lOMoARcPSD|18338319 Comprehensive Nursing ATI Exam Study Guide Comprehensive Nursing Concepts (Drexel University) Studocu is not sponsored or endorsed by any college or university Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Comprehensive ATI Exam Study Guide Hi all! My name is Morgan and I recently graduated from Drexel University’s Accelerated Nursing Program in Philadelphia! This program is 11 months in length, and is designed for students who have completed a prior degree looking to complete their BSN in less than a year. It was one of the hardest things I have ever done, but I am so thankful for my education and where I am today! This study guide is a condensed version of ATI’s Comprehensive Book (pink book) and it literally got me through the ATI Comprehensive Final Exam with flying colors. Each section is divided up between topics, and there are subtopics in each section to help facilitate your learning. Good luck, you got this! Before we start, take a deep breath. ATI is designed to help you better prepare for the NCLEX, and while it is daunting, you will slay the ATI if you follow this study guide and supplement your review with practice questions (from ATI of course!) Set yourself up in a comfortable room, preferably a quiet one with few distractions. Take frequent breaks, drink lots of water, and stretch your legs when needed. YOU and your mental health come first. You’ve got this, we’re rooting for you! Timeline and How to Study If you’re in your last quarter/semester, you’ve probably been thinking about preparing for the ATI Final Exam (or have already started!) Use this timeline as a guide to help space out your review. Feel free to double up on topics or go in any order you’d like! This timeline worked for me, but change it up to make it work for you. Day Week 1 Week 2 Week 3 Week 4 Monday Fundamentals Tuesday Wednesday Friday Adult Med Surg Adult Med Adult Med Surg Adult Med Surg Hematologic, Surg Respiratory Cardiovascular Immune, & GI & Renal Cancers Adult Med Surg Neuro & Musculoskeletal Adult Med Surg Reproductive Maternity Diagnostic Tests & Reproductive System Maternity Newborn Peds Developmental Milestones Peds Procedures, Poisoning, & Others Critical Care Thursday Saturday Sunda y Adult Med Surg Endocrine & Integumentary Break Maternity Signs of Pregnancy & Complications Maternity L&D Maternity Postpartum Break Mental Health Mental Health Critical Care Break Pharm Infectious Disease & Analgesics Break Pharm Pharm Pharm Pharm Calculations & Cardiovascular Neuro & Maternity & Conversions & Respiratory Reproductive Psych Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Table of Contents Fundamentals ● Ethics and Laws ● Admissions ● Nursing Process ○ Lab Values to Know ● Patient Needs ● Duties of Different Professionals ● Death and Dying ● Nursing Procedures ● Important Considerations ● Common Clinical Signs ● Safety and Infection Control ● Transmission Based Precautions ● Nutrition Medical Surgical Nursing ● Respiratory ● Cardiovascular and Peripheral Vascular Disorders ● Hematologic, Immune, and Cancers ● Gastrointestinal System ● Renal System ● Endocrine System ● Neurosensory System ● Musculoskeletal System ● Integumentary System Maternity ● Diagnostic Tests and Reproductive System ● Signs of Pregnancy ● Complications During Pregnancy ● Labor and Delivery ● Postpartum Assessment ● Newborn Assessment Pediatrics ● Developmental Milestones ● Procedures, Poisoning, & Others Mental Health ● Overview ● Disorders ● Extrapyramidal Symptoms & Medications Pharmacology ● Overview ● Important Drugs Downloaded by Galen Grant (galen.grant93@gmail.com) Page # 3 5 6 7 8 9 10 10 11 14 15 15 18 22 25 28 30 34 38 40 44 47 49 51 52 54 56 57 60 69 70 73 77 78 79 lOMoARcPSD|18338319 ● Frequent Monitoring Drugs & Toxicity Diagnostic Lab Tests and Values ● Overview 82 86 Fundamentals Ethics and Civil Law ● Reporting Act ○ Child and elderly abuse ○ Gunshot wounds ○ Communicable diseases ○ Ophthalmia Neonatorum ○ Phenylketonuria ○ Criminal acts ● Incident Reports ○ NEVER place in a patient's chart ○ If a patient wants to leave AMA, it is the provider's responsibility to advise the patient of any risks involved when they refuse care ● Advanced Directives ○ Two Types ■ Living will ■ Durable Power of Attorney: transfers all rights to the designated agent ○ Intended to allow patients to have more control over their health care decisions at the end of life ● Informed Consent ○ Not required in emergency situations ○ Capacity-age (adult), competence (can make choices and understand consequences) ○ Voluntary ■ Freedom of choice without force, fraud, duress, or coercion ○ Informed consent not to be made under the influence of a drug or alcohol ○ The nurse’s signature as a witness on a consent form indicates that the nurse observed the informed consent or the clients authorized representative voluntarily signed the consent form ● When to Question Provider Orders ○ Ambiguous orders ○ Orders that the patient questions ○ Orders when the patient’s condition has changed ○ Orders which do not match with your experience ○ Verbal orders that the doctor has not yet co-signed ● How to Protect your License ○ Do not let anyone else borrow it ○ Do not copy it unless you write COPY on it Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ ○ ○ ● Torts ○ ○ ● ● ● ● ● ● ● If you lose your license, report it immediately Be sure that the Board of Nursing is notified of any changes of address or name Practice nursing according to the scope and standards of the state you work in Civil wrongs Intentional ■ Assault, battery, defamation, false imprisonment, outage, invasion of privacy, wrongful disclosure of confidential information (can fax or email personal information if consent was given) ○ Unintentional (Negligence) ■ Failure of a nurse to perform an act that a reasonable person would or would not perform in similar circumstances ■ Can be an act of omission or commission ■ Occurs when injury results from the failure of the wrongdoer to exercise care Malpractice ○ Professional misconduct that is an unreasonable lack of skill or fidelity in duties ○ Ex; not inserting a foley, not taking appropriate steps to decrease a patient’s temperature, not reporting worsening conditions of the patient to the provider, not preventing falls Libel ○ Written communication that injures a person’s reputation Slander ○ Oral communication that injures a person’s repudiation Assault ○ A threat or an attempt to make bodily contact with another person without the person's consent ○ Ex: threatening to give an injection to a psychotic patient if they do not behave properly Battery ○ Touching another person unlawfully or carrying out a threatened physical harm Good Samaritan law ○ Enacted by individual states to encourage healthcare providers to assist at the scene of accidents and emergencies ■ Care must be provided in good faith and must be gratuitous ■ The nurse must provide care at the level of their scope of practice Liability ○ Individual ■ Everybody is liable to his or her action/conduct ■ Liability must be shared by another person or group (ex; doctors and fellow nurses or a facility such as a hospital) ○ Vicarious Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Liability under the nurse practice act, which defines the standard of care a nurse is expected to perform (ex; wrongfully administering a medication which would result in physical harm to the patient) ● Nursing Implications for breaches in Civil Law ○ Intervene when patient dignity or privacy is violated ○ Properly covering a physical body during procedures ○ Medical records must be released only with written patient consent ○ Clients belongings must be protected and may not be searched without specific authorization Admissions ● Admissions ○ Voluntary ■ When a patient is willingly taken to the hospital to be admitted ○ Involuntary ■ When one is unwilling to go to the hospital, someone else makes the decision for that person ■ In this situation, the patient loses the right to make decisions for themselves ■ Ex; pediatric patients, adults with mental or cognitive impairment ● Discharges ○ Final or Absolute ■ Ex; when you give birth ○ Conditional or Incomplete ■ Ex; discharge to a halfway house, nursing home, group home, OT/PT ■ The patient has a contract with the hospital until final discharge ● Restraints ○ Physical restraints ■ Informed consent is needed ● If a client is unable to consent to the use of restraints, a consent of proxy must be obtained after full disclosure of risks and benefits ● If informed consent is not given, restraining a patient is considered false imprisonment ■ Restraints should be adequate and appropriate for the purpose, must have a doctor's order ■ In emergency situations, restraints may be applied without doctor's orders for a limited time ■ Restraints are only needed when a patient is harmful to self or others and alternative therapies have not worked ■ Check on restraints client every 10-15 minutes ● Documentation must include the time of each check and the neuromuscular status of the client's extremities ○ Chemical Restraints ■ Psychotropic drugs cannot be used to control behavior Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Can be used only for diagnosis-related conditions ■ Inappropriate use of chemical restraints can cause deep sedation, agitation, combativeness, and possible injury to the patient Nursing Process ● Systemically a collection of data and clearly identifies the patient's strengths and problems ○ The process offers improved quality of nursing care ○ Encourages client participation in care and decision-making ○ Always individualized ● ADPIE ○ Assessment, nursing diagnosis/analysis, planning, implementation, and evaluation ■ Always use the five steps in chronological order ○ Remember that assessment always comes before planning or implementation 1) Assessment ● Begins as soon as the patient walks in ○ Involves establishing the database of a client, collection and organization of physical and psychosocial assessment data ○ Collection of physical assessment data ● Verify the data ○ Whenever there is a doubt, verify the data ■ ex; if a patient wants to urinate, assess the symphysis pubis for dissension or swelling. If this tension is present, it confirms the Dell ○ Always question orders you do not agree with ■ ex; ordering Demerol for head injury patient, needs questioning because Demerol depresses the respiratory center ○ Before the administration of any pain medication, ask the patient to rate the pain ■ If the pain is 0-4, try diversional therapies first ■ If the pain is 5-10, give pain meds ● Subjective Data ○ Information perceived only by patient, what they feel ○ Symptoms: patient is nauseous, with chills and pain ● Objective Data ○ Observed by nurse ○ Body temperature, blood pressure, cyanosis 2) Diagnosis & Analysis ● Formulated nursing diagnosis used NANDA ● Analysis ○ To identify the actual potential problems, the cause, or etiological factors ○ Analyzes lab results ○ Identifies immediate needs ○ Determine cause of symptoms, strengths, weaknesses ● Lab Results to Know Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 RBC: 4.5-6.1 million WBC: 4,500-11,000 Hgb: 12-18 Hct: 38-54% Plt: 150-450,00 0 PTT: 35-45 sec PT: 10-15 sec aPTT: 25-35 sec INR: 2-3 Bleeding time: 1-10 min Na: 135-145 K: 3.5-5.1 Mg: 1.6-2.6 Ca: 8.5-10.5 BUN: 10-20 Creat: 0.5-1.5 Lithium: 0.5-1.5 Dig: 0.5-1.5 Cholesterol : 160-190 CKP: 25-175 AST: 8-20 Prostate antigen: 0.18-0.89 Glucose: 70-110 A1C: 4-6% pH: 7.35-7.45 CO2: 35-45 >45: acid <35: alkaline O2: 80-100 HCO3: 22-26 <22: acid >26: alkaline PaO2: 95-100% ● Ability to Make Predictions ○ If a nurse administers Demerol, the nurse should expect it to start to relieve pain within 30 minutes ○ Regular insulin works within the first 30 minutes, therefore, if a nurse administers regular insulin, they should expect that the medication will start working within 30 minutes ■ Ability to synchronize meal times ○ If you remove CSF during a lumbar puncture, it will cause fluid loss and a headache ■ Remember, the positioning for this procedure is the fetal position/knee to chest position at the edge of the bed ■ The first four hours after the lumbar puncture, the nurse then places the patient in a prone position to allow the process of coagulation to take place ■ After this, the nurse places the patient in supine or flat position to apply pressure on the puncture site ○ When taking care of a patient with rheumatoid arthritis, a systemic and autoimmune disease that if left untreated, will affect the heart (carditis) ■ Therefore, the nurse can predict that bed rest will be needed 3) Planning ● Set priority first, short term goals before long term ones ● Consult with family and patient in developing plan of care ● Short-term goals ○ Immediate actions ○ Ex; f a patient is in a state of anxiety due to pain, the best solution is to relieve anxiety by relieving the pain ○ Ex; if a patient is bleeding from a surgical incision site, stop the bleeding by reinforcement of a wound dressing or apply pressure ● Long-term goals Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Takes longer to achieve ○ Sets up priority or prioritizes the goals by using Maslow's hierarchy of needs, ABCs, and safety 4) Implementation ● Carrying out the planning or accomplishing a defined goal, involves implementation of care, reporting significant changes in client's condition, documentation, communicating patient needs to others of the healthcare team ○ Ex; give me orange juice with iron for better absorption ○ Ex; Not giving diuretics at night 5) Evaluation ● Determining the extent at which the goals have been achieved ○ Comparing patient responses to the expected outcome ○ Revising the goal of care to accommodate patient values, Customs, culture, and beliefs ○ Gathering data to indicate effectiveness of each intervention ■ Ex; an evaluation of an anemic woman on iron medication after 3 months showed that her hemoglobin improved effectively Patient Needs ● Maslow's hierarchy of needs ○ Physical needs, physiological: oxygen, food, water, sex, shelter, rest ■ The highest needs that must be satisfied first ■ Airway, breathing, circulation ○ Psychological needs ■ Supporting patients in terms of their needs and problems such as alleviating anxiety and pain ● Ex; placing a suicidal patient on a one-to-one unit ■ Using effective therapeutic communication techniques ■ Pain relief is considered psychosocial ○ Safety and Security ■ Reducing excessive stimulation in the environment ■ Modifying the environment to meet the needs of the patient example includes writing a confused elderly person's name on the door of their room and clearing the environment of clutter of a fall risk patient ■ Safe proof in the environment for children to prevent falls, accidental poison ingestion, and swallowing foreign bodies ○ Love and belonging ■ First loving yourself before you can love anybody else ○ Self-esteem ■ How you feel about yourself ○ Self-actualization ■ Very few people achieve this need, the need to become firm and resolute human being Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Therapeutic relationship ○ The nurse-patient relationship ■ The nurse maintains the prescribed relationship and sustains the trust built during the orientation phase, the longest phase ■ The nurse give the patient assistance needed to achieve the goals of the relationship ■ Termination phase begins on admission and during orientation phase when the patient is made aware of when to terminate the relationship ● Empathy ○ Putting oneself into somebody else’s world and seeing from another person's point of view ○ Temporarily experiencing another person's feelings ○ NCLEX TIP: The answer is always “tell me about/how/why”, never assume ● Sympathy ○ Should never be used in medicine ○ Positive regards ■ Denotes respect or viewing a person as worthy of caring for ○ Non-judgemental ■ Refrain from judging clients based on behavior or their background Duties of Different Professionals ● RN Duties ○ Admission ○ Discharge teaching ○ Blood transfusions ○ Flushing lines and setting IVs ○ Decision making ○ Communication to the rest of the healthcare team ○ Developing the nursing care plan and implementation of teaching ○ Administering chemotherapy ○ Caring for a patient on mechanical ventilation ○ Transcribing physician orders ○ Analyzing assessment data and determining appropriate nursing diagnosis and actions ○ Caring for the critically ill or sickest client ● LPN Duties ○ Suctioning ○ Catheterization ○ Dressing changes ○ Blood transfusion after 1 hour ○ Medication administration ○ Taking vital signs ○ Ostomy care Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● UAP Duties ○ Bed making and Grooming ○ Feeding, but not clients with dysphagia ○ Bathing and ambulating ○ Mouth care ○ Vital signs ○ Emptying ostomy bags ● Never delegate what you can eat: Evaluate, Assess, Teach Death and Dying ● Acronym: DABDA ○ Denial and Isolation ■ Usually defined as the refusal to accept loss ■ Tend to hospital jump to disprove initial diagnosis ○ Anger ■ Feeling of emptiness and anger ■ Reality has begun to penetrate their consciousness ○ Bargaining ■ Changing from “not me” to “yes me, but why now?” ■ Patient pleads for more time to live ■ Good for patients to help them set goals ○ Depression ■ Patient will turn inward, give simple answers and give up on those they love ■ Can be considered silent grief and Mourning period ○ Acceptance ■ Patient is ready and has accepted the death or loss ■ Will detach from family members as a normal reaction ● Pediatric Patients ○ Birth to 1 year ■ Has no meaning ○ 1-4 years ■ Regards death as a temporary separation ○ 5+ years ■ Regards death as permanent and irreversible Nursing Procedures ● Hand-washing ○ Single most important procedure for the prevention of nosocomial infections ● Wounds ○ Clean from inside to the outside ● Order of Donning ○ Gown, mask, cap, gloves ● Order of Doffing ○ Gloves, cap, mask, gown Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Standard Precautions ○ Contact with blood, bodily fluids, excretions, secretions, non-intact skin, and mucous membranes Important Considerations ● BP Cuffs ○ If it’s too small, can cause falsely high blood pressure readings ■ Should be two-thirds of the width of the limb where pressure pressure is being monitored ● Apical pulses ○ Diaphragm of the stethoscope placed at the left fifth intercostal space in the midclavicular line ● Carotid artery ○ Used for pulse in emergency situations ● Circulatory or respiratory problems ○ Vitals should be assessed before hot compresses are placed anywhere ● Risk for falls ○ Hx of falls, advanced age, sensory/motor impairment, urgent need for elimination, postural BP instability ● Wheelchair ○ When assisting the patient, place the chair on the unaffected side of the body ● Latex allergies ○ The patient may also be allergic to avocados, bananas, kiwi, or chestnuts ○ Signs of a reaction may include facial swelling, rhinitis, urticaria, and respiratory distress ● Iodine allergy ○ The patient may also be allergic to shellfish ● Mouth care ○ On an unconscious patient, ensure the patient is in a side-lying semi-Fowler’s position ● Fires ○ RACE ■ Rescue, alarm, contain. and extinguish ● Passive ROM ○ Contraindicated during the inflammatory phase of rheumatologic diseases as well as joints that are dislocated or fractured ○ During these exercises, never push a movement beyond the point at which the client complains of discomfort or when you feel resistance ● Prone-Lying ○ Contraindicated for tracheostomies, cervical injuries, or breathing difficulties ○ GOOD for Covid-19 ● Crutches ○ Have the client Benz the elbows at 20- 30 degrees ● Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ● ○ The length of the crutch should be measured by placing two fingers between the axillary bars and 6-8 inches out from heel ○ When ambulating with a pt who is using crutches, stand on their affected side and use a gait belt ○ When going up the stairs, good leg goes up first, bad leg follows Cane ○ Stand on their affected side and hold onto gait belt ○ Teach the patient to place the cane on their unaffected side so the cane and the weaker leg works together ○ Properly sized cane will extend from the greater trochanter to the floor allowing for 20- 30 degrees flexion Nitro patches/paste ○ Avoid direct contact to prevent headaches Cardiac Catheterization ○ First nursing priority is to assess for bleeding at the site Objective Examination ○ Inspection, auscultation, palpation, and percussion ■ Except in abdominal examination ○ To check for a pulse deficit, two nurses simultaneously auscultate the apical and palpate Radial pulse SIMs position ○ Preferred by pregnant women because of the Comfort it provides when lying down ○ Position of choice for an enema insertion Dorsal Recumbent position ○ Used for examination of the abdomen, breast, anterior chest Lateral position ○ Used for patients who have sensory or motor deficits on one side of the body Knee to chest position ○ Recommended for rectal examinations and patients with heart conditions that cause cyanosis Thoracentesis ○ Patient is in a sitting position bending over the bedside table ○ Ensure that the patient has voided before procedure Paracentesis ○ Patient is an upright position with the feet supported ○ Watch 4 complications such as hypotension and hypovolemic shock ○ Ensure that the patient has voided before procedure Liver biopsy ○ Patient is on their left side ○ After the procedure, place the patient on the right side to put pressure on the insertion site Lumbar puncture Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ○ Obtains CSF for examination, relieving pressure, or to introduce medication ○ Patient is in a lateral knee to chest position or a fetal position Enema ○ Always oil retention enemas before cleansing ones ○ Hold the enema bucket at least 18 in above the level of the patient ○ If the patient complains of cramping, pinch the tubing and ask the patient to breathe slowly NG Tube ○ Measure from the tip of the nose, to the earlobe, to the tip of the xiphoid process ○ Advance the tube at the nasopharynx, at the pharynx, ask the patient to flex their head ○ Ensure proper placement by x-ray or test the acid in a gastric content Orthostatic Hypotension ○ Watch for complaints of vertigo, lightheadedness, fainting, nausea, or a sudden drop in blood pressure (25 systolic and 19 diastolic) when moving the client from a horizontal to a vertical position Dependent edema ○ Most accurate area is the sacral area ○ Usually secondary to right sided heart failure Pap smear ○ First priority nursing action is to wipe the cells immediately across a clean glass slide and fix with spray Sigmoidoscopy ○ Client will receive a clear liquid diet for one day before the test and a warm tap water enema until returns are clear Colonoscopy ○ Patient is sedated and positioned on their left side Returning from procedures ○ Encourage early ambulation and provide oxygen support during ambulation Peritoneal dialysis ○ Involves the use of the peritoneal membrane across which excess waste and fluids move from the blood into the peritoneal vessels into a dialysate solution that has been instilled into the peritoneal cavity ○ Feeding, dwell time, draining ○ Monitor for signs of infection by observing for cloudy color of the dialysate effluent Ophthalmic ointment ○ Start at the inner canthus and extend the medication out word for the outer canthus Snellen chart ○ Used for visual acuity ○ 20/20 Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ The numerator is the distance in feet at which the letter is readable by the person who is normal eyesight ● Skin color changes ○ In dark-skinned individuals, these changes can best be seen in the lips, mucous membranes, earlobes, palms and soles of feet ○ Jaundice is best detected in the sclera of the eyes ○ Cyanosis is best detected in the oral mucosa, conjunctiva, and nail beds ○ Pallor is best detective in the conjunctiva and mucous membranes ● Surgical wounds ○ Compress Jackson-Pratt bulb/hemovac container every 4 hours to monitor drainage Common Clinical Signs ● Babinski reflex ○ Dorsiflexion of the big toe after stimulation of the lateral sole ○ Associated with corticospinal tract lesions ● Brudzinski's sign ○ Flexion of the hip and knee induced by flexion of the neck ○ Associated with meningeal irritation ● Chadwick's sign ○ Sign of vaginal and cervical mucosa ○ Associated with pregnancy ● Chovstek’s sign ○ Facial muscle spasms induced by tapping on the facial nerve branches ● Cheyne-Stokes respirations ○ Rhythmic cycles of deep and shallow respirations often with apneic periods ○ Associated with the central nervous system ● Cullen's sign ○ Bluish discoloration around the umbilicus ○ Indicative of acute pancreatitis ● Harlequin’s sign ○ In the newborn infant, reddening of the lower half of the laterally recumbent body and blanching of the upper half ○ Due to temporary vasomotor disturbances ● Hegar’s sign ○ Softening of the fundus of the uterus ○ Associated with first trimester of pregnancy ● Homan's sign ○ Pain behind the knee induced by dorsiflexion of the foot ○ Associated with peripheral vascular disease, especially venous thrombosis in the calf ● Kernig’s sign ○ Inability to extend leg when sitting or lying with the thigh flexed on the abdomen Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Associated with meningeal irritation ● Kussmaul's breathing ○ Paroxysmal air hunger, associated with acidosis, especially diabetic ketoacidosis ○ Characterized by deep sighing respiratory pattern ● Mcburney's sign ○ Tenderness at mcburney's point, two-thirds of the distance from the umbilicus to the anterior superior iliac spine ○ Associated with appendicitis ● Rovsing's sign ○ Pain in the right lower quadrant when the lower left quadrant is pressed ○ Associated with appendicitis Safety and Infection Control ● Local infection ○ Heat, redness, pain and tenderness, swelling, possible drainage (bloody, serous, purulent), abscess (localized collection of pus), cellulitis (involving cellular and connective tissue) ● Systemic infection ○ Fever, malaise, weakness ○ Will have an elevated WBC count above 11,000 ○ Will have an elevated erythrocyte sedimentation rate above 15-20, indicating the presence of inflammation ● Standard Precautions ○ Used with all patients as a primary strategy for nosocomial infection control ○ Applies to blood and all bodily fluids ● Patient Room Placement ○ Immunocompromised, then airborne, then droplet, then contact ○ Patient will be in private room if they have poor hygiene habits, contaminate the environment, or cannot assist in maintaining infection control ( infants, children, altered mental status in adults) Transmission-Based Precautions ● Airborne ○ Used with pathogens that are transmitted in the air ○ Private room with negative air pressure ○ Place a mask on the patient if they are being transported ○ Ex; Measles, tuberculosis, varicella, shingles (herpes zoster) ● Droplet ○ Used with pathogens transmitted by infectious droplets ○ Involves contact of conjunctiva or mucous membranes of the nose or mouth ■ Happens during coughing, sneezing, talking, or during procedures such as suctioning or bronchoscopy ○ Maintain 3ft distance between the infected patient and visitors ○ Place a mask on the patient when being transported Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Ex; Streptococcus pharyngitis, pneumonia, meningitis from H. Influenza ● Tuberculosis ○ Airborne ○ Transmitted by aerosolization; bacillus multiplies in the bronchi and alveoli resulting in pneumonitis, may lie dormant for many years and be reactivated in periods of stress ○ Signs and symptoms ■ Progressive fatigue, anorexia, nausea, weight loss ■ Irregular menses ■ Low-grade afternoon fevers, night sweats ■ Cough with mucopurulent sputum, occasionally streaked with blood ○ Diagnostic procedures ■ Skin test (mantoux/PPD): does not indicate an active disease is present, but indicates exposure to TB or the presence of an inactive dormant disease ■ Tinne test ■ Sputum smear for the acid-fast bacilli (most reliable) ■ Chest x-ray ● Hepatitis ○ Acute inflammatory disease of the liver resulting in cell damage from the liver cell degeneration and necrosis ○ Signs and symptoms ■ Jaundice (Icterus) ■ Clay-colored stools, tea colored urine ■ Anorexia and right upper quadrant pain ○ Patient teaching ■ Bed rest for severe symptoms ■ Avoid alcohol and hepatic toxic prescriptions (aspirin, Tylenol, sedatives) ○ Mode of transmission ■ A/E: enteric transmission ■ B/C/D: bloodborne transmission ● Lyme's disease ○ Multi-system infection transmitted to humans from ticks ○ Signs and symptoms (Stage 1) ■ Rash (papules that develop into lesions with a clear center), develops at the site of the bite within 2- 30 days, bullseye rash ■ Development of flu-like symptoms within 1 to several months ○ Signs and symptoms (Stage 2) ■ Cardiac conduction defects ■ Neurological disorders including Bell's palsy and paralysis that is not permanent ○ Signs and symptoms (Stage 3) ■ Arthralgias, enlarged and inflamed joints that may persist for several years Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● AIDS ○ Acquired immunodeficiency syndrome ○ Syndrome distinguished by serious deficits and cellular immune function associated with positive human immunodeficiency virus (HIV), evidence clinically by development of opportunistic infections, enteric pathogens, and malignancies ○ Special considerations ■ Monitor for HIV in the blood ■ AIDS syndrome has a CD4 cell count below 200 ■ Opportunistic infections such as pneumonia, stomatitis, and esophagitis may occur ■ CBC will reveal leukopenia with serious lymphopenia, anemia, and thrombocytopenia ● Chlamydia ○ Caused by chlamydia trachomatis, produces infections in men and women (Fallopian tubes, cervix, and urethra) and can also develop in PID ○ Incubation period is 5-10+ days ○ Special considerations ■ Observe for vaginal discharge, burning, bleeding or pain ○ Treatment ■ Doxycycline and erythromycin ■ Penicillin does not treat chlamydia ● Syphilis ○ Chronic infectious disease transmitted through physical contact with syphilitic lesions which are usually found on the skin or the mucous membranes of the mouth and genitals ○ The first sign of disease is an open chancre (open sores) on the genitalia ○ Progression of the disease is marked by the primary, secondary, and tertiary stages ■ Primary: most infectious stage marked by an appearance of open sores, ulcerative lesions that are painless ■ Secondary: highly infectious stage morph by lesions that occur anywhere on the skin ■ Tertiary: spirochetes enter internal organs and cause permanent damage internal organs and cause permanent damage ○ Special considerations ■ Assess for symptoms related to nervous system Invasion such as meningitis, locomotor ataxia (foot slapping and broad-based gait), progressive mental deterioration leading to insanity ■ Assess for cardiovascular damage to the aorta and the valves ○ Diagnostic procedures ■ STS test (blood) ○ Treatment ■ Procaine penicillin G Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Gonorrhea ○ Infection that causes inflammation of the mucous membrane of the genitourinary tract ○ Transmission by sexual intercourse ○ Signs and symptoms (males) ■ Painful urination, pelvic pain, fever, epididymitis ○ Signs and symptoms (females) ■ Usually asymptomatic, but can have vaginal discharge, urinary frequency, and pain ■ PID can lead to sterility ○ Special considerations ■ Infection can be transmitted to babies eyes during delivery which can cause blindness, give prophylactic broad-spectrum antibiotics or 1% silver nitrate to newborns ■ Treat all sexual partners, as patient may become reinfected ● Herpes simplex virus (HSV) ○ Infects external genitalia, vaginal cervix, and penis ○ Develops into painful and draining vesicles ○ Virus is detrimental to fetus; usually C-section is preferred method of delivery ○ Special considerations ■ Maintain appropriate precautions during vaginal exams ■ Maintain isolation precautions during hospitalization ● Venereal Warts ○ Sexually transmitted infection caused by HPV, affect the cervix, urethra, penis, scrotum, anus ○ Warts appear 1-2 months after exposure through intimate sexual contact ○ Special considerations ■ No cure for HPV ■ Suggest and encourage pap smear every year due to high cancer risk Nutrition ● Overview ○ 1 gram of protein is 4 calories ○ Processed and canned foods are high in sodium ○ Fresh fruits and vegetables are low in sodium ○ The order of fuel use ■ Carbohydrates, fat, and then proteins ● Clear liquid diet ○ Gelatin, broth, apple juice, cranberry juice, tea ● Low-residue diet ○ Ordered to reduce fiber for patients with crohn's disease, colon surgery, esophagitis, and diarrhea ○ Clear liquids, fat, eggs, white potatoes Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ■ Avoid dairy products High-residue diet ○ Foods that contain skins, seeds, leaves High-fiber diet ○ Ordered to provide bulk in the stool and bring water into the colon for patients with constipation for diverticulitis ○ Raw fruits and vegetables and whole grains Sodium-restricted diet ○ Ordered for patients with kidney, cardiovascular disease, or hypertension in order to control the retention of sodium and water and lowering blood pressure ■ Avoid canned prepared foods, table salt, prepared seasoning ○ Used in patients with ascites, edema-associated advanced liver and renal disease, congestive heart failure, essential hypertension, and pts receiving adrenocorticoids Bland diet ○ Excludes foods that are chemically and mechanically stimulating or irritating to the GI tract ○ Small, frequent meals ○ Usually for patients with ulcers and post-op patients ■ Avoid fried foods, meat extracts, pepper, and chili powder Low-fat diet ○ Limits foods containing cholesterol and saturated fatty acid ○ Increases foods high in polyunsaturated fatty acids including skim milk, egg whites, lean meats, and fat-free soup Low-purine diet ○ Recommended for patients with gout ■ Avoid organ Meats, shellfish, oily fish Low-oxalate diet ○ Avoid leafy greens, nuts/seeds, beets, raspberries ○ For kidney stones, gout BRAT diet ○ Banana, rice, Apple, tea Gluten-free diet ○ Ordered for patients with malabsorption syndrome such a Celiac disease Cholesterol ○ Levels of 200+ associated with increased risk for CAD ○ Avoid foods with cheese and eggs Vitamin K ○ A deficiency in this may affect blood coagulation ○ Green leafy vegetables are high in vitamin K and should be avoided in patients on coumadin ○ Foods high in potassium also include baked potatoes, avocados, cantaloupe, tomatoes, and orange juice Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Gout ○ Avoid foods such as organ meats, sardines, beans, and lentils, foods high in protein ● Kidney stones ○ To reduce the risk of stone formation, increase intake of fluids ○ Maintain low oxalate diet ● 12 Amino acids ○ Non-essential ○ The liver is able to synthesize these acids ● 8 amino acids ○ Essential ○ The liver is unable to synthesize these ● Vitamin B12 ○ Found only in animal food ○ Needed after a gastrectomy in the form of injections because the intrinsic factor that is necessary for the absorption of B12 is founded a stomach ■ Strict vegetarians should include fortified breakfast cereal as their reliable source of vitamin B12 ■ Treatment of pernicious anemia also requires B12 injections for their life ● Vitamin D ○ Considered a nutrient of concern in elderly patients because they're synthesist is decreased ■ Deficiency includes osteomalacia, which is weakening and softening of the bones ● Calcium ○ Green leafy vegetables are a great source of calcium ○ Patients at risk for renal calculi should adhere to a low calcium diet ○ Pregnant mothers must maintain an adequate calcium intake to prevent from losing stores of calcium ○ Cow’s milk is not suitable for infants under 1 year of age because it is high in protein and calcium that can lead to pediatric dehydration ● Iron ○ Must increase consumption of iron during pregnancy because of maternal red blood cell volume and iron storage in the fetus ○ Increase consumption of spinach, beef, liver, prunes, pork, broccoli, whole bread, and whole cereal ● MAOIs ○ Patient’s who consume foods high in tyramine may experience a hypertensive crisis, advise patients to avoid avocados, figs, bananas, fermented and aged Meats, pepperoni, salami, cheese, foods containing yeast (beer and wine) ● Older adults ○ Those who are bedridden or inactive need small meals with high fiber to prevent constipation Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ○ Dehydration often is missed because they have diminished sense of thirst Cancer and chemotherapy ○ May contribute to the development of malnutrition as a result of the effect on basal metabolism and symptoms such as nausea and decreased food intake ○ Recommendations include eggs and cottage cheese in place of meat Pulmonary disorders ○ Encourage rest periods before meals Dialysis patients ○ Routinely supplemented with calcium, vitamin B6, and folic acid ○ Nephrotic syndrome ■ Hypoalbuminemia, and hyperlipidemia ○ Chronic renal failure ■ Requires supplementation of water soluble vitamins ■ Low protein, low potassium diet Congestive heart failure ○ Offer smaller meals throughout the day due to the frequent fatigue ○ The goal is to minimize cardiac workload and reduce edema ○ Daily weights are the best indicator of fluid balance Type 2 diabetes mellitus ○ The more body fat that the client has, the more resistant to body cells are to insulin Islamic & Orthodox Judaism ○ Both exclude pork from the diet ○ Kosher ○ If meat is consumed, 3-6 hours must pass before dairy can be consumed Medical Surgical Nursing Respiratory ● Pulmonary function tests ○ Effective way to evaluate lung function and capacity ● Hypoxia or respiratory distress ○ Priority intervention is placing the patient in a high Fowler position to facilitate lung expansion ○ Encourage pursed lip breathing to facilitate emptying of alveoli ○ Administer oxygen as prescribed ○ Nasal flaring is important sign in infants ● Bronchoscopy ○ NPO 8-12 hours before procedure ○ Post-procedure- keep patient NPO until gag reflex returns ● Sputum culture ○ Should be raised from deep within the bronchi such a sputum expectorated in the morning ● Thoracentesis Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ○ Removing fluid from chest cavity ○ Place the patient in a sitting position with their head resting over the bedside table Tuberculin skin test ○ Must be read within 48-72 hours, induration larger than 10 mm indicates a positive test Arterial blood gases ○ Determine state of acid-base balances ○ Place sample on ice and send to lab for analysis Breath Sounds ○ Adventitious ■ Crackles, rhonchi, wheezes, pleural friction rub Breath odors ○ Fruity ■ Ketoacidosis ○ Sweet and musty ■ Liver failure ○ Urine-like ■ Uremia, renal failure ○ Foul ■ Lung abscess, bronchiectasis Asthma ○ Recurrent episodes of labored breathing and wheezing ○ Etiology is extrinsic ■ Antigen-and antibody reaction is triggered by food, drugs, or inhaled particles ○ Treatment ■ Bronchodilators such as Albuterol ■ Nebulizers such as Atrovent ■ Place the patient in a high Fowler's Pneumothorax/Hemothorax ○ Partial or complete collapse of a lung as a result of accumulation of air and blood in the intrapleural space ○ Signs and symptoms ■ Respiratory distress, cough, hemoptysis, CP ■ Mediastinal shift to the unaffected side Chronic Obstructive Pulmonary Disease (COPD) ○ Includes emphysema, chronic bronchitis, bronchiectasis, bronchial asthma ○ Recurrent obstruction of airflow is the common link among these diseases ○ Patient teaching ■ Diaphragmatic and pursed lip breathing to help reduce the respiratory rate and increase alveolar ventilation ○ Treatment Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ■ Low concentration oxygen however it is contraindicated in those with chronically elevated CO2 levels Emphysema ○ Loss of lung elasticity leading to destruction of alveoli ○ Characterized by barrel chest and clubbing in the fingers Pulmonary edema ○ Caused by fluid in the lungs when the heart left ventricle fails ○ Characterized by Pink, frothy sputum, dyspnea, confusion Pulmonary emboli ○ Occurs when a pulmonary artery is blocked by a thrombus originating from the peripheral vein ○ Characterized by dyspnea, cyanosis, unexplained hemoptysis, apprehension Chest tubes ○ Closed drainage used to remove fluid and air from the pleural space ○ Observe for fluctuation of fluid with each respiration in the Water Seal chamber ○ Continuous bubbling is abnormal in a water seal chamber, but normal in a suction control chamber ■ Observe for intermittent bubbling in the Water Seal chamber ■ Observe for continuous bubbling in the suction chamber ○ Do not clamp a chest tube during Transportation or ambulation ○ If the chest tube becomes dislodged, have the client exhale forcefully and apply a petroleum jelly gauze dressing over the site ○ If the drainage compartment brakes, clamp the tube nearest to the client until the system integrity can be reestablished Tuberculosis ○ Airborne precautions ○ Signs and symptoms ■ Productive cough, hemoptysis, night sweats, low grade afternoon fever, weight loss ○ Diagnostic tests ■ Acid fast bacteria sputum test x3 times ■ Mantoux skin test, tine test ○ Main difference between pneumonia and TB is the sudden onset of chills and fever in those with pneumonia Pneumonia ○ Droplet precautions ○ Inflammatory process of the respiratory bronchioles and alveoli are space is caused by infection ○ Signs and symptoms ■ Dry cough, productive, rusty colored sputum Pneumocystis carinii pneumonia ○ Infectious disease most commonly associated with HIV Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Requires a total laryngectomy ○ Watch for pink, frothy sputum, which is indicative of congestive heart failure and pulmonary edema ○ Watch for white colored sputum, which is indicative of asthma and chronic bronchitis ○ Watch for green colored sputum, which is indicative of bronchitis, lung abscess, pneumonia, and tuberculosis ○ Watch for red colored sputum, which is indicative of bronchogenic carcinoma or tuberculosis ● Bronchodilators ○ Relax smooth muscles and increased respirations by the effect on the beta adrenergic receptors in the bronchioles ○ Ex; epinephrine (adrenaline), Albuterol ● Anticholinergic bronchodilators ○ Prevent bronchospasms caused by acetylcholine ○ Ex; atrovent, atropine (monitor for tachycardia and hypertension) ● Methylxanthine bronchodilator ○ Relax smooth muscles of the tracheobronchial tree ○ Ex; Aminophylline, Theophylline (watch for tachycardia, hypotension, arrhythmias, GI distress, Tremors, anxiety, headache) ■ Toxic levels can cause arrhythmias and seizures ● Anti-inflammatory agents ○ Mast cell stabilizers inhibit the release of histamine, glucocorticoids reduce inflammation and act as bronchodilators ○ Ex; cromolyn sodium, glucocorticoids, prednisone ● Tuberculosis medications ○ Isoniazid, Rifampin, pyrazinamide, ethambutol ■ Expect all excretions to be orange in color on Rifampin Cardiovascular and Peripheral Vascular Disorders ● Electrocardiogram ○ Record of the heart's electrical activity to determine types and extent of heart damage, cardiac irregularities, and electrolyte imbalances ● Cardiac catheterization ○ Insertion of a catheter into the heart vessels surrounding the heart ○ Collects data such as pressure measurement of various Chambers, cardiac output, determination and confirmation of the presence of coronary vessels ○ Complication includes myocardial infarction, there for chest pain should be reported immediately ● Holter monitor ○ Tape recorded ambulatory EKG ○ Monitor cardiac cycle for 24 hours ○ Teach client to keep a diary and record major activities Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● Serum enzymes ○ Elevation of enzymes such as SGPT, LDH, and CK will show myocardial damage ○ CK, CK-MB, and troponin 1 are all more definitive tests Stable Angina ○ Severe chest pain lasting 5 to 10 minutes ○ Relieved by rest or nitroglycerin Unstable Angina ○ Not relieved by rest or nitro ○ Can progress to MI ○ Will NOT show ST elevation Variant, prinzmetal's Angina ○ Coronary vasospasm at night Myocardial Infarction ○ Cardiac muscle is destroyed to the interruption or insufficient blood supply to one of the major coronary arteries for prolongs time ○ Classic ■ ST elevation Heart Failure ○ Group of symptoms which results from decrease pumping effectiveness of the heart ○ Left-sided ■ Congestion occurs mainly in the lungs due to inadequate ejection of the blood into systemic circulation ■ Produces primarily pulmonary signs and symptoms such as orthopnea, cough, and crackles ○ Right-sided ■ Congestion occurs systemically due to inadequate pumping of the blood from the systemic circulation into the lungs ■ Symptoms include peripheral edema, ascites, jugular vein distention, and hepatomegaly Acute Pulmonary Edema ○ Due to excessive quantity of fluid in the pulmonary interstitial spaces ○ Presenting symptoms include moist rales, and pink, frothy sputum ○ Measured by the depth of the depression of the thumb Disorders of the peripheral vascular system ○ Narrowing, obstruction, or damage to the arteries or veins resulting in ischemia, a lack of blood flow to the tissues or organs involved or Venous stasis Arterial disease ○ Pain is provoked by exercise and activity, relieved by rest, worsened with elevation ○ Intermittent claudication refers to leg pain that occurs after exercise and is relieved after rest Buerger's disease Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ○ Also known as thromboangiitis obliterans ○ Recurring inflammation of the small and medium arteries and veins of the lower extremities ○ Usually the result of occlusion of the vessels by a thrombus formation ○ Occurs largely in younger male to smoke ○ First clinical signs and symptoms include a bluish color to an extremity or a feeling of coldness in the affected limb Raynaud's disease ○ Intermittent construction of cutaneous blood vessels precipitated by exposure to cold, emotional stress, caffeine ingestion, tobacco use ○ Usually in women from the ages of 16 to 40 ○ Patient teaching should include wearing protective cotton gloves ○ Allen's test ■ Used to evaluate circulation in the hand; the patient will make a fist and the nurse will compress the ulnar and radial artery to blanch the hand ■ The patient is asked to open the hand as the nurse releases pressure on one or the other arteries ■ Color returns to hand confirms perfusion Leg measurements to detect swelling ○ Should be done with a patient in dorsal recumbent position ○ Positive homan’s sign will show the presence of thrombophlebitis, which occurs when there is pain in the calf of the leg when the foot is dorsiflexed Aneurysm ○ Localized or diffuse dilation or outpouchings of the vessel wall ○ Patients may complain of back pain or a neurologic pain ○ Patients who complain of sudden onset angina may indicate a rupture or dissection ○ Objective findings ■ pulsating mass, either abdominal, in the chest wall, or in the periumbilical region Varicose veins ○ Abnormally lengthened, dilated, superficial veins, usually saphenous, result from incompetent valves especially in the lower extremities ○ Goal is to promote venous return by encouraging frequent walks, discouraging prolonged sitting, and discouraging sitting with crossed legs ○ Treatment ■ Vein ligation and stripping ■ Post-op care includes elevation of the extremities, compression stockings, an anticoagulant therapy ■ Ensure that compression stockings are removed twice a day for a half hour each to ensure skin integrity Arterial ulcers ○ Caused by peripheral vascular disease Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Arterial stasis ulcers ■ Usually on the tips of toes and indicates arterial insufficiency ■ Progressive disorder that leads to further risk of impaired tissue integrity ● Venous ulcers ○ Caused by chronic venous insufficiency from a clot, varicose vein, valve defects, prolonged immobility, heart failure ● Bruit ○ Caused by turbulent blood flow through stenotic blood vessels ○ Always check clients with dialysis shunt for the presence of bruits and thrills indicating patency ● Deep vein thrombosis ○ To prevent ■ Moving and exercising the legs frequently ○ When already formed ■ Ensure the patient stays on bed rest ● Pacemakers ○ Report uncontrollable hiccupping immediately, as it can indicate a dislodgement ○ Prevent rigorous arm and shoulder movements for 6 weeks after insertion ● Arteriosclerosis ○ Loss of elasticity, thickening, and hardening of arterial walls ○ Usually precedes angina pectoris and myocardial infarction ○ Most common type is atherosclerosis caused by plaque Hematologic, Immune System, & Cancers ● Type and screen ○ AB+/- is universal recipient ○ O- is universal donor ● Transfusions ○ Most common transfusion reaction is fever ○ Only other solution that can be given is normal saline ○ Must be transfused within 4 hours ○ If reaction is suspected, stop transfusion, keep IV access, and replaced transfusion with normal saline ○ If hives is the only reaction during a transfusion, proceed at a lower rate ● HIV ○ CD4 cell count lower than 200 ○ Transmitted through blood, semen, vaginal secretions, urine, feces, saliva and tears ○ Can be vertically transmitted through pregnancy and through vaginal birth ● Essential hypertension ○ No known cause ● Sexual dysfunction drugs ○ Caution with certain antihypertensive drugs ● Buerger's disease Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ○ Also known as thromboangiitis obliterans, which is a chronic inflammation of the arteries and veins, causing secondary inflammation of nerves ○ Exercises help to promote emptying of the blood vessels by gravity Smoking cessation ○ Largest goal of buerger's disease and Raynaud's disease Live vaccinations ○ Contraindicated in immunosuppressed patients and pregnant women Anemia ○ Most common symptoms include fatigue and activity intolerance, pallor, tachypnea, irritability, generalized weakness ○ Iron deficiency anemia ■ Provide the patient with frequent rest periods ○ Pernicious anemia ■ These patients are susceptible to gastric carcinomas ■ B12 injections for life ○ Iron Replacements should be diluted and given through a straw to prevent staining of the teeth ■ If given via IM injection, use z track method to ensure it will not stain skin ■ If given orally, give with orange juice to enhance absorption Sickle cell anemia ○ Clots fast, causes pain ○ Avoid acute episodes by avoiding tight clothing, strenuous exercise, cold temperatures (vasoconstriction), smoking Hemophilia ○ X-linked recessive bleeding disorder, only passed from Mom to male son ○ Patient should be instructed to avoid contact sports Leukemia ○ Risk for injury from infection or bleeding related to pancytopenia Multiple myeloma ○ Most common assessment finding is pathological fractures Thrombocytopenia ○ Decreased number of platelets, which are necessary for clot formation ○ Symptoms ■ Petechiae and bruising DIC ○ The patient begins to hemorrhage after initial hypercoagulability uses up all the clotting factors in the blood (simultaneous bleeding and clotting) ○ Occurs in massive crush injuries, burns, allergic responses ○ The body's clotting ability is exhausted because it is trying to repair so many areas with coagulation ○ Treatment Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Heparin (prolongs the time needed for blood to clot, but it does not thin the blood) ● Epistaxis ○ Have the clients it up and lean slightly forward to avoid vascular pressure on the nose and avoid aspiration of blood ● Immunity ○ Passive ■ Antibodies are obtained from another source ■ Natural- mother to fetus ■ Acquired- injection of antibodies ○ Active ■ The individual will produce their own antibodies ■ Natural- the individual has recovered from a disease and acquired antibodies and memory cells specific for that pathogen ■ Acquired- from a vaccine ● Breast cancer ○ Hard or irregular axillary nodes, skin dimpling, nipple retraction, elevation, and discharge ○ Self exams should be performed monthly, ○ Mammography begins at age 35, yearly ● Cervical cancer ○ Pap smear is a screening tool used for this ● Overall cancer ○ General symptoms include anemia, weakness, weight loss ○ Most common sites of tumor migration ■ Lymph system, lungs, bone, liver, and brain ● Testicular cancer ○ Occurs between the age of 18 and 35 years, mostly in white men ○ Largest risk factor ■ Undescended testicles ○ Normal testes ■ Should feel like small hard boiled eggs, not firm and hard ■ Feel with thumb and forefinger ● Hodgkin's lymphoma ○ Painless progressive enlargement of one or more lymph nodes, as well as the presence of reed-sternberg cells ● Non-Hodgkin's lymphoma ○ Multiple lymph nodes and lymphoid tissues are involved ● Chemotherapeutic drugs ○ Produce bone marrow depression, resulting in a reduced red blood cell count, white blood cell count, and platelet count ○ Anemia, leukopenia, thrombocytopenia Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Radium implant ○ Forceps and containers should be in patients room, never touch with bare hands ○ Decrease time at the bedside and keep radiation exposure to a minimum Gastrointestinal System ● GI bleeding ○ Test for hematocrit and hemoglobin ○ When this occurs high up in the GI tract, the stools will appear black and tarry, as well as sticky ○ When is occurs in the lower portion of the GI tract, the stools will appear bright red ● Vomiting ○ Bright red blood will indicate rapid bleeding ○ Coffee ground blood will indicate slow bleeding ● Diarrhea ○ Occurs with the use of magnesium containing antacids ○ Can lead to transient lactase deficiency ○ Patient teaching ■ Avoid milk when having diarrhea ● Constipation ○ Potential side effects of antacids that contain aluminum ● Fecal impaction ○ Seepage of liquid stools will be a Hallmark sign ● Biliary obstruction ○ Stool will be seen as light, gray, or clay-colored ● H-pylori ○ Used to diagnose stomach ulcers ● Barium contrast ○ The patient should expect an x-ray and a radiopaque ○ The barium should be eliminated from the patient system after it has been introduced the colon to prevent constipation, Mass formation, and possible bowel obstruction ● Upper GI diagnostic tests ○ Patient must be NPO, receive a laxative prep, and push fluids after procedure ○ The patient must remain NPO until the gag reflex returns ● Colonoscopy ○ Pre-procedure includes laxative prep as well as a clear liquid diet that avoids red colored juices and jello ○ Every 10 years ● Sigmoidoscopy ○ Pre-procedure involves an enema ● Gallbladder series ○ Advise the patient to avoid fatty foods prior to the procedure ● Stomatitis Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ○ Inflammation of the oral cavity as a result of trauma or disease ○ Symptoms ■ Excessive salivation and halitosis ○ Patient teaching ■ Bland diet and cold drinks Esophageal hernia ○ Also known as a hiatal hernia ○ Herniation of a portion of the stomach through the esophageal opening in the diaphragm ○ Risk factors ■ Obesity, ascites, muscle weakness, and tumors ○ Symptoms ■ May be asymptomatic or complain of heartburn and reflux, the patient may also complaining of chest pain while lying down ○ Treatment ■ Sleep with the head of the bed elevated advise the patient to remain upright for 30 minutes after all meals GERD ○ Reflux of stomach contents into the esophagus cause regurgitation, heartburn, and irritation ○ Patient teaching ■ Small, frequent meals, increase fluid intake and avoid caffeine, alcohol, coffee, spicy foods, Citrus, and chocolate Peptic ulcer disease ○ Patients commonly experienced an aching, burning feeling and gnawing in their epigastric region ○ The patient will feel more intense pain on an empty stomach ■ Meals help to relieve pain ○ Complication includes bleeding ■ Aspirin should be avoided because it contains salicylates which are irritating to the gastric mucosa ○ Patient teaching ■ Avoid alcohol, smoking, stress, salicylates ○ Treatment ■ Triple therapy including two antibiotics and a proton pump inhibitor (omeprazole) or an H2 antagonist (ranitidine) Gastric Ulcers ○ Pain when eating Duodenal Ulcers ○ Pain is relieved by eating Cholecystitis ○ Inflammation of the gallbladder caused by stones (cholelithiasis) Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Symptoms ■ Pain in the right upper quadrant, sometimes occurs after eating a meal consisting of fried or fatty foods ■ Can radiate to the back ○ Acute phase ■ Patient should be NPO and slowly advance to clear fluids and then a low fat, bland diet as tolerated Hepatitis ○ Inflammation of the liver ○ Symptoms ■ Jaundice, fever, fatigue, loss of appetite, n/v, abdominal pain, joint pain, dark urine, clay colored stools, and diarrhea (only A) ○ Type A ■ Transmitted by excreta, contaminated food products, infected blood transfusion ■ Fecal-oral route ○ Type B ■ Transmitted by blood transfusion or ingestion, sexual route or body secretions, sharing needles ○ Type C ■ Transmitted by contaminated blood ■ No vaccine Pancreatitis ○ The process of autodigestion when the pancreatic enzymes are activated while still in the pancreas, not when they reach the intestines where this is supposed to occur ○ Patient teaching ■ Avoid alcohol ■ Patient will be NPO and slowly advance from clear liquid to a low-fat, small, frequent meal regimen Appendicitis ○ Periumbilical pain followed by elevated temperature, anorexia, nausea, and vomiting ○ Pain is localized at mcburney's point, between the umbilicus and the right iliac crest ○ Rovsing’s sign ■ Occurs when palpation of the left lower quadrant causes pain in the right lower quadrant Diverticulitis ○ Inflammation of the diverticula and surrounding intestine ○ Diverticulosis ■ The presence of multiple inflamed diverticula ○ Diverticula ○ ● ● ● ● Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ■ Outpouching of the intestinal mucosa through the smooth muscle of the intestinal wall at any point in the GI tract ○ A deficiency in fiber has been associated with this condition ○ Patient teaching ■ Liquid or soft diet during the acute phase, advancing to a high fiber and bulk forming diet after the pain subsides ■ Provide High residue diet with brand that is high in protein, calories, vitamins, and iron Crohn's disease ○ Cannot be cured by surgical intervention ○ Affects all layers of the bowel wall, from the mouth to the anus, most often the terminal ileum ○ Symptoms ■ Malaise, fever, rectal bleeding, abdominal pain, fistulas, ulcers ○ High risk for developing colon cancer Ulcerative colitis ○ Can be cured by surgical intervention ○ Symptoms ■ Rectal bleeding, rare to see masses or fistulas ○ Begins in the rectrum and proceeds up to the cecum Pernicious anemia ○ Caused by the failure to absorb vitamin B12 because of a deficiency and intrinsic factor from the gastric mucosa ○ Treatment ■ Vitamin B12 injections monthly for life Dumping syndrome ○ Rapid emptying of large amounts of food into the small bowel following a gastrectomy ○ Patient teaching ■ Encourage drinking liquids between meals instead of with meals Liver biopsy ○ Patient will lie on their left side to expose the liver ○ Post procedure, the patient will be lying on their right side to prevent hemorrhage Colostomy ○ In the descending colon, will consist of formed and soft stools ○ Irrigation ■ 1000 cc's of tap water that is 100 to 105 degrees ■ Bottom of the irrigation bag should be placed at the client's shoulder level Abdominal surgery ○ Peristalsis is temporarily halted and usually does not return for one to two days Sucralfate (Carafate) ○ Coats a duodenal ulcer Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Can cause constipation ● Omeprazole (Prilosec) ○ Proton pump inhibitor that inhibits gastric acid production ● Cimetidine (Tagamet) ○ Histamine antagonist that blocks the secretion of hydrochloric acid ● Metoclopramide (reglan) ○ Increases gastric motility and gastric emptying Renal System ● BUN ○ Blood urea nitrogen analysis will indicate the ability of the kidneys to excrete waste products ○ Will be elevated in renal failure, dehydration, and malnutrition ● Renal concentration test ○ Evaluate the ability of the kidney to concentrate urine ○ Measured by specific gravity (1.001-1.035) ● Intravenous pyelogram ○ IVP, injection of contrast dye for visualization of the absence, presents, location, size, and configuration of each kidney, the feeling of the renal pelvis, an outline of the ureters ● Cystoscopy ○ Visualization of the urethra and bladder ● Urinalysis ○ Can test for several disorders including diabetes mellitus, dehydration, UTI, kidney trauma, and glomerulonephritis ○ This test reflects the damage to the glomeruli with the resultant leaking of protein and red blood cells ● Urine sample ○ Culture and sensitivity can be collected by a clean catch and identifies bacterial count as well as the Infectious agent and it's antibiotic sensitivity ● Creatinine clearance test ○ The best indicator of kidney's filtration function ○ Measures the amount of creatinine filtered by the glomeruli over 24 hours ● Serum creatinine level ○ Best indicator of the status of glomerular filtration ● 24-hour urine collection ○ Empty bladder completely and discard the urine ○ Save all the urine for the next 24 hours ● Acute renal failure (acute kidney injury) ○ Specific gravity of the scanty output will be low because the kidney is unable to concentrate water ○ Can be caused by pyelonephritis and glomerulonephritis Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Patient at high risk include untreated streptococcal infection, bowel incontinence, and renal reflux ○ Rapid onset of oliguria accompanied by a rising BUN level and serum creatinine ■ Typically this is reversible ○ Other symptoms include anorexia, nausea, vomiting, azotemia, weight gain, altered mental status ○ Patient teaching ■ Low protein, sodium, and potassium ■ High carbohydrates ● Glomerulonephritis ○ Inflammation of glomerulus that leads to leakage of RBCs and protein into urine ○ Causes ■ Post strep infection ○ Symptoms ■ HTN, decreased GFR, edema, tea colored urine from hematuria, elevated BUN, proteinuria ○ Treatment ■ Monitor BP, fluid status, watch for hyperkalemia, limit sodium, ensure adequate intake of potassium ● Nephrotic syndrome ○ Changes to glomerulus that leads to massive leakage of protein in urine ○ Symptoms ■ Massive proteinuria, foamy, frothy dark urine, hypoalbuminemia (low protein in blood), edema ○ Treatment ■ Diuretics and IV albumin ■ Low sodium diet ● Chronic Kidney Disease ○ Progressive destruction of the kidney tissue resulting in decreased and a hemostatic function of the kidney ○ Typically irreversible ○ Symptoms include ammonia in the skin and alimentary tract resulting from bacterial interaction with urea leading to inflammation of mucosal membranes ○ Result in retention of phosphate, decreased calcium, all leading to muscle spasms, tetany, increased parathormone release, and eventually demineralization of bones ○ Also results in waste product retention, which leads to depress bone marrow function, decrease red blood cells, renal tissue hypoxia, decreased erythropoietin production, and eventually further depression of bone marrow functioning ○ Patient teaching ■ Increase fluids to flush the kidneys, check urine for protein, blood, and specific gravity ■ Meticulous perineal care is important Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ■ Low sodium, high calcium, iron, vitamin B, C, D Dehydration ○ Reduced urine output, will lead to elevated specific gravity, indicating concentration of particles from water loss Urinary tract infections ○ Pyridium (OTC Azo) is typically used to treat, teach the patient that it will turn the urine orange ○ Discourage the use of bubble baths and encourage urination before and after sexual intercourse Kidney infection ○ Hallmark sign is flank pain, vomiting Acute glomerulonephritis ○ Inflammatory disease of both kidneys that interfere with glomerular filtration ○ Most commonly caused by repeated streptococcal infections during childhood ○ Symptoms ■ Hematuria and proteinuria ○ Treatment ■ No specific cure, diet include sodium and potassium restriction, but increased protein ■ However, if azotemia is present, protein will be restricted Pyelonephritis ○ Acute or chronic inflammation due to bacterial infection of the parenchyma and pelvis of the kidney ○ Symptoms ■ Kidney pain, impaired sodium reabsorption and protein loss Urolithiasis ○ Presents and formation of stones in the renal calculi or pelvis that pass through the lower regions of the urinary tract ○ Symptoms ■ Severe flank pain (renal colic), pallor, sweating, syncope, shocked, and possible vomiting ○ Strain all urine and check for the presence of stones ○ Encourage decreased calcium and increase fluids (3- 4L/day), increase ambulation to help pass the stones ○ Patient teaching ■ Adhere to a low purine diet Dialysis ○ May be permanent, temporary, stationery, ambulatory ○ Access can be external or internal ○ Effectiveness is measured in a decrease in serum creatinine and BUN as well as the reduction in fluid retention ○ Patients typically will have problems with fluid and electrolyte imbalances Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Hemodialysis ■ Complications include dialysis disequilibrium syndrome, hypotension, hypertension, arrhythmias, and transfusion reactions ○ Peritoneal dialysis ■ Complications include peritonitis, hypoalbuminemia, bowel or bladder perforation ■ Cloudy dialysate will indicate peritonitis ● Transurethral resection of the prostate (TURP) ○ Removal of prosthetic tissue by instrumentation through the urethra ○ Venous bleeding is common for several days after the procedure ● Perineal prostatectomy ○ Impotence is expected because the procedure involves nerve transaction ● Urinary diversion ○ Via ileal conduit sometimes called the Bricker’s procedure ○ Involves implementation of ureters into a position of the terminal ileum, with the formation of a stoma ○ Complications ■ Paralytic Ileus ■ Changes in urine color, clarity, quantity, smell (mucus in the urine is normal and expected after the surgery) ■ Changes in stoma color to a Dusky or necrotic color is an emergency ● Autonomic dysreflexia ○ Caused by lesion in the thoracic or cervical cord causing hypertension, sweating, and headaches ○ May occur with blockage in the urine catheter or fecal impaction ● Stress incontinence ○ Encourage kegel exercises Endocrine System ● Overview ○ System is composed of glands and operates simultaneously with the central nervous system to maintain homeostasis ○ Responsible for the regulation of metabolism, use and storage of energy through the use of hormones ○ Through the use of a negative feedback system, these glands regulate the body's metabolic rate and expenditure of energy ○ Hormones ■ Majority are regulated by trophic, stimulating hormones secreted by the pituitary gland ● ACTH and TSH ■ The pituitary is influenced by hormones secreted by the hypothalamus ○ Glands ○ Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Thyroid, pituitary, parathyroid, adrenal cortex and medulla, ovaries and testicles, and pancreas ● Pancreas ○ Secretes two hormones- insulin and glucagon that are necessary for carbohydrate metabolism ○ Insulin in specific is required to control fat and protein metabolism ■ Failure of the pancreas to produce an adequate amount of insulin can lead to diabetes mellitus, which is characterized by glucose intolerance ○ Diabetes mellitus ■ Polyuria, polyphagia, and polydipsia ■ Family history, age, and weight all also play a factor ■ Also assess for the presence of ketones in the urine, which indicates set the body is using fat as the major source of energy ○ Type 1 diabetes ■ Manageable with daily exercise and a Diet low in fat and simple sugars ■ Encourage the patient to have regular timing and consistency of meals ● Insulin ○ Regular insulin ■ Short-acting, Peaks within 2 to 4 hours ○ NPH insulin ■ Intermediate acting, Peaks within six to twelve hours ○ Ultralente insulin ■ Long-acting, Peaks within 14 to 24 hours ● HBA1C ○ Important index of glucose control because it identifies average glucose levels over the past 3 months ● Hypoglycemia ○ Symptoms include diaphoresis, headache, weakness, irritability, and slurred speech ○ Treatment ■ Orange juice or glucose tablet if they are able to swallow ■ IV D50 if unable to swallow/unconscious ● Hyperglycemia ○ Blood glucose levels above 120 ● Diabetic ketoacidosis ○ Complication of insulin dependent diabetes mellitus, caused by the accumulation of ketones in the blood, leading to metabolic acidosis ○ Symptoms ■ Watch the skin, fast, deep labored breathing, acetone, fruity breath ■ Patient will present with kussmaul's respirations ○ Treatment ■ Fluid replacement, electrolyte replacement, insulin therapy (usually a drip) ● Diabetes insipidus Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ○ Caused by a lack of antidiuretic hormone, which is responsible for the reabsorption of water in the kidneys ○ If ADH is lacking, adequate reabsorption of water is prevented, which leads to diuresis, which leads to concentrated blood and dehydration ○ High sodium, high pee ○ Diagnostic procedure ■ SG will be less than 1.005 SIADH ○ Syndrome of inappropriate antidiuretic hormone ○ Results from too much ADH, causing excess water being reabsorbed by the kidneys ○ Low sodium, low pee ○ Diagnostic procedures ■ Urine and serum levels, as well as osmolality levels Thyroid gland ○ Produces levothyroxine and T3 ○ These hormones affect the speed of chemical reactions, the volume of oxygen consumed, and the amount of heat produced by the cells ○ Hypothyroidism ■ Deficiency of thyroid hormone resulting in decreased body metabolism related to decreased oxygen consumption by the tissues ■ Complication includes myxoedema, a severely hypermetabolic State leading to a coma (characterized by non pitting edema in the periorbital and facial area) ■ Patient will present with decreased metabolic rate, hypoventilation leading to respiratory acidosis, hypothermia, hypotension ■ Patient will be on Synthroid for life ○ Hyperthyroidism ■ Defined as excessive secretion of thyroid hormone commonly caused by the over functioning of the thyroid gland, most common form is Graves disease ■ Patient will present with goiter and abnormal protrusion of the eyes, called exophthalmos Addison's disease ○ Hypofunction of the adrenal cortex, adrenal insufficiency ○ Symptoms ■ Weakness, fatigue, n/v, hypotension, tachycardia, low BS/sodium, high potassium/calcium ○ Patient will need replacement therapy for life Cushing's syndrome ○ Patient has a high risk for fluid volume excess ○ Hypersecretions of glucocorticoids ○ Symptoms ■ Moon face, buffalo hump, neck fat, high BS/sodium, low potassium/calcium Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Hypocalcemia ○ Positive signs include trousseau's sign and chvostek's signs ○ Monitor all calcium levels Neurosensory System ● Glasgow Coma Scale ○ Used to assess levels of consciousness and clients with neurological problems ○ Consist of eye-opening, motor response, and verbal response ○ Maximum score of 15 ● Cranial nerves ○ OOOTTAFAGVSH ■ Oh once one takes the airplane flight a great vacation seems heavenly ○ Olfactory (smell) ○ Optic (vision) ○ Oculomotor (pupils/eye movements) ○ Trochlear (eye movement down and medial) ○ Trigeminal (jaw) ○ Abducens (eye side to side) ○ Facial (expressions) ○ Acoustic (hearing/balance) ■ Susceptible to toxicity to aminoglycosides such as erythromycin and Gentamicin ■ Signs of ototoxicity include tinnitus, dizziness, vertigo, nausea, and vomiting ○ Glossopharyngeal (swallowing, gag reflex) ○ Vagus (swallowing, gag reflex) ○ Accessory/spinal (shoulders) ○ Hypoglossal (tongue and speech) ● Meniere's disease ○ Balance disorder that causes vertigo, hearing loss, and tinnitus ○ Patient teaching ■ Encourage the patient to adhere to a low sodium diet, as well as avoiding alcohol, caffeine, and tobacco ● Increased ICP ○ Most significant sign is a decrease in Loc ○ Presentation ■ Widening pulse pressure, lethargy, decrease pulse, increase blood pressure, elevated temperature ■ Sunsetting eyes ○ Nursing care ■ Elevate HOB to 30 degrees ● Retinal detachment ○ Patient will see a veil like curtain individual field as well as flashes of light ○ NOT blindness, NOT painful Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ○ After surgery, patient will need a patch on both eyes and keep the eyes bandaged for 24 hours Cataracts ○ A normally transparent lens becomes cloudy and opaque, leading to Progressive blurring and gradual loss of vision ○ After surgery, teach the patient to avoid increasing intraocular pressure by coughing or rapid head movement Glaucoma ○ Abnormal increase in intraocular pressure that is considered a medical emergency ○ Open-angle ■ Resulting gradual loss of peripheral vision, leading to tunnel vision ○ Narrow-angle ■ hazy/blurred vision Aphasia ○ Complete or partial loss of language skills caused by damage to the cortical areas of the brain's left hemisphere ○ Expressive ■ Provides the patient with a communication board or an alternative way of communication ■ Knowing what you want to say but can’t get it out ○ Global ■ Most severe, when someone is listening to words/communication but cannot understand Hemianopia ○ Characterized by defective vision or blindness in half of the visual field ○ Seen as a symptom of stroke EEG ○ Avoid stimulants prior to the procedure such as coffee or tea Seizures ○ First nursing priority is to protect the head from injury and move anything in the environment that may enter the patient ○ Avoid restraining the patient and stay with them until the seizure is completed ○ Nursing care ■ Place the patient on their left side to prevent aspiration ■ Dilantin may be used to treat seizures, teach patient that it can cause gum hyperplasia and red colored urine ■ Nothing in the mouth Romberg's test ○ Known as the falling test, assesses the patient's ability to maintain balance and assess vestibular function ○ Usually performed in addition to the Weber and Rinne tests, which evaluate hearing acuity Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Kernig's sign and brudzinski's sign ○ Frequently seen in client suffering from meningitis ○ Kernigs’ ■ Present if a lower leg cannot extend due to pain when a client is lying supine with one leg bent over the abdomen ○ Brudzinski ■ Present if a client's hips and knees Flex when they are lying supine with the head lifted for the chest ● Babinski's reflex ○ When the sole of the foot is stroked from the heel to the ball, the toes should curl downward ( negative) ○ If the toes flare up word this indicates a positive test, and is abnormal after the age of 2 years ■ If positive, can indicate head trauma ● Parkinson's disease ○ Progressive, degenerative disorder caused by dopamine depletion and result in a decline in muscular functioning ○ Symptoms ■ Tremor at rest, rigidity, slow movements, shuffling gait, mask like face, emotional lability, drooling, and sweating ○ Nursing care ■ Maintain a safe environment ■ levodopa-carbidopa ● Multiple sclerosis ○ Progressive CNS disorder caused by demyelination in the brain and spinal cord ○ Multiple Foci of demyelination are distributed randomly in the white matter of the brain stem, spinal cord, optic nerves, and cerebrum ○ Symptoms ■ First indication is visual problems ○ Nursing care ■ Provide a safe environment and maximize the patient's independence ● Myasthenia gravis ○ Autoimmune disorder causing disturbances in the transmission of impulses from muscles resulting in extreme muscle weakness and fatigue that increases with exertion and improves with rest, eventually this will lead to fatigue without relief from rest ○ Diagnostic test ■ Tensilon test ● Amyotrophic lateral sclerosis (ALS) ○ Progressive, fatal, motor neuron disease causing Progressive muscular atrophy ○ Nursing care ■ Monitor respiratory function and the patient's ability to swallow Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ■ Cause of death is usually pneumonia secretary to an effective respiratory function Bell's palsy ○ Paralysis of one side of the face, usually due to inflammation of the 7th cranial nerve ○ Patient teaching ■ Usually lasting only two to eight weeks, the patient should prevent corneal drying by using artificial tears Guillain-Barre syndrome ○ Autoimmune disorder characterized by Progressive ascending paralysis that most often ceases within 4 weeks, with complete recovery around 3 to 6 months ○ Causes motor weakness symmetrically and it is sending fashion ■ Weakness starts in the feet and moves upwards ○ Nursing care ■ Maintain an airway, because the airway is compromised when the disease reaches the diaphragm Huntington's disease ○ Inherited disorder causing progressive atrophy of the basal ganglia and portions of the cerebral cortex ○ Symptoms ■ Extreme emotional lability, dementia, and uncontrolled limb movements Spinal cord injuries ○ C3 or above are usually fatal because of the muscles used for breathing are now paralyzed ○ Thoracic and lumbar Injuries affect the legs, bladder, and bowel ○ Nursing care ■ Monitor for autonomic dysreflexia, when the patient will experience bradycardia, facial flushing, and severe headache and hypertension; the brain is unable to send those signals to lower the blood pressure due to the spinal cord injury Head injury ○ Hyperthermia of approximately 105 degrees Fahrenheit is observed ○ When testing cerebrospinal fluid, we are looking for glucose, which indicates that the leakage is CSF fluid ○ Deafness and Virgo indicate that cranial nerve #8 is affected Meningitis ○ Droplet precaution ○ Lumbar puncture ■ Patient will lay on their side with their knees curled up toward the chest ■ Following procedure, patient will be on bed rest for 6 to 8 hours Snellen chart Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Denominator indicates the degree of visual Acuity when the patient is able to read our particular line of letters stand in 20 ft away (numerator) ○ The smaller the denominator, the better the vision Musculoskeletal System ● Overview ○ The skeleton supports and protects the body well the muscles and connective tissue add support and allow for movement ○ The bones story release minerals ○ The bone marrow produces erythrocytes and thrombocytes ● Gout ○ Deposits of uric acid crystals in the synovial joints ○ Gouty arthritis ■ Metabolic disease characterized by urate deposit and pain in the joints, especially in the feet and legs ■ Diagnosis is based on serum uric acid levels, which should be below 8mg/dL ● Purine metabolism ○ Problems with this metabolism results in an increase in uric acid levels in the blood ○ Treatment ■ Allopurinol is the preferred treatment to treat gout ■ Colchicine helps to reduce the pain and swelling during an acute gout attack, important to administer with foods and increase fluids while on this medication ● Rheumatoid arthritis ○ Chronic, progressive disease that destroys synovial bone joints and connective tissue ○ Symptoms ■ Joint swelling, low grade fever, fatigue, weakness, paresthesias ■ Can also cause bilateral and symmetrical stiffness in the joints that is worse in the morning ○ Treatment ■ Humira IM ● Osteoarthritis ○ Non-inflammatory degenerative joint disease marked by Progressive pain that is relieved by rest ○ Typically involves the weight-bearing joints and is characterized by a loss of cartilage on the articular surfaces of the joints, also spur development ○ Pain will be worse during activity and the patient is usually overweight ● Osteoporosis ○ Most common metabolic Bone disorder, causing decreased bone mass and increased risk of fractures ○ Causes ■ Calcium and estrogen deficiency Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ○ Symptoms ■ Gradual loss in height after menopause Bunions ○ May be congenital or acquired by wearing shoes that are too narrow, high heels ○ All of these increase the pressure on the Bursa at the metatarsal phalangeal joint Carpal tunnel syndrome ○ Patients will exhibit a positive tinel's sign, as well as shock-like pain in reaction to percussion of the median nerve at the wrist ○ Patience will also have a positive phalen's sign, which is characterized by hand tingling and numbness with a cute wrist flexion Lupus ○ Characteristic sign is a butterfly rash over the bridge of the nose Hip replacement surgery ○ Primary goal after surgery is to prevent hip adduction and hyperflexion ■ Prevent the patient from bending at the hips Beyond 90 degrees ■ Use abduction pillows between the legs to reduce the risk of a dislocation ○ Patient teaching ■ Avoid Crossing her legs while sitting ■ Use an abduction pillow, or wedge while laying down Lumbar laminectomy ○ The patient should only be moved by way of log rolling Compartment syndrome ○ Secondary edema that causes an increase in the pressure in a closed spaces of the tissue compartment formed by an elastic faccia ○ As the pressure increases, obstruction of the venous circulation and arterial occlusion occur, leading to ischemia ○ Symptoms ■ Progressive pain that is distal to the injury, unrelieved by analgesics ■ Edema, paralysis, decreased or absent peripheral pulses, delayed capillary refill, colder lamp temperature Fat embolism ○ A serious complication that occurs after a bone fracture, especially the long bones ○ Pulmonary circulation is typically where the fat emboli becomes obstructed, which leads dyspnea, chest pain, coughing, tachycardia, and restlessness Pressure ulcers ○ Turn the patient every two hours and elevate bony prominences off the bed to prevent ulcers from occurring ○ Stage 1 ■ A reddened area that does not blanch, treat aggressively Multiple myeloma ○ Bone fractures are a common complication Paget's disease Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ○ Common bone disease that affects middle-aged and elderly people that is marked by inflammation of Bones, softening and thickening of Bones, excessive bone destruction, and unorganized bone repair, resulting in the Bowing of long bones Phantom limb pain ○ Occurs when an amputee complains of severe pain in the removed body part ○ Nursing care ■ Stump care to promote healing ■ Exercise to maintain the tone of the unaffected muscle ■ Physiological support ■ Never assume that they do not have pain in knee removed limb, treat all pain aggressively ■ To reduce swelling, the residual limb should be elevated on a pillow for 24 hours, Check the residual in periodically to ensure that it is lying completely flat Cast care ○ Support drain cast on pillows, do not cover ( allow it to air-dry) ○ Frequently assess pulse is, color, movement, and sensation distal to the cast ○ Monitor neurovascular status of the extremity one to two hours after the application of the cast Skin traction ○ Used for relief of painful muscle spasms ○ Bucks and Russell traction ○ Bryant's traction ■ Vertical suspension where the pelvis is elevated from the bay ○ Skeletal traction ■ Appliance of direct traction to the bone using pins and wires Sprain ○ Soft tissue injury that occurs when a muscle or tendon is excessively stretched Strain ○ Excessive stretching of one or more ligaments that results from twisting movements Heat treatment ○ Increase vasodilation, decrease muscle spasms, joint stiffness, and pain Cold treatment ○ Promote vasoconstriction, decrease swelling, muscle spasms, and pain Cane walking ○ Hold the cane on strong side and advance the cane at the same time as the weak extremity Walker ○ Move walker forward and then step into it Crutches ○ 4-point gait Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Use when weight-bearing is allowed on both extremities ○ 2-point gait ■ Right crotch moves with the left leg and the left crotch moves with the right leg ○ 3-point gait ■ Used when weight-bearing is permitted on one extremity only ○ Swing through gait ■ Used for patients with paralysis of both lower extremities ○ When advancing upstairs, the patient leads with the unaffected leg, and then the crutches and injured leg together Integumentary System ● Overview ○ Priority includes Burns and skin breakdown ○ Composed of hair, skin, nails, sebaceous, and sweat glands ○ Primary nursing interventions include ensuring patient comfort and providing client education regarding medications and procedures ● Skin cancer ○ One out of every seven individuals ○ Leading causes include exposure to the sun, x-rays, Arsenic, and coal ○ Those at highest risk are those with Fair complexion and history of previous melanomas ● Burns ○ Caused by thermal heat, chemical exposure, and electrical current, and smoke inhalation ■ After a chemical burn, wash with water or normal saline ■ After a thermal burn, the most important goal is to maintain fluid and electrolyte balance is, as well as the acid-base balance to prevent complications such as shocked, dice, respiratory and cardiac failure, and acute tubular necrosis ○ Burns destroy the epidermis, allowing tissue fluid to escape and leaving the patient vulnerable to infection ○ Rule of Nines, Palm method ■ Used to determine the extent of the injury ○ Emergent phase ■ Removal from source of burn and stabilization ○ Shock ■ 24 to 48 hours after the injury ○ Diuretic ■ Fluid resuscitation ○ Convalescent ■ Wound care, nutrition, and prevention of gastrointestinal complication ○ Parkland formula Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ■ In the first eight hours following the injury, give ½ of 4mL NSS x kg x % body burned ■ In the following 16 hours, give the other ½ ○ Pulmonary compromise ■ Will show in nasal flaring, hoarseness, sputum, and labored respirations Pressure ulcers ○ Decubiti ○ Breaks in the skin caused by friction or interference with the blood supply to the tissues ○ prevention includes turning the patient every two hours while on bedrest Contact dermatitis ○ Caused by exposure to a physical or chemical allergen ○ Symptoms ■ Itching cosima, raised papules Impetigo ○ Contagious superficial skin infection caused by S. Aureus ○ Characterized by a small, red macule that turns into a vesicle that becomes pustular with honey-colored crusts ○ Can lead to glomerulonephritis Herpes zoster ○ Highly contagious infection that's transmitted by direct contact with vesicular fluid or Airborne droplets ○ Patient will be in isolation Scabies ○ Gray, brown Burrows, epidermal curved or linear ridges and follicular papules ○ Patient will complain of severe itching that occurs mostly at night Maternity Diagnostic Tests & Reproductive System ● Human chorionic gonadotropin (HCG) ○ Test for the presence of human chorionic gonadotropin, a hormone secreted by the placenta ○ Indicates a positive pregnancy test, increases in a woman's blood and urine until the 15th week of pregnancy ○ Urine test kit from the pharmacy will also test for HCG in the urine ● Radio immunoassay ○ Will be positive up until 8 days after ovulation, or 6 days before scheduled menses, results are obtained in 1 hour ● Doppler ○ Auscultation of fetal heart rate is usually done at 10 weeks to 12 weeks of gestation ○ Can also help to rule out fetal abnormalities ● Pelvic sonogram Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ○ Ensure that the patient has a full bladder Fetoscope ○ Used to auscultate fetal heart rate at 18 to 20 weeks of gestation ○ Heart rate is best heard at the center of the pubic hairline ○ Normal fetal heart rate during this time is between 120 and 160 beats per minute Ultrasound ○ Will confirm gestational Sac by week 6 ○ Can provide Imaging of fetal heart motion by week 7 ○ The patient should drink 1-2 L of water prior to the procedure and avoid urinating until the procedure has been completed Daily fetal movement count ○ Assesses feel activity and reported by the pregnant mother ○ Normal includes three movements per hour Amniocentesis ○ Used to detect the presence of biochemical or chromosomal abnormalities such as fetal lung maturity and genetic studies ○ Usually performed between 14 and 16 weeks of gestation ○ Ensure that the client has voided before the procedure Chorionic villi sampling ○ Cervical sampling ○ Similar to an amniocentesis, however, this can be done earlier in pregnancy and it reflects fetal chromosomes, enzymes, and DNA Lecithin/sphingomyelin ratio (L/S) ○ Diagnostic test of the amniotic fluid to determine if the fetus is likely to develop respiratory distress Non stress test ○ Evaluate the response of the fetal heart rate to fetal movement ○ The monitor records fetal heart rate when the mother senses fetal movement, used to assess fetal oxygen ○ In a healthy fetus, the fetal heart rate will accelerate with each movement ○ Patient teaching ■ Prior to the procedure, the patient should eat, empty their bladder, and lie in a SIMs position ■ The patient may drink orange juice or rock her abdomen to stimulate feel move Contraction stress test and oxytocin challenge test ○ Used to induce uterine contractions to correlate fetal movement to the contractions Leopold maneuvers ○ Determines presentation and position of the fetus Alpha- fetoprotein levels ○ Elevated indicate neural tube defects such as spina bifida and hydrocephalus Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Completed at 16 to 18 weeks ○ Will draw the mother's blood to analyze the amount of AFP that the liver normally releases, and how much it's really saying during pregnancy ○ This can also be completed from amniotic fluid extracted from an amniocentesis ● Ovulation ○ Occurs approximately 14 days after the start of the menstrual period ○ The fertilized ovum will stay in the fallopian tube for 4 days before implants in the uterine wall ○ There are seven days between conception and implantation ● Fetal heart rate monitoring ○ Late decelerations ■ Reposition and the mother and notify physician ■ This can indicate placental insufficiency ● Folic acid ○ An expecting mother should take folic acid at least two months before conception and throughout early pregnancy to prevent neural tube defects ● GTPAL ○ Gravida- how many times a woman has been pregnant ○ Para- actual pregnancies that have been born full-term ○ T- how many children have been born premature ○ A- how many abortion or miscarriages ○ L- how many living children the mother has Signs of Pregnancy ● Presumptive sign ○ Always considered subjective, the patient will tell you ○ Menses more than 10 days late, morning nausea, quickening, skin pigmentation changes ● Probable and positive signs ○ Always considered objective, will be tested with diagnostic instruments ○ HCG in urine, Goodell's sign, ultrasound and fetal heart tones ○ Hegar's sign ■ When the uterus becomes globular in shape, softens, and flexes over the cervix, considered a probable sign of pregnancy ○ Goodell's sign ■ Cervical softening do to increase vascularity, congestion, and edema, considered a probable sign of pregnancy ○ Chadwick's sign ■ Bluish discoloration of the cervix, considered a probable sign of pregnancy ● Quickening ○ The first time fetal movement is felt by the mother, around 16 to 20 weeks for a multipara and about 18 weeks for a primipara ● Legal point of viability Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Around 22 weeks ● Nagele’s rule ○ Used to determine the due date of the child ○ The first day of the last menstrual., then count backwards 3 months and add 7 days ● Weight gain during pregnancy ○ 3-4lb during the first trimester ○ 1lb per week for a total of 25 to 35 lb ■ Fetal weight increases the most during the third trimester ● Supine hypotensive syndrome ○ Lie the patient on their left side to promote fetal perfusion ● Varicose veins ○ Constipation contributes to this condition ● Ballottement ○ Techniques that involves the palpating of the uterus in such a way that the rebound of the floating fetus is felt by the examining finger ○ Done during month 4 or 5 Complications During Pregnancy ● Pre-existing diseases ○ Hypertension and diabetes place the mother and an increased risk of developing complications during pregnancy ○ Women who have had more than four pregnancies are also at risk for higher complications ● Gestational hypertension ○ Development of hypertension in a normotensive client without proteinuria ○ Blood pressure returns to normal by postpartum day 10 ● Preeclampsia ○ Pregnancy induced hypertension that includes proteinuria and edema of the face, hands, and ankles ○ More serious symptoms include blurred vision ○ Mild ■ 30mmHg rise in Baseline systolic blood pressure or 15mmHg rise in Baseline diastolic blood pressure ■ Can progress to eclampsia when seizures occur ○ Risks ■ African American and Young primiparous ○ Treatment ■ Magnesium sulfate, given to lower blood pressure and work as an anticonvulsant ● Magnesium sulfate ○ Inhibits uterine contractions ■ Women must also be giving oxytocin in order to strengthen uterine contractions Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ○ Excessive magnesium can cause loss of deep tendon reflexes followed by respiratory depression ○ Treatment ■ Calcium gluconate Gestational diabetes ○ Abnormal glucose tolerance do to decrease effectiveness of insulin during the second and third trimesters ○ If left untreated, it can lead to polyhydramnios (excessive amniotic fluid) or macrosomia(large fetus), as well as preeclampsia, neonatal hypoglycemia, and respiratory distress Placenta previa ○ The placenta completely or partially covers the cervical opening, or the placenta can be implanted low in the uterus without covering any part of the opening ○ Symptoms ■ Painless, bright red bleeding that occurs late in pregnancy Abruptio placentae ○ Bleeding that is accompanied by abdominal and low back pain ○ Blood will be dark in color ○ Mothers are more likely to have infection or hemorrhage Breech position ○ Major complication includes prolapsed umbilical cord Hyperemesis gravidarum ○ Excessive and persistent vomiting during pregnancy that results in dehydration and electrolyte imbalances Leg cramping ○ Typical during the third trimester ○ Encourage the mother to stand with her feet flat on the floor to provide relief Anemia ○ Iron deficiency anemia is the most common during pregnancy Incompetent cervix ○ Dilates prematurely because it is unable to support the weight of the growing fetus ○ If left untreated, an incompetent cervix may result in spontaneous abortion ○ Treatment ■ Placement of a purse string suture (cerclage) in the cervix to close it Spontaneous abortion ○ Vaginal bleeding and abdominal cramping or back pain will be seen Others ○ Ambivalence and mixed feelings are normal reactions during the first trimester of pregnancy ○ Normal heart rate is 120 to 160 ○ A pregnant patient with known cardiac problems should be observed for dyspnea and increased heart rate Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ A woman can continue to having sexual intercourse throughout pregnancy as long as she remains comfortable ● 4 P’s of birth process ○ Power, passage, passenger, psyche ● Complications during pregnancy ○ Bleeding from the vagina at any time or uncontrollable leakage of fluid ○ Unusual abdominal cramps or pain ○ Persistent nausea or vomiting especially in the second and third trimester ○ Persistent headache or blurred vision ○ Swelling of the ankles, hands, and face ○ Painful or burning urination with chills or fever Labor and Delivery ● Designated station ○ Location of the presenting part in relation to the level of the ischial spines ○ Indicates degree of advancement of the presenting part through the pelvis ○ Expressed in centimeters above and below the level of ischial spine (zero) ● Premonitory signs of labor (prodromal) ○ Weight loss of 1-3 lb, a burst of energy or nesting instinct, passage of the mucosal plug ● Progressive, true labor ○ Dilation of the cervix, will have uterine contractions ○ Contractions move from the back to the front of the abdomen and are not relieved by walking ● False labor ○ Contractions decrease with activity ○ Felt typically in the abdomen and are irregular ● Lightning ○ Subjective sensation as a fetus descends the pelvic Inlet, occurring up to 2 weeks before delivery ○ Primipara ■ Will efface and then dilate ○ Multiparous ■ Will dilate and then efface ● Effacement ○ Progressive thinning and shortening of the cervix ○ Progression is referred to by the percentage indicating for effacement at 100% ● Dilation ○ Opening of the cervical os during labor ● Frequency of contractions ○ Time frame in minutes from the beginning of one to the beginning of the next ● Duration of contractions ○ Time from the uterus Contracting until it relaxes Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Relaxation period ○ The end of one contraction to the beginning of the next contraction ● Normal labor ○ Will consist of regular contractions, cervical dilation, effacement, descent, and then the delivery of the fetus divided into four stages ○ Regular contractions will increase in frequency and duration radiating from the lower back to the lower abdomen ● During labor, if bleeding is present, refrain from any vaginal exams ○ Could be a sign of placenta previa or abruptio placentae ● Nitrazine test ○ Determine whether or not the membranes have ruptured ○ Will show the presence of amniotic fluid ● Rupture of membranes ○ Immediate action of the nurse is to check fetal heart rate patterns ○ Nursing care ■ Watch for infection and bleeding ■ Watch for prolapse of the umbilical cord if the head has not engaged ● Variable decelerations ○ Cord compression, can lead to feel hypoxia ● Reassuring fetal heart rate ○ Assess fetal heart rate every 30 minutes during the latent stage, every 15 minutes during the active stage, and every 5 minutes during the second stage of Labor ○ Variability indicate say well oxygenated fetus with a functioning autonomic nervous system, fetal heart rate should accelerate with fetal movement ○ Early and mild variable decels are expected reassuring findings, however, late decelerations are not reassuring ● Latent stage ○ First, dilation of 0-3 cm ○ Contractions are 10 to 30 seconds long and 5 to 30 minutes apart ● Active stage ○ Dilation of 4-7 centimeters ○ Contractions are 30-40 seconds long and 3 to 5 minutes apart, growing in intensity ○ Analgesics cannot be given until the cervix is dilated to at least four centimeters ● Transition stage ○ Dilation of 8-10cm ○ Contractions are 45-90 seconds long and 2 to 3 minutes apart ○ During this stage, there will be an increase in blood ○ During this time, epidurals can be administered ■ Leads to vasodilation and a drop in blood pressure that will interfere with adequate placental perfusion, therefore the mother must stay hydrated during this time ● Second stage of Labor Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Begins with complete dilation and ends with the birth of the infant ○ Nursing care ■ A full bladder might interfere with the laboring process ● Third stage of Labor ○ Begins after the birth of the infant and ends with the expulsion of the placenta ● Fourth stage of Labor ○ The first four hours after placental expulsion in which the patient Begins the recovery process ○ Vitals, bleeding, fundal consistency should all be assessed every 15 minutes for the first hour ● Prolapsed cord ○ The nurse applies manual pressure to the presenting part and the mother will be placed in a knee to chest position ● Preterm labor ○ Risk factors include multiple gestations, abortions, younger than 15 years of age, older than 35 years of age, poor nutrition, alcohol and drug use, and smoking ● Precipitous delivery ○ Where there is no physician, the nurse will apply gentle pressure to the perineum and deliver the head between contractions ● Previous C-section ○ Indication for subsequent pregnancies and deliveries except if the uterine scar is low and transverse ● Amniotic fluid ○ If meconium stained, this is associated with fetal compromise Postpartum Assessment ● The fundus should be palpated in the midline of the abdomen ○ If full bladder, the fundus will be deviated to the left or right ○ A boggy fundus signals uterine atony ■ Massage the fundus until it becomes firm and class are expressed ○ On the day of delivery, the fundus should be at the level of the umbilicus, and eventually fall below the umbilicus by one finger breadth per day until it has contracted into the pelvis by the temp today ● Maternal bradycardia ○ Common for the first 6 to 10 days postpartum ● Elevated temperature ○ Normal, related to the excretion and dehydration from labor ○ Not a concern until it exceeds 100.4 degrees Fahrenheit for 2 days ● Postpartum hemorrhage ○ A loss of more than 500 cc's of blood ○ Can be caused by uterine atony, laceration of the birth canal, retained placental fragments ● Subinvolution Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Failure of the uterus to revert to pre-pregnancy State through gradual reduction in size and placement ● Naloxone ○ Given to counteract respiratory depression in the newborn ● APGAR score ○ Will likely be lowest when the mother has had general anesthesia ● Prolactin ○ Stimulates the secretion of milk from the mammary glands ● Breast engorgement ○ Treatment includes breastfeeding frequently, wearing a supportive bra, and cabbage leaves ● Pitocin (oxytocin) ○ Produces uterine contractions, which can cause fetal anoxia ■ Watch fetal heart rate closely ● Umbilical cord ○ Contains two arteries and one vein ● Rhogam ○ Given to unsensitized Rh negative mothers after delivery of an RH positive infant to prevent the development of sensitization ○ Is also recommended at 26 to 28 weeks gestation Is ineffective against RH positive antibodies that are already in maternal circulation ● Direct Coombs test ○ Done on the cords blood after delivery, if both are negative and the neonate is RH positive, the mother is given rhogam ● Rubella ○ The fetus of a pregnant woman that requires rubella May develop congenital rubella syndrome that includes blindness, deafness, heart defects, mental retardation, cleft lip and palate ● Vitamin K ○ Increase is Prothrombin time in newborns ● HIV and AIDs ○ There's a risk of sending HIV to the newborn, even with aggressive treatment to the mother ● Patient teaching ○ Prior to discharge, the nurse should include infant cord and circumcision care to the mother and family ● Breastfeeding ○ Has an antidiabetogenic effect; teach diabetic mother to use less insulin ○ Begin breastfeeding as soon as possible after delivery Newborn Assessment ● Overview ○ Maintaining a patent Airway is the primary objective in the care of a newborn Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ○ First, the pharynx is cleared with a bulb syringe, followed by the nasal passages ■ First indication of respiratory distress is nasal flaring ■ Normal respirations for newborn is 30-80 breaths per minute ■ Sunken eyes and fontanel's suggest dehydration Lack of eye muscle control is present in all newborns, strabismus will be present ○ The macula, the area of keenest vision, is absent at Birth but developed by 4 months and matures by 8 months APGAR score ○ Used to determine major body systems responses to birth ○ Heart rate, respiratory effort, muscle tone, reflex irritability, and color at one minute, and again at 5 minutes after birth ○ The higher the score, the better the condition is, with a maximum total of 10 ■ While it is not an emergent finding, check gluteal and popliteal folds of the hips to identify hip dysplasia Fontanels ○ Anterior closes by 12 to 18 months of age ○ Posterior closes by the second month of age ○ Bulging can indicate increased intracranial pressure Lanugo ○ Fine hair on the skin that tends to disappear during the first week Mongolian spots ○ Bluish discoloration of the skin, common in African-American babies Vernix caseosa ○ Substance that covers the skin of the newborn, protects the baby from infection Strabismus ○ Normal within the first month of life, newborns to not have binocularity and cannot focus Head circumference ○ Should be equal or larger than the chest ○ The nurse will measure above the eyebrows to the occipital prominence ○ Average is 13 to 14 in Caput succedaneum ○ Soft swollen area on the newborns scalp that extends over suture lines ○ This is a normal finding Circumcision ○ Assess for urinary retention Hydration ○ Indicated in 6-8 wet diapers a day ○ Breastfed baby ■ 6 to 10 small, loose, golden yellow stools per day ○ Formula fed baby ■ Dark green, pastry stools Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Bathing ○ Encourage the mom to keep the baby under a radiant warmer and give a sponge bath ● Umbilical cord care ○ Clean the cord stump three times per day with alcohol ○ Stump will fall off within 1 to 2 weeks ● Meconium stool ○ Expected within 24 to 48 hours ○ Infant cannot be discharged until meconium stool is observed and recorded ● Traditional stools ○ Usually appear by the third day after the beginning of feeding ● Weight loss ○ 5% loss is normal and healthy newborns ○ Brown fat is located in superficial areas, considered a unique source of heat for the newborn ● Sudden infant death syndrome ○ Baby must be lying supine in their bed, with no pillow or blanket ● Hypoglycemia ○ Jitteriness or lethargy ○ In the hospital setting, blood glucose will be taken with a heel stick ● ECMO ○ Extracorporeal membrane oxygenation ○ Used in meconium aspiration syndrome to oxygenate the blood while the lungs heal ● Cocaine-addicted newborn ○ constant crying, jitteriness, poor feeding, emesis, respiratory distress, and seizures ● Phototherapy ○ Newborn should have their eyes protected, and only wear a diaper ○ Turn the child every hour ● Vitamin K ○ Aquamephyton ○ Given to newborns to promote blood clotting and prevent hemorrhage ● Ophthalmia neonatorum ○ Acute conjunctivitis in the newborn often caused by gonorrhea and chlamydia ○ 0.5% erythromycin solution is placed in the newborn's eyes to prevent these contractions of the disease ● Coombs test ○ Indirect ■ During the prenatal period To show previous exposure to RH positive antigens ○ Direct ■ Done on the umbilical cord to indicate RH incompatibility Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Erythroblastosis fetalis ○ Treatment includes a combination of phototherapy and transfusions ○ Rhogam will be given to women at risk for this disease within 72 hours after birth ● Kernicterus ○ Severe jaundice may cause this, which is an accumulation of bilirubin in the brain ○ If left untreated, the newborn is at risk for mental retardation and death ● PKU ○ Phenylketonuria ○ The newborn should be tested within 48 to 72 hours after birth ○ The newborn should be drinking breast milk or formula for 2 to 3 days before the test ○ Is positive, they will avoid aspartame, because it is converted to phenylalanine in the body ○ A synthetic food providing enough protein for growth and tissue repair must be substituted for phenylalanine ● Down syndrome ○ Decrease muscle tension and strength, called hypotonia ■ Hallmark sign at Birth ○ Newborn will also have a deep, straight line across the palm called a SIMIAN crease ○ The newborn will also have slanting eyes and low-set ears ● Physiological jaundice ○ Appears between the 3rd and 5th day of life, last for a week ● Denver developmental screening test ○ Evaluate the development of social, motor, and language skills from 1 months to 6 years of age ○ Infant responses should be quiet- alert ○ Infant demonstrating the rooting reflex should be positive ○ Moro reflex should be positive ○ Prancing movements of the legs while the child is held upright should be positive Pediatrics Developmental Stages ● Birth to one-year ○ Weight will decrease by 10% immediately after birth, and returned to birth weight by two weeks of age ○ Will have no purposeful movements, just primitive reflexes ■ Will respond by blinking, crying, or quieting ■ Newborns have a fixed gaze, and cannot follow objects ■ When placed in a prone position, they will lift their head ■ Hearing is preferential to a female voice ○ Height gain of 2.3 cm per month ○ Weight gain of 150 to 210 grams per week Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Sleep for only 3 to 4 hours and wake for 1 hour in between each session ○ Nursing care ■ Rear facing car seat ■ Baby place in the Supine position while sleeping to prevent SIDS ■ Never allow the newborn to stay alone with another young child ■ Maintain immunization schedule including hepatitis B ○ Toys ■ Bright red colors and toys that make noise ○ Play ■ Solitary ○ Death and dying ■ Hospital stay and death have no significance at this age ● 2 months old ○ Posterior fontanelle closes at this time ○ In the prone position, the newborn can lift their head and neck ■ However, there will be continued to lag on the raising the head when pulled to a sitting position ○ Able to follow objects and consciously turn their head 180 degrees ○ They pay attention to voices and smile responsibly ○ Toys ■ Same with one month old ○ Nursing care ■ Rear facing car seat, pacifier ■ Maintain oral hygiene ■ Raise side rails and never leave baby alone as they can now roll over ■ Immunization schedule includes dtp, HBV, IPV, HIB ■ Post immunization reactions can include fever, cough, or rashes ● 4-5 months old ○ Increase the weariness and interest and surroundings ○ Can make Coos, squeals, and babbles ○ No head lag when pulled to a sitting position ○ Cries for many reasons including hunger, wet diaper, discomfort, and sleep ○ May repeat sounds, smile when spoken to ○ Can lift the chest when on a prone position, can turn from abdomen to back by 4 months and back to abdomen by 6 months ○ Nursing care ■ Prevent aspiration and choking, burp after feeding ■ Baby-proof the home and prevent Falls ■ Introduce solid foods one at a time and in the morning ● 6 months old ○ They will double their weight and have teeth eruption of the two lower incisors ○ Can sit without help and lean forward, they can support themselves with their arms Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ○ Verbalize single consonants and respond to sounds of toys ○ They can bear weight on their legs with support and begin to exhibit stranger anxiety ■ Will be anxious when away from mother, indicating separation anxiety ○ Nursing care ■ Provide finger foods and feed them with spoon and cups ■ Monitor for teething and fever ■ Ipecac syrup is important for the ingestion of poison 9 month old ○ Can grasp objects between thumb and forefinger (pincer grasp) ○ Can pull themselves to stand and crawl ○ They turn to the sound of their name and play peek-a-boo ○ Will search for an object when it is taken away, understand that even though it can no longer be seen ( this is called object permanence) ○ Nursing care ■ Safety concerns due to kinetic ability, and courage self-feeding, rear car seat ○ Toys ■ Colorful items and toys that make noise ○ Death and dying ■ Still do not understand death at this time Toddler from 12 months-18 months ○ Their birth weight will be tripled and height is doubled ○ They will have 6-8 teeth ○ Head circumference and chest circumference are equal ○ They can stand alone and follow simple commands ○ They can use cup, and Spoon, but they prefer their fingers ■ They can point with their index finger ○ Toys ■ Mobiles, bells, and bright colored toys ○ Nursing care ■ Talk to them and name objects to them ■ Praise and discipline when there is a need to ■ Provide good dental and Oral Care ○ Play ■ Solitary 18 months ○ Anterior fontanelle closes ○ They can walk backwards and use a spoon and cup without assistance ○ They can kick and throw balls ○ They can have temper tantrums and have a vocabulary of about 15 to 20 words ○ At this age, they will attach to a security item and begin some sucking ○ Play Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ■ Parallel play is more obvious ○ Nursing care ■ Provide them with a variety of snacks and encourage dental hygiene ■ Toilet training- Readiness will be shown by the ability to hold urine for more than 2 hours and not have a wet diaper, as well as the child willingness to sit on the toilet ■ Encourage parents to go to CPR classes ■ Seat belt facing the front when the child weighs around 20 lb 2 years old ○ They can walk up and down the stairs with both legs, open doors, turn knobs ○ They can transfer objects from one hand to another ○ Development of all 20 deciduous teeth ○ Can start to learn how to tie shoes, ride bicycle, and concentrate on activities longer ○ Bowel training will proceed bladder training ■ Voluntary control of the anal and urethral sphincters is achieved sometime after the child starts to walk ■ Ritualism is needed to maintain reliability and provide a sense of comfort ○ Toys ■ Interested in the sight, smell, texture, and taste of things ■ Objects that can be squeezed, dropped, twisted, or thrown ■ Objects that can be stacked, open, closed, pushed or cold Preschool age ○ Children use their imagination to imitate adult activity and participate in physical games ○ The foundation of writing is during this time and they enjoy drawing and painting ○ More energetic and active and spend a lot of time pretending School-age ○ Enjoy activities that lead to real products such as jewelry, clothes, collections ○ Develop an interest in sports and enjoy having adult like equipment ○ There's a better understanding of rules and playing with others Immunization schedules ○ At Birth ■ Hep B ○ 2 months ■ Polio, DTap, HIB, Hep B ○ 6 months ■ DTap, HIB, Polio, Hep B ○ 12 to 15 months ■ MMR ■ Varicella ○ Before school Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ■ DTap, OPV, MMR ○ Immunizations are contraindicated during infectious state and with pre-existing symptoms such as allergic reaction Rubella ○ Fever, conjunctivitis, and cough Lice ○ Removed by combing the hair with a fine-tooth comb ○ Clothing should be washed in hot water and dried in a hot cycle Fears ○ Infants ■ Stranger anxiety, the sudden appearance of unexpected and looming objects, animals, and Heights ○ Toddlers ■ Separation anxiety, the dark, loud noises, stranger anxiety ○ Preschooler ■ Injuries can lead to something much worse ( what they think) ○ School-age ■ Fear of supernatural beings, injury, storms, staying alone, failure in school, death ○ Adolescents ■ Fear of inept social performance, social isolation, sexuality, drugs, diverse crowd, public speaking, large accidents Death and dying ○ Ages 3-5 ■ Least anxious about death, death means sleep, the dead person is seen as a live but lacks movement, death is a punishment for bad behavior ○ Ages 5 to 10 ■ Death is a cessation of Life, often question what happens after death, death is now considered irreversible Hospitalized child ○ Infants and toddlers will experience separation anxiety ■ Should be the focus of the plan of care ■ Is not uncommon to have a temper tantrum seen in toddlers- before procedures give them an explanation in the way they can understand ○ Preschool-age ■ Demonstrate a need for parents and fear of Mutilation while hospitalized; did you not understand body integrity and body boundaries ■ Therapeutic play will establish rapport with this age child ○ School age and older children ■ Fear a lack of acceptance, body disability, separation from peers ■ Concrete experiences are most meaningful way of learning, which supports the rationale for Pediatric orientation Pro Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Response to pain ○ Infants ■ Irritability and reflux withdrawal to painful stimuli, facial grimacing ○ Toddlers ■ Localized withdrawal in response to pain ○ Preschoolers ■ Low frustration level and strike out physically ■ Wong Baker faces scale should be used ○ School age ■ Passive resistance ● Play ○ Infants ■ Solitary ○ Toddlers ■ Parallel, playing side-by-side and occasionally treating toys ■ Can also be called a associative play ■ Play therapy is one of the most effective strategies to treat this age ○ Preschoolers ■ Dramatic play, the ability to cooperate with others ○ School-age ■ Cooperative play, notoriously competitive at this age ○ Adolescence ■ More verbal and have greater cognitive skills ● Abuse ○ Children will often use play to act out family conflicts, express feelings, and learned behaviors to protect themselves ○ A sexually abused child may be able to express their feelings through ART therapy Pediatric: Congenital Defects ● Neurological conditions ○ Spina bifida ■ First priority is to prevent rupture of the external Sac, prone position ■ Spina bifida occulta - mildest, “hidden” skin that covers opening ■ Closed neural tube defect - spinal cord has malformations of fat, bone, and meninges, can either be no symptoms or cause incomplete paralysis ■ Meningocele - spinal fluid/meninges protrude through vertebral opening, no symptoms OR complete paralysis ■ Meningomyelocele - most severe, spinal cord is exposed through opening in the spine, partial/complete paralysis ○ Hydrocephalus ■ Nursing assessment includes head circumference and palpation of the anterior fontanelle Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Support the head when lifting or turning the infant ○ Bacterial meningitis ■ Infant will have a bulging fontanelle that occurs secondary to intracranial pressure ● Cardiovascular conditions ○ Congenital heart disease ■ First priority is to reduce the workload of the heart ■ Most common complaint from parents is difficulty feeding ■ Child will be tachycardic, often the first symptom the nurse can assess ○ Patent ductus arteriosus ■ Occurs when a structure that shunts blood from the pulmonary artery to the aorta that remains open ○ Tetralogy of fallot ■ Infant will be cyanotic, hypoxic, systolic murmur is heard in the pulmonic area ■ If the child becomes acutely cyanotic and hyperpneic, place the infant in a knee to chest position ○ Coarctation of the aorta ■ A difference in the blood pressure between the upper and lower extremities ○ Cystic fibrosis ■ Thick mucus, foul-smelling fatty stools, salty, sweaty skin, no passage of meconium stool ■ Sweat chloride test is used to confirm ○ Hemophilia ■ Sex-linked genetic disorder ■ Bleeding into joint spaces ■ Drugs that contain salicylates are contraindicated for these children ○ Sickle cell disease ■ Occurs when the patient receives genes from hemoglobin s from each parent ○ Kawasaki disease ■ Mucocutaneous lymph node syndrome ■ Characterized by a fever over 104.5 degrees for 5 days or longer, bilateral conjunctivitis ■ Place the child on cardiac monitoring ● Musculoskeletal conditions ○ Talipes equinovarus ■ Most common form of clubfoot ■ Denis browne splint- used for correction of clubfoot ○ Milwaukee brace ■ Fitted to treat scoliosis and removed for bathing once a day ■ Patient should be monitored for numbness or paresthesias ○ Scoliosis Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Observe for an uneven rib hump noticeable when a child Bend at the waist ■ Screened starting around ten years of age ○ Hip dysplasia ■ Uneven gluteal fold ■ Ortolani’s sign/clickIs a positive diagnostic test ■ Symptoms will be unequal skinfold, limitation of abduction, and unequal knee height ○ Bryant traction ■ Use in infants and toddlers for treatment of a fractured femur and congenital hip displacement ■ Can only be used in children who weigh less than 35 lb ■ The butt will be just slightly off the bed ○ Dunlop traction ■ Used for treating fractures of the humerus ○ Trauma ■ Frank blood, or clear watery drainage that indicates CSF leakage from the ear suggest a basal skull fracture ● Respiratory and ENT conditions ○ Laryngotracheobronchitis ■ Respiratory distress and dyspnea- atmosphere with high humidity will provide relief ○ Bronchiolitis ■ Toddler will be placed in a croupette for treatment and monitored for hypothermia ○ Croup ■ Inspiratory stridor is a Hallmark find ■ Hoarseness, barking cough ■ Treatment → corticosteroids and nebulized epinephrine ○ Pertussis ■ Catarrhal, paroxysmal, and convalescent phase ○ RSV ■ Begins with cold-like symptoms and becomes more severe ■ Spread of infection can be prevented by proper hand-washing ○ Tuberculosis ■ Suspected when a child has a fever, weight loss, and Mild dyspnea ○ Otitis media ■ Occurs because of obstruction of the eustachian tube or passage of the nasopharyngeal secretions in the middle ear ■ An infant’s eustachian tube is shorter and wider, and is a horizontal position so they are at higher risk for developing infection ○ Eczema ■ Occurs in infants younger than 2 years of age Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Infantile eczema will have spontaneous remission by 3 years of age ○ Tonsillectomy ■ Monitor their child for frequent swallowing, which indicates bleeding ■ Milk products may coat the throat and cause the child to clear the throat and irritate the operative site, these should be avoided ■ Coughing, clearing the throat, and blowing the nose should also all be avoided ○ Epiglottitis ■ Life threatening emergency ■ Contraindication for throat cultures because swabbing the throat causes swelling that will block the airway ■ Muffled voice, drooling, dysphagia ■ Treatment → ceftriaxone, vancomycin ● GI conditions ○ Cleft palate (prone)/lip repair (supine) ■ Feed the child with a soft rubber tip syringe place on the side of the mouth ■ Elbow restraints may be used to restrain the upper extremities ■ Child is predisposed to infection because of communication between the nose and mouth ○ Tracheoesophageal fistula ■ Symptoms include drooling, coughing, cyanosis, and regurgitation of feedings ■ The esophagus has a connection ( fistula) to the trachea that leads to risk of aspiration ○ Pyloric stenosis ■ Symptoms typically do not appear until two to three weeks of age ■ Forceful projectile vomiting after feeding ■ Place the infant on their right side after feeding and feed slowly to facilitate emptying of the stomach ○ Intussusception ■ When a portion of the bowel telescopes into a distal portion, usually in males before the age of five ■ The child will kick and draw their legs, cry loudly, and vomiting of bilious or stomach contents ■ Hallmark sign is jelly-like stools ○ Imperforate anus ■ If suspected, no rectal temperatures should be taken ■ A positive sign is the failure to pass meconium stool ○ Celiac disease ■ Intolerance of gluten, patient will have steatorrhea (frothy, pale, bulky, foul-smelling, greasy stools) ○ Hirschsprung's disease Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Distention of a portion of the lower colon caused by a congenital lack of nerve cells in the wall of the colon below the distended section ■ Symptoms include abdominal distension, constipation, bile stained mucus and vomiting ■ There will also be a lack of meconium stool Passage ■ Barium enema is a test that can be performed to see what part of the bowel is distorted ○ Wilms tumor ■ Encapsulated tumor of the kidney ■ Touching or palpating the abdomen may break the capsule and spread the cancer throughout the abdomen Procedures, Poisoning, and Other ● Newborn bathing ○ Do not immerse the newborn until the cord has fallen off ● Eye drops ○ Place at the inner corner of a closed eye ● Ear medications ○ Insect in the child ear ■ Place a small amount of mineral oil ○ When inserting drops, straighten the ear canal back and down for those younger than 2, and pull up and back for those older than 3 ● Painful procedures ○ Refrain from having the parents restrain the child, as this is seen as then making it better ○ Be honest with a child, also tell the child what behavior is appropriate ○ Always refer to medicine as medicine, not as juice or candy ○ Vastus lateralis is the preferred site for an IM injection ● Physical examination ○ Leave the most distressing part to the end ○ Rectal temperature should be taken last ○ Respirations will be observed by looking at the abdomen for a full minute ○ If the child is unconscious, palpate the brachial artery ● Lumbar puncture ○ Lay the child Side Lying with their knee and neck flexed ● Reye's syndrome ○ Associated with the presence of specific diseases and the use of aspirin ● Digoxin ○ Withheld when an infant's pulse is less than 110 or when a toddler's pulse is less than 90 ● Infantile spasms ○ Sudden brief, symmetric muscle contractions accompanied by Rolling of the eyes ● Imipramine Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Tofranil, decreases enuresis in children over the age of six ○ Most effective teaching is to provide reassurance and support ● Pediculosis ○ Nix is the preferred treatment ● Poisoning ○ First action is to identify what was ingested and call the Poison Control Center ○ Ipecac syrup is an emetic administered to children who have ingested non caustic poisonous substances ■ Administer by mixing 15 cc's in a cup of water ○ General fatigue, difficulty concentrating, Tremors, and headache ○ Lead poisoning ■ General fatigue, difficulty concentrating, Tremors, and headache ■ Chelating agents (EDTA) are used to treat, which promotes the urinary excretion of lead ○ Acetaminophen poisoning ■ Jaundice, confusion, and coagulation abnormalities ■ Treatment includes activated charcoal to absorb the acetaminophen, and a possible gastric lavage, and eventually acetylcysteine (mucomyst) ■ Acetylcysteine is the antidote for Acetaminophen Toxicity, and should be administered as a loading dose and Then followed with a maintenance dose ○ Carbon monoxide poisoning ■ Treatment is the hyperbaric oxygen chamber ○ Household chemicals ■ If accidentally sprayed into a child eyes, the first nursing action is to irrigate for 5 minutes ● Child abuse ○ Shaken baby syndrome ■ Symptoms include apnea, seizures, lethargy, drowsiness, bradycardia, subdural and retinal hemorrhages with the absence of external signs of injury ○ Should be suspected when there is a discrepancy between the injury to a child and the expected developmental capability of the child ■ Examples include bite marks, bruises to the face, neck, chest, back, and abdomen, abrasions to the knees or elbows, and bruises suggestive of being hit in various stages of healing ○ The first action to be taken is to notify reporters provide safety for the child ○ Failure to thrive ■ Delayed development without physical cause ○ ADHD ■ Difficult to establish and many times becomes a catch-all diagnosis for children with behavioral problem ■ Treatment includes Ritalin, the child should be monitored for weight loss ○ Clark's rule Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ ■ Used to measure the appropriate pediatric dose by multiplying the adult dose by the child weight in pounds and / 150 Young's Rule ■ Multiplying the adult dose by the child's age in years and dividing the result by the sum of the child age plus 12 years Mental Health Overview ● Abstract thinking ○ The ability to conceptualize and interpret meaning ○ A higher level of intellectual functioning than concrete thinking ● Concrete thinking ○ The inability to conceptualize and comprehend abstract meaning ● Tangential thinking ○ Scattered, not goal-directed, difficult to follow ○ Long story with lots of detail, never gets to the end ■ Seen in people with schizophrenia and delirium ● Circumstantial thinking ○ Describes a patient who talks around the subject and includes unnecessary information ● Flight of ideas ○ Describes the salt pattern in which the client moves rapidly from one topic to the next with loose connections ○ “Flying from one idea to the next without any associations” ○ “The sky is blue, I went to the store yesterday, my dinner tasted good” ● Looseness of an association ○ Describes a pattern in which ideas Lac and apparent logical connection to one another ○ “Derailment” ○ Seen in schizophrenia ● Insight ○ The degree to which the patient understands the situation or problem and its effect on their life ● Judgement ○ The ability to make decisions and behave in an appropriate manner ● Affect ○ A person's mood, feelings, or tone that is observable an outward manifestation ○ May be referred to as inappropriate, flat, or blunted ● Mood ○ Prolonged emotional state that is expressed by the affect ○ Typically a subjective finding ● Delusions Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ○ False, fixed beliefs ○ Can be delusions of grandeur, persecutions, erotic, jealous, and religious ○ Never refute delusional thoughts, this can increase anxiety and reinforced delusions ○ Never ask the patient to elaborate on the delusion Hallucinations ○ Sensory perceptions that can be auditory, visual, tactile, or olfactory ○ Patient appears to be listening to someone that no one else can hear or see ○ Encourage the patient who was hallucinating to engage in activities that divert their attention away, such as watching TV or listening to music with headphones ○ When the patient is experiencing hallucinations, it is important to convey an acceptance of the behavior however let the patient know that we do not see the same things Paranoia ○ Psychosis that is characterized by systematized delusions of persecution or grandeur without hallucinations ○ Never challenge these patients, as this can lead to increased anger and anxiety ○ These patients are easily threatened, avoid touching them or getting to close Nurse to Patient relationship ○ Pre interaction, introduction/orientation, working, termination phase ○ Preparation for ending the relationship will start at the beginning ○ Always remember that nonverbal behavior is more precise indicator of feelings ○ Close ended questions are considered non-therapeutic ○ NO “Why” questions, as they require analysis of the problem and often produce anxiety Paralanguage ○ The use of vocal effects, such as tone and Tempo to convey a message Adaptive Use of Defense Mechanisms ○ Good, will help ease anxiety Maladaptive Use of Defense Mechanisms ○ Bad, will disallow goals to be achieved Proxemics ○ The use of spatial relationships during interaction to communicate meaning Regression ○ An adult who throws temper tantrums, considered maladaptive ○ A 5 year old who begins sucking their thumb again after their brother was bornadaptive ○ A young woman might go stay with her parents after her first fight with her husband Projection ○ When a patient blames someone or something else other than the source ○ “I got in trouble by my boss because he was having a bad day” Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● Reaction formation ○ When the patient acts in opposition to their feelings ○ Treating someone you strongly dislike in a kind way to hide the way you actually feel ● Sublimation ○ Turning anxiety into something good ○ Ex; having a bad day at work but then going to exercise to decrease anxiety ● Intellectualization ○ When the patient over uses rational explanations or abstract thinking to decrease the significance of a feeling or event ○ A woman who was raped takes self defense classes” Disorders ● Depression ○ Patient may require assistance to perform activities of daily living ○ Patient should not be allowed to isolate themselves, and may have a diminished ability to concentrate, which suggests a decrease in overall cognitive functioning ○ Provide structured activities for these patients, as well as small groups to provide social contacts without being too ● ECT (electroconvulsive therapy) ○ Most effective in treating patients with severe depression over a total of 6 to 12 treatments ■ 2-3 treatments are given per week ■ requires preoperative care including consent and NPO status ○ Short term memory loss is the most common complication ○ Succinylcholine → drug to minimize muscle movement during therapy ● Alzheimer's disease ○ Early stages ■ The patient will experience forgetfulness, especially short-term and recent memory loss ■ Nursing care includes maintaining a familiar surrounding and a predictable routine ○ Middle stage ■ Personality changes occur here ■ A calm person may become moody and irritable, as well as agitated ■ Problems with speech and language may appear here, especially Aphasia and anomia ● Expressive aphasia: you know what you want to say but can’t get it out ■ Nursing care includes less concentration required activities ○ Final stages ■ Total memory loss, decreased mobility, incontinence of bowel and bladder ○ Typically these patients die from complications of immobility, such as sepsis or pneumonia Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 Schizophrenia ○ Marked by disturbances in affect, perception, thought content, and form ■ Hallucinations ○ Generally characterized by delusions, whether grandiose, religious, paranoid, nihilistic, or delusions of reference and confusion ■ Word salad, echolalia (repeating what someone says), clang associations (rhyming) ○ Most important nursing care includes maintaining a consistent, predictable environment and preventing sensory overload ○ Medications ■ “Pines”- clozapine, loxapine, olanzapine ■ Haloperidol, risperidone ● Eating disorders ○ Patient will believe that they are grossly obese and commonly uses manipulative ploys to resist weight gain ○ Bulimia ■ Patients are at risk for developing electrolyte imbalances and cardiac arrhythmias ○ Anorexia ■ Patients typically come from families who are controlling and overprotective ■ They use eating as a way of getting control of their lives ■ Highest priority goal is to establish adequate daily nutritional intake and the establishment of a consistent eating plan and monitoring waking ■ The patient should always be monitored before, during, and after meals ■ Typically, these patients will lose the loss of sexual characteristics ■ The temperature of these patients is decreased because of low metabolism, blood pressure and pulse are also lower ● Delirium ○ Characterized by irritability, hypersensitivity to light and Noise, disorientation ○ Sun-downing in demented patients ○ Acute alcohol withdrawal ● Bipolar disorder: manic phase ○ Characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood ○ Diagnosed if a patient has 4 of the following symptoms for the total of 1 week: flight of ideas, inflated self-esteem, unusual talkativeness, increase social, occupational, or sexual activity, decreased need for sleep, physical restlessness ○ Nutritional needs can be met by providing finger foods ○ Nursing care includes ensuring safety and food, and rest, these patients are encouraged to perform large muscle activities, such as swimming. These patients are discouraged from activities that are stimulating and competitive ● Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ○ Seclusion is only appropriate when the patient is engaged in frantic, aimless physical activity, and is at risk for injury ■ Limits should be placed on settings because they have trouble distinguishing boundaries ○ Medications ■ Lithium, risperidone, valproic acid, clonazepam Borderline personality disorder ○ Patients have an intense fear of abandonment, severe body image issues, and impulsivity ■ Most at risk for self-mutilation ○ Nursing care should include firm and consistency in rules ■ Refrain from engaging in third-party conversations ■ Rotate staff members, which will reduce the incidence of splitting ■ Set limits on unacceptable behavior Antisocial Behavior ○ Common response is the lack of concern about their situation as well as the absence of sensitivity to the feelings of persons they have harmed or will harm ○ Set limits on inappropriate behavior ■ Be cautious of manipulative behavior Narcissistic personality disorder ○ Lack of empathy is one of the main characteristics Suicide ○ Those at highest risk usually have a plan, a means of carrying out the plan, and a history of previous attempts ○ Signs of potential suicide ■ Symptoms of depression, patient gives away their possessions, gets their finances in order, makes direct or indirect statements, leaves notes, has an increase in energy ■ As patients improve, their risk for suicide is greater because they're able to mobilize more energy to plan and execute suicide ○ Predisposing factors ■ Males over the age of 50, ages 15 to 19 years of age, poor social attachments, previous attempts, auditory hallucinations overwhelming precipitating event such as the death of a loved one, losing a job, or terminal disease ■ Psychosocial factors include bereavement, retirement, or do social support ○ Suspect suicide risk when patients report that life is not worth living because of unrelieved pain, depression, and poor quality of life Anxiety disorder ○ Patients worry about anything and everything ○ Nursing interventions should be used when patients are experiencing mild to moderate levels of anxiety Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ■ Include helping the client recognize sources of anxiety and teaching a client effective coping mechanisms ○ Anxiety attack nursing care ■ Stay with the patient, decrease stimuli, remain calm, medication as necessary ■ Offer large muscle activities that help drain off excess energy, thus reducing anxiety ○ Panic anxiety ■ Patient will experience severe anxiety resulting in feelings of impending doom or death Post-traumatic stress disorder ○ Etiology involves a life-threatening or catastrophic event ○ Treatment ■ Exposure therapy Phobic disorder ○ Characterized by a persistent fear of an object or situation that presents no real Danger ■ These are commonly viewed as a learned response to anxiety ○ Treatment ○ Exposure therapy- includes systematic desensitization through gradual exposure to the stimuli that causes anxiety Obsessive compulsive disorder ○ Manifested by repetitive thoughts or recurring impulses to perform certain acts ○ Patients have an inability to control intrusive thoughts that repeat over and over, patients are usually aware of the irrationality of their actions but they are unable to stop then ■ Rituals are an attempt to avoid increasing anxiety to a severe level ○ Nursing care ■ Allow the patient to complete their behavior, but set time limits Crisis Intervention ○ Brief, time-limited treatment that focuses on the current situation ○ Purpose is to prevent the development of future mental health problems ○ Family Violence ■ Considered a learned behavior and will typically lead to further violence in offspring ○ Rape survivors ■ May experience the hospital and policy procedures as further violation of their privacy and integrity Substance abuse ○ Denial ■ Typically the common defense mechanism ○ Alcohol withdrawal ■ Appears within 8 to 12 hours Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Includes tremors, anorexia, diaphoresis, irritability, shaky hands ■ Librium will be given to treat the symptoms, works as an anti-anxiety drug ■ Disulfiram is used as a deterrent to compulsive drinking, however, it is contraindicated if the patient drinks alcohol in the previous 12 hours prior to medication administration ■ Klonopin (clonazepam) used to prevent seizures ○ Heroin withdrawal ■ Runny nose, diaphoresis, dilated pupils ○ PCP overdose ■ Patients can be medically treated by acidifying the urine with cranberry juice or NH4Cl, as well as giving a benzodiazepine, and we're straying the patient ○ Methadone ■ Opioid analgesic used to treat narcotic withdrawal syndrome ○ Naloxone (Narcan) ■ Narcotic antagonist used to reverse narcotic induced respiratory depression Extrapyramidal Symptoms and Medications ● Extrapyramidal symptoms ○ Disabling, distressing movement disorders that are associated with antipsychotic medications ○ Akathisia ■ Frequent movements such as pacing, rocking, shifting from one foot to the other, inability to sit still ■ Patient feels in a restlessness, nervousness, feeling unstable ○ Dystonia ■ Involuntary muscle spasms of the tongue, face, neck, and back ■ Patient feels a frightening sudden spasm that may be painful ○ Parkinsonism ■ Shaking of the hands and arms while at rest, stiff posture, muscle rigidity, slow movement, shuffling gait, no swinging of the arms while walking, an expressive face, slowed thoughts ○ Tardive dyskinesia ■ Protrusion or twisting of the tongue, smacking, person, sucking movements of the lips, puffing of the cheeks, chewing movements of the jaw, jerking movements, shoulder shrugging ■ Patient usually feels anxious and nervous ● Haldol/Prolixin ○ Are considered antipsychotic medications ○ Can cause extrapyramidal symptoms that affect voluntary movement ■ Shuffling gait, tremors, restlessness, pill rolling, drooling, uncoordinated jerky movement, dry mouth, and blurred vision Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ■ Most common is akathisia, a form of psychomotor restlessness that can be relieved by pacing Neuroleptic malignant syndrome ○ Life-threatening EPS effect of antipsychotic medications ○ Associated with the rapid increase in temperature Artane/cogentin ○ Anticholinergic medications that may be given to control EPS symptoms ○ Can result in dry mouth ○ Provide the client with hard candy or encourage increased fluid intake Selective serotonin reuptake inhibitors ○ Prozac, Zoloft ■ Onset of a fact within 7 to 21 days Lithium ○ Narrow therapeutic range of 0.5 to 1.5 ○ Blood levels will be monitored ○ Encourage adequate fluid and salt intake ○ Toxicity ■ Vomiting, diarrhea, muscle twitching, ataxia, slurred speech, coma, seizures, and possible cardiac arrest (hyponatremia) MAOI inhibitors ○ Dangerous drug-food, drug-drug interactions ○ Teach patients to avoid foods high in tyramine ■ Aged cheeses, fermented foods, chocolate, vermouth wine ○ Teach patients to avoid over the counter drugs for cough and cold Clozaril ○ Used as an atypical antipsychotic ○ Monitor patient for agranulocytosis, white blood cell levels should be monitored weekly ■ Sore throat, fever, sudden onset of flu like symptoms Disulfiram (antabuse) ○ Teach patient to avoid drinking for two weeks after the last dose ○ Alcohol is present in cough medicine, vinegar, after shave lotion, and some mouthwashes, teach patient to avoid these Pharmacology Overview ● Overview ○ 1 oz = 30 cc/mL ○ 1 tsp = 5 cc/mL ○ 1 tbsp = 15 cc/mL ○ 1,000 mcg in 1 mg ○ 1,000 mg in 1 g Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Always recheck medications if you or the patient has any doubt or confusion ● Medication check ○ First ■ While in the med Room, Check the six rights including right patient, dose, medication, time, reason, route, and documentation ○ Second ■ Before leaving the med room, after drawing up and pulling all meds, recheck ○ Third ■ While in the patient's room, check with the patient themselves and their ID band ○ Never leave medication on the patient's bedside with the assumption that they will take it, always watch the patient take it or assist them with administration ● Antihypertensives ○ Hold medication if systolic blood pressure is less than 100 ● Anti-arrhythmic ○ Hold medication if heart rate is less than 60 ● Medication administration ○ Never crush enteric-coated tablets, long-acting tablets ○ For patients with swallowing difficulty, provide soft food that is easier to swallow than liquid Important Drugs ● Aspirin ○ Administration ■ Take with meals or an 8-oz glass of milk to reduce stomach irritation ■ Stop taking for 5 days before surgery ■ Avoid giving to children who have a fever or other symptoms of a viral infection due to the risk of development Reye's syndrome ■ Avoid chewable aspirin for one week after a tonsillectomy, or any other dental surgery ○ Overdose ■ Hearing loss, confusion, ringing in the ears, dizziness, seizures, difficulty breathing ○ Contraindications ■ Diabetic patient- if taking aspirin, it may cause false urine glucose test, aspirin may increase the effect of antidiabetic medication causing low blood glucose levels ■ Other anticoagulants due to the increase risk of bleeding ○ Allergy to aspirin ■ Avoid ibuprofen ● Chlorothiazide ○ The body loses water and potassium ● Prednisone Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ○ Acts on the body's metabolism to increase blood glucose and decrease potassium ○ Monitor the patient for any signs of infection ○ Teach the patient about tapering off the drug, avoid stopping the medication abruptly Steroids ○ Monitor patients for hyperglycemia Ibuprofen ○ Take with food or antacid to reduce stomach upset ○ Contraindications ■ Do not take if allergic to aspirin ■ Do not take if causes for stomach ulcers NSAIDs ○ Elderly patients receiving them on a routine basis should be monitored for congestive heart failure and hypertension as a result of fluid retention Iron supplements ○ Take with food or immediately after meals to reduce stomach upset ○ Side effects ■ Constipation, nausea, and black stools ○ Contraindications ■ Do not take at the same time as antacids Constipation ○ If a side effect of medication, teach the patient to increase their fluid intake, exercise regularly, And increase their fiber intake Hypokalemia ○ Dizziness, tiredness, weakness, leg cramps, nausea, GI upset Isoniazid (INH) ○ Used in combination with other drugs, usually Rifampin, to treat tuberculosis ○ Side effects ■ Vitamin B6 deficiency and GI upset ■ Serious- abdominal pain, yellowing of the skin and eyes, dark urine, all indicates inflammation of the liver ○ Pyridoxine ■ Vitamin B6, counteracts the side effects ○ Patient teaching ■ Avoid swiss cheese and tuna, as these foods can cause chills, headache, tiredness, rapid and pounding heartbeat Rifampin ○ Used in combination with isoniazid to treat tuberculosis ○ Side effects ■ Orange-colored urine, saliva, tears, sweat, and feces ■ Negate birth control pills ■ Nausea and vomiting Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ● ■ Thrombocytopenia Streptomycin ○ Can cause damage to cranial nerve number 8 Theophylline ○ Main action is to relax bronchial smooth muscles ○ Administration ■ Give with food to prevent GI upset ○ Toxicity ■ Dizziness, vomiting, agitation, apical pulse above 200 Aminophylline ○ Most common side effect is hypotension Digoxin ○ Apical pulse is essential for the accurate measurement of the heart rate before Administration ○ Toxicity ■ Visual disturbances such as green halos Levodopa Carbidopa (sinemet) ○ Effects may not occur until several weeks after Administration ○ Nursing care ■ Advise patients to moderately restrict protein intake ■ Watch for orthostatic hypotension Morphine ○ Monitor patients for bradypnea Levothyroxine sodium ○ Side effects include rapid heart rate and palpitations Coumadin ○ Therapy is be gone after anticoagulation has been established by another drug ○ Used on an outpatient basis for long-term anticoagulant therapy ○ Patient teaching ■ Advise patients to shave with an electric razor, use soft toothbrushes, and Report any coffee grounds or bloody vomit or stool Heparin ○ Protamine sulfate is an antidote for overdose ○ Never massage the area after injection Lovenox ( enoxaparin) ○ During the administration, the air bubble should not be removed from the pre-filled syringe Zidovudine ○ Can cause bone marrow problems ○ Patient teaching ■ Notify provider with the development of chills, fever, and sore throat Chemotherapeutic agents Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ○ Patient teaching ■ Avoid those with infections and large crowds do to immunosuppression ● Dilantin ○ Patient teaching ■ Teach patient to maintain a comprehensive oral hygiene program due to the risk of gingival hyperplasia ■ Advise the patient that this drug can also cause constipation and drowsiness and irritation to GI tissues ● Lithium ○ Expected range is 0.6 to 1.2 ○ Not metabolized, excreted unchanged by the kidneys ○ Toxicity ■ Can begin at 1.4, increase to 2 ■ Symptoms include diarrhea, nausea, vomiting, drowsiness, muscle weakness, coma, convulsions, and death ■ Treatment includes gastric lavage, fluid balance correction, and Mannitol to increase urine excretion ○ Contraindications ■ Avoid diuretics, non-narcotic pain medications, and anti-inflammatory drugs, as these cannot increase the level of lithium ○ Patient teaching ■ Take with meals to avoid GI upset ■ Teach the client to maintain adequate fluid and sodium levels in order to prevent toxicity ■ Patient will have blood draws every month to watch stability of levels ● Amitriptyline (elavil) ○ Teach the patient that the full facts may not occur until 2 to 4 weeks after beginning therapy ● MAOI inhibitors ○ Isocarboxazid ■ Avoid foods high in tyramine ● Narcotics ○ Before Administration, assess the patient for any respiratory depression ● Burns ○ Silver nitrate solution 0.5% for treatment, including a wet dressing 1-2x daily ○ Silver sulfadiazine 1% cream can be placed with a light dressing ○ Mafenide acetate (sulfamylon) Placed on the wound using an open exposure method, applied up to four times a day ■ This medication is known to be painful on application, premedicate the patient before application Frequent Monitoring Drugs & Toxicity ● Acetaminophen Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ○ Contraindicated in liver disease ○ Toxicity can be shown in hepatic necrosis Aminoglycosides ○ Monitor for ototoxicity ( vestibular and cochlear), nephrotoxicity, neurotoxicity, and hypersensitivity ○ Monitor for tinnitus, hearing loss, vertigo, rash, dizziness, or difficulty urinating Amitriptyline (elavil) ○ Contraindicated in narrow angle glaucoma and with MAOI inhibitors ○ Side effects include drowsiness, sedation, lethargy, dry mouth and eyes, blurred vision, hypotension, and tachycardia ○ Advise patients to use sunscreen Carbamazepine ( Tegretol) ○ Contraindicated in bone marrow suppression ○ Toxicity can be shown in drowsiness, dizziness, and ataxia ○ Advise patient to use sunscreen and where medical alert bracelet Chlordiazepoxide ( Librium) ○ Contraindicated with comatose patients with CNS depression or narrow angle glaucoma ○ Toxicity can be shown in drowsiness, dizziness, delirium tremens may occur in alcohol withdrawal patients Disopyramide (norpace) ○ Contraindicated in cardiogenic shock, second or third degree heart blocks, and sick sinus syndrome ○ Toxicity can be shown in symptoms of congestive heart failure Diazepam (Valium) ○ Contraindicated in comatose patients with CNS depression, and narrow angle glaucoma ○ Toxicity can be shown in sedation with Ataxia, dizziness, and slurred speech Digoxin ○ Contraindicated in uncontrolled ventricular arrhythmias or AV blocks ○ Side effects include anorexia, nausea, vomiting, visual disturbances, and bradycardia Doxepin ○ Contraindicated narrow angle glaucoma ○ Toxicity can be shown in sedation, fatigue, blurred vision, hypertension, dry mouth, and constipation ○ Advise patients are always wear sunscreen Glucocorticoids ○ Contraindicated in serious infections ○ Monitor patient for adrenal insufficiency, with symptoms such as hypotension, weight loss, weakness, nausea and vomiting, lethargy, confusion, and restlessness Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ○ Other serious side effects include depression or Euphoria, personality changes, hypertension, decrease wound healing, patiki eye, ecchymosis, hyperglycemia, hypoglycemia, hypernatremia, fluid retention, osteoporosis, cushions appearance via moon face and buffalo hump ○ Patient teaching ■ Monitor patient's blood sugar, b u n, and creatinine levels ■ Medication should not be abruptly discontinued, taper off over the course of two to four weeks Lithium ○ Contraindicated in severe cardiovascular renal disease, as well as dehydrated or debilitated patients ○ Toxicity can be shown in vomiting, diarrhea, slurred speech, Kris coordination, drowsiness, muscle weakness and twitching ○ Patient teaching ■ Effects will be seen within 1 to 3 weeks after the start of initial therapy ■ Maintain adequate sodium and fluid intake to avoid toxicity Lidocaine (Xylocaine) ○ Contraindicated in advanced AV block ○ Toxicity can be shown in confusion, blurred or double vision, nausea, vomiting, ringing of the ears, Tremors, convulsions, difficulty breathing, severe dizziness, and bradycardia Magnesium sulfate ○ Contraindicated in patients with hypermagnesemia, hypocalcemia, anuria, and heart block ○ Toxicity can be seen in decreased respiratory rate, bradycardia, arrhythmia, hypotension, flushing, sweating, and hypothermia ○ Patient teaching ■ Monitor neuro status before and throughout therapy and initiate seizure precautions Phenobarbital ○ Contraindicated in comatose patients with CNS depression ○ Toxicity can be seen in confusion, drowsiness, dyspnea, slurred speech, and staggering Phenytoin (Dilantin) ○ Contraindicated in science bradycardia and heart block ○ Toxicity can be seen in nystagmus, Ataxia, nausea, confusion, slurred speech, and dizziness Propranolol (Inderal) ○ Contraindicated in decompensated congestive heart failure, pulmonary edema, cardiogenic shock, bradycardia, and heart blocks ○ Toxicity can be seen in bradycardia, dizziness, drowsiness, dyspnea, bluish fingernails or palms, and seizures Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ○ Caution diabetic patients to closely monitor blood sugar levels Quinidine ○ Contraindicated in conduction defects and digitalis glycosides toxicity ○ Toxicity can be seen in tinnitus, hearing loss, visual disturbance, headache, nausea, and vomiting ○ Cardiotoxicity includes QRS widening and asystole, as well as ventricular ectopic beats, paradoxical tachycardia, and arterial embolism Salicylate ○ Contraindicated in hypersensitivity to aspirin or other salicylates, bleeding disorders, or thrombocytopenia ○ Toxicity can be seen in tinnitus, headache, hyperventilation, mental confusion, lethargy, diarrhea, and sweating Theophylline ○ Contraindicated in uncontrolled arrhythmias and hyperthyroidism ○ Toxicity can be seen in anorexia, nausea and vomiting, stomach cramps, diarrhea, confusion, headache, flushing of the skin, increased urination, insomnia, and tacky arrhythmias ○ First signs of toxicity include tachycardia, ventricular arrhythmias, and seizures Valproic acid (depakene) ○ Contraindicated in hepatic impairment ○ Toxicity can be seen in anorexia, nausea and vomiting, yellowing of the skin and eyes, fever, sore throat, weakness, facial edema, lethargy, unusual bleeding or bruising, and seizures Insulin ○ 100 units of insulin in each mL of U100 syringe ○ Regular insulin is the only one that can be given IV, is clear in color ○ NPH and lente insulin are cloudy due to zinc precipitate ○ 100 units of 70/30 insulin contains 70 units of intermediate insulin and 30 units of regular insulin ○ Regular insulin ■ Onset of 30 minutes to 1 hour ■ Peaks within two to five hours ○ NPH insulin ■ Onset of 1 to 1 1/2 hours ■ Peaks Within 4 to 12 hours ○ Lente SC ■ Insulin zinc suspension that peaks with an 8 to 12 hours ○ Both lente and NPH should be mixed by Rolling between the Palms prior to withdrawing the dose ○ Insulin can be left at room temperature for up to 4 weeks ○ Mixing insulin Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ■ Regular insulin should be withdrawn first followed by the intermediate acting insulin ■ Inject air into NPH insulin ■ Inject air into regular, short-acting insulin ■ Keep the needle and the regular insulin and draw up regular ■ Finally, draw up NPH ○ Current vials of insulin being used should not be refrigerated due to the possibility of local irritation insight ○ Always rotate sites to prevent lipodystrophy, never massage the site after injection ○ Oral anti-diabetic drugs ■ Stimulate beta cells of the pancreas to secrete more insulin and to decrease insulin resistance at receptor sites ○ Sliding scale ■ Administered based on glucose levels for short-term management ○ Interactions ■ Salicylates with insulin can cause hypoglycemia ● Complementary drug therapy ○ All has potential adverse drug interactions with normal FDA-approved drugs ○ Black cohosh ■ Contraindicated with antihypertensive medication due to increasing the effect of these medications ○ Garlic, ginger root, and Ginkgo can suppress platelets aggregation and increase the risk of bleeding for patients taking aspirin an anticoagulant such as Heparin and Warfarin Diagnostic Lab Tests and Values Overview ○ ABGs ■ Provide information necessary to manage a patient's respiratory ( ventilation) and metabolic ( Renal) acid base an electrolyte status ■ Must be sent on Ice to the lab ■ PCO is 35 to 45 ■ HCO3 is 22 to 28 ■ PO2 is 85-100 ■ O2 is 95-100% ○ PH level ■ Inversely proportional to hydrogen ion concentration ■ As hydrogen ion concentration decreases, the pH will increase ○ Alkalosis, the pH is elevated ○ Acidosis, the pH is decreased Bicarbonate measures the metabolic component of the acid base equilibrium, related to kidney and renal function Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ○ PCO2 is the measurement of ventilation capacity, the faster and more deeply want to breathe is, the more CO2 that is blown off ○ O2 saturation is an indication of percentage of hemoglobin in the oxygen ■ Tissues are well perfused when the numbers read 92% to 100% ■ Determine this by using pulse oximeter ELISA ○ Test for antibodies to HIV in serum or plasma ○ Most widely used serologic test for AIDS Western blot ○ Done if the Elisa is inconclusive, this one is highly predictive of HIV infection Cardiac catheterization ○ Done to visualize the heart chambers, arteries, and great vessels ○ After the procedure, patients should stay on bed rest for 4-8 hours ○ Assess the pulses in both extremities, watch for bleeding, hematoma, and possible absence of a pulse Direct Coombs test ○ Demonstrates if the patient’s RBCs have been attacked by antibodies against them, usually seen with Rh negative mothers Indirect Coombs test ○ Detect circulatory antibodies against RBCs CPK, Ck-MB, CP serum tests ○ Used to detect muscle injury ○ CPK is usually found in the heart muscle, skeletal muscle, and brain, and are elevated when an injury occurs to these cells ○ CK-MB isoenzyme levels are helpful in quantifying the degree of myocardial infarction Serum creatinine test and BUN ○ Used to diagnose impaired renal function ○ Elevated results indicate renal injury or disease Creatinine clearance ○ A measure of glomerular filtration rate ○ The ability of the glomeruli to act as a filter is decreased by diseases such as glomerulonephritis, acute tubular necrosis, and other primary renal diseases ○ Requires a 24-hour urine collection and a serum creatinine level as well Glucose tolerance test ○ Evaluate patient's ability to tolerate a standard oral glucose load ○ Evaluated by obtaining serum and urine specimen for glucose determinations before glucose Administration, as well as at 30 minutes, 1 Hour, 2 hours, and 4 hours after ○ Fasting should be 70-115 ○ 30 min - <200 ○ 1 hour- <200 Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ● ● ● ● ● ● ● ● ○ 2 hours- <140 ○ 3 hours- 70-115 Glycosylated hemoglobin (HBA1C) ○ Used to monitor diabetes treatment and measures the amount of glucose in the blood over the course of 100 to 120 days Barium enema ○ Series of X-ray films that visualize the colon ○ May be used to diagnose incorrect intussusception in children Cholesterol ○ Should be <200 Hemoglobin ○ A measure of the total amount of hemoglobin in the peripheral blood, reflecting the number of red blood cells in the blood ○ Decreased amount indicates anemia Hematocrit ○ Percentage of red blood cells in the total volume of blood ○ Decreased amount indicate anemia Holter monitoring ○ Continuous recording of electrical activity of the Heart by using ECG that records during unrestricted activity, rest, and sleep Intravenous pyelography ○ X-ray study that uses radiopaque contrast dye to visualize the kidneys, renal pelvis, ureters, and bladder MRI ○ Contraindicated in obese patients, confused and agitated patients, unstable patients that require continuous life support equipment, and those with implantable metal objects Pap smear ○ Used to detect neoplastic cells in a cervical and vaginal secretions ○ Should be performed yearly and women who are over 18 amd sexially active Paracentesis ○ Have the patient urinate and empty the bladder ○ Position the patient in a high Fowler position with the feet supported Partial thromboplastin (PTT) ○ Assesses the intrinsic system and common pathway of clot formation ○ Used to assess patients on heparin, their levels will be one to two times higher than normal ○ Normal level is 60- 70 seconds Prothrombin time (PT) ○ Evaluate the extrinsic system and common pathway in a clotting mechanism ○ Used to assess patients on warfarin, their levels will be one to two times the normal range Downloaded by Galen Grant (galen.grant93@gmail.com) lOMoARcPSD|18338319 ● ● ● ● ○ Normal level is 11 to 12.5 seconds Platelet count ○ Actual count of the number of platelets per cubic millimeter of blood ○ Normal level is 150-400,000 BUN ○ Blood urea nitrogen, directly related to the metabolic function of the liver and excretory function of the kidneys ○ Those with elevated levels may have renal disease or injury, as well as azotemia HCG ○ Blood test or urine test to detect HCG in the blood of a woman who might be pregnant ○ These levels will appear as early as 10 days after conception Uric acid ○ Nitrogenous compounds that is a product of purine catabolism ○ When levels are elevated, the patient may have gout Downloaded by Galen Grant (galen.grant93@gmail.com)
