Nclex boot camp Goal To pass the NCLEX in 75 questions 1. 2. 3. 4. 5. ❖ ❖ ❖ ❖ ❖ ❖ Supplies Qbank from a NCLEX prep of choice Video access: Youtube Nclex prep of choice Notebook with dividers to write down rationales. Nclex planner avail with this packet. Anxiety Relief Positive daily affirmations. Mindfulness Stretching Think of it as just another cumulative final. Remember you have 90% chance at passing just because you graduated. People pass everyday and so will YOU! 1. 2. 3. 4. 5. Instructions Pick 4 topics per day. Watch videos on each topic Listen to audio on said topics and take notes. Take 150-200 questions over these topics each day. Remediate the questions you get wrong by writing the rationale and going back to the videos and lecture for clarification. General strategies ❖ Take it slow ❖ Read the question and try to answer it before you look at the given answers. ❖ Never leave the patient alone. ❖ Safety first ❖ Avoid traps such as; always, never, every. ❖ Call the HCP only when there are no nursing interventions available. ❖ Never pass the buck ❖ Think of SATA as concept questions and not lists. For example the concept of Hypoxia what does a hypoxic patient look like? Restlessness, agitation and confusion. Test Taking strategies In NCLEX world In NCLEX world, you are one nurse with only one patient. All the orders you need are written. The only time the nurse would need to call the doctor is after intervention has failed and there is nothing else the nurse can do. If you call the physician about concerns, never call about something that is expected with the disease process, which is why it is essential for nursing students to know expected signs and symptoms of the disease versus signs and symptoms of potential complications. TIPS decision tree ❖ 1. Identify the topic 2. Assessment before implementation 3. Apply maslow 4. Apply ABC rules 5. Evaluate, is this going to give me a positive outcome STEP 1: Read each question carefully from the first word to the last word. Do not skim over the words or read them too quickly. STEP 2: Look for hints in the wording of the question stem. The adjectives most, first, best, primary, and initial indicate that you must establish priorities. The phrase further teaching is necessary indicates that the answer will contain incorrect information. The phrase client understands the teaching indicates that the answer will be correct information. STEP 3: Step 3. Reword the question stem in your own words so that it can be answered with a yes or a no, or with a specific bit of information. Begin your questions with what, when, or why. We will refer to this reworded version as the Reworded Question in the examples that follow. STEP 4: If you can’t complete step 3, read the answer choices for clues. Simple nursing ❖ ❖ ❖ Www DAR What is the question really asking SATA strategies For questions regarding symptoms or presentation of a disorder, think concept based, how is the body going to present with this specific conditions Food choices remember your diets, baked fish or chicken are great scapegoats! Toddlers and manica should have finger foods. In kidney disorders diets should be low in protein except for nephritis. ❖ ❖ ❖ ❖ ❖ ❖ ❖ Focus on critical thinking & memorization. Don't cram for the exam. Study the exam itself. Take plenty of practice tests. . Come prepared. Try to visualize each situation. Eliminate the false answers first. Keep your cool. Use prioritization techniques Look at disease process, acute will beat chronic Fresh post op ( under 12 hours) New admit ( under 24 hours) Use of the phrase "newly or just admitted" or "newly diagnosed" Always a priority ❖ Hypoglycemia ❖ HEMORRHAGE ❖ High fever over 105 F ❖ Pulseless or breathless The more vital the organ, the higher the priority ❖ - Most vital is the brain ❖ - Next is the lungs ❖ - Heart ❖ - Liver ❖ - Kidneys ❖ - Pancreas Remember Abc isn’t always the answer! The plan Day 1 ❏ ❏ ❏ ❏ MED SURG:Skin Fundies: ventilation OB: Pregnancy Pharm: Antibiotics Day 4 ❏ ❏ ❏ ❏ MED SURG: Respiratory Fundies: OB: respiratory issues of the newborn Pharm: respiratory meds Day 2 ❏ ❏ ❏ ❏ MED SURG: Endocrine Fundies: Fluids & Electrolytes OB: LABOR Pharm: Endocrine meds ❏ ❏ ❏ ❏ MED SURG: Cardiac Fundies: Hemodynamics OB: Complications Pharm: cardiac meds ❏ ❏ ❏ ❏ MED SURG: Eyes & ears Fundies: Assessment of ears and eyes OB: Labor & Delivery Pharma: Ophthalmic meds ❏ ❏ ❏ ❏ ❏ MED SURG: Immune Fundies: Blood tests/ disease transmission Psych : Grief Peds : Development Pharm: Anticoagulants MED SURG: Neuro Fundies: Neuro assessment OB: Neuro of the newborn Pharma: CNS drugs and neuro interventions ❏ ❏ ❏ MED SURG: Comprehensive Fundies: PPE Psych : Personality disorders Pharm: Comprehensive MED SURG: Musculoskeletal Fundies: Traction OB: Pharm Pharm: Musculoskeletal Day 12 MED SURG: Comprehensive Fundies: Pain management Psych : Mood disorders Pharm: Antidepressants Fundies: Ethics/ management Psych : Age associated disorders ❏ ❏ ❏ ❏ ❏ Day 13 ❏ ❏ ❏ ❏ MED SURG: Renal Fundies: Elimination OB: Repeat wk 1 Pharm: urinary meds Day 9 ❏ Day 11 ❏ ❏ ❏ ❏ ❏ ❏ MED SURG: GI Fundies: Positioning/ Med admin OB: NEWBORN Pharm: GI meds Day 6 ❏ ❏ ❏ ❏ Day 8 Day 10 ❏ ❏ ❏ ❏ Day 5 Day 7 ❏ ❏ Day 3 ❏ ❏ MED SURG: Comprehensive Fundies: Blood transfusion reactions Peds : skin/ immune disorders Psych : Stress disorders Pharm: comprehensive Day 14 ❏ ❏ ❏ ❏ MED SURG: Comprehensive Fundies: Oxygen Psych : developmental disorders Pharm: Comprehensive FUNDAMENTALS IMPORTANT FACTS Diet and Nutrition PATIENT CENTERED CARE ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ The client is for EEG this morning. Prepare him for the procedure by rendering hair shampoo, excluding caffeine from his meal and instructing the client to remain still during the procedure. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation. 47. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast selfexamination, testicular self-examination, and chest X-ray. Tertiary prevention is treatment to prevent long-term complications. On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the meaning of the items. 50. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient. In an infant, the normal hemoglobin value is 12 g/dl. 52. A patient indicates that he’s coming to terms with having a chronic disease when he says something like: “I’m never going to get any better,” or when he exhibits hopelessness. Pain Management ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Only the patient can describe his pain accurately. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli. Patient-controlled analgesia (PCA) is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer. An Asian-American or European-American typically places distance between himself and others when communicating. Active euthanasia is actively helping a person to die. Brain death is irreversible cessation of all brain function. Passive euthanasia is stopping the therapy that’s sustaining life. Voluntary euthanasia is actively helping a patient to die at the patient’s request. A back rub is an example of the gate-control theory of pain. Pain threshold, of pain sensation, is the initial point at which a patient feels pain. . The difference between acute pain and chronic pain is its duration. Referred pain is pain that’s felt at a site other than its origin. Alleviating pain by performing a back massage is consistent with the gate control theory. Pain seems more intense at night because the patient isn’t distracted by daily activities. Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. ❖ Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence. ❖ Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. ❖ Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. ❖ Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid. Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Most of the absorption of water occurs in the large intestine. Most nutrients are absorbed in the small intestine. When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?” A vegan diet should include an abundant supply of fiber. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values. 59. To induce sleep, the first step is to minimize environmental stimuli. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as well as the amount of strength required to move the patient. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily). To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet. 63. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow. Vitamin C is needed for collagen production. Bananas, citrus fruits, and potatoes are good sources of potassium. Good sources of magnesium include fish, nuts, and grains. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron. The nitrogen balance estimates the difference between the intake and use of protein. A Hindu patient is likely to request a vegetarian diet. No pork or pork products are allowed in a Muslim diet. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.” Milk is high in sodium and low in iron. Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense. Increased gastric motility interferes with the absorption of oral drugs. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance. When feeding an elderly patient, essential foods should be given first. For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass. ❖ Isometric exercises are performed on an extremity that’s in a cast. ❖ Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile. ❖ A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection. ❖ A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia. ❖ Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record. ❖ A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant. ❖ A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant. ❖ Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant. ❖ 145. Usually, patients who have the same infection and are in strict isolation can share a room. ❖ 146. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease. According to Erik Erikson, developmental stages are: ❖ Trust versus mistrust (birth to 18 months) ❖ Autonomy versus shame and doubt (18 months to age 3) ❖ Initiative versus guilt (ages 3 to 5) ❖ Industry versus inferiority (ages 5 to 12) ❖ Identity versus identity diffusion (ages 12 to 18) ❖ Intimacy versus isolation (ages 18 to 25) ❖ Generativity versus stagnation (ages 25 to 60), and ❖ Ego integrity versus despair (older than age 60). ❖ An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system. ❖ The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point. ❖ The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential. ❖ PPE & Infection control 4 Points for NCLEX-RN Safety and Infection Control ❖ ❖ ❖ ❖ #1 Standard Precautions. #2 Contact Precautions. #3 Droplet Precautions. #4 Airborne Precautions. PPE for Standard Precautions Droplet Precautions:– Surgical masks within 3 feet of patient ❖ Gloves – Use when touching blood, body S: SEPSIS, scarlet fever, strep P: Pertussis, parvovirus, pneumonia I: Influenza D: Diphtheria E: Epiglottitis R: Rubella M: Mumps, meningitis, mycoplasma, meningeal pneumonia AN: Adenovirus ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ fluids, secretions, excretions, contaminated items; for touching mucous membranes and non intact skin Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated Pharyngeal Diphtheria Epiglottitis, (caused by Haemophilus influenzae type b) Flu (contact and droplet) Meningococcal Disease: Sepsis, Pneumonia, meningitis Mumps (infectious parotitis) Pneumonia Mycoplasma Pneumonia Parvovirus B19 (erythema infectiosum or 5th disease) Pneumonic Plague Adenovirus (contact and droplet) Streptococcal pharyngitis Whooping Cough (pertussis) Rhinovirus Scarlet fever Rubella (German Measles) Airborne Precautions: Particulate respirator M: Measles T: TB V: Varicella ❖ ❖ ❖ ❖ Chickenpox (varicella) (Airborne and Contact) Herpes Zoster (Varicella Zoster(disseminated) Shingles (Airborne and Contact) Measles (Rubeola) M. Tuberculosi Contact Precautions: Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces) • In some instances these are required for entering patient’s environment M: Multidrug resistant organism R: Respiratory infection S: Skin infections W: wounds E: Enteric c-diff E: Eye infection ❖ ❖ ❖ ❖ ❖ ❖ Medication-Resistant Organisms: MRSA, VRE, extended spectrum beta lactamase producers (ESBLs), Klebsiella pneumoniae carbapenemase (KPC) Diarrhea infections or of unknown origin: C.diff, norovirus, rotavirus…..USE SOAP AND WATER FOR HAND WASHING NOT hand-sanitizer. ➢ NOTE: Hepatitis A. (if patient is diapered or incontinent pt)..remember it is spread through stool Skin infection: impetigo, lice, scabies, herpes simplex, chickenpox (airborne and contact), skin diphtheria, shingles (airborne and contact) Wound infections with excessive drainage or staphylococci Pulmonary infections: RSV, parainfluenza Eye infection: conjunctivitis Electrolytes Cheat Sheet HYPO (135145) Na ❖ ❖ ❖ ❖ ❖ ❖ ❖ Salt Soy sauce Pork Cott/amer Cheese Spinach Pickles (3.55.0) K ❖ ❖ ❖ ❖ ❖ ❖ Avocados Raisins Cantaloupe Bananas Skim milk Spinach Causes HYPER S&S A - Adrenal insufficiency I - H20 intoxication D - Diuretics S - SIADH ❖ ❖ ❖ ❖ ❖ ❖ ❖ Causes Tachycardia Normal/↓/↑ BP Headache Personality change Weakness Hyperactive BS Seizures D - Fluid deprivation I - IV hypertonic solution excess V - Vitamins “Sodium” supplement A - Amount of Na intake excess Interventions W - Weights daily A - Administer Iv hypertonic solutions I-I&O T -Thiazide diuretics G - GI loss ❖ Tachydysrhythm (Vomiting) ias O – Osmotic ❖ Ortho Diuresis hypotension T – Thiazides and ❖ Lethargy/fatigue Loop diuretics ❖ ↓ BS, constipation S – Severe Acid ❖ Anorexia Imbalance ❖ Muscle Hweakness Hyperaldosteronism ❖ “U” waves on O - Other meds EKG such as Corticosteroids T- Transcellular Shift (9-11) Ca ❖ ❖ ❖ ❖ Yogurt Cheese/mil Sardines Rhubarb ❖ ❖ ❖ ❖ M- medications Ace, spironolactone, NSAIDS A- Acidosis: metabolic and respiratory C- Cell destruction (burn, trauma, Injury) H- Hypoaldosteronism I- intake excess K N- nephrons/ renal failure E- excretion : impaired ❖ ❖ ❖ ❖ ❖ Bradydysrhythmi as Tall “T” waves on EKG Cardiac arrest ↑BS Diarrhea Paresthesias M - Monitor EKG D - Diet, limit green leafy veggies and avocado K - Kayexalate administration I - IV sodium Bicarb, Calcium Gluconate D - Dialysis ❖ Dysrhythmias H - Hyperparathyroidism ❖ Pallor A - Antacids ❖ HTN M - Malignancies cancer ❖ ↓ LOC cells release excess ca+ Disorientation ❖ ↓ DTR ❖ ↓ BS, constipation Interventions (1.32.1) Mg ❖ Interventions Hypotension Bradycardia Tetany muscle spasm Laryngospasm/s tridor ↑ DTR, ↑ BS diarrhea + Trousseau sign + Chvostek sign D - Diuretics I- I&O C - Calcium channel blockers /Calcium Gluconate ❖ HYPO: seizures, tetany, anorexia, tachycardia, HTN, mood changes ❖ HYPER: ↓ DTR, N/V, bradycardia, hypotension, coma ❖ FOODS: spinach, avocado, tuna, oatmeal and milk Normo/↓ HR Normal/↓/↑ BP Irregular HR ↑BS Thirst Restlessness Dyspnea Muscle weakness M - Monitor sodium intake/ Labs A - Alka-Seltzer, aspirin , and cough preps shouldn’t be administered G - gravity of urine monitoring I - I&O C - Cardiac monitoring Interventions A- Assess EKG and ABG I - IV Potassium Chloride D - Diet: green leafy veggies ***NEVER PUSH POTASSIUM IV*** ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Interventions D - Diet, cheese, milk, soy sauce, salt, bacon, beef broth R - Restrict fluids and NPO A - Antibiotics C - Corticosteroids I - Insulin D - Diuretics S&S Interventions F - sodium containing fluids I - IV phosphate L - Lasix M - Monitor Labs and I&O ❖ HYPO: muscle pain & weakness, bone pain, confusion ❖ HYPER: circumoral & peripheral parenthesis, muscle spasms, tetany ❖ FOODS: tuna, beef liver, pork, milk and yogurt. (2.54.5) Ph Stroke Super Sheet Types of stroke TIA: May be a sign of impending stroke. Symptoms occur suddenly but do not last long. CVA: Prolonged ischemia to the cerebral vasculature with cerebral anoxia lasting longer than 10 mins that causes long term irreversible damage Hemorrhagic : Rupture of an existing aneurysm causing profound bleeding the cerebral cavity. ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Thrombosis Embolism Ruptured aneurysm Risks factors ❖ ❖ ❖ ❖ ❖ ❖ ❖ Atherosclerosis Hypertension Anticoagulation therapy : hemorrhagic Diabetes Stress Obesity Oral contraceptives Priorities in acute phase 1. 2. 3. 4. 5. 6. 7. 8. Loss of control on the right side of the body. performs tasks that have to do with logic, such as in science and mathematics. Impaired speech and language “ aphasia” Slow, inhibited. Aware of deficits, depression, anxiety. Impaired ability to comprehend language and math. ❖ ❖ the body. performs tasks that have do with creativity and the arts. Left side neglect Spatial-perceptual deficits Denies and minimizes problems Rapid performance and short attention span. May be impulsive. Unable to discern safety issues Impaired judgement Impaired concept of time Position every two hours Frequent range of motion to avoid contractures Place antiembolism stockings if ordered Frequent skin and mouth care Monitor gag reflex Provide soft diet Maintain airway & administer 02, monitor vitals Assess the time the symptoms started Focused neuro assessments Maintain a BP of 150/100 to maintain brain perfusion. Suction as needed but no longer than 10 seconds Monitor for ICP Give IV fluids, prepare to administer tPa if indicated ( symptom onset of less than 3 hours) May be prepared for endarterectomy Left side stroke Right side stroke Loss of control on the left side of Long term care ❖ ❖ Causes ❖ ❖ ❖ ❖ Important to know General assessment ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Pulse: slow and bounding Cheyne stokes respirations Hypertension Headache, nausea & vomiting Facial drooping Nuchal rigidity Visual changes Ataxia Dysarthria Dysphagia Impaired speech Bowel and bladder dysfunction Paralysis ❖ ❖ ❖ ❖ Agnosia: inability to recognize familiar objects or persons Apraxia: loss of ability to execute or carry out skilled movements voluntarily Hemianopia: blindness in one half of the visual field Homonymous hemianopsia: loss of visual field on the same side in both eyes Neglect syndrome: unaware of the affected side Proprioception: altered position sense that places the pt at increased risk of injury Medical management Patient goals The major goals for the patient and family may include: ● Improve mobility. ● Avoidance of shoulder pain. ● Achievement of self-care. ● Relief of sensory and perceptual deprivation. ● Prevention of aspiration. ● Continence of bowel and bladder. ● Improved thought processes. ● Achieving a form of communication. ● Maintaining skin integrity. ● Restore family functioning. ● Improve sexual function. ● Absence of complications ❖ ❖ ❖ ❖ ❖ Recombinant tissue plasminogen activator would be prescribed unless contraindicated, and there should be monitoring for bleeding. Increased ICP. Management of increased ICP includes osmotic diuretics, maintenance of PaCO2 at 30-35 mmHg, and positioning to avoid hypoxia through elevation of the head of the bed. Endotracheal Tube. There is a possibility of intubation to establish patent airway if necessary. Hemodynamic monitoring. Continuous hemodynamic monitoring should be implemented to avoid an increase in blood pressure. Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing NCLEX SHOCK SHEETS Shock is a state that is the result of inadequate tissue perfusion which creates an imbalance between the delivery of 02 and the requirements of 02. Remember, most types of shock (hypoperfusion) are caused by dysfunction in one or more parts of the perfusion triangle: 1. The pump (the heart) 2. The pipes, or container (blood vessels) 3. The content, or volume (blood) Types ❖ ❖ ❖ ❖ Hypovolemic shock: decreased blood volume. A type of hypovolemic shock is hemorrhagic shock, which results from blood loss. Neurogenic shock: nervous system injury leading to vasodilation in the periphery causing inadequate perfusion to the vital organs. Anaphylactic shock: severe allergic reaction that leads to vasodilation and bronchoconstriction. Cardiogenic shock: inadequate pumping of the heart. Can be due to heart disease or heart attack. Hypovolemic shock: ❖ ❖ ❖ ❖ ❖ ❖ ❖ Assessment Tachypnea Tachycardia Hypotension Confusion Loc changes cardiogenic shock ❖ ❖ ❖ ❖ ❖ Bleeding from cuts Bleeding from other injuries Internal bleeding, such as in the gastrointestinal tract Burns Diarrhea Excessive perspiration Vomiting Septic shock: Caused by overwhelming infection leading to vasodilation. It is treated in hospital by antibiotics, fluid replacement, and vasoconstrictors. Anaphylactic shock: Caused by allergens that trigger widespread vasodilation and movement of fluid out of the blood into the tissues. Neurogenic shock : Caused by the sudden loss of the sympathetic nervous system signals to the smooth muscle in vessel walls. Hypovolemic shock ❖ ❖ ❖ ❖ ❖ Causes Treatments for all types and stages Hypovolemic pain of angina develop dysrhythmias complain of fatigue express feelings of doom hemodynamic instability. ❖ Support of the respiratory system with supplemental oxygen and/or mechanical ventilation to provide optimal oxygenation (see Chapter 21) ❖ Fluid replacement to restore intravascular volume: 3;1 ratio with 0.9% NS or LR, if a colloid is prescribed is Hypovolemic Monitor ❖ ❖ ❖ ❖ ❖ O2 sat Lung sounds for overload Cvp Urine output : voiding is the best indicator that shock is reversed. Monitor vitals q 15 until stable when giving vasoactive medications Initiate parenteral nutritional support Modified trendelenburg Blood transfusion Lacate H&H ❖ ❖ ❖ Monitor vitals Monitor 02 and prevent ischemia Monitor ekg ❖ ❖ ❖ ❖ ❖ Cardiogenic usually albumin ❖ Vasoactive medications to restore vasomotor tone and improve cardiac function: Alpha adrenergic and beta blockers ❖ Nutritional support to address the metabolic requirements that are often dramatically increased in shock Cardiogenic shock ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ First line treatment is oxygenation 2-6 l/min to maintain o2 of 90% Fluid replacement Iv morphine for chest pain to decrease preload A fluid bolus should never be given rapidly, because rapid fluid administration in patients with cardiac failure may result in acute pulmonary edema. Dobutamine Nitroglycerin Dopamine. norepinephrine, epinephrine, milrinone, vasopressin, and phenylephrine Antiarrhythmic Medications Mechanical ventilation NCLEX FLUIDS QUICK SHEET Hypotonic Solutions Hypertonic Solutions These are volume expanders. Think how big a party can get when you add extras into your home “ space” These extra folks act like the large particles in hypertonic solutions. The pull the fun from the party to the body ( vasculature) These are tricky, at first they go the vascular space then shift to pull fluid into the cells. These rehydrate when you are diuresing. Hypertonic solutions pull fluid from the 3rd space into the vascular space. Example: D.25W ½ NS 0.33% NS Example : D10W 3% NS 5% NS D5LR D51/2 NS D5N5 TPN ALBUMIN They rehydrate but do not cause hypertension. Monitor FLUID VOLUME EXCESS ❖ CVP ❖ PULSE ❖ In a ICU Monitor Watch for cellular edema because of all of the fluid shifting into the cell they could fill up and lyse USES Renal failure Heart failure Nausea Vomiting Burns Hemorrhage Cellular dehydration associated with hypernatremia ❖ USES Hyponatremia Ascites Burns Large amounts of fluids shifting into the 3rd space Isotonic Solutions These fluids are the well behaved fluids, why? Because they stay where you put them! They are similar to the bodies normal fluid osmolality. Once you put them in the vascular space they stay there! These are usually given to elevate BP. NS is the basic solution for blood replacement. Examples: NS LR D5W D51/4 NS USES: When abundant fluid loss has occurred Hemorrhage Excess sweating Nausea Vomiting Burns Trauma Remember Do not use these in clients with HTN,HF,Renal failure. They can cause fluid overload and hyponatremia. Drug Moa Indication Contraindicatio n / adverse effects dose / route Nursing action Phytonadione Vit K Helps�prevent� bleeding�by� activating� clotting�factors�� Prevention and treatment of hypoprothromb inemia Pain, swelling, flushing, , dizziness, rapid heartbeat, sweating IM Subcut, IV (Children 1 mo): 1– 2 mg single dose. Monitor for frank and occult bleeding pulse and BP frequently;. Apply pressure to all venipuncture sites for at least 5 min; avoid unnecessary IM injections. Erythromycin Erythrocin Suppresses protein synthesis at the level of the 50S bacterial ribosome Infections caused by susceptible organisms including infantile hypertrophic pyloric stenosis, pancreatitis,inter stitial nephritis.rash. benzyl alcohol should be avoided in neonates. IV/ P.O PO (Neonates ): Ethylsuccinate —20– 50 mg/kg/day divided q 6– 12 hr. IV (Children 1 mo): 15– 50 mg/kg/day divided q 6 hr, maximum 4 g/day. Monitor for allergic reaction. HEp B vaccine Causes a primary immune response. Provides immunity against HEP B Do not give if baby is already + �5�mcg/0.5�mL� ;�5�mcg/mL�;� 10�mcg/0.5�mL Assess patient anaphylaxis (hypotension, flushing, chest tightness, wheezing, fever, d HEP B IG BayHep B, Nabi-HB Confers passive immunity to hepatitis B infection post exposure hepatitis b infection in neonates born to HBsAg- + women, provides passive immunity. erythema at IM site, pain, swelling, tenderness Hypersensitivity to immune globulins, glycine, or thimerosal. IM : 0.5 mL within 12 hr of birth. Assess patient anaphylaxis (hypotension, flushing, chest tightness, wheezing, fever, dizziness. Drug Mode of Action indications Contraindications/ side effects dose/route Nursing actions Hydrocod one bitartrate/ acetamin ophen (Norco)/ Lortab Bind to opiate receptors in the CNS. Management of moderate to severe pain. Avoid chronic use Dizziness, sedation, respiratory depression, hypotension ROUTE PO —2.5– 10 mg q 3– 6 hr as needed; Monitor respirations Do not give laxatives Rho(d) immune globulin (human) Prevent production of anti-Rho(D) antibodies in Rho(D)negative patients who were exposed to Rho(D)positive blood. Administered to Rho(D)-negative patients who have been exposed to Rho(D)- positive blood by: Pregnancy or delivery of a Rho(D)-positive infant, Prior hypersensitivity reaction to human immune globulin; Rho(D)- or Dupositive patients. HTN, hypotension, anemia ROUTE IM/IV 600 IU (120 mcg) w 40– 125 mg qid, after meals and at bedtime (up to 500 mg/day) Assess vital signs periodically during therapy Simethico ne Gas-X Passage of gas through the GI tract by belching or passing flatus Relief of painful symptoms of excess gas in the GI tract that may occur postoperatively Not recommended for infant colic None significant ROUTE 40– 125 mg qid, after meals and at bedtime (up to 500 mg/day) Assess patient for abdominal pain, distention, and bowel sounds prior to and periodically throughout Docusate PeriColace, Promotes incorporation of water into stool, resulting in softer fecal mass Prevention of constipation (in patients who should avoid straining, such as after MI or rectal surgery) Hypersensitivity; Abdominal pain, nausea, or vomiting, ROUTE PO : 2 tablets once daily at bedtime; maximum 4 tablets twice daily. Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Drug MOA Indication Contraindicati on/ Side effects route/dose Nursing actions Surfactant (beractant) Replaces surfactant in premature infants Treatment of respiratory distress syndrome in premature infants. None O2 desaturation Intratracheal: (4 mL/kg birth weight); 4 doses may be given in first 48 hr of life, q 6 hr apart Monitor ECG, heart rate, color, chest expansion, o2 sat, and ET tube patency continuously Continuous bedside monitoring for 30min Caffeine citrate Decrease periods of apnea Short-term treatment of idiopathic apnea of preemie infants between 28 and 33 wk gestational age. Hypersensitivity Tachycardia, feeding intolerance, gastritis ROUTE IV/PO Maintenance dose— starting 24 hr after loading dose 5 mg/kg necrotizing enterocolitis (abdominal distension, vomiting, bloody stools, lethargy). Prostaglan din E1 (alprostadil ) relaxes smooth muscle of the ductus arteriosus Temporary maintenance of patent ductus arteriosus in neonates Respiratory distress syndrome Seizures, cerebral bleeding, ROUTE IV 0.05– 0.1 mcg/kg/min initially; may be increased up to 0.4 mcg/kg/min until satisfactory response respiratory rate, heart sounds, and neurological status frequently ampicillin Binds to bact cell wall Treat bacterial infections Hypersen to PCN Seizures, pseud colitis ROUTE IM/IV Children 40 kg): 100 – 200 mg/kg/day in divided doses q 6– 8 hr (not to exceed 12 g/day). Observe for anaphylaxis (rash, pruritus, laryngeal edema, wheezing). HMF (human milk fortifiers) enzymes Increased digestion of fats, carbs, and proteins in the GI tract. Pancreatic insufficiency Hypersen to hog proteins Shortness of breath, dyspnea ROUTE PO (Children 1 yr): 2000 – 4000 lipase units per 120 mL of formula/breast milk. Monitor stools for high fat content Stools will be foulsmelling/frothy. Assess patient for allergy to pork Assessment of Growth and Development of the Infant Head Should measure 13.75 cm at birth -Posterior fontanel should close by 2nd month -Anterior fontanel should close in 12-18 months Well checkup schedule ● Second week of life ● 2, 4, 6, 9 months of age. Height and weight - In the first 6 months birth weight doubles and baby should grow 6 inches By 12 months birth weight should triple and baby should grow 10-12 in. Skelton Is made up of cartilage at 3month gestation and continues to ossify and grow throughout life. Bone age, injury, abuse or nutritional deficits can be determined by X-Ray. Circulation Hemoglobin and RBCs decrease when respiratory system takes over until 3 months of age Neuro - ● ● ● ● 0-1 month: extensive sleep, dependent, eye contact 0-3 months: smiles and fixes on faces,solitary play 3-6 mo: enjoys peekaboo, smiles at familiar faces 6-12 mo: knows name, gives and takes objects, understands easy commands. ● 0-3 mo: Cries, grunts and Coo 0-6 mo: babbling, vowels, half consonants 12 mo: 1-2 words, imitation, responding to simple commands ● ● ● ● ● ● ● ● Age Focuses 8-12 in away Eyes wonder and cross Likes black and white/ high contrast patterns. Prefers human face to other patterns Hearing is fully mature, may turn toward sound Likes sweet smells, dislikes sour Likes soft sensations Likes to be handled gently Emotional growth ● ● ● ● 0-1 mo: general tension 1 mo: happy and sad emotions 6 mo: separation anxiety 6-12 mo: stranger anxiety, shows curiosity by 12 months . Nutrition Language ● RR: 30 but can range from 20-50 with increase or decrease of activity. BP: 85/60 mmHg Temp: 98.6 Psychological milestones Jerky quivering arm movements, Brings hands to mouth , makes fists Head flops back if unprepared Strong reflexes 5-8 feedings per day - 3 meals 2 snacks Progresses from sleeping 20 hours a day to 10-12 hours at night and two naps by 12 months,place awake child in crib to sleep Social Milestones ● HR is taken apically) Nerve cells grow and coordination begins in an orderly pattern. Physical milestones ● ● ● ● ● ● Vitals HR: 70 resting - 180 awake and crying ( accurate ● ● ● ● ● Rapid growth causes a need for the greatest amount of nutrients 4-6 mo- 12mo: breast milk or commercial formula, introduction of solid foods. One food at a time starting with veggies. You may need to supplement Vit C/D iron, fluoride. 6mo: iron rich foods are needed to supplement 7-8mos: self feeding begins by grasping and bringing food to mouth. Ends with use of utensils WIC program helps children and women get proper nutrition when they qualify Theroist Stage Description Nursing care Birth -18 mo Sigmund Freud Oral Pleasure center in mouth Encourage self feeding. Avoid putting objects in mouth 1st year Erik Erikson Trust vs mistrust Depends on parents to meet needs to create trust Encourage bonding and family relationships Birth -2 yrs Jean Piaget Sensorimotor stage Coordinates sensory experiences with Plan tactile activities with use of colorful materials Assessment of Growth and Development of the Toddler 1-3 years Physical growth slows Communication and mobility skills increase Stubbornness , explore, dependent Begin to explore Autonomy “ I DO MYSELF” Bed rituals are important - Safety ● ● Height and weight Gain 5 to 10 LBs per year Grow 3 inches per year Normal to go on food jags Learns to stand alone and walk, 1 year Need 12-14 hours a day of sleep 3 years need 10-12 hours Discipline Training and instructing to produce positive behavior patterns ● ● ● ● ● ● Proper restraint in car seat Never leave the toddler alone in water even buckets pose a drowning risk Put away poisons and medications with locks Burns from hot appliances and water are common ● Well visits ● ● ● ● ● ● ● ● ● ● ● Lordosis and pot belly, organs adapt moderately to stress Well established walking Growth is slowed and stable Bones and muscles still immature requires nutrition an exercise for adequate development ● Social Milestones ● ● ● ● ● Many emotions in one day Increased use of emotion language and understanding of emotion causes/ consequence understanding Nutrition Language ● ● ● ● Well established walking Hand eye coordination Progressive development of fine motor skills They begin to draw and write Bladder control is gained , with occasional relapses Brain is 90% developed by age 5 Emotional growth Moves to parallel play, mostly imitates role models Does Not share readily until later toddler years Separation anxiety is overcome easily ● ● 15 mo for shots Annually after that Assess growth/ development, caregiver skill,and relationship between toddler and parent Psychological milestones Physical milestones ● Self control is gradual 2yrs: begin accepting responsibility Consistency and timing are key Calmly remove the child from the situation Tell child the behavior is bad, not them Vocabulary begins to increase names objects, body parts, animals, and familiar locations Primary method of communication Continuous questioning “why” Toys that talk are preferred Brief sentences ● ● ● ● ● ● ● Require about 1000-1400 calories a day Toddlers should be active 60 min a day Fruites: 1-1.5 cups Veggies: 1-1.5 cups Grains : 3-5 oz Protein : 2-4 oz Dairy : 2-2.5 cups Allow children to eat when hungry instead of forcing meals. Age Theroist Stage Description Nursing care 18 mo- 3 years Sigmund Freud Anal Pleasure center in the anus Encourage the family to teach good hygiene 1- 3 years Erik Erikson Autonomy vs shame and doubt Mastering environment and building self esteem Support bonding and family relationships 2-7 Jean Piaget Pre operational Sensory / action coordination, symbolic thinking. Represent world Plan drawing and writing, tactile experiences. Use colorful materials to Assessment of Growth and Development of the preschool child Well checkup schedule Growth rate has slowed -Language and play change remarkably - soak up info “little sponges, let them choose their own clothes” - 3yrs still chubby faced - 5 yrs leaner and taller and better coordinated but can't distinguish fantasy from real life. ● ● Boosters and vaccines 4-6yrs Annual exams for growth and health Height and weight - Skelton Gains 3-5 lb a year and grows 2.5 in. a year By 12 months birth weight should triple and baby should grow 10-12 in. Gross motor skills improve by age 5 they can climb, jump, catch and throw A ball and ride a bicycle. 5 yrs, leaner taller and better coordinated, teach them to wash hands thoroughly Bathing and brushing teeth still need supervised, can't wash own hair. Dentition The skull is 90% of adult size by age 6 Early preschool insidious teeth have completely emerged ,you floss their teeth. End of preschool teeth have erupted w/ incisors being first. Aware of their sexuality May be attracted to parent of the opposite sex Parents should teach accurate sexual info Teach the difference between good and bad touch Calm matter of fact response to masturbation Teach safety and privacy regarding genitals ● ● ● ● ● ● ● Social Milestones ● ● ● ● ● Preschoolers use imitative play, all types of play are needed for development Dramatic play: act out situations and control it Cooperative play: organized groups Associative play: play together but unorganized and no leader Solitary : playing alone away from groups ● ● ● ● 3-4: non communicative w/ language 4: communicate with language 4-5: use naughty words Converse in a way they can understand Delays can be caused by: hearing impairment, lack of stimulation, Age Theroist Develop imagination May have an imaginary friend Magical thinking May be afraid of the dark or have nightmares 4:Temper tantrums, pushing, hitting, and manipulating environment Discipline: teach the child responsibility and self control and consistency. Taking favorited away is more effective than hitting Emotional growth ● ● ● ● 0-1 mo: general tension 1 mo: happy and sad emotions 6 mo: separation anxiety 6-12 mo: stranger anxiety, shows curiosity by 12 months . Nutrition Language ● Vision Still immature Distance judgement faulty Screen for amblyopia 20/20 vision by age 6 Depth perception occurs at 8-10 yrs old. Psychological milestones Physical milestones ● ● ● ● ● ● - ● ● ● ● ● ● Do not need large quantities of food, keep portions small. Requires high amount of protein Erratic appetite, frequent small meals are better Guide them when choosing food Provide healthy snacks Rituals are important. Stage Description Nursing care 3-6 yrs Sigmund Freud Phallic Pleasure center in the genitals Explain to the family and teach hygiene 3-5 yrs Erik Erikson Initiative vs guilt Child develops a conscious and sense of right and wrong Monitor and protect from injury and poisoning. Encourage them to ask questions 2-7 yrs Jean Piaget Pre operational phase The child sees the world egocentrically Plan drawing and writing activities. Assessment of Growth and Development of the school aged child 6-10yrs Head Should measure 13.75 cm at birth - Well checkup schedule ● Annual physicals School starts Thinking skills develop ● ● ● ● Height and weight - - Growth is slow and steady gains 5-6 lb a year. Grows 2.5 in. a year until pre-teen. Spine straightens and abdomen flattens Long bone growth is noted Dentition Starts to lose baby teeth at about 6 - Neuro Substance abuse ● ● ● ● Eruption of permanent teeth begins -Refines motor and cognitive skills - Engages in meaningful tasks ● Teach family values Teach right and wrong Set rules and enforce Teach facts about drugs and alcohol Actively listen ● ● ● ● ● ● ● Slowed growth, graceful on their feet Strength and abilities double Loss of baby teeth Structural bone changes Girls begin to experience secondary sex characteristics Social Milestones ● ● ● ● ● ● ● ● Language is refined vis grammar education Ability to use words to express knowledge Narrative skills improve Able to make inferences Able to evaluate speech and messages Age Theroist ● ● ● Help develop a positive attitude of sexuality Sexual roles Satisfaction with being a boy or girl Displays a sense of duty and accomplishment Applies energy from play to complete tasks Develops positive sense of self Magical thinking, sit still for short periods Understands taking turns , enjoys groups Enjoys real life activities Give consistent rules, positive attention, and clear expectations, questions parents standards, Emotional growth Develop confidence in family and explore relationships outside of family Peers become important Motivated by accomplishment success/ failure have a strong impact ● ● ● ● Greater understanding of complex emotions Understands they can have more than one emotion Greater ability to control emotion Uses strategies to redirect feelings Nutrition Language ● The birds and the bees Psychological milestones Physical milestones ● ● ● ● ● Booster tetanus and diphtheria Visit the dentist 2x a year Screening for scoliosis at 10-11 Vision and hearing screen . ● ● ● ● ● Requires more food for increased energy demands Choose foods from all food groups Food jags and increased appetite are normal Limit fat intake, supervise snack habits Offer choices. Stage Description Nursing care 6-10 yrs Sigmund Freud Latency Preparing for adult life but awaiting maturity Encourage sibling and peer contact. Assess for sexual activity in later stage 6-10 yrs Erik Erikson Industry vs Inferiority Developing sense of self worth and talent Provide activities based on talents and abilities 2-7 yrs Jean Piaget Pre operational phase The child sees the world egocentrically Plan drawing and writing activities. Assessment of Growth and Development of the Adolescent 11-18yrs Early adolescents Well checkup schedule ● 2x during teens ● Immunizations, hearing, vision, scoliosis, thyroid and pelvic for sexually active girls.. ● BP, height and weight -puberty : reproductive maturity - starts at age 10 in girls and ends with menstruation - starts age 12 in boys and ends sperm production Growth - Girls achieve 98% of height of 16 Skeletal growth outpaces muscle growth Nonvoluntary with early menses, 13-15 ovulation begins Boys : grow rapidly from 13-20 Muscle strength and coordination develop rapidly Larynx becomes enlarged Both sexs : body takes on contours Primary sex organs develop, hormonal activity increases Bone growth continues until 20s Anorexia and bulimia can happen due to body image issues Psychological milestones Physical milestones ● ● ● ● ● ● ● ● ● ● ● Girls : 9-11: growth spurts last 18 months Grows 3 in annually until menarche Begin to develop figure Boys: 11-13: slower and steadier than girls Changes in penis testes and scrotum Nocturnal emissions “ wet dreams” ● ● Social Milestones ● ● ● ● Emotional growth Greater focus on peers develops a separate self from parents Moral development Less egocentric Focused on mixed gender friendships ● ● ● ● ● Able to communicate complex thoughts Age Rebellious Emotional highs and lows Focus on appearance Sexually active teens may have impaired self image Privacy becomes important. . Nutrition Language ● They wonder who they are What will they become More mobile Seek out intimate relationships Most are heterosexual, homosexuality can be difficult emotionally Body image is closely related to self esteem Underdevelopment causes anxiety ● ● ● ● Theroist Rapid growth causes a need for the greatest amount of nutrients Appetite increases and teens eat frequently Food choices not always wise May skip meals Can have nutritional deficits of vit A, D and B. folic acid, iron and zinc. Due to menses girls need additional iron. Stage Description Nursing care Puberty Sigmund Freud Genital Pleasure center in the genitals Encourage safe sex, educate on teen pregnancy and STI 10-20yrs Erik Erikson Identity vs role confusion Integrating multiple roles, self image and peer pressure Support self esteem, be honest maximize positive aspects of image and minimize defects 11adulthood Jean Piaget Formal operational stage Reasons in more abstract idealistic ways Discuss conditions openly with client. Allow privacy to discuss BURNS What happens? ❖ ❖ ❖ ❖ ❖ ❖ Priorities Plasma seeps into the tissues due to increased capillary permeability usually within the first 24 hours. Your patient may present in a state of shock therefore you will see increased pulse, respirations, and hypotension. Cardiac output decreases because there is less volume to pump The kidneys aren't being perfused therefore they hold onto fluids therefore causing decreased urine output Initially you vasodilate. Once epinephrine is secreted then you vasoconstrict and shunt blood to the vital organs. ADH & Aldosterone are secreted to retain water and sodium to help increase blood volume. ❖ ❖ ❖ ❖ ❖ Fluid replacement Monitoring the airway is your first priority. Look for signs of inhalation injury such as; singed nasal hairs or bruns in mucosa or mouth, head, neck or face. Coughing up soot or black secretions. Administer 02 at 100% Most common airway injury is carbon monoxide poisoning. Determine if the burn occured in an open or closed area. ❖ ❖ Fluid replacement: You must know the time the burn occurred because replacement therapy is based on 24h from the injury occured. Formula : Calculate the amount needed for 24h then divide by 2. Then give the first half of the fluid in 8 hrs. ( 4 mL * Kg* % TBSA = total fluid replacement for the first 24 hrs) Emergency management ❖ ❖ ❖ ❖ Wrap the patient in a blanket to put out the flames to hold in body heat and keep out bacteria. Douse in cool water Cover in a clean dry cloth Remove jewelry Rule of 9’s Head and neck: 9% Trunk :18% front. 18% back Genitals: 1% Arms : 9% each for the whole arm Legs : 18% each for the whole leg Nursing considerations Give a tetanus immunization Monitor for hyperkalemia because of cellular destruction Administer antacids to prevent a curling's ulcer Place an NG tube to prevent paralytic ileus Replace calories Monitor for contractures Pt should be on reverse isolation Monitor for infection Place the patient on telemetry You want to give medications IV because they work faster. Perform frequent circulatory checks: ❖ Pulse ❖ Skin temp ❖ Skin color ❖ Capillary refill Insert a foley Call the MD if urine is brown or red Monitor NG tube output Treatments ❖ Albumin helps by: ❖ ❖ ❖ ❖ ❖ ❖ ❖ Hold c spine in the field Place on cardiac monitor for 24 hours At risk for Vfib Monitor renal studies : hemoglobin and myoglobin can build up and case renal issues. Increasing vascular volume Increasing blood pressure Increasing cardiac output Increased kidney perfusion Think shock reversal and opposites. Nursing considerations for fluid replacement ❖ ❖ Monitor for increased urine output. This is the best way to know that shock is reversing and the kidneys are reprofusing. Monitor for fluid volume excess Chemical burns Electrical burns ❖ ❖ Hypertonic solutions: Albumin, because it keeps fluid into the vascular space. Priority is to remove the chemical and rinse it off! Classification of burns ❖ ❖ ❖ First-degree burns:They result in pain and reddening of the epidermis Second-degree burns(partial thickness burns) affect the epidermis and the dermis (lower layer of skin). They cause pain, redness, swelling, and blistering. Third-degree burns (full thickness burns) go through the dermis and affect deeper tissues. They result in white or blackened, charred skin that may be numb. PRIORITY AND DELEGATION ABC’S ❖ ❖ ❖ A: Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction. ❖ B: Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration. ❖ C: Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output. ❖ D: Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern. ❖ E: Everything else. This category includes such issues as writing any incident report and completing the patient chart. When evaluating needs, this category is never the highest priority. Rule utilitarianism is known as the “greatest good for the greatest number of people” theory. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society. TIPS You can separate the tasks into categories that help you decide what to do first. I generally separate them into the following categories: ❖ Things that require action before they can happen ❖ Things that are time sensitive ❖ Things that other people can do ❖ Patient schedules/appointments ❖ How many items a patient needs to have done DO NOT delegate what you can EAT! or PACET P – Planning A – Assess (Primary/Initial) C – Collaboration (with RT, OT, PT, ETC) E – Evaluate (for trends) T – Teach ➢ ➢ Assessment, teaching, i.v. meds, evaluation, unstable patient cannot be delegated to an Unlicensed Assistive Personnel. LVN/LPN cannot handle blood. MED SURG IMPORTANT FACTS Eyes and Ears ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ Use of high-pitched voice is inappropriate for the client with hearing impairment Rinne’s test compares air conduction with bone conduction. Vertigo is the most characteristic manifestation of Meniere’s disease. . Low sodium is the diet for a client with Meniere’s disease. A client who had cataract surgery should taught to call his MD if he has eye pain. Risk for Injury takes priority for a client with Meniere’s disease. Irrigate the eye with sterile saline is the priority nursing intervention when the client has a foreign body protruding from the eye. Snellen’s Test assesses visual acuity. Presbyopia is an eye disorder characterized by lessening of the effective powers of accommodation. The primary problem in cataract is blurring of vision. The primary reason for performing iridectomy after cataract extraction is to prevent secondary glaucoma. In acute glaucoma, the obstruction of the flow of aqueous humor is caused by displacement of the iris. Glaucoma is characterized by irreversible blindness. Hyperopia is corrected by convex lens. Pterygium is caused primarily by exposure to dust. A sterile chronic granulomatous inflammation of the meibomian gland is chalazion. The surgical procedure which involves removal of the eyeball is enucleation. Romberg’s test is a test for balance or gait. BONES ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ NEURO ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ If the client with increased ICP demonstrates decorticate posturing, observe for flexion of elbows, extension of the knees, plantar flexion of the feet. The nursing diagnosis that would have the highest priority in the care of the client who has become comatose following cerebral hemorrhage is Ineffective Airway Clearance. The initial nursing action—for a client who is in the clonic phase of a tonic-clonic seizure—is to obtain equipment for orotracheal suctioning. The first nursing intervention in a quadriplegic client who is experiencing autonomic dysreflexia is to elevate his head as high as possible. Following surgery for a brain tumor near the hypothalamus, the nursing assessment should include observing for inability to regulate body temp. Post-myelography (using metrizamide (Omnipaque) care includes keeping head elevated for at least 8 hours. 36. Homonymous hemianopsia is described by a client had CVA and can only see the nasal visual field on one side and the temporal portion on the opposite side. Ticlopidine may be prescribed to prevent thromboembolic CVA. To maintain airway patency during a stroke in evolution, have orotracheal suction available at all times. For a client with CVA, the gag reflex must return before the client is fed. Clear fluids draining from the nose of a client who had a head trauma 3 hours ago may indicate basilar skull fracture. An adverse effect of gingival hyperplasia may occur during Phenytoin (DIlantin) therapy. . Urine output increased: best shows that the mannitol is effective in a client with increased ICP. . A client with C6 spinal injury would most likely have the symptom of quadriplegia. Falls are the leading cause of injury in elderly people. Bone scan is done by injecting radioisotope per IV and then x-rays are taken. To prevent edema on the site of sprain, apply cold compress on the area for the first 24 hours. To turn the client after lumbar Laminectomy, use the logrolling technique. Carpal tunnel syndrome occurs due to the injury of median nerve. Massaging the back of the head is specifically important for the client with Crutchfield tong. A one-year-old child has a fracture of the left femur. He is placed in Bryant’s traction. The reason for elevation of his both legs at 90º angle is his weight isn’t adequate to provide sufficient countertraction, so his entire body must be used. . Swing-through crutch gait is done by advancing both crutches together and the client moves both legs past the level of the crutches. The appropriate nursing measure to prevent displacement of the prosthesis after a right total hip replacement for arthritis is to place the patient in the position of right leg abducted. . Pain on non-use of joints, subcutaneous nodules and elevated ESR are characteristic manifestations of rheumatoid arthritis. Teaching program of a patient with SLE should include emphasis on walking in shaded area. Otosclerosis is characterized by replacement of normal bones by spongy and highly vascularized bones. COMMUNITY & ETHICS ETHICS ❖ ❖ ❖ ❖ ❖ ❖ ❖ COMMUNITY Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values. A third-party payer is an insurance company. Intrathecal injection is administering a drug through the spine. When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked. ❖ ❖ ❖ Communication and Patient Education ❖ ❖ . The steps of the trajectory-nursing model are as follows: ❖ Step 1: Identifying the trajectory phase ❖ Step 2: Identifying the problems and establishing goals ❖ Step 3: Establishing a plan to meet the goals ❖ Step 4: Identifying factors that facilitate or hinder attainment of the goals ❖ Step 5: Implementing interventions ❖ Step 6: Evaluating the effectiveness of the interventions Two goals of Healthy People 2010 are: ❖ Help individuals of all ages to increase the quality of life and the number of years of optimal health ❖ Eliminate health disparities among different segments of the population. ❖ A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local park. ❖ If a patient isn’t following his treatment plan, the nurse should first ask why. ❖ When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs. ❖ Ethnocentrism is the universal belief that one’s way of life is superior to others’. ❖ When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter. ❖ Prejudice is a hostile attitude toward individuals of a particular group. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient. Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm. Nonmaleficence is the duty to do no harm. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns. ❖ ❖ ❖ Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn. Process recording is a method of evaluating one’s communication effectiveness. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning). When communicating with a hearing impaired patient, the nurse should face him. . When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge. 1. A client has come into your clinic for a psychiatric follow up. They have lost 10% of her body weight since the last time you saw them. Which of the following signs and symptoms would you find in a client suffering from anorexia nerviosa? Select all that apply. A.) Fluid and electrolyte imbalances B.) Heat intolerance C.) Amenorrhea D.) Weight loss of 25% under normal weight E.) Presence of lanugo 2. Which of the following statements if made by the nurse( who)is most helpful in the following scenario: An elderly patient at the end of life is being visited by relatives, one of them starts crying and asks the nurse to stay with them for a few minutes, but the nurse has other patients to take care of. A.) “ I don’t think it’s okay for me to interrupt your family time.” B) “ If you would like I could stay and sit with you.” C.) “ I can have the clergy come and sit with you.” D.) “ I am busy but I think I could stay with you for a few minutes.” Clinical manifestations of Anorexia Nervosa include several symptoms. One can expect amenorrhea, dry skin, cold intolerance, extreme weight loss, bradycardia and even dysrhythmias which can be life-threatening. It is important to keep a close eye on electrolytes in these patients. 3- A client was recently diagnosed with End-Stage Kidney Disease (ESKD) and was informed of the necessity of starting renal replacement therapy. This morning the client was found trying to attempt suicide by hanging himself in the bathroom, using gown ties. He was stabilized and relocated to the psychiatric ward. Which of the next nursing actions should be taken first in this patient? A.) Deliver constant 1:1 observation with the client B.) Locate the client in a room close to the nurses’ station C.) Evaluate the client risk for a subsequent suicide attempt D.) encourage the client to communicate his feelings about his diagnosis B) The end of life process can be confusing, frightening, sad, or concerning for family members. The family may inquire about the process and what to expect, some may need comforted and reassured. The nurse should aid the family in times of grief to get them to successfully and therapeutically pass through the grief process ,this includes sitting with the family as needed. A.) Is incorrect because it is not therapeutic for the nurse to decline the family's request, the family could view this as dismissive and see the nurse as unconcerned about their loved one. C.) Is incorrect due to the amount of time it may take for the clergy to arrive to the bedside although this is an appropriate intervention it is not the most therapeutic. Rationale B) The end of life process can be confusing, frightening, sad, or concerning for family members. The family may inquire about the process and what to expect, some may need comforted and reassured. The nurse should aid the family in times of grief to get them to successfully and therapeutically pass through the grief process ,this includes sitting with the family as needed. A.) Is incorrect because it is not therapeutic for the nurse to decline the family's request, the family could view this as dismissive and see the nurse as unconcerned about their loved one. C.) Is incorrect due to the amount of time it may take for the clergy to arrive to the bedside although this is an appropriate intervention it is not the most therapeutic. D.) is incorrect because this is the least therapeutic and most dismissive, the family may already feel as though they are “bothering” the nurse. The nurse could delegate tasks to other nurses and UAP
