished and they may need
encouragement to drink sufficient water to prevent dehydration.
•
The average adult drinks 2 to 3 liters of water per day.
•
Normal lab values to know:
•
•
Sodium: 135 - 145 mEq/L
•
Potassium: 3.5 - 5.1 mE1/L
•
Chloride: 96-106 mEq/L
•
Bicarbonate: 22 - 29 mEq/L
Elimination
•
In constipation, increase fluid to 3000 mL/day (unless contraindicated).
•
Small frequent loose stools or seepage of stool are often indicative of a fecal impaction.
•
Use transparent drainage bag initially for assessment of stoma and drainage.
•
Avoid foods that cause odor, gas, diarrhea, or may block ileostomy.
•
The majority of residents in nursing homes are incontinent but incontinence is not a normal
sequela of aging.
Points to Remember 2
Pain
•
Allow the client to rate the degree of pain (typically using a 10 point scale) and later to assess
(and chart) degree of relief from pain relief measures.
•
Self-control methods to manage pain: distraction, massage, guided imagery, relaxation,
biofeedback, and hypnosis.
•
Initiate pain relief before the pain becomes unbearable.
•
Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks and
valleys of nurse-administered narcotics; clients typically use less pain medication overall
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than clients receiving nurse-administered narcotics.
•
Be sure to assess and monitor respiratory rate for client on PCA; naloxone (Narcan) is used
to reverse the effects of narcotics.
Mobility
•
There should be at least two inches between axilla and top of arm piece of crutch to prevent
pressure on the brachial plexus.
•
Prevent deformities and complications such as contractures, thrombophlebitis, and pressure
ulcers by regularly turning and positioning the client in good alignment.
•
Discontinue range of motion exercises at point of pain.
•
Use non-skid, rubber tips on crutches and canes to prevent slipping.
Points to Remember
The following are basic critical thinking guidelines for safe drug administration.
Before administration
•
Assist health care team to gather general baseline data
•
vital signs, including height and weight
•
allergies, co-morbidities
•
laboratory results
•
hepatic, pulmonary, renal, neurologic, nutritional, and cardiovascular status
•
•
Identify client factors, including the affect of developmental status, cultural factors, and
history of drug action, safe to use during pregnancy
•
Determine purpose of therapy
•
indication for drug
•
desired therapeutic outcome
•
•
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Know expected side effects, adverse effects and/or toxic effects and how to prevent or treat
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adverse effects
•
Reconcile medication profile with client, family, nursing staff, provider
•
Verify prescription and client, including dose, time, calculations, dosing range, dispensing
method
After administration
•
Assist health care team to check client response to therapy and report findings
•
therapeutic effect
•
adverse effects or toxicity
•
•
Document findings including data requiring action or follow-up nursing care
•
Document nursing care including care given before and after drug administration
•
Evaluate care and processes, including any med errors or problems
Reinforce client teaching: assist health care team to implement client teaching plan
•
What to report
•
How to administer
•
Food, substances, activities to avoid
•
Need for follow-up care and testing
•
How and when to activate emergency services or contact provider
Points to Remember 2
The following is a list of basic nursing care to prevent or minimize common adverse effects of drug
therapy.
•
Nausea, vomiting, anorexia
•
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Nursing care: collaborate for antiemetic, eliminate triggers, maintain NPO status
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•
Monitoring: assist health care team to
•
check fluid and electrolyte balance; bowel sounds and elimination pattern; food intake
•
track blood pressure; skin and mucous membranes for moisture; urinary output; and
serum sodium, potassium and chloride
•
•
Assist health care team to implement client teaching plan:
•
progress from NPO to clear liquids to small, frequent meals
•
breathing techniques
•
avoid triggers
••
•
Constipation
•
Nursing care: provide fluid, fiber, stool softener, encourage ambulation
•
Monitoring: assist health care team to check bowel sounds, pattern; review diet for fluid,
fiber
•
Assist health care team to implement client teaching plan: increase fluid, fiber; ambulate;
establish bowel habits
•
•
Diarrhea
•
Nursing care: provide hygiene, skin care, close supervision to prevent injury
•
Monitoring: assist health care team to check bowel pattern, fluid and electrolytes balance,
weakness, skin, cultures
•
Assist health care team to implement client teaching plan: increase fluid intake, wash
hands, avoid irritating foods
•
•
Rash, allergy
•
Nursing care: screen for allergies, previous reactions, provide skin care
•
Monitoring: assist health care team to check airway, breathing, blood pressure, skin,
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pruritus, cultures
•
Assist health care team to implement client teaching plan: report dyspnea, pruritus, hives,
worsening condition
•
•
Hypotension, dizziness
•
Nursing care: maintain supine position, encourage fluids, review med profile; protect client
•
Monitoring: assist health care team to check vital signs, SaO2, ECG, level of
consciousness, urinary output
•
Assist health care team to implement client teaching plan: remain in bed; ask for help to
stand; avoid alcohol, sedation
•
Points to Remember 3
The following is a list of adverse effects associated with drug classes or types and associated
nursing care and client teaching
•
Antihypertensives: orthostatic hypotension, fluid and electrolyte imbalance
•
Nursing care: assist with activity; eliminate drug interactions, vasodilators, central nervous
system depressants
•
monitoring: assist health care team to check blood pressure for hypotension if they are
taking a diuretic also, pulse, breath sounds, serum electrolyte levels, edema, dizziness
•
assist health care team to implement client teaching plan: get help to stand, report dizziness;
avoid alcohol, sedatives, over-the-counter agents, caffeine, change positions slowly.
Reinforce client to take blood pressure and pulse daily.
•
•
Anticholinergic agents: dry mouth, constipation, blurred vision
•
nursing care: provide sips of water and oral care; assist with activity; remove environmental
hazards
•
monitoring: assist health care team to check bowel pattern, vision, oral mucous membranes
•
assist health care team to implement client teaching plan: frequent oral care, avoid
dangerous activity, ask for help to stand
•
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•
Anticoagulants and anti-platelet agents: bleeding
•
nursing care: minimize invasive procedures, shaving; provide gentle oral care; assist with
activity
•
monitoring: assist health care team to check bleeding, coagulation tests, complete blood
count, bruising; remove adverse drug and food affects
•
assist health care team to implement client teaching plan: avoid dangerous activity, wear
MedicAlert® identification, avoid NSAIDs, alcohol, avoid eating food rich in vitamin K
•
•
Anticonvulsants: CNS depression, myelosuppression: infection and bleeding
•
nursing care: assist with activity; protect airway, breathing; minimize invasive procedures
•
monitoring: assist health care team to check seizure activity, complete blood count with
differential, temperature, regional redness, swelling, or drainage, monitor liver enzyme tests
•
assist health care team to implement client teaching plan: wear MedicAlert® identification,
avoid dangerous activity, wash hands, avoid crowds, need for follow-up care and testing,
avoid alcohol
•
•
Antidysrhythmics: new or more dangerous dysrhythmias, changes in blood pressure
•
nursing care: maintain fluid and electrolytes balance, SaO2 >95%, sinus rhythm; assist with
position changes
•
monitoring: assist health care team to check pulmonary function test, EKG, blood pressure,
pulse, SaO2, serum electrolytes, level of consciousness
•
assist health care team to implement client teaching plan: ask for help to stand; report
irregular pulse and technique for counting pulse, call doctor if the client develops
palpitations, weakness, loss of appetite
•
•
Antiinfective agents: renal and hepatic dysfunction
•
nursing care: obtain cultures before administration, verify administration guidelines, screen
for renal and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugs
•
monitoring: assist health care team to check renal function tests, liver enzyme tests,
jaundice, dark stool or urine, nausea and vomiting
21
Nclex
•
assist health care team implement client teaching plan: report nausea, vomiting, dark stool
or urine, jaundice; need for follow-up care and testing, reinforce take all medications as
prescribed, report any allergic reaction, report sudden weight gain as this may indicate
adverse effects on the kidney
•
•
Loop, thiazide diuretics: circulatory collapse, myelosuppression, fluid and
electrolytes imbalance, ototoxicity
•
nursing care: verify infusion guidelines, blood pressure, serum electrolytes, and urinary
output before giving
•
monitoring: assist health care team to check serum sodium and potassium, breath sounds,
edema, blood pressure, urinary output
•
assist health care team to implement client teaching plan: report palpitations, weakness,
irregular pulse, decreased urinary output, temperature
•
•
Female hormones: thromboembolic disorders, increased risk of breast and endometrial
cancer, hyperglycemia, hypercalcemia, depression, seizures
•
monitoring: assist health care team to check peripheral perfusion, edema; leg pain,
tenderness; serum calcium, glucose, cytology
•
assist health care team to implement client teaching plan: report lumps and abnormal
bleeding, muscle twitching
Drug Classifications
The following is a list of the major drug classifications. "Memory tricks" are included where
applicable.
•
A
•
Antianemics: prevention and treatment of anemias
•
Antianginals
▪
nitrates: used to treat and prevent attacks of angina; acute treatment
▪
calcium channel blockers and beta blockers are used prophylactically for longer-term management
•
•
Antianxiety agents
▪
22
benzodiazepines: better for intermittent or short-term use in the management of anxiety
Nclex
▪
•
•
buspirone, paroxetine, venlafaxine: better for long-term use
Antiarrhythmics: suppression of cardiac arrhythmias
▪
generally classified by their effects on cardiac conduction tissue (Class IA, IB, IC, II, III & IV)
▪
atropine and digoxin: also used as antiarrhymics
•
•
Antiasthmatics: management of acute and chronic episodes of reversible bronchoconstriction
•
Anticholinergics
▪
atropine: bradyarrhythmias
▪
ipratropium: bronchospasm
▪
atropine: also used as ophthalmic mydriatic
▪
benztropine: management of Parkinson's disease
•
•
Anticoagulants: prevention and treatment of thromboembolic disorders
•
Anticonvulsants: decrease the incidence and severity of seizures due to different etiologies
•
Antidepressants
•
Antidiabetics
▪
insulin: type 1 diabetes mellitus
▪
oral agents used primarily in type 2 diabetes mellitus
•
•
Antidiarrheals: for control and symptomatic relief of acute and chronic nonspecific diarrhea
•
Antiemetics: used to manage nausea and vomiting due to many causes, including surgery, anesthesia,
and antineoplastic and radiation therapies
•
Antifungals:memory trick - most end with "AZOLE"
•
Antihistamines
▪
23
used for relief of symptoms associated with allergies and as adjunctive therapy in anaphylactic
Nclex
reactions
▪
•
•
Antihypertensives: including, but not limited to, the following
▪
ACE inhibitors: treatment of choice for hypertension;memory trick - most end with "PRIL"
▪
angiotension receptor blockers:memory trick - most end with "SARTAN", including losartan
(Cozaar), valsartan (Diovan)
▪
beta blockers (see below)
▪
calcium channel blockers (see below)
•
•
Anti-infectives: treatment and prophylaxis of various bacterial infections
•
Antineoplastics: used in the treatment of various solid tumors, lymphomas, and leukemias
•
Antiplatelet agents: used to treat and prevent thromboembolic events, e.g., stroke, myocardial
infarction
•
Antipsychotics
•
Antipyretics: used to lower fever of many causes, including infection, inflammation, and neoplasms
•
Antirheumatics: used to manage symptoms of rheumatoid arthritis and slow down joint destruction and
preserve joint function
•
Antituberculars: used in the treatment and prevention of tuberculosis
•
Antiulcer agents
•
•
•
•
some are used to treat insomnia and Parkinson-like reactions
B
24
▪
used in the treatment and prophylaxis of peptic ulcer and gastric hypersecretory conditions, e.g.,
Zollinger-Ellison syndrome
▪
memory trick - most end with "PRAZOLE", including omeprazole (Prilosec), pantoprazole
(Protonix), esomeprazole (Nexium)
Antivirals:memory trick - many end with "CY[I]CLOVIR", including acyclovir (Zovirax), valacyclovir
(Valtrex)
Nclex
•
Beta blockers:
▪
used in the management of hypertension, angina pectoris, tachyarrhythmias, migraine headache
(prophylaxis), MI (prevention), glaucoma (opthlalmic use), CHF (carvedilol and sustained-release
metoprolol only), hyperthyroidism (management of symptoms only)
▪
memory trick - most end with 'OLOL", "ALOL" or "ILOL"
•
•
•
•
Bone resorption inhibitors
▪
used to treat and prevent osteoporosis in postmenopausal women
▪
also used to treat osteoporosis due to corticosteriod therapy, treatment of Paget's disease of the bone,
and management of hypercalcemia
•
C
•
Calcium channel blockers
▪
used in the treatment of hypertension (amlodipine, diltiazem, felodipine, isradipine, nicardipine,
nifedipine, nisoldipine, verapamil)
▪
also used in the treatment and prophylaxis of angina pectoris or coronary artery spasm (amlodipine,
diltiazem, felodipine, nicardipine, verapamil)
▪
memory trick - most end with "DIPINE"
•
•
•
•
Corticosteriods:
▪
used in replacement doses (20 mg of hydrocortisone or equivalent) systematically to treat
adrenocortical insufficiency
▪
larger doses are usually used for their anti-inflammatory, immunosuppressive, or antineoplastic
activity
•
D
•
25
Diuretics
▪
thiazide diuretics and loop diuretics are used alone or in combination in the treatment of
hypertension or edema due to CHF or other causes
▪
potassium-sparing diuretics have weak diuretic and antihypertensive properties and are used to
Nclex
conserve potassium in clients receiving thiazide or loop diuretics
▪
•
•
•
H
•
•
•
Hormones
▪
used in the treatment of deficiency states including diabetes (insulin), diabetes insipidus
(desmopressin), hypothyroidism (thyroid hormones), and menopause (estrogens or
estrogens/progestins)
▪
hormones may be used to treat hormonally sensitive tumors (androgens, estrogens)
•
I
•
•
•
•
•
osmotic diuretics are often used in the management of cerebral edema
Immunosuppressants:
▪
most are used in the prevention of transplantation rejection reactions
▪
others are used in the management of selected autoimmune diseases (nephrotic syndrome of
childhood and severe rheumatoid arthritis)
•
L
•
Laxatives: used to treat or prevent constipation or to prepare the bowel for radiologic or endoscopic
procedures
•
Lipid-lowering agents:
▪
used as a part of a total plan, including diet and exercise, to reduce blood lipids in an effort to reduce
the morbidity and mortality of atherosclerotic cardiovascular disease and its sequelae
▪
memory trick - many end with "STATIN", e.g., atorvastatin (Lipitor), simvastatin (Zocor),
rosuvastatin (Crestor)
•
M
•
Minerals/electrolytes/pH modifiers
▪
26
used in the prevention and treatment of deficiencies or excesses of electrolytes and maintenance of
optimal acid/base balance for homeostasis
Nclex
▪
•
•
•
•
•
•
•
N
•
Nonopioid analgesics: used to control mild to moderate pain and/or fever
•
Nonsteroidal anti-inflammatory agents: used to control mild to moderate pain, fever, and various
inflammatory conditions, e.g., rheumatoid arthritis and osteoarthritis
•
Opioid analgesics: used in the management of moderate to severe pain
•
Sedative/hypnotics
O
S
▪
used to provide sedation, usually prior to procedures
▪
selected agents are useful as anticonvulsants, skeletal muscle relaxants, adjuncts in general surgery
and adjuncts for the treatment of alcohol withdrawal syndrome
•
•
•
•
•
•
acidifiers and alkalinizers are also used to promote urinary excretion of substances that accumulate in
some disease states, e.g., kidney stones
Skeletal muscle relaxants
▪
used to treat spasticity (associated with spinal cord diseases or lesions)
▪
used as adjunctive therapy in the symptomatic relief of acute painful musculoskeletal conditions
▪
IV dantrolene is also used to treat and prevent malignant hyperthermia
•
T
•
Thrombolytics: used for the acute management of coronary thrombosis (MI), massive pulmonary
emboli, deep vein thrombosis, and arterial thromboembolism
•
Vascular headache suppressants
V
▪
27
used for the treatment of vascular headaches, e.g., migraine and cluster headaches;memory trick many end with "TRIPTAN", including sumatriptan (Imitrex)
Nclex
▪
other agents are used for suppression of frequently occurring vascular headaches, e.g., some beta
blockers and calcium channel blockers
Medications Causing Confusion in the Elderly
• Antidepressants (tricyclic)
•
medications: amitriptyline (Elavil and others), doxepin (Sinequan), imipramine
(Tofranil and others)
•
clinical considerations: decreased plamsa clearance; prolonged half-life
•
•
Antiemetics
•
medications: prochlorperazine (Compazine), promethazine (Phenergan)
•
clinical considerations: central nervous system anticholinergic effect
•
•
Antihistamines
•
medications: diphenhydramine (Benadryl), hydroxyzine (Atarax and others)
•
clinical considerations: central nervous system anticholinergic effect
•
•
Antipsychotics
•
medications: chlorpromazine (Thorazine and others)
•
clinical considerations: increased sensitivity; half-life may be prolonged because of
altered hepatic function
•
•
Benzodiazepines
•
medications: lorazepam (Ativan), diazepam (Valium), midazolam
•
clinical considerations: decreased plasma clearance; prolonged half-life; active
metabolites resulting from longer-acting agents prolong duration of action and
accumulate with frequent dosing
•
•
Narcotics
•
28
medications: morphine (MS Contin and others), meperidine (Demerol),
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hydromorphone (Dilaudid), fentanyl (Sublimaze)
•
•
•
clinical considerations: active metabolites resulting from longer-acting agents prolong
duration of action and accumulate with frequent dosing; increased risk of
accumulation of drugs or metabolites
Sedative-hypnotics
•
medications: zolpidem (Ambien), temazepam (Restoril)
•
clinical considerations: central nervous system anticholinergic effect
•
•
Other
•
medications: digoxin (Lanoxin), nifedipine (Procardia and others), predniSONE
(Deltasone), cimetidine (Tagamet), rantidine (Zantac)
•
clinical considerations: central nervous system anticholinergic effect
•
Points to Remember
Specimens
•
Obtain all specimens using gloves and sterile collection equipment.
•
Seal all specimen containers tightly, usually placed in a biohazard plastic bag.
•
Label all specimens with client's name, content, date obtained, and sequence number if
more than one specimen taken.
X-rays and other diagnostic tests
29
•
Anticipate a two view minimum.
•
Joints above and below suspected fracture are included.
•
Not all fractures show on x-ray; diagnosis may rely on clinical evidence.
•
Especially in children, x-rays of the unaffected limb may be needed for comparison.
•
Following a laproscopy, carbon dioxide trapped in the abdomen may cause discomfort
Nclex
and even shoulder pain.
•
Be sure to remember to ask client if s/he is allergic to shellfish prior to any test using
Iodine-based contrast media.
Nasogastric or Intestinal Intubation
•
Placement of tube is confirmed by x-ray when first inserted.
•
Check placement of tube by aspirating stomach contents and testing for pH thereafter
(for gastric placement - should be less than 5).
Ostomies
•
A stoma has no feeling, so touching it causes no pain or sensation to the client.
•
A colostomy may not function for 5 to 7 days after surgery.
•
Initially ileostomy drainage may be copious and green in color changing to brown once
client resumes normal diet for a few days.
•
The bowel must be totally healed before attempting irrigation of a colostomy.
•
Infection, diet or medication may cause spillage between normal colostomy evacuations.
•
Findings of bowel perforation include sudden rigid, painful abdomen (called 'boardlike') with an absence of bowel sounds and no output from colostomy except small
amount of blood.
•
There will always be some mucus in urinary diversions that involve segments of bowel,
such as ileal loop or continent urinary diversion.
Casts
30
•
A cast may be heavy or impair mobility due to its location or type of casting material.
•
Analgesics given 20 to 30 minutes before casting reduce pain; analgesics such as
Valium or Versed may be given to minimize recall of the reduction process.
•
A cast should be snug but not restrict circulation.
Nclex
•
For proper drying, casts must dry from inside out; covering delays drying.
•
Cast may smell sour but should never smell foul.
•
Elevation on two to three pillows and use of ice bags may reduce or minimize swelling.
•
Report signs of neurovascular impairment immediately (compartment syndrome is a
medical emergency).
Traction
•
Maintain established line of pull and counter traction continuously.
•
Prevent friction between device and body.
•
Maintain proper body alignment; use draw sheets to pull clients up in bed.
•
Effective traction correctly aligns affected bones and body parts.
•
Pain and spasms should be relieved by traction; if pain or spasms remain at the same
level or increase, further data collection and health care provider notification are needed.
•
Client does not have to keep other body parts immobile.
Tracheostomy
31
•
Clients with new tracheostomy tubes may have bloody secretions for 24 to 48 hours
after the procedure or after a tube change.
•
Tracheostomy obturator should be attached to head of bed in a secure, clear package at
all times.
•
Pediatric tracheostomy tubes do not usually have an inner cannula.
•
Children have shorter necks so stoma care may be more difficult.
•
Yeast infections can form under moist tracheostomy dressings and around the neck
where ties are found.
•
Clients with these problems may need more frequent tracheostomy care:
Nclex
•
•
•
Tracheal stomatitis
•
Pneumonia
•
Bronchitis
•
Short, fat neck
•
Excessive perspiration
Always have another nurse or family member assist with tracheostomy care to minimize
accidental dislodgement or extubation.
•
Because the upper airway is functioning minimally, expect more secretions.
•
Drainage after a tracheostomy tube insertion should be minimal in the initial 24 hours.
Suctioning and chest physiotherapy
•
Suction no sooner than 2 to 3 hours after client has eaten a meal.
•
Apply suction for no longer than 10 seconds; apply oxygen prior to and immediately
after suctioning.
•
Be sure to have emesis basin and tissues at hand.
•
Administer any bronchodilating medications at least 1/2 hour before chest
physiotherapy.
Catheterization
•
Intermittent catheterization at home may be a clean, not sterile, procedure.
•
Full bladders in clients with high thoracic spinal cord injuries may stimulate
hypertensive crisis.
Surgery
32
•
Time frames for surgical consents vary among states and facilities.
•
Primary responsibility for obtaining surgical consent rests with the surgeon.
Nclex
•
Informed consent cannot be obtained if the client has an altered level of consciousness,
is mentally incompetent, or is under the influence of mind-altering drugs.
•
Essential to all preop teaching is discussion of all preop and postop routine procedures,
along with a demonstration/return demonstration by client of postop exercises.
•
Outpatient surgeries exceed inpatient surgeries in many facilities.
Radiation
•
Radiation is more effective on local or regional neoplasia while chemotherapy is more
systemic in its effects.
•
Only certified nurses may administer chemotherapeutic agents.
•
Ionizing radiation will damage both normal and cancerous cells resulting in side effects
of the site and surrounding tissues.
•
Clients receiving external radiation are not radioactive at any time during or after the
procedure.
•
Clients with internal radiation are not radioactive; the implant or injection is within the
body.
•
If the source of radioactivity is metabolized, the client's secretions and excretions may
be radioactive for a time, based on the half-life of the isotope.
•
33
•
Urinary and bowel excretions - flush toilet twice afterwards
•
Restrict contact - no contact with children or pregnant women for three to seven days
Wounds
•
Never touch a wound without wearing gloves.
•
Remove old dressings with clean gloves by lifting from the center of the dressing, not
the edges.
•
First postoperative dressing change is performed by health care provider.
•
Give analgesic before dressing change, scheduled so that medication peaks during
Nclex
change process.
•
Follow principles of surgical asepsis
•
If drains are present, remove dressing one layer at a time to avoid dislodging the drain.
•
Pressure dressings should not be removed until written order from health care provider.
•
If dressing must be changed frequently, Montgomery straps will prevent skin
breakdown from frequent tape removal.
•
Wounds out of the client's field of vision or reach or if a client has motor problems in
hands or fingers require the client to have help in the dressing change.
Hemodyalysis
•
NEVER take a blood pressure or draw blood from the arm with the fistula.
•
Monitor patency of fistula; auscultate for a bruit and palpate for a thrill.
Surgical Asepsis
• Surgical asepsis includes the practices that destroy all microorganisms and their spores
•
Steam under pressure
•
Gas
•
Radiation
•
Chemicals
•
•
•
•
34
Sterile technique involves procedures that keep an object or area free from living
organisms
•
A sterile object remains sterile only when touched by another sterile object, or, in
other words, sterile touching sterile remains sterile
•
The skin cannot be sterilized and is, therefore, non-sterile
Surgical asepsis is used for many procedures, including
Nclex
•
Care of surgical wounds, i.e., dressing changes
•
Catheterizations
•
Tracheostomy care
•
Suctioning
•
Surgery
•
•
Principles of surgical asepsis
•
Only sterile objects may be placed on a sterile field
•
Always hold your hands above the level of your elbows
•
Do not reach over the sterile field
•
The edges of a sterile field or container are considered contaminated (depending on the
resource, this is approximately 1 to 2 inches surrounding the border)
•
•
A sterile object becomes contaminated under the following conditions:
•
Sterile touching clean becomes... contaminated
•
Sterile touching contaminated becomes... contaminated
•
Sterile touching questionable is... contaminated
•
A sterile object or sterile field that is not in the range of vision is... contaminated
•
An object held below a person's waist is... contaminated
•
When a sterile object comes in contact with a wet, contaminated surface, it is
considered contaminated (through capillary action)
•
A sterile object becomes contaminated with prolonged exposure to air
•
Points to Remember
35
Nclex
36
•
The average age at diagnosis for pernicious anemia is 60 years-old; monthly injections
are prescribed to correct the deficiency.
•
Vitamin B12 deficiency is the number one cause of nutritional dementia and one of the
main causes of peripheral neuropathy in the elderly; it may be a contributing factor in
depression (B12 is a cofactor in the production of serotonin).
•
A peptic ulcer is a sore in the lining of the stomach or duodenum; treatment may include
medications to block stomach acids or antibiotics.
•
A client with esophageal varices must be monitored for bleeding, e.g., melena stools,
hematemesis, tachycardia.
•
The rupture of esophageal varices is life threatening and associated with a high mortality
rate.
•
Ulcerative colitis and crohn's disease are chronic inflammatory intestinal diseases with
unknown etiology.
•
When assessing a client, frequent liquid stools can be indicative of a fecal impaction or
intestinal obstruction - not diarrhea!
•
Diverticula are most common in the sigmoid colon.
•
Clients with diverticulosis are often asymptomatic.
•
A deficiency in dietary fiber is associated with diverticulitis.
•
Ascending colostomy drains liquid feces, is difficult to train and requires daily
irrigation; descending colostomy drains solid feces and can be controlled.
•
Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.
•
Most obstructions occur in the small bowel.
•
Most large bowel obstructions are caused by cancer.
•
Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise,
altered bowel habits, nausea and vomiting.
•
Management of cirrhosis is directed towards avoiding complications, which is achieved
Nclex
by maintaining fluid, electrolyte and nutritional balance.
•
Hepatitis develops in three stages: pre-icteric (pre-jaundice) or prodromal; icteric; and
post-icteric (post-jaundice).
•
Common symptoms of hepatitis include abdominal pain, dark-colored urine, pale stools
and pruritus; jaundice may occur in some, but not all, cases.
•
Pancreatitis is often associated with excessive alcohol ingestion.
•
Pancreatic cancer is an insidious disease that often goes undetected until its later stages;
it is the fourth leading cause of cancer deaths among both men and women.
Points to Remember
37
•
After a urinary catheter is removed, the client may have some burning on urination,
frequency and dribbling but these symptoms should subside within 24 to 48 hours.
•
Co-trimoxazole (Bactrim) remains the drug of choice to treat urinary tract infections
(unless the client is allergic to sulfa).
•
After a transurethral resection of the prostate (TURP), tell clients that because the threeway Foley catheter has a large diameter, they will continuously feel the urge to void for
24 to 48 hours.
•
After prostatic surgery, it is normal for the client's urine to be blood-tinged and for him
to pass medium to small blood clots and tissue debris for 24 to 48 hours.
•
Because the prostate gland receives a rich blood supply, it is a priority to observe clients
undergoing a prostatectomy for bleeding and shock.
•
Chlamydia is the most common sexually transmitted bacterial infection in the U.S. If
untreated, it can cause PID in women and epididymitis in men.
•
HPV vaccine Gardasil® protects against types of HPV that cause most cervical cancers
and can help protect against genital warts in both young men and women.
•
Be sure to assess the site of the AV fistula of the client receiving hemodialysis for the
thrill (it feels like water running through a thin hose) and bruit (a swishing or swooshing
sound heard on auscultation).
•
Clearly communicate that no blood pressures or blood draws should be taken on the arm
Nclex
with the fistula.
•
Recent studies have shown that foods high in calcium, including dairy products, may
help prevent kidney (calcium) stones.
•
Many STD's are reportable to the CDC.
•
When CD4 cell count falls below 200, the client is at high risk of developing
opportunistic infections.
•
Common management of HIV infection is the highly active antiretroviral therapy
(HAART) regimen.
•
Adherence prolongs the life of an HIV infective client.
Points to Remember
Endocrine System
•
The endocrine system controls maturation, development, growth, and regulation within
the body; the functions of the endocrine and nervous systems are interrelated.
•
Endocrine disorders may be caused by
•
38
•
hyper- or hyposecretion of hormones
•
hyporesponsiveness of hormone receptors
•
inflammation of glands
•
tumors
Pancreas
•
In the pancreas, the beta cells in the islets of Langerhans make insulin.
•
Clients with type 1 diabetes typically test blood sugar 4 times a day (before meals and at
bedtime); those using an insulin pump may test more frequently.
•
Treatment for type 2 diabetes typically includes oral antidiabetic agents.
•
Hypoglycemia, allergic reactions, lipodystrophy, and Somogyi effect are problems
Nclex
associated with insulin therapy.
•
Exercise increases the body's metabolic rate that results in a decrease in blood sugar and
an increase in insulin sensitivity.
•
Illness can disrupt metabolic control and raise blood sugar, which results in an increased
need for insulin.
•
Glycated hemoglobin (HbA1c) provides a good estimate of how well diabetes has been
managed in the past 2 to 3 months. A HbA1c of 6% or less is normal; diabetics should
try to keep their HbA1c below 7%.
•
Diabetes is the leading cause of heart disease, stroke, adult blindness and nontraumatic
lower limb amputations.
•
The highest incidence of diabetes is among Native Americans.
•
Target blood glucose levels before a meal is between 90 to 130 mg/dL; 1 to 2 hours after
a meal it should be less than 180 mg/dL.
•
Diabetic ketoacidosis (DKA) occurs more commonly in type 1 diabetes whereas
hyperosmolar hyperglycemic nonketotic syndrome (HHNS) occurs most often in clients
with type 2 diabetes.
Points to Remember
General Information
•
For contusions, strains, and sprains, apply ice for the first 24 to 48 hours to relieve pain
and reduce swelling, and then apply heat as necessary.
•
Gout is a type of painful arthritis that is made worse by diuretics, consuming alcoholic
beverages and eating a purine-rich diet (anchovies, sardines, organ meats, yeast,
legumes, asparagus, cauliflower and mushrooms).
•
Rheumatoid arthritis affects joints symmetrically (bilateral involvement); osteoarthritis
affects joints asymmetrically.
•
Diagnosis of osteoporosis is a combination of assessing clinical risk factors and a bone
mineral density assessment.
•
39
Dual x-ray absorptiometry (DXA) measures the bone mineral density of the spine and
Nclex
hips; a T-score of +1 to -1 is considered "normal" and a score of -2.5 or lower
indicates osteoporosis.
•
•
•
Osteoporosis cannot be detected by conventional x-ray until more than 30% of bone
calcium is lost.
The classic finding of the autoimmune condition of systemic lupus erythematosus is the
butterfly rash over cheeks and nose.
•
When performing a musculoskeletal assessment on a client with Paget's disease, note
the size and shape of the skull; the skulls of these clients will be soft, thick and enlarged.
•
Clients at high risk for acute osteomyelitis are typically elderly, diabetics, and have
peripheral vascular disease.
Orthopedic Surgery
•
Suspect compartment syndrome for someone whose pain is out of proportion to the
injury or is unrelieved by narcotics; compartment syndrome can lead to permanent
muscle and nerve damage without quick (surgical) intervention.
•
After hip replacement surgery, pulmonary embolism may occur even without
thrombosis in a foot or leg.
•
Remind clients to use incentive spirometer and perform exercises in bed (ankle pumps,
quadriceps sets, gluteal sets) to help prevent thrombi from forming.
•
After a hip pinning or femoral-head prosthesis
•
•
•
Clients should not to force hip into more than 90° of flexion, adduction or internal
rotation since these will cause dislocation and severe pain.
•
Clients should be instructed to sit in a straight, high chair, use a raised toilet seat, and
not to cross their legs.
Neurovascular checks include: pain, sensation, skin temperature, skin color, capillary
refill, pulses, and movement.
Points to Remember
•
40
Only certified (registered) nurses may administer chemotherapeutic agents.
Nclex
•
Clients undergoing chemotherapy should avoid crowds and persons with infections and
to report signs of infection.
•
Radiation has local effects related to site irradiated; chemotherapy is more systemic.
•
Biological therapies (interferons, interleukins, colony-stimulating factors, monoclonal
antibodies, vaccines, gene therapy, and nonspecific immunomodulating agents) use the
body's immune system to fight cancer or to lessen the side effects that may be caused by
some cancer treatments.
•
Although clients receiving internal radiation are not radioactive, the implant or injection
is radioactive; treat waste products and body fluids as radioactive.
•
Although clients with cancer may experience pain at any time during their disease, pain
is usually a late symptom of cancer.
•
Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal
antibodies, especially infliximab (Remicade), since they will allow TB to fulminate.
•
Melanoma is the most dangerous form of skin cancer and the leading cause of death
from skin disease.
•
Lung cancer is the leading cause of cancer deaths in both men and women (exception the leading cause of cancer deaths in Hispanic women is breast cancer).
•
Most Pancreatic cancer has a very poor prognosis since it's often advanced when first
discovered.
•
The cause of liver cancer is cirrhosis, which may occurs with hepatitis B or C.
Individuals should be vaccinated for HBV. The Centers for Disease Control and
Prevention recommends that all baby boomers are tested for HCV.
•
Administration of HPV vaccine Gardasil® is recommended for both boys and girls to
prevent cervical cancer.
Points to Remember - Pediatric
41
•
There are 12 major types of childhood cancers; leukemias and cancers of the brain and
central nervous system account for more than half of the new cases.
•
Children typically have longer treatment plans than adults due to their increased
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metabolic rate and rate of cell turnover.
•
Cure rate is improving for most types of pediatric malignancies.
•
During nursing assessment of a child with Wilm's tumor, do NOT palpate the abdomen
•
Neuroblastoma is a cancer that actually begins in utero.
•
An active child who suddenly becomes lethargic and exhibits symptoms of childhood
cancer, e.g., weight loss, pain, and fever, should be evaluated by a health care provider.
•
Acute leukemia can advance very quickly; a child with anemia and bruising should be
evaluated for leukemia.
•
Osteosarcoma is more common than Ewing's sarcoma but both are tumors of the bone.
•
Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena
cava syndrome, septic shock.
•
Pediatric cancer is a highly charged emotional arena. Be calm and collected in dealing
with both parents and patients
•
All cancer victims and their families need support and encouragement. Families with
children who have cancers can be especially affected. Other children in the family may
need as much or more attention and support than the parents.
Points to Remember - CPR
CPR
•
42
Compressions - Airway - Breathing ("C-A-B")
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The healthcare provider should not delay activating the EMS but check the victim for
two things simultaneously: response and breathing.
•
The current emphasis is on establishing good chest compressions with 30
compressions preceding the 2 ventilations.
•
•
Start compressions within 10 seconds of recognizing cardiac arrest.
•
Push hard and fast on the chest, without interruption, at a rate of at least 100
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compressions a minute, allowing complete chest recoil after each compression.
•
For adults, compress the chest at least 2 inches using 2 hands.
•
For children, compress the chest approximately 2 inches using 1 or 2 hands.
•
For infants, compress the chest approximately 1.5 inches using 2 fingers or the thumbs
of both hands.
•
•
For the adult victim, give 30 compressions and 2 breaths (30:2 ratio) with either 1 or 2
rescuers.
•
For the child or infant victim, give 30 compressions and 2 breaths (30:2 ratio) when
there is 1 rescuer; with 2 rescuers, infant and child CPR becomes 15 compressions and 2
breaths (15:2 ratio).
•
Minimize interruptions in compressions to less than 10 seconds.
•
Give effective breaths that make the chest rise and avoid excessive ventilation.
•
Individuals with ventricular fibrillation or pulseless ventricular tachycardia should
receive chest compressions until a defibrillator is ready; defibrillation should then be
performed immediately.
•
There are 4 universal steps for using any AED
•
POWER ON the AED
•
ATTACH the AED pads
•
ANALYZE the rhythm
•
SHOCK if advised
•
Points to Remember - Shock & Trauma
Shock
•
43
Types of shock are classified according to etiology: CHANS (Cardiogenic,
Hypovolemic, Anaphylactic, Neurogenic and Septic shock).
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•
In shock, the first hour of treatment is most critical; early detection is key.
•
There are different ways to categorize shock; basically shock presents three potential
problems:
•
•
•
Not enough fluid in the blood vessels.
•
Fluid has moved outside the vessels, so cannot be pumped to the organs.
•
Heart cannot pump fluid that is present in the vascular space.
The major problem in shock is tissue hypoxia.
Trauma
•
The initial assessment of the trauma client is the most important step.
•
If client has head injury, the most important data collection is level of consciousness,
next is pupil response to light; changes in vitals signs are very late signs.
•
With trauma clients, assume spine is injured until proven otherwise; while the airway is
being opened, the cervical spine should be immobilized.
•
When treating a trauma client, a quick check of the ABCs is the priority. After you
know the client is breathing and has a pulse, vital signs can wait while any bleeding is
stopped and other interventions (such as starting IVs) are started.
Points to Remember
Pediatric Cardiovascular
44
•
Common types of acyanotic defects with increased pulmonary blood flow include atrial
septal defect, ventricular septal defect and patent ductus arteriosus; those with decreased
pulmonary blood flow include coarctation of the aorta, aortic stenosis and pulmonary
stenosis.
•
In cyanotic heart disorders, such as tetralogy of fallow, tricuspid atresia and
transposition of the great vessels, major concerns are polycythemia or increased
hemoglobin and hematocrit, which can lead to thrombus formation.
•
Acquired cardiac disorders include bacterial endocarditis, acute rheumatic fever,
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hyperlipidemia, Kawasaki disease, and cardiomyopathy.
Pediatric Respiratory
•
Children's airways are smaller, more flexible and shorter than adult's and are therefore
more prone to obstruction than adults
•
Acrocyanosis is a common finding in a newborn.
•
Stridor usually indicates an upper airway concern, while wheezing indicates a lower
airway disorder.
•
Signs of increased breathing work are tachypnea, retractions, abnormal positioning,
shortness of breath and fatigue.
•
Asthma is not a disease but an inflammatory disorder.
•
Epiglottitis, acute tracheitis, and status asthmaticus are acute medical emergencies.
•
Never attempt to directly visualize epiglottis with tongue depressor on child with any of
the croup syndromes (laryngitis, tracheitis, epiglottitis) because it can trigger
laryngospasm.
•
The best way to stop the spread of respiratory syncytial virus (RSV) is meticulous hand
washing; the virus is transmitted by direct contact with fomites.
•
Cystic fibrosis in an inherited disease that affect the respiratory, gastrointestinal and
(male) reproductive systems; it may also affect the sweat glands.
•
Children with cystic fibrosis should eat a high protein, high calorie diet and take vitamin
supplements (especially A, D, E, and K).
Points to Remember 2
Pediatric Neurology
45
•
A positive Babinski reflex is normal in children until one year of age; thereafter, this
and other abnormal posturing is an ominous sign.
•
Acute bacterial meningitis is a medical emergency requiring swift intervention.
•
The care of the unconscious child focuses on respiratory management, neurological
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assessment, monitoring intake and output, providing appropriate medications and
evaluating outcomes.
•
Children with congenital neurological disabilities will often develop complications in
other body systems.
•
Cerebral palsy is a neuromuscular disorder and is characterized by problems with
perception, language, and/or intellectual function.
•
With increased intracranial pressure, the head of the bed should be elevated
approximately 15° to 30° with the child's head maintained in midline alignment.
•
The most common complications of shunting systems used to treat hydrocephalus are
bacterial infection and obstruction.
Pediatric Endocrine
•
Untreated infant hypothyroidism will lead to mental retardation.
•
A major concern of precocious puberty is rapid bone growth, which can result in early
fusion and short stature.
•
The vast majority of children with new-onset diabetes mellitus type 1 will experience a
"honeymoon" period when their bodies secrete insulin and their need for exogenous
insulin decreases.
Pediatric Musculoskeletal
•
Children with structural defects/disorders require regular follow-up evaluation until they
reach skeletal maturity.
•
Children under one year of age generally do not experience fractures.
•
Since many musculoskeletal disorders begin with trauma, it is important to assess ABC
(airway, breathing and circulation) first.
•
There are usually no symptoms of scoliosis. Most cases are discovered during mandated
school screenings (usually in 5th or 6th grades).
Points to Remember 3
Pediatric Genitourinary
46
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•
One gram of diaper weight equals one milliliter of urine.
•
Children with urine output less than one milliliter/kilogram/hour should be closely
monitored for possible renal failure.
•
Acute renal failure should be suspected in a child with decreased urine output, edema
and/or lethargy, and who is dehydrated, recovering from surgery or in shock.
•
In a child with ambiguous genitalia, the criterion for choice of gender and rearing is
typically not genetic sex, but the infant's anatomy
Pediatric Gastrointestinal
•
Whenever a newborn coughs, chokes, and turns blue with feeding, suspect
tracheoesophageal fistula (note the 3 C's - cough, choke, and cyanosis.)
•
Any newborn failing to pass meconium stool within the first 24 hours of life and who is
prone to constipation or or has decreased stool frequency in the first month of life,
should be evaluated for Hirschsprung's disease.
•
Dehydrated infants and children face greater morbidity risk than adults because children
differ in body composition and metabolic rate, and their fluid-regulation systems have
not matured.
Points to Remember
During pregnancy
•
Maternal understanding of various disease processes and recommended therapies may
provide impetus for self-care.
Nutrition
47
•
Fetal problems from anemia of mother include growth retardation with associated
morbidity and mortality.
•
Daily logs of dietary intake may help the client focus on positive improvement.
•
Pica is the craving by, pregnant client, for non-food substances from low serum iron
levels.
•
Failure to correct nutritional imbalances in pregnancy can result in:
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•
•
fetal complications - intrauterine growth retardation, central nervous system
malformations and fetal death
•
maternal complications - severe dehydration, metabolic alkalosis, ketosis, cardiac
dysrhythmias and death for the woman.
Cardiovascular
•
Normal pregnancy cardiovascular changes increase the heart's workload.
•
Cardiac output maximizes at approximately 28 weeks; is increased during labor and is at
its highest during first hour postpartum.
•
Failure to detect blood incompatibility with the fetus can result in red blood cell
hemolysis and severe morbidity or mortality; RhoGAM should be administered to all
sensitized client's within 72 hours following delivery, miscarriage, or abortion.
•
Cardiac disease in pregnancy can deteriorate rapidly.
•
Client must verbalize understanding of cardiac findings indicating complications.
•
Class II to IV cardiac clients should have induction, regional anesthesia and should not
push during birth; legs should never be higher than the heart and should be monitored
intensively following delivery.
•
Class II to IV cardiac clients should labor side-lying, in semi-Fowler's position to
facilitate cardiac emptying; pulse oximetry should be used to monitor tissue perfusion;
and cardiac monitoring should be maintained.
•
Anemia in pregnancy is associated with complications of abortion, infection, pregnancy
induced hypertension, preterm labor and heart failure.
Endocrine
48
•
If the maternal pancreas is unable to increase insulin production sufficiently, gestational
diabetes mellitus results.
•
Euglycemia is the most important factor in avoiding maternal/fetal complications.
•
Maternal hyperglycemia results in glucose crossing the placenta and the fetus
manufacturing insulin.
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•
Insulin in the fetus acts as a growth hormone producing a large-size, macrosomic infant.
•
Newborns of diabetic mothers may incur birth injury, hyperbilirubinemia,
hypoglycemia, and neurologic damage.
•
Maternal insulin needs are dramatically reduced following delivery.
Points to Remember 2
Labor and Delivery
49
•
Vaginal birth is the birth method of choice and interventions should be directed at
accomplishing that goal
•
Prolonged labor at any stage should be evaluated for fetal, pelvic or uterine dysfunction.
•
Pain and anxiety can impede the laboring progress.
•
Maintenance of a calm, soothing environment is necessary.
•
Efficient and effective gathering of supplies and personnel is imperative.
•
Maintain eye contact and verbal contact with woman to provide support.
•
Assist mother to birth as slowly as possible to prevent maternal/newborn trauma.
•
Be prepared to assist with the newborn transition to extrauterine environment.
•
Inform and support mother in any emergency.
•
Prepare for expeditious birth - usually cesarean.
•
Cesarean birth is utilized to rescue the infant when fetal, pelvic or uterine dysfunction
cannot be overcome.
•
Surgical interventions have associated complications of increased infection, increased
postoperative hemorrhage, increased morbidity and potential of increased mortality.
•
Surgical delivery (C-section) of the newborn reduces mechanical compression of the
chest. It may potentiate respiratory difficulties in the newborn such as transient
tachypnea of the newborn.
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•
Severe postpartum hemorrhage may result in organ failure, disseminated intravascular
coagulation (DIC), and/or mortality.
•
Estimation of bleeding is critical.
•
Uterine massage is the first line of defense against excessive hemorrhage.
•
Oxytocins are used to contract the uterus during the laboring process and after delivery.
Points to Remember
Temperature-related Disorders
•
Never rub or massage an area affected by frostbite; massaging the ice crystals under the
skin can cause irreparable damage to underlying tissues.
•
Thermal injuries can be caused by heat, chemicals, electricity, and also secondary to
radiation.
•
People at risk for heat-related emergencies are those who work or exercise outdoors,
elderly people, young children, and people with health problems.
•
Acute concerns in burn cases include airway status, pain, shock, infection and fluids.
•
Keloids are overgrowths of scar tissue that follow skin injuries. Dark-skinned
individuals tend to form keloids more readily than lighter skinned individuals.
Noninfectious Skin Disorders
50
•
Atopic dermatitis (eczema) is a recurring, non-infectious, inflammatory skin condition
with no known cause. It is most common in infants, but most children outgrow it.
•
Seborrheic dermatitis, is also known as "cradle cap" or dandruff.
•
The goal is to prevent diaper dermatitis, or diaper rash, from occurring by using
preventative measure, e.g., frequent diaper changes and good skin care.
•
Contact dermatitis can be caused by foods, solutions, allergens, plants.
•
Since isotretinoin is a known teratogenic, it is sold only under a special program
approved by the FDA called iPLEDGE. Female clients using this medication for severe
acne vulgaris must have negative pregnancy tests before and during treatment and must
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use 2 effective forms of birth control.
Infectious Skin Disorders
•
Herpes simplex 1 affects areas above the waist (for example, "cold sores" of the lip);
herpes simplex 2 affects areas below the waist (for example, genital herpes)
•
Moniliasis candidiasis (or "thrush") is an opportunistic fungal infection that can be
acquired at birth or can develop as a result of taking antibiotics, using inhaled steroids; it
is also one of several AIDS defining illnesses.
•
Tinea does have a circular appearance but it is caused by a fungal infection, not worms
(as the name "ringworm" might suggest).
•
Pediculosis Capitis (head lice) are transmitted through close contact or, for example,
sharing combs or hats with someone who has head lice; they do not jump and cannot fly.
Wounds
•
•
•
•
51
•
Determine tetanus immunization status for anyone with a wound injury.
•
Prognosis for wound healing depends on a variety of factors, including the type of
wound, the underlying injury, and the basic health of the client, including presence of
any chronic diseases, nutritional status, age, and if the person smokes.