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Rapid Prep NCLEX Review Course Archer Review Welcome! ● ● ● Please stay Please stay mut muted ed so tha thatt there there is no back backgro ground und nois noise. e. If you you have have a questio question n please please enter enter it in the chat chat,, or use use the the ‘raise ‘raise hand’ hand’ feature, so that I can un-mute you and you can ask your question. We will will be taking taking a 5-10 5-10 minute minute breaks breaks thro throughou ughoutt the cours course, e, and and a half half hour break for lunch. Introduction ● ● Morgan Morg an Tay aylo lorr, BSN, BSN, RN RN,, CCR CCRN N Pedi Pe diat atri ric c nu nurs rse e at he hear artt ● Uni nits ts I’v ’ve e wo work rked ed on on:: ● Current positi Current position: on: Childr Children’s en’s Reso Resource urce Unit… a little little bit of everyt everything hing pediatrics! Fun fact: fact: I got marr married ied in my my backya backyard rd this this year year because because….CO ….COVID. VID. My niece niece and nephew totally stole the show! ● ○ ○ ○ ○ ○ ○ PICU PCICU NICU Mother-Baby ED Bone Bo ne Ma Marr rrow ow Tra rans nspl plan antt Part I - Fundamentals Archer Review - NCLEX Rapid P Prep rep Lab Values Need to know NCLEX numbers! Complete Blood Count (CBC) ● Hemoglobin (Hgb) ○ ○ ● Hematocrit (Hct) ○ ○ ● 4.5-5.5 mil illlion Whi hite te Bl Bloo ood d Ce Cell lls s (WB (WBCs Cs)) ○ ● Female: 37-47% Male: 42 42-52% Red Bl Bloo ood d Ce Cell lls s (R (RBC BCs s) ○ ● Female le:: 12 12-16 g/ g/dL Male le:: 14-18 g/dL 5,000 - 10,000 Platelets ○ 150,000 - 400,000 Metabolic Panel ● ● Sodium - 135-145 Potassium - 3.5 - 5 ● ● Tot otal al pr prot otei ein n - 6. 6.2 2 - 8. 8.2 2 Albumin - 3.4 - 5.4 ● ● ● ● ● Calcium - 8.5 - -10.5 Magnesium - 1.5 - 2.5 Chloride - 95 - 105 Pho hos sph phor oru us - 2. 2.5 5 - 4. 4.5 5 Glucose 70-100 ● ● ● ● ● Bilirubin - <1 Ammonia - 15 - 45 AST - 10 - 40 ALT - 7 - 56 ALP - 40 - 120 ● ● ● BUN - 5 - 20 Crea eati tini nine ne - 0. 0.6 6-1 -1..2 GFR - >60 Coagulation Panel ● ● ● Activa Activated ted parti partial al thro thromb mbopl oplast astin in time time (aPTT) (aPTT) ○ Tests ests tthe he int intrin rinsic sic coagul coagulati ation on cas cascad cade e ○ Not Not on anti antico coag agul ulan ants ts:: 30 - 40 sec secon onds ds ○ On Hepar Heparin, in, ‘the ‘therap rapeut eutic ic aPTT’ aPTT’ is 1. 1.5-2 5-2.5x .5x norm normal. al. Proth rothro rom mbin Tim ime e ((P PT) ○ Tests ests tthe he ext extrin rinsic sic coagu coagulat lation ion cascad cascade e ○ 10 - 12 seconds In Inte tern rnat atio iona nall Norma Normaliz lized ed R Rat atio io (INR (INR)) ○ It is calcul calculated ated from a PT and is is used used to monit monitor or how how well well warfarin warfarin is working. working. ○ Not Not o on n ant antic icoa oagu gula lant nts: s: <1 ○ Taking aking war warfar farin, in, ‘th ‘thera erapeu peutic tic INR INR’’ - 2-3 Cardiac Labs ● Troponin ○ Troponins Tropon ins are a group of proteins found in skeletal and cardiac muscle fibers that regulate muscular contraction. ○ ○ ○ Test measures the level of cardiac-specific cardiac-specific troponin in the blood to help detect heart injury. Seve Severa rall ttyp ypes es of tr trop opon onin in Normal = 0-0.4 BNP ● ○ When there is fluid retention, the heart senses the need to pump harder to move fluid forward, and releases BNP. BNP. Test for CHF Normal <125 ○ ○ Lipid Panel ● ● ● ● Tot otal al ch chol oles este tero roll <20 <200 0 HDL > 60 LDL < 100 Tri rigl gly ycer erid ides es <15 150 0 Misc. ● HbA1C ○ ○ ○ Non on-d -dia iab bet etic ic:: 4-5 4-5.6 .6% % Tar arge gett leve levell for for dia diabe beti tics cs - <7 <7% % >6.5% - Diabetic ABG Interpretation Get it right, every time! Normal Values pH 7.35-7.45 Bicarbonate (HCO3) 22-28 CO2 35-45 Bicarb = BASE CO2 = ACID Step 1: Compensated or uncompensated? Uncompensated! NO! No Compensated! Is the pH normal?? 7.35-7.45 YES! Are the CO2 and HCO3 normal? Yes Normal!! Step 2: Acidotic or alkalotic? But… what if it’s compensated?! If the pH is between 7.35 and 7.45, but you have determined that the gas is compensated, it is an acidosis if the pH is <7.4 and an alkalosis if the pH is >7.4…. Essentially whatever whatever side it is closest to! Step 3: Metabolic or Respiratory? CO2 > 45 = TOO MUCH acid = acidotic < 35 = NOT ENOUGH acid = alkalotic HCO3 > 26= TOO MUCH base = alkalotic < 22 = NOT ENOUGH base = acidotic Putting it all together 1. Comp Compen ensa sate ted d or un unco comp mpen ensa sate ted d 2. Alk lkal alos osis is or ac acid idos osis is 3. Meta Me tabo boli lic c or or res respi pira rato tory ry Let’s practice together! Your our patient has the following following arterial blood gas values: Y pH 7.58 CO2 41 HCO3 38 1. pH 7.36 CO2 69 HCO3 37 Comp Co mpen ensa sate ted d or un unco comp mpen ensa sate ted? d? ○ The pH is in OUT OUT of of norma normall rangerange- this this is UNC UNCOMP OMPEN ENSA SATE TED. D. 2. Al Alk kal alos osis is or ac acid idos osis is ○ 3. The pH is is highe higherr than than 7.45 7.45 - this this is AL ALKA KALOS LOSIS. IS. Meta Me tabo boli lic c or or res respi pira rato tory ry ○ There Ther e is a high amou amount nt of HCO3, HCO3, a base, base, correla correlating ting with with our alkalos alkalosis is - this is MET METABOL ABOLIC. IC. UNCOMPENSATED METABOLIC ALKALOSIS Your our patient has the following following arterial blood gas values: Y pH 7.36 CO2 69 HCO3 37 1. pH 7.36 CO2 69 HCO3 37 Comp Co mpen ensa sate ted d or un unco comp mpen ensa sate ted? d? ○ The pH pH is in norma normall range, range, but but the CO2 CO2 and and HCO3 HCO3 are not not - this this is COMPE COMPENSA NSATED TED.. 2. Al Alk kal alos osis is or ac acid idos osis is ○ 3. The pH is norm normal al - but but close closerr to 7.35 7.35 - this this is AC ACIDO IDOSI SIS. S. Meta Me tabo boli lic c or or res respi pira rato tory ry ○ There Ther e is a high amount amount of CO2, CO2, an acid, acid, correlating correlating with with our acidosis acidosis - this this is RESPIRA RESPIRATOR TORY Y. COMPENSATED RESPIRA RESP IRATORY TORY ACIDOSIS Break Back at…. Fluids Fluid Volume Excess Causes ● ● ● ● E xce ssiv fluid id in inta take ke Pxc Oe inss taive kee flu IV flui fluid d adm admin inis istr trat atio ion n Exce Ex cess ssiv ive e so sodi dium um in inta take ke ● ● ● Kidney failure Cong Co nges esti tive ve he hear artt fa fail ilur ure e Liver failure Assessment ● ● High blo bloo od pr pressure Jugu Ju gula larr ven venou ous s dis diste tent ntio ion n ● ● ● ● Edema Weight gain Crackles Sho horrtn tnes ess s of bre rea ath Complications ● ● ● ● ● H bsloo ocdinpr pgressure Thigirhd blo pa Fluid in in th the lu lungs Dilu Di luti tion onal al Hy Hypo pona natr trem emia ia Dilu luttional anemia Nursing Interventions ● ● Monitor I&O’s Daily weight ● ● ● Diuretics Hypotonic IVF Dialysis Fluids Fluid Volume Deficit Causes Isotonic ● ● ● ● ● Hypertonic Wat ater er lo loss ss = so solu lute te lo loss ss Trauma Diarrhea Vomiting Sweating Assessment ● ● ● ● Low bl blood pr pressure Tachycardia Weak pulses Concentrated uri urine ○ ○ ● Hig igh hs sp pec ecif ific ic gr gra avi vity ty Hig igh h uri urin ne osm osmol ola ali litty Thirsty ● ● ● ● ● ● ● Wate terr los loss s > so solu lute te lo loss ss Ther Th ere e is is mor more e sol solut ute e in in the the blood and less water Cell Ce lls s ar are e “s “shr hriv ivel eled ed up up”” Polyuria DKA ESRF Seve Se vere re fl flui uid d re rest stri rict ctio ion n Hypotonic ● ● ● ● Wat ate er lo loss < so solu lute te los oss s Ther Th ere e are are le less ss so solu lute tes s in in the blood and more water Hyponatremia Cells are swollen Complications ● ● Decrea Decr ease sed d pe perf rfus usio ion n to or orga gans ns Hypovole lem mic sh shock ● MODS Nursing Interventions ● ● ● ● Strict I& I&O’s Monitor BP BP and HR HR Daily weight IV fluids ○ ○ ○ Isotonic Isoton ic deh dehydr ydrat ation ion - give give iso isoton tonic ic IV IVF F Hypoto Hyp otonic nic deh dehydr ydrat ation ion - hive hive hyp hypert erton onic ic IVF IVF ■ Wi Will ll hel help p pull pull wat water er out out of of swol swolle len n cell cells s Hypert Hyp erton onic ic deh dehydr ydrat ation ion - give give hyp hypoto otonic nic IVF ■ Wil Willl help help mo move ve wa water ter int into o shri shrivel veled ed up cel cells ls IV Fluids Must know types and uses! Isotonic IV Fluids IV fluid with osmolarity similar to blood. Does NOT cause a shift in fluid. ● ● ● 0.9& Sod 0.9& Sodiu ium m Chl Chlor orid ide e (Nor (Norma mall Salin Saline) e) Lac acta tate ted d Rin Ringe gerrs (LR (LR)) D5W Uses ● ● Increa Incr ease se th the e intr intrav avas ascu cula larr vol volum ume e Blood loss ● ● ● ● ● Surgery Iso soto toni nic c deh dehy ydr drat atio ion n Fluid loss Maintenance fl fluids Patients wh who ar are NP NPO Hypotonic IV Fluids IV fluid with osmolarity lower than blood. Moves fluid out of blood vessels into cells and interstitial spaces. ● ● ● 0.45% Sodium Chloride (½ Normal Saline) 0.33% or 0.2% Sodium Chloride 2.5% Dextrose in Water (D2.5W) Uses ● ● DKA HHNS ● Hypernatremia Hypertonic IV Fluids IV fluid with osmolarity higher than blood. Moves fluid out of cells and interstitial spaces and into blood vessels. ● ● ● ● 1.5%, 3% 3%,, or 5% Sodium Chloride D5NS D5LR D10W Uses ● ● Hyponatremia Cerebral edema Hyponatremia Fluids and electrolytes Definition Low sodium level in the blood. Sodium - Na+ ● ● ● ● The most The most abu abund ndan antt extr extrac acel ellu lula larr cati cation on Regu Re gula late tes s wat water er in in the the cel cells ls of of the the body body Wate terr fo foll llow ows s sod sodiu ium m Sod odiu ium m is is im impo port rta ant in in:: ○ ○ ○ The brain Nerves Muscle cells Lab Values Normal sodium: 135 - 145 mEq/L Less than 135 mEq/L is considered hyponatremic Euvolemic hyponatremia Water in the body increases, but the sodium level stays the same. Causes: ● ● ● ● ● SIADH Adr dre ena nall ins insuf ufffic icie ien ncy Addison’s di disease Polydipsia Exce Ex cess ssiv ive e hy hypo poto toni nic c IV IVF F Hypovolemic hyponatremia Water and sodium are both lost. Causes: ● ● ● ● ● ● Vomiting Diarrhea NG suction Diuretics Burns Exc xce ess ssiv ive e sw swea eati ting ng Hypervolemic hyponatremia Water in the body increases, which dilutes the amount of sodium in the serum causing a ‘dilutional’ or ‘relative’ hyponatremia. hyponatremia. Causes: ● ● ● ● ● ● ● ● CHF Kidney failure Nep eph hro roti tic c synd ndrrom ome e Liver failure Wate terr in into tox xic icat atio ion n Fres eshw hwat ate er subm subme ers rsio ion n Psyc Ps ycho hoge geni nic c po poly lydi dips psia ia Excess Exc essive ive IV admi adminis nistra tratio tion n of hyp hypoto otonic nic flu fluids ids Assessment Neuro ● ● ● ● ● ● Musculoskeletal CV Seizures ● Confusion Lethargy Stupor Cerebral edema ● Increased ICP Hypovolemia ○ ○ ○ ○ Weak pulse Weak Tachycardia Hypotension Dizziness Hypervolemia ○ ○ Bounding pulses Hypertension ● ● ● ● ● ● Abdominal cramps Weakness Sha Sh all llow ow res espi pirrat atio ion ns Decr De crea ease sed d de deep ep te tend ndon on re refl flex exes es Muscle spasms Orth Or thos osta tati tic c hyp hypot oten ensi sion on GI/GU ● ● Decreased UOP Loss of ap appetite ● Hype Hy pera ract ctiv ive e bow bowel el so soun unds ds Treatment hyponatremia a Hypovolemic hyponatremi ● ● ● Must re Must rest stor ore e vol volum ume e AN AND D sod sodiu ium m Mil ild d - 0.9 0.9% % NS NS (is (isot oton onic ic)) Seve Se vere re - 3% 3% NS NS (hy (hype pert rton onic ic)) Hypervolemic hyponatrem hyponatremia ia ● ● ● Euvolemic hyponatrem hyponatremia ia ● ● ● ● ● Res estr tric ictt fr free ee wa watter Demeclocycline Tolvaptan Sodium ta tablets Enco En cour urag age e hig high h sal saltt foo foods ds Restri Rest rict ct fr free ee wa wate terr int intak ake e Osmotic di diuretic ics s Avoi oid d hig high h sa salt fo foo ods Replacing sodium ● ● ● Replace sodium slowly Replace 0.5 mEq/hr Changing the sodium level too quickly causes fluid shifts ○ Cerebral edema ○ Central pontine Myelinolysis (CPM) ■ Monitor for numbness and weakness in the feet! Nursing interventions ● ● ● ● Enco En cour urag age e incr increa ease sed d oral oral sod sodiu ium m inta intake ke ○ Bacon ○ ○ ○ ○ ○ ○ ○ Butter Canned food Cheese Hot dogs Lunch meat Processed food Table salt Someti Some time mes s sodi sodium um tab table lets ts pre presc scri ribe bed d Moni Mo nito torr lith lithiu ium m leve levels ls if ap appl plic icab able le Mon onit ito or neu neurro st stat atus us!! NCLEX Question The nurse is findings caring for a patient with a sodium of apply. 122 mEq/L. Which of the following assessment does she suspect? Select level all that a. b. c. d. Confusion Abdominal cr cramp mps s Incr In crea ease sed d ur urin ine e out outpu putt Hypo Hy poac acti tive ve bo bowe well sou sound nds s Answer: A and B A is correct. A sodium level of less than 135 mEq/L is indicative of hyponatremia - too little sodium in the blood. When sodium falls below 125 mEq/L, it is considered "severe" hyponatremia. Confusion is a common neurological symptom of acute or severe hyponatremia. Sodium plays a very important role in the brain, and low levels of this electrolyte can be devastating producing symptoms ranging from confusion, lethargy, and stupor, to seizures and cerebral edema B is correct. Abdominal cramps is another symptom of hyponatremia. Because water follows sodium, sodium, when there are decreased levels of sodium in the blood there is decreased fluid. This creased a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping. C is incorrect. Increased urine output is not a sign of hyponatremia. Decreased urine output rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. This is due to the relationship of sodium with water. With decreased levels of sodium, less water is pulled pu lled into the extracellular space and the intravascular volume is decreased causing decreased renal blood flow and therefore decreased urine output. D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium plays an important role in muscle cells as well, and when levels are too low there is cramping, spasms, and hyperactive bowel sounds. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Hypernatremia Fluids and electrolytes Definition High sodium level in the blood. Sodium - Na+ ● ● ● ● The most The most abu abund ndan antt extr extrac acel ellu lula larr cati cation on Regu Re gula late tes s wat water er in in the the cel cells ls of of the the body body Wate terr fo foll llow ows s sod sodiu ium m Sod odiu ium m is is im impo port rta ant in in:: ○ ○ ○ The brain Nerves Muscle cells Lab Values Normal sodium: 135 - 145 mEq/L Greater than 145 mEq/L is considered hypernatremic Causes Hypervolemic hypernatremia a Hypovolemic hypernatremia Hypervolemic hypernatremi Water deficit Sodium gains > water gains ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● Hypertonic IVF ○ (⅕%, 3%, 5%) Sodi So dium um bi bica carb rbo ona nate te administration Incr In crea ease sed d so sodi dium um in inta take ke Corticosteroids Cushing’s Hyp ype era rald ldos oste tero roni nism sm Conn’s Sy Syndrome Insu In suff ffic icie ient nt fr free ee wa wate terr wi with th enteral tube feeds Sodium deficit Dehydration NPO Diarrhea Vomiting V omiting Fistulas Osmotic diuretics Post-obstructive diuresis Euvolemic hypernatremic ● Inc ncre reas ased ed in insen ens sib ible le water loss ○ ● ● Hyperventila lattion Central DI Nephrogenic DI The loss of fluids leads to a relative increase in the amount of Na+ in the blood. Assessment Neuro ● ● ● ● ● ● Restless Agitated Lethargic Drowsy Stupor Coma Musculoskeletal ● ● ● Twitching Cramps Weakness CV ● ● ● ● Fever Edema +/- BP Weak W eak - bounding pulses Other ● ● Flushed skin Decreased UOP ● Dry mouth Assessment findings depend on the type of hypernatremia volume status is important! Treatment Hypervolemic hypernatremia Hypovolemic hypernatremia ● ● ● Find th Find the e cau causa sati tive ve ag agen entt ● and discontinue ○ 3% ad administration? ○ Ald ldos oste terron one e ex exc ces ess s? Loop diuretics Free Fr ee wa wate terr adm admin inis istr trat atio ion n Euvolemic hypernatremic Isotonic fluid administration ● Free water “relatively ely ○ NS is “relativ administration hypotonic” to the body ○ Based on the free in hypernatremia. water deficit ● PO in inttak ake e be bett tter er tha han n IV because patient is euvolemic Monitor neuro status Correct imbalance SLOWLY - Risk for cerebral edema NCLEX Question The nurse is caring for a patient whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms does she suspect are caused by the patient’s sodium level? Select all that apply. a. b. c. d. Lethargy Dry Dr y mu muco cous us me memb mbra ran nes Tachypnea Cyanosis Answer: A and B A is correct. Sodium plays a very important role in the brain, and imbalances in the serum sodium level can cause major neurological changes. The patient who is hypernatremic, or has a sodium level greater than 145 mEq/L is at risk for changes in their level of consciousness ranging from restlessness and agitation to lethargy, stupor, and coma. B is correct. The patient who has a high sodium level, greater than 145 mEq/L will have dry mucous membranes. This is due to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes the dry mouth and mucous membranes. C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very important role in the brain and nerves as well as water balance. The major symptoms to monitor for will be neurological, not respiratory. D is incorrect. Cyanosis, or a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but will not result in cyanosis. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult H ealth Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Hyperkalemia Fluids and electrolytes Definition High potassium level in the blood. Potassium ● ● ● ● ● Found mostly Found mostly insid inside e the the cells cells - most most abund abundant ant intra intracellu cellular lar catio cation. n. Normal Norm al value value is for seru serum m level level - the potass potassium ium in in the blood blood,, outside outside of the the cells. Respon Res ponsib sible le for ner nerve ve imp impuls ulse e con conduc ductio tion n Important Impo rtant in muscl muscle e contrac contraction tion - heart heart musc muscle le and and skele skeletal tal muscle muscle.. Impo Im port rtan antt in ac acid id-b -bas ase e ba bala lanc nce e ○ Aci cido doti tic c → inc incre rea ase sed d K+ K+ Lab Values Normal potassium: 3.5 - 5.0 Greater than 5.0 is considered hyperkalemic. Causes ● ● ● ● ● ● ● ● ● ● Too much much potas potassium sium move moved d from from intrac intracellula ellularr to extr extracell acellular ular ○ Burns ○ Tissue da damage Adr dre ena nall ins insuf ufffic icie ien ncy Renal failure Dehydration Excessive K+ K+ in intake Acidosis Dia iabe bettic ke keto toa aci cido dos sis ACE in inhibitors NSAIDS Pota Po tass ssiu iumm-sp spar arin ing g di diur uret etic ics s Assessment ● ● ● ● ● ● Muscle we weakness Muscle tw twitches Numbness Cramping Shallo Sha llow w res respir pirati ations ons → resp respira irator tory y fail failure ure Imp mpa air ired ed con contr trac acti tili lity ty ○ ○ ○ Weak pulses Bradycardia Hypotension ● ● Decreased UOP Hype Hy pera ract ctiv ive e bo bowe well sou sound nds s ● ● Diarrhea EKG CHANGES EKG Changes ● ● ● ● ● Wide, flat P waves Prol Pr olon ong ged PR in inte terrval Wide Wi dene ned d QRS in inte terv rval al Dep eprres ess sed ST seg egm men entt Tal all, l, pe peak aked ed T wav aves es Can lead to heart block, asystole, or V-fib Treatment Interventions depend on severity of hyperkalemia and the symptoms present ● ● ● MONIT MONI TOR CAR CARDI DIAC AC RH RHYT YTHM HM Also Al so wat watch ch the the res respi pira rato tory ry,, rena renal, l, and GI complications Disc Di scon onti tinu nue e any any pot potas assi sium um supplements ○ ○ ● ● Given Give n if EK EKG G cha chang nges es ar are e pre prese sent nt to protect the myocardium Drive potassium into cells ○ ○ ○ ● ● D5W + regular insulin Albuterol Bicarbonate Reduce Red uce total body potassium ○ ○ IV potassium PO supplements Potass Pota ssiu ium m res restr tric icte ted d die diett IV Ca Calc lciu ium m glu gluco cona nate te or ch chlo lori ride de ○ ● Kayexalate Diuretics ■ Hydrochlorothiazide ■ Lasix Dialysis ○ Used when severe hyperkalemia is not responding to other interventions NCLEX Question The nurse is evaluating her patient’s lab results and notes that the potassium is 5.5 mEq/L. She reviews the telemetry monitor, looking for which of the following signs? Select all that apply. a. b. c. d. Inverted T waves Wide Wi den ned QRS in inte terv rval al Tall ll,, pea peake ked d T wa wave ves s Prominent UU-wa wave ves s Answer: B and C A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia. In hyperkalemia, there are Tall, peaked T waves. Inverted T waves is a sign of hypokalemia. B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes patients may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST segment, and tall, peaked T waves. C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a very common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart block, ventricular fibrillation, or even asystole if left untreated. D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This patient is experiencing hyperkalemia. Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult H ealth Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Hypokalemia Fluids and electrolytes Definition Low potassium level in the blood. Potassium ● ● ● ● ● Found mostly Found mostly insid inside e the the cells cells - most most abund abundant ant intra intracellu cellular lar catio cation. n. Normal Norm al value value is for seru serum m level level - the potass potassium ium in in the blood blood,, outside outside of the the cells. Respon Res ponsib sible le for ner nerve ve imp impuls ulse e con conduc ductio tion n Important Impo rtant in muscl muscle e contrac contraction tion - heart heart musc muscle le and and skele skeletal tal muscle muscle.. Impo Im port rtan antt in ac acid id-b -bas ase e ba bala lanc nce e ○ Aci cido doti tic c → inc incre rea ase sed d K+ K+ Lab Values Normal potassium: 3.5 - 5.0 Less than 3.5 is considered considered hypokalemic. hypokalemic. Causes ● ● Loop diuretics Laxatives ● ● ● ● ● Glucocortic ico oid ids s Pota Po tass ssiu ium m de defi fici cien entt di diet et Polydipsia Cus ushi hing ng’’s synd ndro rome me NGT suction ● ● ● ● ● ● Assessment ● Decr De crea ease sed d dee deep p te tend ndon on re refl flex exes es ● ● ● ● ● ● ● ● ● ● Weakness Flaccidity Shal Sh allo low w res espi pirrat atio ions ns Conf Co nfus usio ion n → Le Lettha harrgy Decreased LO LOC Orth Or thos osta tati tic c hyp hypot oten ensi sion on Wea eak, k, th thrrea eady dy pu puls lse e Polyuria Constipation Nausea/vomiting ● ● Decrea Decr eas sed bow bowel el sou soun nds Card Ca rdia iac c dys dysrh rhyt ythm hmia ias s Vomiting Vomiting Diarrhea Wound W ound drainage Sweating Alkalosis Hyperinsulinism EKG Changes ● ● ● ● ● Slight Slig htly ly pr prol olon onge ged d PR in inte terv rval al Slig Sl ight htly ly pe peak aked ed P wav wave e ST depression Flat Fl at/s /sha hallo llow/ w/in inve vert rted ed T wa wave ves s Prominent uu-waves Treatment ● ● ● Place Plac e on on car cardi diac ac te tele leme metr try y Moni Mo nito torr resp respir irat ator ory y and and ren renal al sta statu tus s Moni Mo nito torr oth other er el elec ectr trol olyt ytes es ○ ● ● ● ● Hold lasix Hold lasix or oth other er pot potass assium ium was wastin ting g drug drugs s Hold digoxin Die iett ric rich h in in pot pota ass ssiu ium m Oral Or al pot potas assi sium um sup suppl plem emen ents ts ○ ● Magnesium Magn esium,, sodium sodium,, calcium calcium,, and and glucos glucose e are are all all inter-r inter-relate elated! d! Give Gi ve wi with th fo food od to pr prev even entt GI GI ups upset et IV po pota tass ssiu ium m sup suppl plem emen ents ts IV potassium supplement administration ● ● NEVER GIVE IV PUSH Give Giv e acc accord ording ing to ins instru tructi ctions ons;; SLO SLOWL WLY Y ● Moni Mo nito torr IV sit site e very very ca care refu full lly y ○ ○ Can ca cau use ph phle leb bit itis is If extr extrava avasat sation ion occ occurs urs wil willl cause cause tis tissue sue da damag mage e NCLEX Question The nurse is reviewing her patient assignment for the shift and has each of the following patients. Which patient is most at risk for f or hypokalemia? a. b. c. d. A pat patie ient nt with with hype hypere reme mesi sis s gravi gravida daru rum m A pa pati tien entt in in ren renal al fa fail ilur ure e A pa pati tien entt in di diab abet etic ic ket ketoa oaci cido dosi sis s A pa pati tien entt wit with h thi third rd de degr gree ee bu burn rns s Answer: A pregna ncy complication that is characterized by severe nausea, vomiting, A is correct. Hyperemesis gravidarum is a pregnancy weight loss, and possibly dehydration. The intense vomiting is why this condition puts the patient at risk for hypokalemia. Gastrointestinal fluids are rich in potassium, and any patient losing large amounts of their stomach acid will be at risk for hypokalemia. This could include vomiting, NG tube suctioning, or diarrhea. B is incorrect. A patient innormally renal failure will be at risk hyperkalemi hyperkalemia, not hypokalemia. Theleading kidneystowill kidneys be unable to excrete potassium as they do, and there will for be a build up ofa, potassium in the blood hyperkalemia. C is incorrect. A patient in diabetic ketoacidosis will be at risk for hyperkalemia, not hypokalemia. hypokalemia. When a patient is in diabetic ketoacidosis (DKA) glucose is unable to be transported into cells due to the lack of insulin. The body resorts to breaking down fat cells for energy, which produce ketones and drive the blood pH down. Due to the acidity and high glucose content of the blood, fluid and potassium are driven out of the cells and into the blood, causing hyperkalemia. If the patient was experiencing an alkalosis, they would wo uld be at risk for hypokalemia. D is incorrect. A patient with third degree burns will be at risk for hyperkalemia, hyperkalemia, not hypokalemia. Burns destroy tissue and lyse cells, causing large amounts of intracellular potassium p otassium to be released into the vascular space therefore causing hyperkalemia. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult H ealth Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Hypercalcemia Fluids and electrolytes Definition High level of calcium in the blood. Calcium ● ● ● ● ● Stored in the Stored the bones, bones, absorb absorbed ed in the the GI syst system, em, and and excret excreted ed by the kidney kidneys s Plays Pla ys an impo importa rtant nt role role in bones bones,, teeth, teeth, neve neves, s, and and muscle muscles s Impo Im port rtan antt for for co coag agul ulat atio ion n Is co cont ntro rolllled ed by PT PTH H and and Vi Vita tami min nD Has an inv invers erse e rela relatio tionsh nship ip with with Pho Phosph sphoru orus s Lab Values Normal calcium: 8.4 - 10.2 A calcium level greater than 10.2 is considered hypercalcemia. Causes ● ● ● ● ● ● ● ● ● Hype perrpa para ratthy hyro roid idis ism m Cancer of of th the bo bones Thiazide di diuretics Renal failure Vitamin D toxic iciity Exce Ex cess ssiv ive e inta intake ke of of calc calciu ium m Exce Ex cess ssiv ive e in inta take ke of Vi Vita tami min nD Glucocortic ico oid ids s Immobility Assessment Neuromuscular ● ● ● Weakness Flaccidity Decreased deep tendon reflexes Cardiovascular ● ● ● Bradycardia Cyanosis Deep vein thrombosis Gastrointestinal ● ● ● Fatigue ● ● ● ● ● Decreased LOC ● Neuro Decreased peristalsis Hypoactive bowel sounds Abdominal pa pain Nausea Vomiting Constipation Kidney stones EKG Changes Shortened QT interval Prolonged PR interval Treatment ● ● ● ● ● ● ● Enc ncou ourrag age e PO PO hy hydr drat atio ion n IV flu fluid ids s - NS pre prefe ferrre red d Redu Re duce ce di diet etar ary y int intak ake e of of cal calci cium um Loop di diuretics Calcium binders Cortic Cor ticost ostero eroids ids - usef useful ul when when the the cause cause is Vita Vitamin min D toxi toxicit city y Calc Ca lciu ium m rea reabs bsor orpt ptio ion n inh inhib ibit itor ors s ○ ○ ○ ○ ● ● Phosphorus Calcitonin Bispho Bis phosph sphona onates tes - Espec Especial ially ly useful useful if the the cause cause is is malign malignanc ancy y NSAIDS Dialysis Cardiac mo monitoring NCLEX Question patient who has a serum calcium level of The nurse is caring for a patient of 13.2 mg/dL. Which of the following medications does she expect to administer? Select all that apply apply.. a. b. c. d. Phosphorus Calcitonin Vitamin D IV cal alc ciu ium m glu gluco cona nate te Answer: A and B A is correct. The normal serum calcium level is 8.4-10.2 mg/dL. This patient has a high serum calcium level, or hypercalcemia. Phosphorus is a medication the nurse n urse would expect to administer to treat hypercalcemia. Phosphorus and calcium have an inverse relationship, so by increasing the serum level of phosphorus the nurse can decrease the serum level of calcium. Oral phosphate is the preferred method of administering phosphorus. If given IV, IV, Calcium Phosphate forms and precipitates in the tissues. This “precipitation phenomenon” reduces serum calcium levels very quickly. B is correct. Calcitonin is a medication the nurse nu rse would expect to administer to treat hypercalcemia. Calcitonin is a thyroid hormone that decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration. C is incorrect. Vitamin D should be avoided in hypercalcemia. Vitamin D enhances the absorption of calcium and can therefore increase the level of serum calcium, which we do not want to do when the patient’s level is already high. D is incorrect. IV calcium gluconate is given to patients that are hypocalcemic, not hypercalcemic. It can treat the tetany that occurs when a patient is severely hypocalcemic. It can also be given to protect the cardiac muscle if a patient has severe hyperkalemia or hypermagnesemia. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Break Back at…. Hypocalcemia Fluids and electrolytes Definition Low level of calcium in the blood. Calcium ● ● ● ● ● Stored in the Stored the bones, bones, absorb absorbed ed in the the GI syst system, em, and and excret excreted ed by the kidney kidneys s Plays Pla ys an an impor importan tantt role role in bon bones, es, nev neves es,, and and musc muscles les Impo Im port rtan antt for for co coag agul ulat atio ion n Is co cont ntro rolllled ed by PT PTH H and and Vi Vita tami min nD Has an inv invers erse e rela relatio tionsh nship ip with with Pho Phosph sphoru orus s Lab Values Normal calcium: 8.4 - 10.2 A calcium level less than 8.4 is considered hypocalcemia. Causes ● ● ● ● Renal failure Acute pa pancreatit itis is Malnutrition Malabsorption ○ ○ ● ● ● ● ● Celiac disease Crohn’s di disease Alcoholism Bulimia Vit ita ami min n D def efic icie ienc ncy y Hypo pop par arat athy hyrroi oidi dis sm Hyperphosphatemia Assessment Neuromuscular ● ● ● ● ● ● ● Irritability Paresthesias Tetany Muscle spasms Seizures Chvostek’s si sign Trousseau’s sign Cardiovascular ● ● ● ● Decreased contractility Bradycardia Hypotension Weak pulse Gastrointestinal ● ● ● Hyperactive bowel sounds Cramping Diarrhea EKG Changes Prolonged ST segment Prolonged QT interval Treatment ● PO cal calc ciu ium m su supp pple lem men entts ● ● ● ● IV cal calc ciu ium m su supp pple lem men entts Muscle relaxants Decreased st stimuli Calcium rich die diett ○ ○ Admini Admi nist ster er wi with th Vit itam amin in D Incr In cre eas ase es ab abso sorp rpti tio on NCLEX Question The nurse is reviewing her patients laboratory findings and notes that one of her patients has a serum calcium level of 7.2 mg/dL. She knows that of each of the following patients, which ones are most likely to have this result? Select all that apply. apply. a. b. c. d. e. The pat patien ientt with with brea breast st cance cancerr and and bone bone meta metasta stases ses The Th e pa pati tien entt wit with h ob obes esit ity y The Th e pat patie ient nt wit with h Vit Vitam amin in D toxi toxici city ty The Th e pati patien entt with with hyp hypop opar arat athy hyro roid idis ism m Pati Pa tien entt wit with h chr chron onic ic ren renal al fa fail ilur ure e Answer: D and E A is incorrect. The patient with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to bone destruction from osteoclasts and the leak of calcium into blood. In addition, malignancies often cause "paraneoplastic hypercalcemia" by secreting substances called "PTH-related peptides" that have actions similar to Parathormone ( PTH). B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in celiac and crohn’s disease patients, can cause hypocalcemia due to decreased absorption, but obesity would not cause this. C is incorrect. The patient with Vitamin D toxicity would put a patient at risk for hypercalcemia, or a serum calcium level greater than 10.2 mg/dL. This is due to the relationship between Vitamin D and calcium; Vitamin D enhances the absorption of calcium. Therefore, Vitamin D toxicity would lead to increased absorption of calcium and a hypercalcemic state. D is correct. The patient with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 8.4-10.2 mg/dL, so with this patient’s level of 7.2 they have too little calcium in the blood. The patient who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels, or hypocalcemia. E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for hypocalcemia in kidney disease: increased phosphorus and a nd decreased renal production of activated Vitamin D (1,25 Dihydroxy vitamin D). Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues and bones, causing hypocalcemia. The kidney is responsible for activating Vitamin D and restoring calcium balance. In the setting of renal diseases, one loses the capacity to activate vitamin D and calcium level drops. For these reasons, physicians often order phosphate binders to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/ ESRD. NCSBNClientNeed: Topic:Physiological Integrity Subtopic:Risk potentialreduction Reference: Cooper,K.,& , K.,& Gosnell,K.(2019). l ,K.(2019). Study Guide forFoundations andAd ultHealth Nursing-E-Book.Elsevier HealthSciences. Subject: Fundamentals ofcare Lesson: Fluids &Electrolytes Hypermagnesemia Fluids and Electrolytes Definition High level of magnesium in the blood Magnesium ● ● ● ● ● ● Stored Stor ed in th the e bon bones es an and d car carti tila lage ge Plays Pla ys a major major rol role e in sk skele eletal tal mus muscle cle con contra tracti ction on Impo Im port rtan antt for for ATP fo form rmat atio ion n Activ iva ates vi vitamins Nece Ne cess ssar ary y fo forr ce cellu llula larr gr grow owth th Is di dire rect ctly ly re rela late ted d to ca calc lciu ium m Lab Values Normal magnesium: 1.6-2.6 mg/dL A magnesium level over over 2.6 mg/dL is considered hypermagnesemia. hypermagnesemia. Causes ● ● ● ● Excess Exce ssiv ive e di diet etar ary y in inta take ke Too many many mag magnes nesium ium co conta ntaini ining ng medi medicat cation ions s Over Ov er-c -cor orre rect ctio ion n of hypo hypoma magn gnes esem emia ia Renal fa failure Assessment Neuromuscular ● ● ● ● Weakness Shallow breathing Slo low wed reflexes Decreased deep tendon reflexes Cardiovascular ● ● ● ● Bradycardia Hypotension Vasodilation Cardiac ar arrest Neuro ● ● ● Drowsy Lethargy Coma EKG Changes Flat P wave Prolonged PR interval Widened QRS complex Tall T wave Treatment ● ● ● ● ● Treat the cause Hold Ho ld any any flu fluid ids s or or meds meds co cont ntai aini ning ng Mag Mag Loop diuretics Calcium gluconate Dialysis NCLEX Question The nurse is caring for a patient with a serum magnesium level of 3.2 mg/dL. She knows that which of the following could have caused this electrolyte abnormality? Select all that t hat apply. apply. a. b. c. d. Renal failure Alcoholism Anorexia Diarrhea Answer: A A is correct. The normal magnesium level is 1.6-2.6 mg/dL. This patient has a level of 3.2, and is experiencing hypermagnesemia. Renal failure can cause hypermagnesemia due to the fact that the process that keeps the levels of magnesium in the body at normal levels does not work properly in people with kidney dysfunction. B is incorrect. Alcoholism is a risk factor factor for hypomagnesemia, and this patient has hypermagnesemia. Hypomagnesemia is the most common electrolyte abnormality observed in alcoholic patients. There is a loss of magnesium from tissues and increased urinary loss, and chronic alcohol abuse depletes the total body supply of magnesium. C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. This is due to malnutrition and a lack of dietary intake of magnesium. D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this patient has hypermagnesemia. Magnesium is absorbed in the GI tract, and with diarrhea there is decreased absorption of magnesium leading to hypomagnesemia. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Hypomagnesemia Fluids and Electrolytes Definition Low level of magnesium in the blood Magnesium ● ● ● ● ● Stored Stor ed in th the e bon bones es an and d car carti tila lage ge Plays Pla ys a major major rol role e in sk skele eletal tal mus muscle cle con contra tracti ction on Impo Im port rtan antt for for ATP fo form rmat atio ion n Activ iva ates vi vitamins Nece Ne cess ssar ary y fo forr ce cellu llula larr gr grow owth th ● Is di dire rect ctly ly re rela late ted d to ca calc lciu ium m Lab Values Normal magnesium: 1.6-2.6 mg/dL A magnesium level less than 1.6 mg/dL is considered hypomagnesemic. hypomagnesemic. Causes ● ● ● ● ● ● Alcoholism Malnutrition Malabsorption Hypo pop par arat athy hyrroi oidi dis sm Hypocalcemia Diarrhea Assessment Neuromuscular ● ● ● ● ● Neuro Numbness Tingling Tetany Seizures Increased de deep tendon reflexes EKG Changes Prolonged QT interval Flattened T wave ● ● Psychosis Confusion Gastrointestinal ● ● ● Decreased motility Constipation Anorexia Treatment ● Treat the cause ○ ● ● Stop Sto p diuret diuretics ics,, amino aminogly glycos coside ides, s, phosp phosphor horus… us….. .. Mon onit ito or ca card rdia iac c rh rhyt ythm hm Adm dmin inis iste terr mag magn nes esiu ium m ○ ○ PO - Mag Magne nesi sium um hy hydr drox oxid ide e IV - giv given en ve very ry sl slo owly NCLEX Question The nurse is caring for a patient with a magnesium level of 1.1 mg/dL. Which of the following signs and symptoms does she closely monitor for? Select all that apply. a. b. c. d. Diarrhea Psychosis Tetany Decr De crea ease sed d dee deep p ten tendo don n ref refle lexe xes s Answer: B and C A is incorrect. While diarrhea can be an initial cause of hypomagnesemia, it is not an assessment finding indicative of magnesium levels already low. Once the patient has low magnesium levels, they have decreased GI motility leading to constipation, not diarrhea. B is correct. Psychosis is an assessment finding consistent with hypomagnesemia. This patient’s magnesium level is below normal, 1.6-2.6 mg/dL, therefore the nurse will need to monitor for potential signs and symptoms of hypomagnesemia. From a neurological perspective pe rspective this can range from confusion to psychosis. C is correct. Tetany is another assessment finding consistent with hypomagnesemia for which the nurse should monitor. Other neuromuscular assessment findings consistent with hypomagnesemia include numbness, numbne ss, tingling, seizures, and increased deep tendon reflexes. D is incorrect. Decreased deep tendon reflexes is not an assessment finding consistent with hypomagnesemia, rather increased deep tendon reflexes r eflexes would be. Remember, Magnesium calms the body, so when there are low levels of it the patient will be excitable - seizures, increased reflexes, and psychosis can occur. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Hyperphosphatemia Fluids and Electrolytes Definition High level of phosphorus in the blood. Phosphorus ● ● ● ● Major role is in in cellular cellular metab metabolism olism and ener energy gy produ production ction (A (ATP) TP) Makes Mak es up up the the phosp phosphol holipi ipid d bilay bilayer er of of cell cell membr membrane anes s Larg La rge e com compo pone nent nt of bo bone nes s and and te teet eth h Has an inv invers erse e rela relatio tionsh nship ip wit with h Calc Calcium ium Lab Values Normal phosphorus: 3.0-4.5 mg/dL A phosphorus level above above 4.5 mg/dL is considered hyperphosphatemic. Causes ● ● ● ● Renal fa failure Tum umor or ly lys sis synd ndro rom me Exce Ex cess ssiv ive e diet dietar ary y inta intake ke of of phos phosph phor orus us Hypo Hy popa para rath thyr yroi oidi dism sm → Hy Hypo poca calc lcem emia ia Assessment Not very common! Doesn’t produce many symptoms. Symptoms are related to the hypocalcemia secondary to hyperphosphatemia. Neuromuscular Cardiovascular ● ● ● ● Numbness Tingling Tetany Muscle spasms ● ● ● Decreased contractility Bradycardia Hypotension ● ● ● Seizures Chvostek’s si sign Trousseau’s si sign ● Weak pulse Gastrointestinal ● ● ● Hyperactive bowel sounds Cramping Diarrhea Treatment ● Phosphate binders ○ ● Given with food Man ana age hypo poc cal alc cem emia ia NCLEX Question The nurse is caring for a patient with a phosphorus level of 5.0 mg/dL. She knows that which of the following are possible causes of this condition? a. b. c. d. Tum umor or ly lysi sis s syn synd dro rom me Hyp Hy pop opa ara rath thyr yroi oid dis ism m Hypercalcemia Renal fa failure Answer: A, B, and D A is correct. This patient has a phosphorus level of 5.0, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including phosphorus) are spilled out into the blood causing an increase in their serum levels . B is correct. Hypoparathyroidism is a cause of hyperphosphatemia. The patient who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels, or hypocalcemia. Because calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus. Thus, hypoparathyroidism causes hyperphosphatemia. C is incorrect. Hypercalcemia is a cause of hypophosphatemia hypophosphatemia.. This patient has a phosphorus level of 5.0, which is greater than the normal 3.0-4.5 mg/dL, not less than. Phosphorus and calcium have an inverse relationship, when there are high levels of calcium there are ar e low levels of phosphorus. Thus, hypercalcemia would wou ld cause hypophosphatemia. D is correct. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be excreted as readily as it normally would and increased levels of phosphorus build up in the blood causing hyperphosphatemia. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Hypophosphatemia Fluids and Electrolytes Definition Low level of phosphorus in the blood. Phosphorus ● ● ● ● Major role is in in cellular cellular metab metabolism olism and ener energy gy produ production ction (A (ATP) TP) Makes Mak es up up the the phosp phosphol holipi ipid d bilay bilayer er of of cell cell membr membrane anes s Larg La rge e com compo pone nent nt of bo bone nes s and and te teet eth h Has an inv invers erse e rela relatio tionsh nship ip wit with h Calc Calcium ium Lab values Normal phosphorus: 3.0-4.5 mg/dL A phosphorus level below below 3.0 mg/dL is considered hypophosphatemic. Causes ● ● ● ● ● ● ● Malnutrition Starvation TPN Ref efe eed edin ing g synd ndrrom ome e Hype Hy perp rpar arat athy hyro roid idis ism m → hy hype perc rcal alce cemi mia a Alcoholism Renal fa failure Assessment Musculoskeletal ● ● ● ● Weakness Rhabdomyolysi s Decreased bone density Fractures Cardiovascular ● ● ● ● Decreased stroke volume Decreased cardiac output Weak pulses Hypotension Neuro ● ● ● Irritability Seizures Coma Treatment ● ● Treat the cause Stop St op dru drugs gs tha thatt decr decrea ease se pho phosp spho horu rus s ○ ○ ○ ● Phos Ph osph phor orus us re repl plac acem emen entt ○ ○ ● ● Antacids Calcium Osmotic di diuretic ics s PO IV - given slowly Pho hos sph phor oru us ric rich h die diett Diet lo low in in ca calc lciium ○ No da dair iry y, de decr crea ease sed d gr gree eens ns.. NCLEX Question The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. Which of the following foods should the nurse review as good choices? Select all that apply. a. b. c. d. Leafy greens Garlic Nuts Whole milk Answer: B and C A is incorrect. While leafy greens are good choices for many vitamins and minerals, they do not contain a lot of phosphorus. Therefore, this would not be a good choice to recommend to a patient that needs a diet rich in phosphorus. B is correct. Garlic is a food rich in phosphorus and would be an appropriate recommendation recommendation for the client needed to incorporate more phosphorus in their diet. C is correct. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake i ntake of this important mineral. Cashews, almonds, and brazil nuts all are very high in phosphorus. D is incorrect. Whole milk is rich in calcium, but does not have a lot of phosphorus. This This would not be an appropriate recommenda recommendation. tion. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Hyperchloremia Fluids and Electrolytes Definition High level of chloride in the blood. Chloride ● ● ● ● ● Most ab Most abun unda dant nt ex extr trac acel ellu lula larr ani anion on Works Wo rks wit with h sodi sodium um to mai mainta ntain in flui fluid d bala balance nce Binds Bin ds with with hyd hydrog rogen en ions ions to to form form stom stomac ach h acid acid - HCl HCl Inve In vers rsel ely y re rela late ted d to to bic bicar arbo bona nate te Dire Di rect ctly ly rela relate ted d to sodi sodium um and and pota potass ssiu ium m Lab Values Normal chloride: 96-108 mEq/L A chloride level greater than 108 is considered hyperchloremic. Causes ● ● ● ● Dehydration Metabolic ac acidosis Acute re renal fa failure Cus ushi hing ng’’s dis ise eas ase e Assessment ● ● Produces very few symptoms Sign Si gns s and and symp sympto toms ms of of hype hypern rnat atre remi mia a Treatment ● ● Tre reat at th the e und under erly lyin ing g cau cause se Cor orre rec ct th the imb imbal alan anc ce ○ ○ ○ ● Bicarb Bica rbon onat ate e ad admi mini nist stra rati tion on Discon Dis contin tinue ue any sod sodium ium con contai tainin ning g me meds ds No NS fo forr IVF IVFs s - con consid sider er LR in inst stea ead d Monito Mon itorr all elect electrol rolyte ytes s - it’s it’s usual usually ly not not the only only imbal imbalanc ance! e! NCLEX Question The nurse is caring for a patient who has a chloride level of 115 115 mEq/L. Which of the following medications does she prepare to administer? a. b. c. d. Bicarbonate Norrmal Saline IVF No Lact La ctat ate ed Ri Rin nge gerrs IV IVF F Lasix Answer: A and C A is correct. Bicarbonate is a medication commonly commonly used to decrease the chloride level. This patient has hyperchloremia, as their chloride level is 115 mEq/L, which is above the normal range of 96-108 mEq/L. It is therefore appropriate to administer bicarbonate to lower the chloride level in this patient. B is incorrect. Normal Saline, or 0.9% NaCl, N aCl, contains chloride. As the name suggests - NaCl, or Sodium Chloride Chloride.. If the patient has a chloride level of 115 mEq/L, they have hyperchloremia, as their chloride level is above the normal range r ange of 96-108 mEq/L. It would therefore not be appropriate for the nurse to prepare to administer normal saline to this patient. C is correct. Lactated Ringers IVF is the appropriate choice for IV fluids for the patient with hyperchloremia. Normal Saline should be avoided as to prevent increasing the chloride level further. Hydration is a very important component in treating hyperchloremia, so providing IVF for hydration is appropriate, it just needs to be the correct fluid. D is incorrect. Lasix, also known as furosemide, is a potassium wasting diuretic. This medication may be used in patients with hyperkalemia to lower the level of potassium, but it will not have an affect on their chloride level. It would therefore not be appropriate for the nurse to prepare to administer lasix to this patient. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Hypochloremia Fluids and Electrolytes Definition Low level of chloride in the blood. Chloride ● ● ● ● ● Most ab Most abun unda dant nt ex extr trac acel ellu lula larr ani anion on Works Wo rks wit with h sodi sodium um to mai mainta ntain in flui fluid d bala balance nce Binds Bin ds with with hyd hydrog rogen en ions ions to to form form stom stomac ach h acid acid - HCl HCl Inve In vers rsel ely y re rela late ted d to to bic bicar arbo bona nate te Dire Di rect ctly ly rela relate ted d to sodi sodium um and and pota potass ssiu ium m Lab Values Normal chloride: 96-108 mEq/L A chloride level less than than 96 is considered hypochloremic. Causes ● ● ● ● ● Volume overload CHF Wate terr in into tox xic icat atio ion n Met eta abo boli lic c al alk kal alos osis is Salt losses: ○ ○ ○ ○ ● ● Burns Sweating Vomiting Diarrhea Cystic Fi Fibrosis Add ddis ison on’’s Dis isea eas se Assessment ● ● Produces very few symptoms Sign Si gns s and and sym sympt ptom oms s of hy hypo pona natr trem emia ia Treatment ● ● Tre reat at th the e und under erly lyin ing g cau cause se Cor orre rec ct th the imb imbal alan anc ce ○ ● Norm No rmal al Sa Sali line ne - 0.9 0.9% % Na NaCL CL Monito Mon itorr all elect electrol rolyte ytes s - it’s it’s usual usually ly not not the only only imbal imbalanc ance! e! NCLEX Question wit h a chloride level of 90 mEq/L. She The nurse is assigned to care for a patient with knows that which of the following are causes of this electrolyte imbalance? Select all that apply. a. b. c. d. Fluid Flui d vo volu lume me exc xces ess s Metabolic aci acidosis Vomiting Constipation Answer: A and C A is correct. The normal level for chloride is 96-108 mEq/L. Since this patient has a level of 90 mEq/L, which is under the normal range, they are experiencing hypochloremia. Fluid volume excess is a cause of hypochloremia. This is due to a dilutional effect. There is not actually less chloride in the blood, but because there is increased fluid volume, there is a dilutional effect causing a relative hypochloremia. B is incorrect. Metabolic acidosis is not a cause of hypochloremia. Metabolic alkalosis instead can cause hypochloremia. C is correct. Vomiting is a common cause of hypochloremia. The stomach acid is hydrochloric acid, or o r HCl. This acid contains large amounts of chloride, and a nd when the patient vomits and loses this stomach acid, they lose chloride causing hypochloremia. This loss of HCl also causes metabolic alkalosis. D is incorrect. Constipation does not cause hypochloremia. Diarrhea can cause hypochloremia due to excessive loss of gastrointestinal contents that contain chloride. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Risk potential reduction Topic Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences. Subject: Fundamentals of care Lesson: Fluids & Electrolytes Break Back at…. Pharmacology Must know meds for NCLEX success! Antianxiety Agents ● ● ● ● ● Alp lprrazola lam m (Xa (Xanax) Lorazepam (A (Ativan) Mid idaz azol olam am (Vers rsed ed)) Diazepam (Va (Valiu ium m) Bus uspi piro rone ne (Bu Busp spar ar)) Ativan Therapeutic class: antianxiety agent Indication: anxiety, sedation, seizures Action: general CNS depression Nursing Considerations: ● ● ● Avoid alcohol Moni Mo nito torr for for resp respir irat ator ory y depr depres essi sion on Ant ntid idot ote e - flu flum maz azen enil il Antiarrhythmics ● ● ● Amiodarone Adenosine Procainamide Adenosine Therapeutic class: Antiarrhythmic Indication: SVT Action: Slows conduction conduction through the AV node, interrupts re-entry pathways pathways through AV node, restoring normal sinus rhythm Nursing Considerations: ● ● There will There will be a peri period od of asy asysto stole le after after admi adminis nistra tratio tion n Warn Wa rn the the patient patient - it will will feel feel like like someone someone kick kicked ed them them in the chest chest!! ● Warn the fam family ily - they they will will flat flatlin line e on the the moni monitor tor!! Anticoagulants ● ● ● ● Heparin Clopidogrel Warfarin Enoxaparin Heparin ● Class Cla ssific ificati ation: on: Ind Indire irect ct Thr Thromb ombin in Inh Inhibi ibitor tor ○ ● How it works ○ ○ ○ ○ ● Anticoagulant! Thrombin Throm bin → conve converts rts fibri fibrinog nogen en to fibr fibrin in → Fibrin Fibrin forms forms clots clots!! Antithrombin III inhibits Thrombin Heparin EN ENHANCES antithrombin III This stops stops throm thrombin bin from from being being activat activated, ed, which which theref therefore ore preven prevents ts clots clots from form forming. ing. This Thi s is is the the int intrin rinsic sic coa coagul gulati ation on pat pathwa hway y End result? SLOWS DOWN CLOTTING. Basic Information ● Uses ○ ● Administration ○ ○ ● To pr prev even entt bl bloo ood d cl clot ots s ■ Strokes ■ Chronic a-fib ■ Post-operativ ive ely Subcutaneous Intravenous Titration ○ Patients Pati ents on on a heparin heparin drip have have aPTT aPTT levels levels draw drawn n q4-6 hour hours s to titrate titrate the the drip. drip. Important Nursing Considerations ● Bigg Bi gges estt sid side e eff effec ectt to mo moni nito torr for for = bleeding bleeding!! ○ ○ ○ ○ ● Hematu Hema turi ria a - Pin Pink k tin tinge ged d uri urine ne Hema He mate teme mesis sis - bl bloo oody dy vo vomi mitu tus s Bruising Downtrending H&H Anti An tido dote te = pro prota tami mine ne su sulf lfat ate e Heparin Induced Thrombocytopenia and Thrombosis (HITT) ● ● Complic Comp licat atio ion n of of Hep Hepar arin in th ther erap apy y Usual Us ually ly occ occurs urs 5-1 5-10 0 days days afte afterr Hepar Heparin in expo exposur sure e ● ● Suspect in any patien Suspect patientt on Hepar Heparin in who who has an unexpla unexplained ined plate platelet let drop drop Clin Cl inic ical al ma mani nife fest stat atio ions ns:: ○ ○ ○ ○ ○ ● Comp Co mpli lica cati tion ons s - cl clot otti ting ng!! ○ ○ ● Skin lesi Skin lesion ons s at hep hepar arin in inje inject ctio ion n site sites s Chills Fever Dyspnea Chest pain DVT PE Treatment ○ Discontinu Disco ntinue e ALL hepa heparin rin and and start start a differe different nt antico anticoagul agulant! ant! Warfarin Therapeutic class: Anticoagulant Indication: venous thrombosis, pulmonary embolism, A-fib Action: disrupts liver liver synthesis of of Vitamin K dependent dependent clotting factors Nursing Considerations: ● ● Mon onit ito or for bl blee eed din ing g Monitor PT and INR ○ ○ ● Therap Ther apeu euti tic cP PT T: 1.3 1.3-1 -1.5 .5 Ther Th erap apeu euti tic c INR INR:: 2.5 2.5-3 -3.5 .5 Antidote: Vi Vitamin K Anticonvulsants ● ● ● ● ● ● Phe heny nyto toin in (Di Dila lant ntin in)) Carbamazepine Divalproex Gabapentin Lamotrigine Levetiracetam Phenytoin Therapeutic class: Anticonvulsant Indication: Seizures Action: blocks sustained sustained high frequency frequency repetitive firing of action potentials Nursing Considerations: ● ● Therap Ther apeu euti tic c le leve vel: l: 10 10-2 -20 0 mc mcg/ g/mL mL Side Si de eff effec ect: t: gin gingi giva vall hype hyperp rpla lasi sia a ○ ○ Regula Regu larr den denta tall che check ck-u -ups ps Use Us e sof softt bri brist stle le to toot othb hbru rush sh Antidepressants ● ● ● ● ● ● ● Bupropion MAOIs SSRIs Fluoxetine Paroxetine Sertraline TCAs Monoamine Oxidase Inhibitors Examples: tranylcypromine, isocarboxazid, phenelzine, selegiline Indication: Depression Action: blocks monoamine monoamine oxidase enzymes enzymes to increase increase the levels of ALL neurotransmitters ( dopamine, norepinephrine, epinephrine, serotonin) Nursing Considerations: ● Avoi Av oid d food foods s that that are are hi high gh in in tyra tyrami mine ne.. ○ ○ ○ ● Aged cheeses Wine Pickled meats Side effect - hypertensive crisis SSRIs Examples: Fluoxetine, Sertraline, Escitalopram, Citalopram Indication: Depression Action: Prevent reuptake reuptake of serotonin serotonin increasing the availability availability of serotonin in the the body. Nursing Considerations: ● Monitor for serotonin syndrome ○ ● Hyperten Hype rtension, sion, confu confusion, sion, anxie anxiety ty,, tremor tremors, s, ataxia ataxia,, sweatin sweating. g. Suicide precautions important for 2-3 weeks ○ When the patien patient’s t’s mood mood starts starts to to improve, improve, they are are are an inrease inreased d risk for for suicide suicide ○ Why? Why ? They They now now have have the the energy energy to to follow follow thro throug ugh h with with a plan. plan. TCA’s Examples: Amitriptyline, Nortriptyline, Protriptyline Indication: Depression Action: Prevents the reuptake of norepinephrine norepinephrine and serotonin serotonin increasing these these neurotransmitters in the body.. Nursing Considerations: ● Monitor for anticholinergic side effects ○ Dry mo mouth uth,, con consti stipat pation ion,, urin urinary ary ret retent ention ion Antihistamines ● ● ● ● ● Diphenhydramin ine e Promethazine Cimetidine Famotidine Ranitidine Diphenhydramine Therapeutic class: Antihistamine Indication: Allergy, Allergy, anaphylaxis, sedation Action: Antagonizes effects effects of histamine, CNS depression Nursing Considerations: ● ● Mon onit ito or for for dr drow ows sin ines ess s Anti An tich chol olin iner ergi gic c ef effe fect cts s Antihypertensives ● ACE in inhibitors ○ ○ ○ ● Angi An giot oten ensi sin n II II Rec Recep epto torr Blo Block cker ers s ○ ● Losartan Calc Ca lciu ium m Ch Chan anne nell Bl Bloc ocke kers rs ○ ○ ○ ○ ● Captopril Enalapril Lisinopril Amlodipine Diltiazem Nifedipine Verapamil Beta Be ta-b -blo lock cker ers s (ne (next xt cl clas ass) s) Enalapril Therapeutic class: ACE inhibitor Indication: Hypertension, CHF Action: Blocks conversion conversion of angiotensin angiotensin I to angiotensin II, II, increases renin renin levels and decreases aldosterone leading to vasodilation Nursing Considerations: ● ● Can cause a dry cough - should be discontinued if it does. Monitor BP Losartan Therapeutic class: Angiotensin II receptor blocker (ARB) Indication: hypertension, DM neuropathy, CHF Action: inhibits vasoconstrictive vasoconstrictive properties properties of angiotensin angiotensin II Nursing Considerations: ● ● ● Monitor BP Mon onit ito or flu luid id le lev vel els s Moni Mo nito torr ren renal al an and d liv liver er st stat atus us Amlodipine Therapeutic class: Calcium channel blocker Indication: Hypertension, angina Action: Blocks transport transport of calcium calcium into muscle cells inhibiting excitation and contraction Nursing Considerations: ● ● Monitor BP Can cause gingival hyperplasia Beta Blockers ● Propranolol ● ● Atenolol Metoprolol Propranolol Therapeutic class: antiarrhythmic Indication: hypertension, angina, arrhythmias, cardiomyopathy, cardiomyopathy, alcohol withdrawal, anxiety Action: blocks Beta Beta 1 and 2 adrenergic receptors Nursing Considerations: ● ● Do not discontinue abruptly, discontinue them slowly, Can mask the signs of hypoglycemia hypoglycemia;; important to monitor blood sugars. sugars. Cardiac glycosides ● Digoxin Digoxin Therapeutic class: Cardiac glycoside Indication: Heart failure, a-fib, a-flutter, CHF, cardiogenic shock Action: Increases Increases contractility (how (how strong the heart heart pumps), and the the rate (how fast the heart beats). Acts on the cellular sodium-potassium ATPase, ATPase, making the heart more efficient! Nursing Considerations: ● Mon onit ito or for to tox xic icit ity y ○ Visio Vi sion n chang changes, es, blu blurre rred d vision vision,, yello yellow/g w/gree reen n vision vision Toxicity Monitor for toxicity in any patient taking digoxin! Therapeutic lab level: .5-2ng/mL ● Ear arly ly sig signs ns//sym ympt pto oms ms:: ○ ○ ○ Nausea & vomiting Anorexia Vision changes - yellow/green halos Monitor for these signs and symptoms and report them to the health care provider early! Risk factors for toxicity ● Pati Pa tien ents ts wi with th hy hypo poka kale lemi mia a (K< (K<3. 3.5) 5) ○ ● ● ● **If your your patien patientt is on a loop diuret diuretic, ic, and and digoxin, digoxin, they they are are more likely to become become toxic!* toxic!*** Patien Pati ents ts wit with h hypo hypoma magn gnes esem emia ia (Mg< (Mg<1. 1.8) 8) Pati Pa tien ents ts wit with h hype hyperc rcal alce cemi mia a (Ca>1 (Ca>10. 0.5) 5) The elderly! ○ These patients These patients have have decrease decreased d renal renal and liver liver function, function, making making itit harder harder for them them to clear clear any drugs, so digoxin levels can build up and become toxic more quickly! Important Nursing Consideration When should you HOLD your digoxin dose?? In general, if the pulse is less l ess than 60, you should hold digoxin. This will be slightly different in different age groups. Always Always check your order! Anti-Infectives ● Aminogly lyc cosides ○ ● ● Ciprofloxacin Levofloxacin Macrolides ○ ○ ● ● Gentamicin Fluoroquinolones ○ ○ ● Erythromycin Azithromycin Vancomycin Peni Pe nici cill llin ins s & Ceph Cephal alos ospo pori rins ns ○ Amoxicillin ○ ○ Ampicillin Cephalexin Anti-viral ○ ● Acyclovir Antifungal ○ ○ ○ Amphotericin B Metronidazole Nystatin Gentamycin Therapeutic class: Anti-infective; aminoglycoside Indication: Gram negative infections Action: Inhibition of bacterial bacterial protein synthesis synthesis Nursing Considerations: ● ● Monitor for tinnitus Do no nott adm admin inis iste terr wit with h pen penic icilillin lin Ciprofloxacin Therapeutic class: Anti-infective; fluoroquinolone Indication: Infection Action: Inhibits synthesis synthesis of bacterial bacterial DNA Nursing Considerations: ● ● Can cause QT prolongation Decr De crea ease ses s ef effe fect cts s of ph phen enyt ytoi oin n Vancomycin Therapeutic class: antibiotics class: Anti-infective; glycopeptide antibiotics Indication: Infection; sepsis Action: kills bacteria bacteria in the intestines Nursing Considerations: ● ● ● Monitorr for Monito for oto ototox toxici icity ty and nep nephro hrotox toxici icity ty Red-man syndrome Admini Adm iniste sterr over over at leas leastt 60 minute minutes; s; centr central al line line prefer preferred red.. Amoxicillin Therapeutic class: Anti-infectives; aminopenicillin Indication: Infections; skin, respiratory, respiratory, endocarditis Action: Inhibits synthesis synthesis of bacterial bacterial cell wall leading to cell death Nursing Considerations: ● ● Monitor fo for rash Moni Mo nito torr ki kidn dney ey fu func ncti tion on ○ BUN, Cr Antipsychotics ● Haloperidol ● ● Quetiapine Olanzapine Autonomic Nervous System Medications ● ● ● ● Dobutamine Dopamine Atropine Benztropine Atropine Therapeutic class: Antiarrhythmic; anticholinergic Indication: excessive secretions, sinus bradycardia, heart block Action: Inhibition of acetylcholine, acetylcholine, increasing the HR, causing bronchodilation, bronchodilation, and decreasing secretions. Nursing Considerations: ● ● Monitorr for Monito for uri urinar nary y rete retenti ntion on and co const nstipa ipatio tion n Avoi Av oid d in pa pati tien ents ts wi with th gl glau auco coma ma Respiratory Medications ● ● ● ● Theophylline Albuterol Guaifenesin Montelukast Albuterol Therapeutic class: Bronchodilator Indication: Asthma, COPD Action: Binds to Beta2 adrenergic receptors receptors in the airway leading to relaxation of the smooth muscles in the airways Nursing Considerations: ● Be very very caut cautious ious when using in patient patients s with with heart heart diseas disease, e, diabetes diabetes,, glaucoma, or seizures. Diuretics ● Loop diuretics ○ ○ ○ ● Pota Po tass ssiu ium m spar sparin ing g diur diuret etic ics s ○ ○ ○ ● Bumetanide Furosemide Torsemide Triamterene Amiloride Spironolactone Thiazide di diuretics ○ Chlorothiazide Chlorthalidone ○ ○ Hydrochlorothiazide Indapamide ○ Loop Diuretics ● Examples: ○ ● Mec echa han nis ism m of ac acti tion on:: ○ ○ ● Increase Incre ase urinar urinary y output, output, edem edema, a, CHF CHF, blood blood pressur pressure e manage management ment.. Nurs Nu rsin ing g co cons nsid ider erat atio ions ns:: ○ ● Act on the loop of Henle to increase urine output by affecting sodium reabsorption within the nephron. Inhibits Inhib its the sodium sodium pota potassium ssium chlori chloride de cotransp cotransporter orter causin causing g sodium sodium to be excret excreted ed in the urine therefore increasing diuresis. Uses: ○ ● Bumetanide, Furosemide Furosemide,, Torsemide Monitor potassium levels These The se are are the mos mostt effec effectiv tive e of all diu diuret retics ics.. Potassium Sparing Diuretics ● Examples: ○ ● Mec echa han nis ism m of of ac acti tion on:: ○ ○ ● Hypert Hyp erten ensio sion, n, edem edema, a, swel swellin ling, g, hypo hypokal kalem emia. ia. Nurs Nu rsin ing g co cons nsid ider erat atio ions ns:: ○ ● Inhibit sodium Inhibit sodium and potass potassium ium exchan exchange ge via sodium sodium chann channels els in the the distal distal parts of of the nephro nephron. n. This Th is ‘s ‘spa pare res’ s’ po pota tass ssiu ium! m!!! Uses: ○ ● Tri riam amte tere rene ne,, Amil Amilor orid ide, e, Spironolactone Spironolactone,, Eplerenone Monitor potassium levels These medicatio These medications ns are are not as as strong strong as as other other diuretic diuretics, s, so are often often combine combined d with a loop or thiazide diuretic! Thiazide Diuretics ● Exampl Exa mples: es: Chl Chloro orothi thiazi azide, de, Chl Chlort orthal halido idone, ne, Hydrochlorothiazide Hydrochlorothiazide,, Indapamide, ● Metolazone. Mec echa han nis ism m of ac acti tion on:: ○ ○ ● Uses: ○ ● These diuretics These diuretics act on the distal distal convolu convoluted ted tubule tubule to inhibit inhibit the sodium sodium-chlo -chloride ride cotrans cotransport porter er.. This increas increases es sodium sodium in the the filtrate filtrate causing causing an increa increased sed amount amount of of water water reabsorpt reabsorption ion and and therefore increased urinary output. Hypertensio ion n, CH CHF Nurs Nu rsin ing g Co Cons nsid ider erat atio ions ns:: ○ ○ Monito Moni torr ele elect ctro roly lyte te le leve vels ls Monitor BP GI Medications ● ● ● ● ● ● Bisacodyl Lactulose Metoclopramide Ondansetron Omeprazol Pantoprazole Ondansetron Therapeutic class: Antiemetic Indication: Nausea/vomiting Action: blocks effects effects of serotonin serotonin on vagal nerve nerve and CNS Nursing Considerations: ● Administer Admin ister slow slowly ly.. Fast Fast push push can caus cause e QT prolo prolongatio ngation n and VT VT. Omeprazole Therapeutic class: Proton-pump inhibitor Indication: GERD, ulcers Action: prevents the transport of H ions into the gastric gastric lumen by binding to gastric parietal cells to decrease gastric acid production Nursing Considerations: ● ● Admini Admi nist ster er 3030-60 60 min minut utes es be befo fore re mea meall Repo Re port rt bl blac ack, k, ta tarr rry y sto stool ols s Non-opioid Analgesics ● Acetaminophen ● NSAIDS ○ Aspirin ○ ○ Ibuprofen Naproxen Acetaminophen Therapeutic class: antipyretic, non-opioid analgesic Indication: Pain, fever Action: Inhibit the synthesis synthesis of prostaglandins prostaglandins which play a role in transmission transmission of pain signals and fever response Nursing Considerations: ● ● Max dail ily y dose = 4g Mon onit ito or liv liver er fu func ncti tion on ● Anti An tido dote te = n-a n-ace cety tylc lcys yste tein ine e NSAIDS - Non-steroidal anti-inflammatory drugs Examples: Aspirin, ibuprofen, ketoprofen, naproxen Indication: Pain, inflammation, fever Action: Block prostaglandin prostaglandin which causes causes inflammation, pain, and and fever. fever. Nursing Considerations: ● Can cause prolonged bleeding ○ ● Typi ypical cally ly avoid avoided ed in tra traum uma a and and surgi surgical cal pati patient ents s Can cause peptic ulcers Acetylsalicylic Acid (Aspirin) Therapeutic class: Antipyretic, non-opioid analgesic Indication: Pain - arthritis. Stroke and MI prophylaxis Action: Inhibits the production production of prostaglandins prostaglandins which leads to to a reduction of fever fever and inflammation, decreases platelet aggregation leading to a decrease in ischemic diseases Nursing Considerations: ● Risk of of bleeding ○ ○ ● Don’t admi Don’t admini nist ster er with with othe otherr antic anticoa oagul gulan ants ts D/c pr prior to to su surgery Don’ Do n’tt giv give e to to ped pedia iatr tric ic pa pati tien ents ts ○ Reye’s syndrome can occur with viral infections Opioids ● Morphine ● ● ● ● Fentanyl Hydromorphone Methadone Oxycodone Morphine Therapeutic class: Opioid analgesic Indication: Pain Action: Binds to opiate receptors in the CNS and alters perception perception of pain while producing a general depression of the CNS. Nursing Considerations: ● ● CNS depressant ○ Decrea Dec reased sed resp respira iratio tion, n, decr decreas eased ed hea heart rt rate, rate, etc etc.. ○ Moni Mo nito torr res respi pira rato tory ry ra rate te Antidote = narcan Obstetric Medications ● Oxytocin ● ● ● Terbutaline Magnesium-sulfate Methergine Oxytocin Therapeutic class: Hormones; oxytocics Indication: Induction of labor; PPH Action: Stimulates uterine uterine smooth muscle muscle causing it to contract contract Nursing Considerations: ● ● ● Mon onit ito or co cont ntrrac acti tion ons s Monitor fetus Warn mot mother her con contra tracti ctions ons wil willl be mor more e painf painful ul Magnesium-sulfate Therapeutic class: Electrolyte Indication: Hypomagnesemia, torsade de point, pre-eclampsia, seizures, asthma exacerbation Nursing Considerations: ● Moni Mo nito torr for for hype hyperm rmag agne nese semi mia a ○ ● Conf Co nfus usio ion, n, di dizz zzin ines ess, s, we weak akne ness ss,, decreased reflexes Give IV slowly Steroids ● ● ● ● ● Betamethasone Dexamethasone Cortisone Fluticasone Met eth hyl ylpr pred edni nis sol olon one e Methylprednisolone Therapeutic class: Corticosteroids Indication: Inflammation, allergy allergy,, autoimmune disorders Action: Suppress inflammation and normal immune immune response Nursing Considerations: ● Moni Mo nito torr for for to too o muc much h ste stero roid ids s ○ ● Cush Cu shin ing’ g’s s symp sympto toms ms;; buf buffa falo lo hum hump p Side ef effects ○ ○ ○ Immunos Imm osu uppr pre ess ssio ion n Hyperglycemia Osteoporosis ○ Dela De laye yed d wo woun und d he heal alin ing g Lunch Break Back at…. Lines, Tubes, and Drains Must know nursing knowledge! NG Tube Tubes s What is a nasogastric tube? ● Tub ube e ins inser erte ted d in in the the na nare re ● that terminates in the stomach Uses: ○ ○ ○ ○ Enteral nu nutrition Decompression Medi Me dica cati tion on adm admin inis istr trat atio ion n Remo Re mova vall of st stom omac ach h co cont nten ents ts after an overdose Insertion 1. Per erffor orm m han hand d hy hygi gien ene e 2. Ex Expl plai ain n the the proc proced edur ure e to th the e pati patien entt 3. Meas Measure ure from the earlob earlobe e of the patient patient to the the nose, nose, then then to the xiphoid xiphoid process. This is how deep you will insert the NG tube. 4. Mar Mark k the the dep depth th of of inser insertio tion n on on the the NG tub tube e 5. Lu Lubr bric icat ate e the the ti tip p of th the e tu tube be.. 6. Inse Insert rt the the tube to the the nasophar nasopharynx, ynx, and ask ask the patie patient nt to swall swallow ow and and tuck tuck their chin to their chest. 7. Con Contin tinue ue advan advancin cing g the tube tube to to the prede predeter termin mined ed depth depth.. 8. 9. V erif place nt. of th the e NG NG tub tube. e. Ser ecify uyrepla thceme th e ment tube tu Placement verification ● Gold Go ld sta stand ndar ard d - x-r x-ray ay vi visu sual aliz izat atio ion n ● ● Aspira Aspi rati tion on of ga gast stri ric c co cont nten ents ts Ausc Au scul ulta tati tion on of of air air over over the the epi epiga gast stri rium um Chest Tubes What is a chest tube? ● ● ● Tub ube e inse insert rted ed int into o the the pleu pleura rall spac space e of the lungs. Help He lps s to to rem remov ove e air air or or flu fluid id tha thatt has has caused the lung to collapse Also Al so pl plac aced ed af afte terr ca card rdia iac c su surg rger ery y to help drain blood and fluid from around the heart. Nursing Considerations - Drainage system ● ● ● ● Always keep Always keep the the drainage drainage sys system tem below below the level level of the the patient’ patient’s s chest chest Ensure Ens ure the tub tubing ing is is free free of of kink kinks s and and drain draining ing free freely ly There The re shou should ld be be no dep depend endent ent loo loops ps in the the tubi tubing ng Mon onit ito or the dra rain inag age e ○ ○ ○ ○ Color - serous - serosanguinous. Know WHY the patient has a CT! Odor - none Consistency - thin-thick Amount - no more than 100ml/hr. More? Call the doc!! ■ Mark hourly Nursing Considerations - Water Seal Chamber ● Wate aterr will will flu fluctu ctuate ate as the pat patien ientt brea breathe thes s ○ ○ Increa Incr ease se dur durin ing g insp inspir irat atio ion n Decr De crea ease se dur durin ing g expi expira rati tion on ● Bubbling….. Okay or not okay? ○ ○ ○ Some bubbling - expected. Air is leaving the pleural space. Excessive bubbling - not okay. There is a leak somewhere. No bubbling - investigate further. Lung could be re-expanded - good news. Or, there could be a kink - you need to fix this. What to do if the chest tube comes out ● ● Cov over er th the e sit site e wi with th a sterile dressing Tape on 3 sides ○ ● ● Air can Air can es esca cape pe th this is wa way y. If If you tape on 4 sides you might cause a tension pneumothorax Call th the provider STAY WITH THE PATIENT Foley Catheter What is a foley catheter? ● ● ● Catheter Cathet er plac placed ed into into the ureth urethra ra and and up to the the patien patient’ t’s s bladde bladderr Foley cathe catheters ters are ‘indwe ‘indwelling’ lling’ or left left for for an exten extended ded period period of time time Urin Ur ine e dra drain ins s in into to a dr drai aina nage ge ba bag g Inserting a foley catheter 1. Was ash h your your han hands ds and and don don ste steri rile le glo glove ves s 2. Plac Place e the the tip tip of the the cat cathe hete terr in lub lubri rica cant nt 3. Cle lean an wi with th be bettad adin ine e a. b. 4. 5. 6. 7. Females: Use Females: Use the non-do non-domina minant nt hand hand to spread spread the labia. labia. Use Use three three swabs: swabs: one on on the left, left, one on the right, and the last one down the middle. Male: Ma le: Clean Clean the the periperi-ure urethr thral al open opening ing with with three three swab swabs. s. Using the Using the dominan dominantt hand, hand, inser insertt the the cathete catheterr into into the the urethr urethral al opening opening Once Onc e urine urine is obse observed rved,, advance advance the cathet catheter er anothe anotherr one to two two inches inches Attach Att ach the the pre-f pre-fille illed d syrin syringe ge to the the port port and and inflat inflate e the ball balloon oon Connect Conn ect the the drainage drainage syst system em to the the cathete catheterr and secu secure re per per facility facility proto protocol. col. Nursing Must Know ● ● ● The here re sho hou uld ne nev ver be be dependent loops in the tubing. This can lead to urine backing up in the bladder. Inse In sert rtin ing g a fol foley ey ca cath thet eter er req requi uire res s sterile technique to prevent infection. CAUTIS CAU TIS (cat (cathet heter er acqui acquired red urin urinary ary trac tractt infect infection ions) s) are UTIs caused by a catheter.. The hospital is not reimbursed for these infections, so there is a lot catheter of emphasis on preventing them. ○ Most fac acil ilit itie ies s use use a bundle to prevent CAUTIS ■ Al Alwa ways ys re remo move ve as so soon on as po poss ssib ible le ■ Da Dail ily y cl clea eani ning ng an and d ca care re Blakemore What is a Blakemore tube? ● ● ● Tube ins insert erted ed thr throug ough h the the nos nose e down down the esophagus and into the stomach with balloons that can be inflated to stop bleeding esophageal varices. Also Al so cal calle led d Seng Sengst stak aken en-B -Bla lake kemo more re or or Minnesota tube. It put puts s pres pressu sure re on on bleed bleedin ing g esop esopha hage geal al varices to stop the bleeding. Nursing Must Know KEE P A PAIR MUST KEEP PAIR OF SCISSORS AT THE BEDSIDE IN CASE OF EMERGENCY If the gastric balloon becomes displaced it can compress the trachea and cause respiratory arrest. If that happens, cut the gastric balloon port to let the air escape and restore the patient's airway. Endotracheal Tube What is an endotracheal tube (ETT)? ● Invasive Inva sive,, artificia artificiall airway airway used used when when the patie patient nt is unabl unable e to protec protectt their their own airway. ● ● ● Plasti Plas tic c tu tube be in inse sert rted ed in into to th the e tracheal through the mouth or nose Main Ma inta tain ins s an ai airw rway ay to de delilive verr oxygen and positive pressure to the lungs “Breathing tu tube” Nursing Must Know ● After place placement ment of of an ETT ETT,, placemen placementt should should be veri verified fied by by a chest chest x-ray x-ray ● Assess for equal breath sounds bilaterally ○ ○ The ETT ETT can can becom becomes es displ displace aced d into into the R main main ste stem m bronch bronchus us Ensure Ensu re that that breath breath sounds sounds are are heard heard equally equally bilate bilaterally rally or or the tube tube may may need need to be be repositioned. Tracheostomy What is a tracheostomy tube? ● ● ● ● An art artif ific icia iall airwa airway y used used for for lon longg-te term rm needs. Stom St oma a is is mad made e in in the the ne neck ck an and d the the tube inserted into the trachea. Brea Br eath thin ing g is is th thro roug ugh h the the tracheostomy tube, not the nose and mouth. Used for: ○ ○ ○ ○ Tra rach che eal ob obst stru ruct ctio ion n Slow vent weanin ing g Tracheal damage Neur Ne urom omus uscu cula larr da dam mag age e Nursing Must Know ● INF NFEC ECT TIO ION N PREV PREVE ENT NTIO ION N ○ ○ ○ ○ ● The natu natural ral defe defense nses s of the the nose nose and and mouth mouth are are bypass bypassed ed Therefore Ther efore this patie patient nt is at highe higherr risk for a resp respirato iratory ry infect infection ion Daily trach care Close Clo se mo monit nitori oring ng for res respir pirato atory ry infe infecti ction on Only On ly suc sucti tion on to to the the pre pre meas measur ured ed dep depth th ○ Sucti Su ctioni oning ng too too deep deep can cause cause dam damag age e or cause cause laryng laryngosp ospasm asm EKG P-wave: normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: 60-100 Regularity: Regular Normal Sinus Rhythm P-wave: Normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: <60 Regularity: Regular Causes: -Sleep -Inactivity -Very athletic -Drugs -MI Sinus Bradycardia P-wave: Normal PR Interval: 0.12-0.20 QRS: <0.12 Rate: >100 Regularity: Regular Sinu Sinus s Tachy Tachycard cardia ia P-wave: “saw-tooth” PR Interval: none QRS: <0.12 Rate: 250-400 Regularity: Regular or Irregular Causes: -Caeine -Exercise -Fever -Anxiety -Drugs -Pain -Hypotension -Volume depletion Causes: -Heart disease -MI -CHF -Pericarditis Atrial Flutter P-wave: ‘wavy’ PR Interval: none QRS: <0.12 Rate: >400 Regularity: irregular Causes: -Heart Disease -Pulmonary Disease -Stress -Alcohol -Caeine Atrial Fibrillation Fibrillation P-wave: hidden PR Interval: immeasurable QRS: <0.12 Rate: 150-250 Regularity: Regular Causes: -Caeine -CHF -Fatigue -Hypoxia -Altered pacemaker in heart ing. n e t a re ife th tolerate, l e b CAN patients T! Some ome do NO s Supraventricular Supraven tricular Tachycardi achycardia a (SVT) (SVT) P-wave: none PR Interval: none QRS: >0.11 - ‘wide & bizarre’ Rate: 150-250 Regularity: Regular Causes: -MI -Ischemia -Digoxin toxicity -Hypoxia -Acidosis -Hypokalemia NG I N E EAT R H !! T A I E M F LI TH Y H ARR -Hypotension Ventricular Tachycardia (V-Tach) P-wave: none PR Interval: none QRS: none Rate: none Regularity: Irregular Causes: -MI -Ischemia -Hypoxia -Acidosis -Hypokalemia -Hypotension -Most common cause of IN G N E T EA R H !! T A I E M F I L HYTH ARR sudden death Ventricular Fibrillation (V-fib) P-wave: possible to have some random p-waves PR Interval: none QRS: none Rate: none Regularity: n/a Causes: -Follows VT/VF in cardiac arrest -Acidosis -Hypoxia -Hypokalemia -Hypothermia -Overdose T LIFE- G!!! N IN E T A HRE Asystole Growth & Development Theories of psychosocial development Erikson - Stages of Psychosocial Development Piaget - Stages of Cognitive Development Infants ● Eriks Eri kson' on's s sta stages ges of ps psych ychoso osocia ciall dev develo elopme pment nt ○ ● Piaget Pia get's 's st stage ages s of Cog Cognit nitive ive dev develo elopme pment nt ○ ● ● ● Tru rust st vs. vs. mist mistru rust st:: Bir Birth th - 18 mo mont nths hs Sens Se nsor orim imot otor or:: Bir Birth th - 2 yea years rs Soc ocia iall smi smile le:: 6-8 6-8 we week eks s Obje Ob ject ct pe perm rman anen ence ce:: 9 mon month ths s Stra St rang nger er an anxi xiet ety: y: 9 mon month ths s Toddlers ● Erikson stage: ● Piaget stage: ● ○ Auton Au tonom omy y vs. vs. Sha Shame me and Do Doubt ubt - 18mo18mo-3 3 years years ○ Preo Pr eope pera rati tion onal al sta stage ge - beg begin ins s at age age 2 Parallel play ○ ● Children Child ren play play adjacent adjacent to each each other other,, but do not not try to influe influence nce one one another' another's s behavior behavior.. Symbolic play ○ The ability ability of childre children n to use object objects, s, actions actions or ideas ideas to represen representt other other objects, objects, actions, actions, or or ideas as play. Preschoolers ● Erikson stage ○ ● Piaget stage ○ ● Play that that involve involves s the divisio division n of efforts efforts amon among g children children in orde orderr to reach reach a commo common n goal. goal. Magical thinkin ing g ○ ● Stil St illl preo preope pera rati tion onal al un unil il 7 ye year ars s Cooperative pla lay y ○ ● Init In itia iati tive ve vs vs.. Gui Guilt lt - 3-5 3-5 ye year ars s The belief belief that that one's one's own own thoughts thoughts,, wishes, wishes, or desire desires s can influen influence ce the exte external rnal world. world. Do no nott yet yet ha have ve a con conce cept pt of ti time me School Age ● Erikson stage ● Piaget stage ● ○ Indu In dust stry ry vs. vs. Inf Infer erio iorit rity: y: 5-1 5-13 3 year years s ○ Concre Con crete te ope operat ration ional al sta stage: ge: 7-1 7-11 1 yea years rs Social Soc ial inter interact action ion with with peer peers s prior prioriti itized zed ove overr family family Adolescents ● Erikson stage ○ ● Piaget stage ○ ● Iden Id enti tity ty vs. vs. con confu fusi sion on:: 13-2 13-21 1 year years s Form Fo rmal al ope opera rati tion onal al sta stage ge:: 12+y 12+yea ears rs Risk Ri sky y be beha havi vior or in incr crea ease ses s Young Adults Ad ults ● Erikson stage: ○ Inti In tima macy cy vs. vs. Iso Isola lati tion on:: 21 - 39 39 year years s Middle Adults ● Erikson stage: ○ Genera Gen erativ tivity ity vs. sta stagna gnatio tion: n: 4040-65 65 yea years rs Old Adults ● Erikson stage: ○ Inte In tegr grit ity y vs. vs. De Desp spai air: r: 65 65+ + yea years rs Isolation Precautions Standard ● Per erffor orm m han and d hy hygi gien ene e ● ● ● Use PPE Use PPE if you exp expect ect to be be expos exposed ed to to bodily bodily flu fluids ids Disi Di sinf nfec ectt pati patien entt equi equipm pmen entt Follllow Fo ow sa safe fe in inje ject ctio ion n pr prac acti tice ces s ○ 1 nee needl dle, e, 1 syr syrin inge ge,, 1 ti time me Contact ● PPE to wear: ○ ○ ● Pati Pa tien entt dedi dedica cate ted d equi equipm pmen entt ○ ○ ○ ● ● Gown Gloves Dispos Disp osab able le st stet etho hosc scop ope e BP cuff Thermometer Limitt tra Limi trans nspo port rt of pa pati tien entt Appr Ap prop opri riat ate e pa pati tien entt pl plac acem emen entt ○ ○ Sin ing gle pa pati tie ent ro roo om Same Sa me in infe fect ctio ions ns gro group uped ed tog toget ethe herr ● Infect Infe ctio ions ns re requ quir irin ing g co cont ntac actt precautions: ○ ○ ○ MRSA VRE Dia iarr rrh heal il illn lne ess sses es Droplet ● PPE to wear: ○ ○ ● Limi Li mitt tra trans nspo port rt of pa pati tien entt ○ ○ ● Mask Eye cover ■ Gog ogg gle les s or or fa face sh shie ield ld When tr When tran ansp spor orti ting ng,, pla place ce ma mask sk on on patient. Tea each ch pat patie ient nt to cou cough gh int into o elb elbow ow Appr Ap prop opri riat ate e pa pati tien entt pl plac acem emen entt ○ ○ Sin ing gle pa pati tie ent ro roo om Same Sa me in infe fect ctio ions ns gro group uped ed tog toget ethe herr ● Infect Inf ection ions s req requir uiring ing dro drople plett pre precau cautio tions: ns: ○ ○ ○ ○ ○ Influenza Pertussis Mumps RSV Rhinovirus Airborne ● ● PPE to wear: ○ Respirator ■ N95 or PAPR ○ ○ Gown Gloves ○ ○ ○ ○ Tuberculosis Measles Chickenpox Diss Di ssem emin inat ated ed her herpe pes s zost zoster er Positive Posit ive pr pres essu sure re wh when en po poss ssib ible le Private room Appr Ap prop opri riat ate e hea healt lthc hcar are e per perso sonn nnel el ○ ○ ● Infect Inf ection ions s req requir uiring ing air airbor borne ne pre precau cautio tions: ns: Air irbo borrne is isol olat atio ion n roo room ○ ○ ● ● Restric Rest rictt susc suscep epti tibl ble e pers person onne nell from from entering room. Limi Li mitt numb number er of of peop people le nee neede ded d to ent enter er room. Limi Li mitt tra trans nspo port rt of pa pati tien entt ○ Put mask Put mask on on pat patie ient nt if the they y mus mustt leav leave e the room. Restraints When is it appropriate to use restraints? ● Is you yourr patie patient nt a dan danger ger to them themsel selves ves or othe others? rs? ○ ○ ● ● Patien Pati entt try tryin ing g to to har harm m the thems msel elff Comba Com bativ tive e patie patient nt tryi trying ng to to harm harm team team mem member bers s Are the they y tryi trying ng to to pull pull out out thei theirr IVs IVs or or airwa airway? y? Delirious pa patie ien nts ○ ○ Don’tt kno Don’ know w wh wher ere e th they ey ar are e Are afr afraid aid and at ris risk k for for har harmin ming g the themse mself lf Always, always, always, AL ALWA WAYS YS remove the restraints restraints as soon soon as possible! Use Use other methods when appropriate - redirection, orientation, sedation as ordered. Different types of restraints Soft wrist restraint Mitts Different types of restraints Posey bed Vest Document, document, document! What MUST be documented when you have a patient in restraints: ● ● ● ● Start an and st stop titimes Reas Re ason on re rest stra rain ints ts ar are e ind indic icat ated ed Plan of care Assessment ○ ○ ESPECIA ESPE CIALL LLY Y impor importa tant nt to chec check k for skin skin brea breakdo kdown wn Look at at skin under under all restrai restraints, nts, note note any rednes redness, s, and use use preventa preventative tive measu measures res to protec protectt skin. NCLEX Question Which of the following situations represents an appropriate time to place your patient in restraints? Select all that apply. a. b. c. d. Whe When n they they are tryi trying ng to pull pull at at the their ir lines, lines, ttub ubes, es, and and drain drains. s. Wh When en the their ir fam family ily memb member er a ask sks s you you to. to. Wh When en you you ffee eell itit is is nec neces essa sary ry.. Wh When en the they y are are a dang danger er to to them themse selv lves es.. Answer: A and D A is correct. It is appropriate to place your patient in restraints, with an order from your healthcare provider, if the patient is trying to pull out their lines, tubes, and drains. This makes them a danger to themselves and can cause harm, so restraints may be appropriate. B is incorrect. A family family member may request restraints, but this is not an appropriate reason to initiate initiate restraints. You should explain to the family member other options and what you are trying to do for their loved one before initiating restraints. You must C is incorrect. Just because you feel that restraints are necessary does not mean you may initiate them. You speak with your healthcare provider and explain why you think restraints are necessary to obtain an order. D is correct. If your patient is a danger to themselves, and other interventions are not keeping them safe, it is appropriate to request an order for restraints from your healthcare provider. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. practice . Elsevier Health Sciences. Subject: Fundamentals Lesson: Safety End of Part I! Break Back at…. Part II: System by System Archer Review - NCLEX Rapid P Prep rep Cardiac Anatomy & Physiology Blood flow through the heart Hemodynamics ● Preload ○ ● Afterload ○ ● Stren Str ength gth of con contra tracti ction on of the the he heart art mu muscl scle e Stroke volume ○ ● How easi easily ly the the heart heart muscl muscle e expan expands ds when when fille filled d with with blood blood Contractility ○ ● Pressure Pres sure agai against nst which the left vent ventricle ricle must pum pump p to eject bloo blood d Compliance ○ ● Amoun Am ountt of bloo blood d retur returnin ning g to righ rightt side side of the the hear heartt Volum olume e of blood pump pumped ed out out of of the the ventric ventricles les with with each each contr contractio action n Cardiac output ○ The amoun amountt of blood blood the the heart heart pumps pumps through through the circula circulatory tory system system in a minute minute Cardiac Output WHY is cardiac output SO important?! ● ● ● ● Tissue pe perfusio ion n! End or organ fu function Delivery Deliv ery of oxygen oxygen and nutri nutrients ents to each each and and every every cell in the body body!! Poo oorr car cardi diac ac ou outp tput ut?? ?? ○ ○ ○ ○ ○ Decreased Decrea sed LOC LOC (not (not eno enough ugh blo blood od flow flow to the the BRA BRAIN) IN) Chestt pain, Ches pain, weak weak periphe peripheral ral pulses pulses (not (not enoug enough h blood blood flow flow to the HEAR HEART) T) SOB,, crackl SOB crackles, es, rale rales s (not (not enough enough bloo blood d flow flow to the the LUNGS LUNGS)) Cool,, clammy Cool clammy,, mottled mottled extrem extremities ities (not enou enough gh blood blood flow flow to to the SKI SKIN) N) Decrea Dec reased sed UOP UOP (no (nott enough enough bloo blood d flow flow to the the KIDNE KIDNEYS YS)) CO = SV X HR INCREASED DECREASED CO Bradycardia Arrhythmias Pulseless v-tach V-fib Asystole SVT Hypotension MI Cardiac muscle disease CO ● ● ● Increased blo loo od volume...sometimes Tac achy hyca card rdia ia.. ...s .som omet etim imes es Medications ○ ○ ○ ● ACE Inhibitors ARBS Nitrates Inotropes Coronary Artery Artery Disease (CAD) What is coronary artery disease? ● ● The mos mostt commo common n type type of of cardi cardiova ovasc scula ularr disea disease se.. Inclu lud des two types ○ ○ Chr hro onic st sta abl ble e an angi gin na Acut Ac ute e cor coron onar ary y synd syndro rome me (a (aka ka MI MI)) Chronic Stable Angina ● Chro Ch roni nic c dis disea ease se ca caus used ed by narrowing of coronary arteries and plaque build up. Ther Th ere e ar are e per perio iods ds of de decr crea ease sed d blood flow to the heart muscle Decr De crea ease sed d bloo blood d flow flow lea leads ds to decreased oxygen, and ischemia. Isch Is chem emia ia ca caus uses es ch ches estt pai pain n ● ● ● Treatment ● Nitroglycerin ○ ○ ○ ○ ○ ○ Venou enous s and and arterial arterial dilat dilation ion → decre decreased ased afte afterload rload → increas increased ed CO CO Given sublin ing gual Admi Ad mini nist ster er 1 pill pill q5 q5 minu minute tes s for for 3 dose doses s Do not swallow Keep Ke ep in a dark dark bot bottle tle in dry dry,, cool cool pla place ce Expe Ex pect cted ed si side de ef effe fect ct = hea heada dach che e Education ● DECR DE CREA EASE SE THE THE WOR WORKL KLOA OAD D OF TH THE E HEAR HEART! T! ○ ○ ○ ○ ○ ○ ○ Rest Do not overeat No caffeine Avo void id tem tempe pera ratu ture re ext extre reme mes s No smoking Pro rom mot ote e wei eig ght lo loss ss Reduce stress Myocardial Infarction (MI) What is a myocardial infarction Myocardial infarction = acute coronary syndrome = unstable angina ● ● There is decre There decreased ased blood flow to to the heart heart,, leading leading to decr decrease eased d oxygen, oxygen, and not only ischemia, but also necrosis necrosis.. Goal Go al is is to to act act qui quickl ckly y and and lim limit it the the dam damage age.. Assessment ● Chest pain ○ ○ ○ ● ● ● ● Crushing Radi Ra diat atin ing g to to lef leftt arm arm or ja jaw w Betw Be twee een n sh shou ould lder er bl blad ades es Epigas Epig astr tric ic disc discom omfo fort rt/i /ind ndig iges esti tion on Fatigue SOB Vomiting Labs ● CPK-MB ○ ○ ● Troponin ○ ○ ● Cardia Card iac c spe speci cifi fic c iso isoen enzy zyme me Incr In crea ease ses s with with dam damag age e to ca card rdia iac c cell cells s Cardiac bi biomarker Incr In crea ease ses s wit with h myo myoca card rdia iall dam damag age e Myoglobin ○ ○ ○ Pro rote tein in in musc scle le ce cell lls s Increa Inc reases ses wit with h dam damage age to AN ANY Y mus muscle cle cel celll Negative Nega tive result results s can help rule out an an MI, but positiv positive e results results are are not not specific. specific. Treatment ● Cath lab within 90 minutes for PCI ○ ● ● ● ● Espe Es peci cial ally ly imp impor orta tant nt ifif it’s it’s a STE STEMI MI!! Oxygen Aspirin Nitroglycerin Morphine Education ● Quit smoking ● ● Increa Incr ease se act activ ivit ity y grad gradua uall lly y Diet ○ ○ ○ ● Low fat Low salt Low ch cholesterol Exercise ○ ○ Avo void id is isom omet etri ric c exe exerc rcis ises es Wal alki king ng is a go good od ch choi oice ce NCLEX Question A 45-year-old man is rushed to the ER with reports of substernal substernal chest chest pain and diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER nurse understands that nursing interventions would focus on which priority? a. Increase oxygenation to the heart and reduce the heart’s workload b. Prevent complications and confirm a diagnosis of myocardial infarction c. Alleviate the patient’s anxiety d. Pain relief Correct answer: A A is correct. The client is show showing ing signs and sym symptoms ptoms of myocardial myocardial infarction. The priority for nursing care should be focused on increasing oxygen delivery to the heart and reducing its i ts workload to prevent further damage. B is incorrect. Confirming the diagnosis should be done; however however,, since the client is already exhibiting signs of reduced myocardial oxygenation (chest pain), the nurse should prioritize oxygen delivery to the client. C is incorrect. It is i s the nurse’s responsibility to alleviate the client’s anxiety; however however,, the nurse should prioritize oxygenation to the client. D is incorrect. Pain relief should be important in the care of the patient with myocardial infarction; however, it should not take priority over myocardial oxygenation. Heart Failure What is heart failure? The inability of the heart muscle to pump enough blood to meet the body's needs for blood and oxygen. ● ● ● Often Often res result ults s as a c comp omplic licati ation on of of other other diseas diseases es #1 ca caus use e of HF is hy hype pert rten ensi sion on Other causes: ○ ○ ○ ● Cardiomyopathy Endocarditis MI Two types: Left and Right Left-sided Heart Failure Left side of the heart cannot move blood forward to the body. Blood is backing up in the LUNGS LUNGS.. Assessment: ● ● ● ● ● ● Pulmo Pulm ona narry con cong ges esti tion on Wet lung sounds Dyspnea Cough Blo loo od tin ting ged sp sputum S3 ● Orthopnea Right Heart Failure Right side of the heart cannot move blood forward to the lungs. Blood is backing up in the BODY BODY.. Assessment: ● ● ● ● ● ● ● ● Jugula Jugu larr ven venou ous s dis diste tent ntio ion n Dependent ed edema Hepatomegaly Splenomegaly Ascites Weight gain Fatigue Anorexia Treatment ● ● DECREA DECR EASE SE THE THE WOR WORKL KLOA OAD D OF TH THE E HEAR HEART! T! Primar Pri mary y stra strateg tegy y is is to to decre decreas ase e after afterloa load: d: ○ ○ ● Incr In crea ease se co cont ntra ract ctil ilit ity y ○ ● ACE Inhibitors ■ Arte Arterial rial dilat dilation→ ion→ decre decreased ased afte afterload rload → Incre Increased ased strok stroke e volume volume ARBS ■ De Decre crease ase BP → decre decrease ased d after afterloa load d → Incre Increase ased d CO Digoxin Diuresis ○ Pt ne need eds s hel help p red reduc ucin ing g exc exces ess s flu fluid id Education ● Tak ake e diur diuret etic ic med medic icat atio ions ns in in the the AM AM ● ● Monitorr elec Monito electro trolyt lyte e level levels s whil while e on diu diuret retics ics Low sodium diet ○ ● Elevate the HOB ○ ● Will Wi ll he help lp wit ith h diu diure res sis Daily weight ○ ○ ○ ● This Th is he help lps s dec decre reas ase e fl flui uid d Same time Same scale Same clothes Repo Re port rt any any in incr crea ease se of of 2-3 2-3 lbs lbs in on one e day day Hypertension What is hypertension? High blood pressure! Normal <120/80 Elevated 120-129/80 Hypertension >130/>80 Hypertensive Crisis >180/>120 Causes & Risk Factors ● ● ● ● ● ● ● ● ● Family history Afr fric ican an am amer eric ican an rac ace e Increased age Obesity HLD CAD Stress Smoking High salt intake ● Caffeine Assessment ● Ofte Of ten n asym asympt ptom omat atic ic unt untilil ver very y seve severe re ● ● ● ● ● ● Vision changes Headaches Dizziness Nosebleeds SOB Angina Complications ● ● ● ● ● Stroke MI Renal Failure Heart Failure Vision lo loss Treatment & Education ● Medications ○ ○ ○ ○ ● Diet ○ ○ ○ ○ ○ ● ACE inhibitors Beta Blockers CCB Diuretics DASH Low salt Avo void id ca cafffe fein ine e and and al alco coho holl Weight loss Smokin ing g ce cessation Lifestyle ○ Less Le ss si sitt ttin ing g mo more re wa walk lkin ing g NCLEX Question A hypertensive hypertensive client has prescribed antihypertensive medication. The client tells a clinic nurse that she prefers to take an herbal substance to help lower her blood pressure. Which is the most appropriate response for the nurse? A.Tell the client that herbal s A.Tell substances ubstances unsafe unsafe and should neve neverr be used B. Encourage the client to discuss the use of herbal substances with her attending physician C. Teach the client how to take her blood pressure and ask her to monitor it every fifteen minutes D. Tell Tell the client that if she takes the herbal substance it will require the nurses to check her blood pressure closely Answer: B The most appropriate response is B. Although the use of herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are on conventional medication therapy are discouraged from using herbal materials with similar pharmacological effects because the combination may lead to an excessive reaction of unknown interaction effects. The nurse would advise the client to discuss the use of the herbal substance with her attending physician. Options A, A, C, and D are inappropriate nursing actions. Shock What is shock?? ● ● A stat state e where where the the vital vital organs organs are not not receiv receiving ing adequa adequate te oxygen oxygenation ation.. This lack of oxygen oxygenation ation caus causes es organ organ damag damage e and forc forces es the the cells cells to use anaerobic metabolism to create energy….produc energy….producing ing lactate. ● Card Ca rdio iova vasc scul ular ar sys syste tem m is com compo pose sed d of: of: ○ ○ ○ ● The blood The va vasculature The heart A disr disruptio uption n in any any of these these three comp component onents s can can cause cause a lack lack of of oxygen oxygen delivery to the organs, causing shock. ● Which Whi ch compo componen nentt is ‘brok ‘broken’ en’ det determ ermine ines s the type type of of shock shock.. Types of Shock Hypovolemic Cardiogenic Distributive Hypovolemic Shock Pathophysiology ● ● ● ● Low blood flow Ther There e is a llos oss s of the the c cir ircu cula lati ting ng v vol olum ume e Not Not e eno noug ugh hb blo lood od to en ente terr tthe he hear heartt (preload), which decreases cardiac output. The bod body yw will ill vasoco vasoconst nstric rictt tto oc comp ompens ensate ate.. Causes ● Hemorrhage ● ● Traumatic injury Dehydration ○ ○ ● Vomiting Diarrhea Burns Assessment ● Compensation ○ ○ ○ ○ ● Weak Pale Tachycardic Anxious Failing ○ ○ ○ ○ ○ Hypotension Weak pu pulses Tachycardic Decreased LOC Pale ○ Cool ○ ○ Clammy Decreased UOP Treatment ● Fix the cause ○ ○ ● Replace volume ○ ○ ● Stop vo Stop vomi miti ting ng/d /dia iarr rrhe hea a Stop bleeding ■ Repair in OR Isotonic IVF ■ NS ■ LR Blood pr products Support perfusion ○ Vasopressors Cardiogenic Shock Pathophysiology ● The hea heart rt fails fails to to pump pump suffic sufficien ientt blood blood out out to the the organ organs s ● ● ● “Pump failure” Something Some thing is stoppin stopping g the hear heartt itself itself from from getting getting blood out to to the body Without Witho ut suffi sufficient cient blood deliv delivered ered to the the body body, there there is inade inadequate quate oxygenation Lack Lac k of oxy oxygen gen imp impair airs s norma normall cellu cellular lar met metabo abolis lism m ● Causes ● ● ● MI Cardiac ta tamponade Pulmonary em embolis ism m Assessment ● Dec ecrrea eas sed pe perrfu fus sio ion n ○ ○ ○ ○ ○ ● Hypotension Weak pulses Cool, pa pale le,, cl clammy Decreased UOP Decreased LOC Volume overload ○ ○ ○ ○ ○ JVD Crackles SOB Muffle led d he hear artt so soun und ds S3 Treatment ● TREAT THE CAUSE ○ ○ ○ ● Imp mprrov ove e cont contrrac acti tili lity ty ○ ○ ● MI ■ PCI ■ CABG PE ■ Thrombolytics Tamponade ■ Peri rica card rdio ioce cen nte tesi sis s Dopamine Dobutamine Decrease aft afterload ● ● ● IABP LVAD Transplant ○ ○ Diuretics Dobutamine Distributive Shock Pathophysiology ● ● ● ● ● ● Something Someth ing caus causes es an immu immune ne or auto autonom nomic ic respo response nse in in the body body This Th is al alte ters rs va vasc scul ular ar to tone ne The res result ult is mas massiv sive e peri periphe pheral ral va vasod sodila ilatio tion n With so much much vaso vasodilati dilation, on, the the blood blood press pressure ure is inadequ inadequate ate to to provide provide blood flow to the vital organs. Without Witho ut suffi sufficient cient blood deliv delivered ered to the the body body, there there is inade inadequate quate oxygenation Lack Lac k of oxy oxygen gen imp impair airs s norma normall cellu cellular lar met metabo abolis lism m Causes ● Anaphylactic ○ ● Neurogenic ○ ● Alle lerrgic reactio ion n SCI Septic ○ ○ Systemic inf infection Causes Cau ses rel relea ease se of inf inflam lamma mator tory y cyto cytokin kines es Assessment ● ● ● ● ● ● Decreased oxygen Hypotension Tachycardia Tachypnea Warm, flu flus shed sk skin Decreased LOC Specific: ● Anaphylactic ○ ○ ○ ○ ● Neurogenic ○ ○ ● Hives Rash Swelling Wheezing SCI Priapism Septic ○ Hyperthermic ○ Infection Treatment ● Anaphylactic ○ ○ ○ ● Neurogenic ○ ○ ● Epinephrine Cortic ico osteroids Bronchodilators Cooling Supportive ca care Septic ○ ○ IV antibiotics IVF Break Back at…. Respiratory Anatomy & Physiology Respiratory System Anatomy Terminology ● Ventilation ○ ● Oxygenation ○ ● Airr mov Ai movem emen entt in an and d out out of th the e lun lungs gs Oxyg Ox ygen en in th the e blo blood odst stre ream am Perfusion ○ Oxyg Ox yge en in in th the tis tissu sue es Gas exchange The delivery of oxygen from the lungs to the bloodstream, and the elimination of carbon dioxide from the bloodstream to the lungs. Occurs in the alveoli through passive diffusion. Lung Sounds Chronic Obstructive Pulmonary Disease (COPD) What is Chronic Obstructive Pulmonary Disease? ● ● A gr grou oup p of of lun lung g di dise seas ases es th that at block airflow and make it difficult to breathe. Includes: ○ ○ ○ ● Emphysema Chr hro onic br bro onch chit itis is Asthma Dama Da mage ge is no nott re reve vers rsib ible le.. Categories ● ● ● Emphysema ○ Destructi Destruction on of alveol alveolii is due to to chronic chronic inflamm inflammation ation.. There There is decreas decreased ed surface surface area area of the alveoli for participation in gas exchange. Chron ronic Bronc ronch hit itiis ○ There is chroni chronic c inflamm inflammation ation with a producti productive ve cough cough and and excess excessive ive sputu sputum m Asthma ○ A respi respirator ratory y condition condition marke marked d by spasms spasms in the the bronchi bronchi of of the lungs, lungs, causin causing g difficul difficulty ty in breathing. There is chronic inflammation inflammation of bronchi and bronchioles, bronchioles, and excess mucus. Assessment ● ● Barrel ch chest Acc cce ess sso ory mus usc cle us use e ○ ○ ○ ● ● Retractions Nasal flaring Tracheal tug Congestion Lung sounds ○ ○ ○ Diminished Crackles Wheezes ● ● ● Acidotic Hypercarbic Hypoxic Treatment ● Che hes st phy phys sio ioth ther erap apy y ● ● Inc ncre reas ased ed fl flui uid d int inta ake Be ver very y care careful ful wit with h oxy oxygen gen adm admini inistr strati ation! on! ○ ○ ○ ● ● ● ● In the the norma normall patient patient,, hypercar hypercarbia bia stimu stimulates lates the body to breat breathe. he. This patie patient nt has has been been hype hypercarb rcarbic ic for for an exte extended nded perio period d of time For them, them, hypo hypoxia xia has has becom become e the the driving driving facto factorr to stimu stimulate late brea breathin thing g Bronchodilators Corticosteroids Encourage Enco urage purs pursed ed lip breat breathing hing to help expir expire e comple completely tely.. Eat small small frequ frequent ent meals meals to avoid avoid overd overdisten istention tion of of the stom stomach ach which impedes the diaphragm. Asthma What is Asthma? ● ● ● ● A re resp spir irat ator ory y con condi diti tion on mark marked ed by spasms in the bronchi of the lungs, causing difficulty in breathing. Ch Chro roni nic c inf infla lamm mmat atio ion n of of bro bronc nchi hi and bronchioles. Excess mucus. Re Resu sult lt of an alle allerg rgic ic reac reacti tion on or hypersensitivity. Pathophysiology 1. 2. 3. 4. 5. Airway is Airway is abnorm abnormall ally y reacti reactive ve - heigh heighten tened ed sensi sensitiv tivity ity Tri rigg gger er ca caus uses es a res respo pons nse e Inflam Inf lammat mation ion and and exc excess ess muc mucus us prod product uction ion occ occur ur Bronc Bro nchos hospas pasm m dec decrea reases ses the air airway way dia diamet meter er Airf Ai rflo low w beco become mes s obst obstru ruct cted ed After many asthma asthma reactions, airway airway remodeling occurs occurs which causes causes scarring and changes to lung tissue. Triggers A - Allergens S - Sport / Smoking T - Temperature change H - Hazards M - Microbes A - Anxiety Diagnosis ● Spirometry ○ ○ ○ ● Ass sse ess sses es lu lun ng fu funct ctio ion n Measures Meas ures how much much air air is inhaled inhaled,, exhaled exhaled,, and how quickly quickly it is exhale exhaled d Done Don e every every year year to asse assess ss progr progress ess and and treat treatmen mentt respon response se Peak Flow Meter ○ ○ ○ Evaluates Evalua tes the the amoun amountt of air air that that can be be exhale exhaled d in 1 secon second d Basel Ba seline ine est estab ablish lished ed whe when n the the child child is heal healthy thy Used Use d to asse assess ss the the severi severity ty of the ast asthm hma a exace exacerba rbatio tion n ■ Gr Gree een n = goo good d - 8080-10 100% 0% of pe pers rson onal al bes bestt ■ Yell ellow ow = cau cautio tion n - 5050-70 70% % of pe perso rsona nall best best ■ Red Re d emerge emer genc ncy y <50% <50% of of pers person onal al bes bestt Assessment ● Shortness of of br breath ● Unable to speak ○ ● ● Cough Incr In crea ease sed d wor work k of of bre breat athi hing ng ○ ○ ○ ● ● ● Evalua Eva luate te how how many many works works they they can can say say before before taki taking ng a breat breath h Retractions Tracheal tug Head bobbing Wheeze Pro rolo lon nge ged d ex expi pirrat atio ion n Can’t Can ’t hear hear any any breat breath h sounds sounds? ? Compl Complete ete obs obstru tructi ction. on. Complication - Status Asthmaticus ● ● ● Asthma Asth ma att attac ack k that that is is ref refra ract ctor ory y to to treatment Lead Le ads s to to seve severe re res respi pira rato tory ry fa faililur ure e Can Ca n pro progr gres ess s to to dea death th if un untr trea eate ted d Treatment - acute exacerbation ● Airw Ai rway ay,, brea breath thin ing, g, cir circu cula lati tion on!! !! ● ● Oxyge gen n admi admini nis str trat atio ion n B-A -Ad dre rene nerrgi gic c ago agoni nis sts ■ ■ ● Corticosteroids ■ ● ● ● Open up airway Albuterol Can Ca n be be giv given en IV IV,, IM IM or or PO PO Ipr pra atr trop opiu ium m Br Brom omid ide e Magnesium sulf lfa ate Theophylline Treatment - long-term control ● Inha In hale led d Co Cort rtic icos oste tero roid ids s ○ ○ ● B-A -Ad dre rene nerrgi gic c ago agoni nis sts ○ ○ ● Albute Albu tero roll & Ter erbu buta tali line ne Relaxe Rel axes s smoot smooth h musc muscles les and sto stops ps bron broncho chospa spasm sm Leu euk kot otrrie iene ne mo modi difi fier ers s ○ ○ ● Budeso Bude soni nide de & Flu Fluti tica caso sone ne Take daily Mont ntel elu uka kast st so sodi diu um Blocks Blo cks leuko leukotri triene enes s from from over over respon respondin ding g to trigg triggers ers All lle ergen control ○ ○ ○ Cle lea an en environment Mini Mi nimi mize ze dus dust, t, pet pet dan dande derr, and and mold mold No se seco con ndh dha and sm smo oke NCLEX Question The nurse is assessing a 6 year old patient with asthma. Which of the following findings is of most concern? a. b. c. d. Ex Exp pira irato tory ry wh whee eezi zin ng Silent chest Cough Head bobbing Answer: B A is incorrect. Expiratory wheezing is an expected finding when a patient is having an asthma exacerbation. This occurs when there is inflammation in the airways and air trapping, making it hard for the patient to fully exhale all of the air in their lungs. The wheezing is audible as they attempt to exhale. Although it is a significant finding, it is not the finding of most concern in this question, because the patient still has a patent airway airw ay.. B is correct. Silent chest is the assessment finding of most concern. This refers to the inability to auscultate any lung sounds. There is complete obstruction of the patient's p atient's airway, and therefore the inability to move air. When complete obstruction occurs, this is a medical emergency. This assessment finding is of most concern because the patient has lost their airway. C is incorrect. A cough is an expected finding when a patient is having an asthma exacerbation. This finding finding is not of most concern. D is incorrect. Head bobbing is an indication of increased work of breathing in the pediatric patient experiencing an asthma exacerbation. It occurs when the child's head moves forward each time they take a breath. This finding is significant and an indication that further support is needed, ne eded, but it is not the priority priority.. It is a ‘B’ for breathing, wh while ile there is another a assessment ssessment finding falling under the A priority for airway. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiologica Physiologicall adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric NCLEX Question A 15-year-old 15-year-old admitted for status asthmaticus has been stabilized. Which activity would be most appropriate for the client? a. b. c. d. Completing a jigsaw puzzle Talking with friends on the phone Watching Watching basketball on television Putting together a necklace Correct Answer: Answer: B A is incorrect. Teenagers need an op opportunity portunity to interac interactt with peers during their times of sickness to have an outlet to express their concerns. Completing a jigsaw j igsaw puzzle does not give the teenager an opportunity to achieve this. B is correct. Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Talking to friends over the phone enables the client to achieve this. C is incorrect. T Teenagers eenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Watching Watching television does not give the teenager an opportunity to achieve this. D is incorrect. Teenagers Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Arts and crafts do not give the teenager an opportunity to achieve this. Acute Respiratory Respiratory Distress Distress Syndrome Syndrome (ARDS) What is ARDS? ● “an acu “an cutte co cond ndit itio ion n characterized by bilateral pulmonary infiltrates and severe hypoxemia in the absence of evidence for cardiogenic pulmonary edema” ● ● Fluid Flui d co coll llec ects ts in al alve veol olii Depr De priv ives es bo body dy of ox oxyg ygen en Pathophysiology ● ● ● ● ● Inflammat Infla mmatory ory resp response onse in the lungs caus causes es an an injury injury to to the capil capillary lary endothelium basement membrane, interstitial space, and alveolar epithelium of the pulmonary system. The damag damage e to the lungs lungs caus causes es increa increased sed capil capillary lary membr membrane ane perme permeabilit ability y allowing fluid to fill the alveoli. This impairs gas exchange. The produ products cts of cell cell damage damage caus cause e the forma formation tion of of a hyalin hyaline e membrane membrane,, which further prevents oxygen exchange. With Wi th imp impai aire red d gas gas ex exch chan ange ge,, respiratory acidosis occurs. The dam damage age to to the lun lungs gs that that occ occurs urs can not be be revers reversed. ed. Causes Anything that causes lungs!! causes an inflammatory reaction in the lungs!! ● ● ● ● ● ● Sepsis Trauma Burns Asp spir irat atio ion n pn pneu eum mon onia ia Overdose Near drowning Assessment ● Chest x-ray ○ ○ ● Diffus Diff use e bi bila late tera rall in infi filt ltra rate tes s “Whited-out” Hypoxemia ○ ○ ○ ○ ○ Pale Cool Dusky Mottled Low SpO2 Treatment UNDE RLYING YING CONDITION CONDI TION TREAT THE UNDERL ● Intu In tuba bati tion on and and mec mecha hani nica call vent ventila ilati tion on ○ ● ● Prone Prevent in infection ○ ● High PEEP VAP Pre rev vent bar arot otrrau aum ma Pulmonary Edema What is Pulmonary Edema? A buildup of fluid in the lungs due to blood backup in the pulmonary vasculature. Pathophysiology ● ● ● ● ● ● Blood Bloo d back back up ups s in th the e pulm pulmon onar ary y vei veins ns.. There The re is inc increa reased sed pres pressur sure e in the the pulmon pulmonary ary vei veins ns.. Increase Incr eased d pressur pressure e causes causes fluid to to shift shift from from the capilla capillaries ries into the the alveoli alveoli and interstitial space. Flui Fl uid d bui build lds s up up in in the the al alve veol oli. i. This Th is ca caus uses es im impa pare red d gas gas ex exch chan ange ge Impared Impa red gas gas excha exchange nge leads leads to hypoxe hypoxemia, mia, hyper hypercarb carbia, ia, and and respira respiratory tory acidosis. Causes ● Decr De crea ease sed d ca card rdia iac c ou outp tput ut ○ ● Heart failure Pulm Pu lmon onar ary y hy hype pert rten ensi sion on Assessment ● ● ● ● ● ● ● ● Tachypnea Dyspnea Tachycardia Diaphoresis Crackles Cough Pin ink k tinged sputum ‘Wet’ ch chest xx-ray Treatment ● Oxygen ○ ○ ○ ○ ● ● ● Nasal cannula Face mask CPAP Intubation Monitor ABGs Monitor pe perfusion Medications ○ ○ Diuretics Nitroglycerin ○ ACE In Inhibitors Pulmonary Embolism What is a Pulmonary Embolism? ● ● ● ● Life thr Life threa eate teni ning ng blo blood od clo clott in th the e lung lungs s Can be caused caused by an embol embolism ism from from a vein enter entering ing the the lung, lung, or a clot clot during during surgery. The clo clott decre decrease ases s perf perfusi usion on caus causing ing hyp hypoxe oxemia mia Can lea lead d to to righ rightt hear heartt fail failure ure if untr untreat eated. ed. Assessment ● ● ● ● ● ● ● Anxiety Dyspnea Chest pain Hypoxemia Rales Diaphoresis Hemoptysis Treatment and Nursing Interventions ● ● ● Anticoagulants Thrombolytics Positioning ○ ○ Blood clot: ■ High fowler ’s ’s ■ Pr Promo omotes tes maxi maximu mum m lung lung expan expansio sion n and assi assists sts with with brea breathi thing ng Air embolism: ■ Durant’s ma maneuver ■ Le Left ft lat later eral al tre trend ndel elen enbu burg rg ■ This should should prev prevent ent an an air embolis embolism m from lodg lodging ing in ght ght lungs. lungs. Will Will stay in in the right right heart. Pneumonia What is Pneumonia? ● ● Inflammat Inflam mation ion of the lun lung g aff affect ecting ing the alv alveol eolii Alveoli ○ ● Tiny Ti ny air air sacs sacs of the the lungs lungs whic which h allow allow for for gas gas excha exchange nge Alve Al veol olii beco become me fil fille led d with with pus pus and and liq liqui uid d Classifications ● Viral ○ ● ● ● ● Caused Cau sed by by viruses viruses such such as RSV RSV, adenov adenoviru irus, s, and and influe influenza nza Bacteria Fungal Che hem mic ical al ir irrrit itat atio ion n Aspiration ○ ○ When forei foreign gn bodies bodies such as food food and secre secretion tions s enter enter the the lungs lungs Cause Cau se inflam inflamma matio tion n and infec infectio tion n leadin leading g to pneu pneumon monia ia Diagnosis ● Chest x-ray ○ ● “Pa “P atc tch hy inf infil ilttra rattes es”” Sputum culture ○ Will Wi ll id iden enti tify fy a bac bacte teri rial al so sour urce ce Assessment ● ● ● ● ● ● High fever Cough Tachypnea Crackles Chest pain Work of breathing ○ ○ ○ ○ ○ Retractions Tracheal tug Nasal Flaring Grunting Head bobbing Treatment ● Maintain airway ○ ○ ● Monitor breathing ○ ○ ○ ● Suction Monitor SpO2 Assess Asse ss for for inc incre reas ased ed wor work k of bre breat athi hing ng Prov Pr ovid ide e sup suppo port rt as ne need eded ed Humidif ifie ied d ox oxygen Mai aint nta ain cir irc cul ulat atio ion n ○ ○ Monito Moni torr fo forr de dehy hydr drat atio ion n IVF IV F ifif una unabl ble e to to tol toler erat ate e PO PO ● ● ● ● ● ● ● Che hes st ph phy ysio ioth the era rapy py Isolation Antipyretics Analgesia Cough su suppressant Expectorants Anti An tibi biot otic ics s if ba bact cter eria iall NCLEX Question The nurse is reviewing the discharge teaching with a family who will be taking their 12 year old diagnosed with pneumonia home today today.. Which of the following points should she review? Select all that apply apply.. a. b. c. d. Enc Encour ourage age you yourr ch child ild to d drin rink k lo lots ts o off wa water ter.. Admin Administer ister the fu fullll cou course rse o off anti antibioti biotics, cs, eve even n if yo your ur chi child ld sta starts rts to feel b better etter.. Cal Calll you yourr ped pediat iatric rician ian iiff the there re is ttan an sp sputu utum m whe when n whe when n chi child ld co cough ughs s Adm Admini inister ster ibu ibupro profen fen if you yourr c chil hild d has has a ffeve everr Answer: A and B A is correct. It is appropriate teaching to have the parents encourage their child to drink lots of water. Pneumonia can frequently cause dehydration, due to tachypnea and increased insensible fluid losses. Parents should encourage adequate hydration to promote fluid and electrolyte balance while their child is recovering from pneumonia. B is correct. It is very important to teach parents pare nts to administer the full course of antibiotics, even if their child starts to feel better. If the parents stop administering antibiotics part of the way w ay through the course, they will be promoting antibiotic resistance and the chance that the infection could return. C is incorrect. The parents do not need to call the pediatrician if there is tan sputum when the child coughs. This is a normal finding of pneumonia and should be expected. If there is a new onset of green sputum, this could indicate the development of a bacterial pneumonia and the need to call the pediatrician. D is incorrect. It is not appropriate to administer ibuprofen if the child has a fever. Ibuprofen is an analgesic, and does not have antipyretic properties. If the child develops a fever, the parents should be encouraged to administer acetaminophen, which is an antipyretic. NCSBN Client Need: Topic: Health promotion and maintenance Subtopic:Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Respiratory Break Back at…. Neurology Anatomy & Physiology Impulse transmission Neurotransmitters Intracraniall Pressure Intracrania Intracranial Pressure ● ● ● The pre The press ssur ure e ins insid ide e of of the the sk skul ulll Normal = 5-15 Monr Mo nroo-Ke Kell llie ie hy hypo poth thes esis is ○ ● The skull skull is a rigid contain container er filled filled with: blood blood,, brain, brain, and CSF CSF. If one of of those those three three increases, increases, another must decrease. Caus Ca uses es of in incr crea ease sed d IC ICP: P: ○ ○ ○ ○ Tumor Bleeding Hydrocephalus Edema Cerebral Perfusion Pressure Cerebral Perfusion Pressure ● The amou amount nt of pres pressur sure e availab available le for perf perfusi usion on to the the brain brain ● CPP = MAP - ICP ● ● Normal = >70 If CPP CPP is is <70, <70, ther there e is not not enou enough gh bloo blood d flow flow to the the brai brain n Neurological Injuries Skull Injury ● Open fracture ○ ● Closed fr fracture ○ ● Torn dura Dura is intact Bas asil ilar ar skul ulll fr frac actu ture re ○ ○ ○ Battle’s sign → Bruising over the mastoid process Raccoon eyes → Periorbital bruising Cere Ce rebr bros ospi pina nall rhin rhinor orrh rhea ea ■ Test dra rain inag age e fo for CS CSF ● Halo test ○ ● Glucose NEVER NEV ER INSERT INSERT AN NG TUBE TUBE IN A PA PATIEN TIENT T WITH A BASILA BASILAR R SKULL SKULL FRACTUR FRACTURE E Epidural Hematoma ● ● ● ● Ruptur Rupt ure e to th the e midd middle le men menin inge geal al art arter ery y Fast bleed High pressure Char Ch arac acte teri rist stic ic pat patte tern rn of of symp sympto toms ms:: ○ ● Injury → loss of consciousness → recover → body compensates and they seem okay → body is unable to compensate anymore and neuro changes begin ■ Agitation ■ Restlessness ■ Pupil chance “Talk “T alk and die phe phenom nomeno enon” n” - med medica icall emerg emergenc ency y ● Tre reat atm men entt - bu burrr hol hole e Subdural Hematoma ● ● ● ● Venous bleed Slow Sl ower er an and d le less ss pr pres essu sure re Common Com monly ly see seen n in chr chroni onic c geri geriatr atric ic pat patien ients ts Tre reat atme ment nt:: cr cran anio ioto tomy my Stroke What is a stroke? “A disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a leading cause of disability in the United States. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts” …..There is a lack of oxygen to the brain, and that causes damage! This lack of oxygen can be: ● ● Hemorrhagic Ischemic Pathophysiology - Hemorrhagic stroke ● ● ● A vessel vessel rup ruptur tures es and and b blee leeds ds iinto nto the bra brain. in. As the blood accu accumulat mulates, es, there is in increa creased sed pres pressure sure on tthe he b brain rain The ruptu rupture re c can an be caus caused ed by a wea weakene kened d ve vessel ssel,, suc such h as in an aneur aneurysm. ysm. “Worst headache of my life” Pathophysiology - Ischemic stroke ● ● ● Blood Blood fflow low to tthe he b brai rain n is blo block cked ed b by y a bloo blood d cl clot. ot. There There is a los loss s of b bloo lood d cir circu culat lating ing to to thi this s ar area ea of the b brai rain. n. The lack of blood leads to a lack of oxygen, causing ischemia and damage. Assessment ● FAST ○ ○ ○ ○ ● ● ● Facial droop Arm drift Speech pr problems Tim ime e - ca call 911 ASAP - Time is brain cells! Altered LOC ○ Confusion ○ Lethargy ○ ‘Not ac acting ri right” Aphasia Apraxia ● ● Loss of vision ○ Abno Abnorm rmal al pupi pupill res respo pons nse e ○ Hemianopia Dysphagia Treatment Ischemic ● Perm Pe rmis issi sive ve hy hype pert rten ensi sion on ○ ● ● ● Antithrombotic ics s ○ ○ ○ ● Ensu En sure re th ther ere e is is per perfu fusi sion on to th the e bra brain in Hemorrhagic tPA Brea Br eak k up up clo clott to to res resto tore re bl bloo ood d flo flow w Must Mu st be don done e qui quick ckly ly - door door to tP tPA A = 60 60 min Perc Pe rcut utan aneo eous us thro thromb mbec ecto tomy my ○ ○ Surgic Surg ical al re remo mova vall of of cl clot Done in IR Get the Get the bl blee eedi ding ng un unde derr con contr trol ol If ca caus used ed by an an aneu eury rysm sm:: ○ ○ ● ● Coiling - IR Clipping - OR Craniotomy EVD NCLEX Question You are working in the Emergency Department when a patient with a suspected stroke arrives. According According to the American Heart Assoc Association iation (AHA), the general immediate assessment and stabilization should include: (Select all that apply) a. b. c. D. Activate the stroke team Check and treat the glucose Order an immediate CT or MRI of the brain Administ Administer er tPA tPA Answers: A, B, and C According to the AHA, the immediate gene general ral assessmen assessmentt and stabilization should should include: assess the ABCs and vital signs, provide oxygen as needed, obtain an IV IV,, check glucose and treat as needed, perform an essential neurologic screening, activation of the stroke team, order an immediate CT or MRI of the brain, and obtain an ECG. All of these actions should be included within the first 10 minutes after arrival at the ED. The decision of whether or not to give tPA will depend on the results of the CT scan or MRI. If the provider determines that there is no brain hemorrhage, the team should complete the fibrinolytic checklist before deciding whether or not to give rtPA. Seizures What are Seizures? ● ● ● Seiz Seizur ures es a are re n not ot a dis disea ease se iin n th them emse selv lves es They They ar are eas symp ymptom tom of a an n un under derlyi lying ng diso disorde rderr. Epilepsy ○ ○ “A neurologi neurological cal diso disorder rder marked marked by by sudden sudden recurrent recurrent episod episodes es of sensory sensory disturb disturbance ance,, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.” No othe otherr unde underl rlyi ying ng dis disor orde derr Classifications Seizures Partial ‘focal’ Simple Complex Generalized ‘non-focal’ Tonic/Clonic ● ● ● ● Partial - limited to a specific area of the brain Generalized - Involves the entire brain Simple - No loss of consciousness. Complex - Impared consciousness ranging from confusion to non responsive ● ● ● Tonic/Clonic - Phases of tonic and clonic spasm Myoclonic - sudden, brief contractions of a muscle or group of muscles Absence - Loss of consciousness; staring off into space. Treatment ● Anticonvulsants ○ ○ ● ● Myoclonic Rapid acting - lorazepam Long acting - phenytoin Very imp import ortant ant to moni monitor tor for the therap rapeut eutic ic level levels s Never Nev er stop stop tak taking ing sudd suddenl enly y - can can caus cause e a seiz seizure ure Absence Seizure Precautions NCLEX Question Seizure precautions have been ordered for a patient admitted to the psychiatric unit. Which of the following nursing interventions is not appropriate when initiating seizure precautions? Select all that apply. a. b. c. d. Pad the side rails of the bed Lower side rails while the patient sleeps Remove hard or sharp objects from the bed Use four point restraints to prevent injury e. Adhere a fall risk bracelet to the seizure prone patient Answers: B and D The correct answers are B and D. Padded bed rails should remain up while the patient sleeps. Patients should be provided with a call light so that they may call for help if needed. Four-point restraints are not appropriate for the seizing patient and could result in injury. Choice A is incorrect. When initiating seizure precautions, the nurse should ensure that the side rails are padded. Choice C is incorrect. All sharp objects should be removed from a patient’s bed when instituting seizure precautions. Choice E is incorrect. Patients prone to seizures should wear a fall risk bracelet to alert members of the health care team to the patient’s need for increased Spinal Cord Injury (SCI) What is a Spinal Cord Injury? ● ● ● ● Dama Damage ge to the the spinal spinal cord cord causes causes permanen permanentt changes changes in strength, strength, sensa sensation tion and and other other body functions below the site of the injury. Sym Sympto ptoms ms depend depend on locati location on of the inj injury ury The higher higher the inj injury ury - the more more functi function on that that is lost. lost. Injuries ab above T6: ○ Monitor for autonomic dysreflexia Autonomic dysreflexia ● Synd Sy ndro rome me cha chara ract cter eriz ized ed by by ○ ○ ○ ○ ○ ○ ○ ○ Sudden Sudd en se seve vere re hyp hyper erte tens nsio ion n Bradycardia Headache Nasal stuffiness Flushing Sweating Blurred vision Anxiety Causes Treatment 1. 2. Sit the Sit the pa pati tien entt up up to lo lowe werr the their ir BP Find Fi nd th the e ca caus use e an and d tr trea eatt a. b. c. d. e. Full bl Full bla add dde er? Cat ath h Cons Co nsti tipa pate ted? d? Re Remo move ve im impa pact ctio ion n Pres Pr essu sure re inj injur ury? y? Rep Repos osit itio ion n Pain Pa infu full sti stimu muli? li? Re Remo move ve st stilu ilumi mi Cold Co ld roo room? m? Cha Chang nge e the the temp temper erat atur ure e 3. Ant ntih ihy ype perrte tens nsiv ive es a. Hydralazine Meningitis What is Meningitis? ● ● Inflam Infl amma mati tion on of of the the spin spinal al cor cord d or bra brain in.. Caus Ca used ed by a vir virus us or ba bact cter eria ia.. ○ Bact Ba cter eria iall is mor more e dan dange gero rous us Assessment ● ● Nuchal rigidity Photophobia Treatment ● ● ● ● Steroids Analgesics Anti An tibi biot otic ics s - on only ly if ba bact cter eria ial! l!!! Iso sola lati tion on p pre rec cau auti tion ons s ○ ○ ● Vir iral al - cont contac actt pre preca caut utio ions ns Bact Ba cter eria iall - Dr Drop ople lett pre preca caut utio ions ns ■ Bact Bacterial erial meni meningiti ngitis s is VER VERY Y conta contagiou gious!! s!! Medi Medical cal emer emergenc gency!! y!! Prevention ○ Hib vaccine ○ Recommended Recommend ed for college students due to living in close quarters in dorms Day 1done! See you tomorrow morning at 8:00 am! Welcome to Day 2! You’ve got this!! Gastrointestinal Pancreatitis What is pancreatitis? Inflammation of the pancreas. No. 1 cause = alcoholism Pathophysiology ● ● Digestive Digest ive enzy enzymes mes act activa ivate te insid inside e of the the pancre pancreas. as. This Thi s caus causes es aut autodi odiges gestio tion n of of the the pancr pancreas eas.. Assessment ● Pain ○ Increa Inc reases ses wit with h eatin eating g due due to inc increa reased sed enz enzyme ymes s ● ● ● ● ● ● ● ● Abd bdom omin inal al di dis ste tent ntio ion n Ascites Abdominal mass Rigid abdomen Cullen’s sign Gray Tur urne ner’ r’s s sig ign n Fever Nausea & vomiting ● ● J Hayupnodteicnesion Treatment ● ● ● ● ● ● NPO NGT to suction Bed rest Pain medications Steroids GI pr protectants ○ ○ ○ Pantoprazole Ranitidine Antacids ● M○oniFl touid rdI& O’elec sectr Flui and el and trol olyt yte e bal balan ance ces s ● ● Daily weight NO ALCOHOL Ulcerative Colitis & Crohn's Disease What is Ulcerative Colitis? ● Infl In flam amma mati tion on of of the the larg large e inte intest stin ines es.. What is Crohn's Disease ● Inflammation Inflammat ion AND erosio erosion n of the ileum ileum and anywh anywhere ere throug throughout hout the small small and large intestines. Assessment ● ● ● ● ● ● ● ● Rebound ten tenderness Cramping Diarrhea Vomiting Dehydration Weight loss Rectal bleeding Bloody stools ● ● Anemia Fever Treatment ● ● ● ● ● ● ● Low fiber diet Avoi oid d col cold d or or hot hot foo oods ds No smoking Antidiarrheals Antibiotics Steroids In sever severe e cases cases may end up up surgica surgically lly remov removing ing affec affected ted portio portion n of the intestines. ○ ○ Ileostomy Colostomy Appendicitis Appendiciti s What is appendicitis? ● ● ● ● Inflam Infl amma mati tion on of th the e app appen endi dix x Most Mo st co comm mmon on ag age e = 10 ye year ars s Mostt comm Mos common on abd abdomi ominal nal sur surger gery y in in child children ren Perf Pe rfor orat atio ion n mor more e com commo mon n in ch child ildre ren n Diagnosis ● Physical exam ○ ○ ○ ● Labs ○ ○ ● Severe pain Pain Pa in in RL RLQ Q - Mc McBu Burn rney ey’s ’s Po Poin intt Reb ebo oun und d te ten nde dern rnes ess s CBC sho show ws ele eleva vate ted d WB WBC Elevated CRP Imaging ○ CT sh show ows s inf infla lame med d app appen endi dix x Assessment ● Abdominal pa pain ○ ○ ○ ○ ● ● ● ● Usually Usua lly be begi gins ns as ge gene nera raliz lized ed pa pain in As inf inflam lammat mation ion pro progre gresse sses, s, loca localiz lizes es to RL RLQ Q Reboun Reb ound d ten tender dernes ness s → ind indica icates tes per perito itonit nitis is Sudde Su dden n relie relieff of the pai pain n indic indicate ates s perfo perforat ration ion Nausea Vomiting Decreased app appetite Fever Management ● ● Tre reat atme ment nt - app appen ende dect ctom omy y Pre-op ○ ○ ● No heat heat - this this can can aggrava aggravate te inflam inflamed ed appen appendix dix and and cause cause rupt rupture ure Posit Po sition ion rig right ht sid side, e, low Fow Fowler’ ler’s s for for com comfo fort rt Post-op ○ ○ ○ ○ IV Fluids IV antibiotics Pain management NPO NP O unt until il re retu turn rn of bo bowe well sou sound nds s ○ Wound care NCLEX Question 1. The nurse nurse is reassess reassessing ing her patien patientt diagnosed diagnosed with with appendi appendicitis citis.. The patient patient expres expressed sed 8/10 8/10 pain at her last assessment, and now states she has no pain. The nurse did not administer any pain medication. What is the appropriate nursing action? a. Do Docu cume ment nt th the e pa pain in sc scor ore e b. As Asse sess ss th the e pa pati tien ent’ t’s s ab abdo dome men n c. No Noti tify fy th the e hea healt lthc hcar are e pro provi vide derr d. Pa Palp lpat ate e McB McBur urne ney’ y’s s poi point nt Answer: C A is incorrect. When a patient diagnosed with appendicitis has sudden relief of pain, it is a sign of possible rupture of the appendix. This is a surgical emergency and the patient must be taken to the operating room quickly. It is not appropriate for the nurse to document the pain score without further intervention. B is incorrect. It is not appropriate to simply assess the patient’s abdomen without further intervention. Sudden relief of pain is concerning for rupture of the appendix and requires another action. C is correct. The nurse should immediately notify the healthcare provider of this change in the patient’s status. A sudden change of 8/10 pain to no pain in the patient diagnosed with appendicitis could indicate rupture, and the healthcare provider needs to be immediately notified. D is incorrect. The patient with appendicitis will likely have pain at McBurney’s point, but this patient is expressing a sudden relief of their pain. This needs to be evaluated for possible rupture, and therefore the nurse should immediately notify the healthcare provider. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Endocrine Hepatitis What is hepatitis? ● ● ● ● Inflam Infl amma mati tion on of th the e liv liver er.. Can Ca n pro progr gres ess s to to cir cirrh rhos osis is Types A, B, C, D, D, and E - caus caused ed by diff different erent viral infec infections tions Seve Se vere re cas cases es can can lea lead d to a hep hepat atic ic com coma. a. Hepatic coma ● ● Protein Protei n in yo your ur diet diet is brok broken en down down int into o ammon ammonia. ia. Liver Liv er is is suppo supposed sed to conv convert ert the amm ammoni onia a into into urea urea.. ○ ● ● Kidn Ki dney eys s can can ex excr cret ete e ure urea. a. When there is inflamm inflammation ation of the the liver liver due due to hepat hepatitis, itis, the ammoni ammonia a builds builds up instead of being converted to urea Increased ammonia levels can cause a hepatic coma. Assessment ● ● ● ● ● Alt lte ered level of consciousness Difficult to to aw awake Hyperreflexia Asterixis Fetor Treatment ● ● ● ● Lactulose ○ ○ The binding of ammonia prevents ammonia from moving from the colon into the blood ○ Allows Allows tthe he am ammon monia ia to be ex excre creted ted d decr ecreas easing ing s seru erum m amm ammoni onia a Bacteria in the colon digest lactulose into chemicals that bind ammonia Cleansing enema Decreased pr protein Mon onit ito or se seru rum m amm ammon onia ia Cirrhosis What is Cirrhosis? ● ● ● ● A chronic chronic disease disease of of the liver marked marked by degene degeneratio ration n of cells, inflam inflammati mation, on, and fibrou fibrous s thickening thickening of tissue. Liver Liver c cell ells s destr destroye oyed d and and repla replaced ced with with scar scar tiss tissue ue This impairs impairs blood flow to the liver causi causing ng portal portal hyperten hypertension sion Causes: ○ Alcoholism ○ Hepatitis Assessment ● ● ● ● ● ● ● Pal alpa pabl ble, e, fi firm rm li liv ver Abdominal pa pain Dyspepsia Decr De crea ease sed d se seru rum m al albu bumi min n Ascites Splenomegaly Incr In crea ease sed d li live verr en enzy zyme mes s ○ ○ ● ALT AST Anemia Treatment ● ● ● ● ● ● ● ● ● Antacids Vitamins Diuretics Stricts I& I&Os Daily weights Rest Ble leed edin ing g pre prec cau auti tio ons Paracentesis Skin care f the o s n o i r funct f clotting o j a m on o f t he One o the producti ctors. iver is l fa g risk Liver edin e l b = e damag ● ● Low pro Low prote tein in,, low low so sodi dium um di diet et Be very careful with drug doses. The liver cannot metabolize as well; most doses need to be decreased. Especially important with : ○ ○ Narcotics Acetam Ace tamino inophe phen n (as (as a rule rule,, avoid avoid in live liverr patie patients nts)) Genitourinary Glomerulonephritis What is Glomerulonephritis? An acute inflammation of the kidney at the level level of the nephron. Pathophysiology ● ● ● ● There is an There an inflam inflammat matory ory reac reactio tion n in the glom glomeru erulus lus of of the kidn kidney ey Anti An tibo bodi dies es lo lodg dge e in in the the gl glom omer erul ulus us This Thi s decre decrease ases s the the filter filtering ing capa capabil bility ity of of the kidn kidney ey Usua Us ualllly y ca caus used ed by an in infe fect ctio ion n ○ #1 = strep Assessment ● ● ● ● ● ● ● S Moarle aitsheroat Headache Flank pain Hypertension Edema Decreased UOP ○ ○ ● Increa Incr ease sed d urin urine e spe speci cifi fic c gra gravi vity ty Sediment in urin ine e Inc ncre reas ased ed BU BUN N and Cr Treatment ● Anti An tibi biot otic ics s fo forr str strep ep in infe fect ctio ion n ○ ● ● ● ● ● Ensur En sure e client client tak takes es the the entir entire e course course of of antib antibiot iotics ics Stri Strict ct int intak ake e and and outp output ut m mea easu sure reme ment nt Rest Monitor B BP P Rep epla lac ce fl flui uid d lo los sses Diet ○ Decreased pr protein ○ Decreased so sodiu ium m ○ Increased carbs Nephrotic Syndrome What is nephrotic syndrome? A kidney disorder that causes yo your ur body to pass too much protein in your urine. Causes: ● ● ● ● In Infe fect ctio ion: n: ba bact cter eria iall or vi vira rall NSAIDS Cancer Lupus ● Diabetes ● ● Strep INFLAMMATION Pathophysiology ● ● ● An inflam inf lammat matory respon res ponse seulus insthe the glomer glo ulus. s. Large Lar ge holes hol es inory the the glomer glo merulu form, form , merulu allowin allo wing g protein to leak into the urine. urine. Prot Pr otei ein n lea leave ves s th the e bl bloo ood d ○ ○ ● ● ● ● Proteinuria Hypoproteinemia No protei protein n in the blood? blood? Patie Patient nt cannot cannot hold onto fluid → third third spacin spacing g Fluid is collect collecting ing in the tissue tissues, s, but the circul circulating ating blood volum volume e is low low. RAAS kick kicks s in in to to replac replace e low low blood blood volum volume e --> --> caus causes es rete retention ntion of sodiu sodium m and water With Wit h no prote protein in in the the blood blood to to hold hold it, furt further hers s third third spac spacing ing Assessment ● ● ● Anasarca Blood clots High cholesterol ● ● ● Proteinuria Hypoalb lbu uminemia Edema ● Hyperlip ipid ide emia Treatment ● ● ● ● ● ● ● Diuretics ACE in inhibitors Prednisone Statins Anticoagulation Dialysis Diet ○ ○ High protein Low sodium NCLEX Question Prednisone is to be given to a 4-year-old child with nephrotic syndrome. Which symptom would the nurse be alert for as a sign of a the most serious side effect of the medication? a. b. c. d. Respiratory rate of 12 breaths per minute Weight gain and increased hair growth Metabolic acidosis Decreased ACTH levels; stomach, muscle weakness, muscle pains Answer: D A is incorrect. Decreased Decreased resp respirations irations are not a common common side ef effect fect of prednisone in children. B is incorrect. Prednisone can result in Cushingoid appearance; however,, it is not a severe side effect of the medication. C is incorrect. Prednisone however does not have metabolic acidosis as a side effect. D is correct. Prednisone can lead to adrenal suppression, which is a potentially life-threatening side effect of the drug. Renal Failure Terminology ● Acut Ac e K Kid idne ney y In Inju jury ry (A (AKI KI) ) ) is a sudden episode of kidney failure or kidney ○ ute Acute kidney injury (AKI (AKI) ○ ● damage that happens within a few hours or a few days. AKI causes a build-up of waste products in your blood and makes it hard for your kidneys to keep the right balance of fluid in your body. Acut Acute e Ren Renal al Fail Failur ure e (AR (ARF) F) Chro Chroni nic c Ki Kidn dney ey D Dis isea ease se ((CK CKD) D) ○ Chronic kidney disease (CKD (CKD)) means your kidneys are damaged and can't filter blood the way they should. The disease is called “chronic “chronic”” because the damage to your kidneys happens slowly over a long period of time. This damage can cause wastes to build up in your body. Causes ● PrePr e-re rena nall - Bloo Blood d cann cannot ot get get to to the the kidn kidney eys s ○ ○ ○ ● Hypotension Hypovolemia Shock IntraIntr a-re rena nall - Ther There e is dam damag age e insi inside de of of the kidney ○ ○ ○ Glom ome erul ulo oneph phrritis Neph Ne phro roti tics cs sy synd ndro rome mes s Nep eph hrot oto oxic dr dru ugs ■ Contrast ■ ● Aminog ogllycos osiides Post-rena Post-r enall - Som Someth ething ing is bloc blockin king g urin urine e from from leaving the kidneys ○ ○ ○ Kidney stone Tumor Uret Ur ethr hral al ob obst stru ruct ctio ion n Phases 1. Olig Ol uric phas ph Lasts ts 1 to to 3 wee weeks ks.. a.igur Deic cre asase e UeO-P Las b. c. 2. Fluid vo Flu volu lum me ex exce cess ss Hyperkalemia Diuret Diu retic ic phas phase e - reco recover very y can can take take up up to 12 12 month months s a. b. c. d. Sudd dde en in incr cre eas ase e in in UOP UOP Flu Fl uid vo volu lum me de defi fici citt Hypokalemia Shock Assessment ● Labs Lab s (dep (depend end on what what pha phase se the the pati patient ent is in!! in!!): ): ○ ○ ○ ○ ○ ○ ○ ● ● Increased BUN & Cr Increa Inc reased sed urin urine e specif specific ic gravit gravity y (durin (during g oligur oliguric ic phase) phase) Decreased H&H Hyperkalemia Hyp ype erp rpho hosp spha hate tem mia Hypocalcemia Meta tabo boli lic c ac acid idos osis is Hypertension Heart failure ● ● ● ● Anorexia Nausea & vomiting Itching Osteoporosis Treatment ● ● ● Clo los se fol follo low w up up wit with h PCP PCP Regula larr la lab b work Dialysis NCLEX Question Which of the following are (are) sign(s) and symptom(s) of renal failure? Select all that apply. a. b. c. d. Metabolic alkalosis Metabolic acidosis Hyperkalemia Hypomagnesemia Answer: B and C The signs and symptoms of renal failure include metabolic acidosis and hyperkalemia, among many other signs and symptoms. Choice A is incorrect. Metabolic alkalosis can occur as the result of vomiting, Cushing’s syndrome, and other causes, not including renal failure. Choice D is incorrect. i ncorrect. Hypomagne Hypomagnesemia semia can occur as the result of diarrhea, pancreatitis, and burn, among other causes, not including renal failure. Dialysis Types A treatment that gets rid of the bodies unwanted unwanted toxins, waste waste products and excess fluids by filtering the blood. 1. Per erit ito one nea al Di Dial aly ysis 2. Hemodialysis 3. Cont Contin inuo uous us Re Rena nall Rep Repla lace ceme ment nt T The hera rapy py Hemodialysis ● ● ● Don one e 33-4 tim times es per we week ek.. Pati Pa tien entt mu must st be an anti tico coag agul ulat ated ed Will cause rapid fluid shit (300-800 mL/min) ○ ○ ○ ● Monitor BP Moni nito torr ele elect ctro roly lyttes Not all ca can n tol ole era ratte Pati Pa tien entt mus mustt hav have e a fi fist stul ula a ○ ○ ○ No BPs BPs/s /sti tick cks s in the the arm arm of of the the fist fistul ula a Palpate a thrill Auscultate a br bruit Peritoneal Dialysis ● ● ● ● ● Uses Use s the the per perito itonea neall membr membrane ane as the fil filter ter instead of a machine Process: ○ Dia Dialys lysate ate is inf infuse used d into into per perito itonea neall cavi cavity ty (2,000-2,500 mLs) ○ Dw Dwel ells ls fo forr abo about ut 10 mi minu nute tes s ○ Flu Fluid id is dra draine ined, d, tak taking ing the tox toxins ins alo along ng with it. Drai Dr aina nage ge sh shou ould ld be cl clea earr - cloudy drainage indicates an infection. Ensu En sure re all all of of the the dias diasty tyla late te com comes es off off.. ○ Tur urn n side side to to side side ifif decr decrea ease sed d flui fluid d returns. Thi This s is bett better er for for pati patient ents s who who canno cannott toler tolerate ate the fluid shifts in hemodialysis Continuous Renal Replacement Therapy (CRRT) ● ● ICU treatment Done Do ne con conti tinu nuou ousl sly y to avo avoid id flu fluid id shi shift fts s ○ Only On ly ab abou outt 80 80 mL mL at a tim time e Sexually Transmitted Diseases (STDs) Herpes Simplex Virus (HSV) ● Transmission ○ ○ ○ ○ ● Viral inf Viral infect ection ions s spread spread by touc touchin hing g the the infec infected ted are area a Stil St illl con conta tagi giou ous s is is asy asymp mpto toma mati tic c Type I - cold sores Typ ype e II II - gen enit ita al so sore res s Risk Fa Factors ○ ○ ○ Immuno Immu noco comp mpro romi mise sed d pa pati tien ents ts Mult Mu ltip iple le se sexu xual al pa part rtne ners rs Unproteted se sex ● Assessment ○ ○ ○ Raised, erythematous blisters Open up and then crust over as they heal Painful ● Treatment ○ ○ No cure Mana Ma nage ged d with with ant antiv ivira irall medi medica cati tion ons s Syphilis ● ○ ● Assessment ○ Chancre-like sore ○ ○ Progresse Progre sses s in 4 sta stages ges;; conta contagio gious us even even in late latent nt phase Risk Fa Factors ○ ○ ● ● T○ranSe smxual issl iconta on Sexua co ntact, ct, con contac tactt with with blo blood, od, inin-ute utero ro IV drug use Mult Mu ltip iple le se sexu xual al pa part rtne ners rs Diffuse rash Organ damage ■ Hearing and vision loss ■ Dementia ■ Chest pain Treatment ○ ○ ○ Organ dam Organ damage age can be pre preven vented ted if cau caught ght ear early ly Peni nici cill llin in - 1st 1st ch cho oic ice e Other abx ■ Do Doxy xycy cycl clin ine, e, ce ceft ftri riax axon one e Gonorrhea ● Transmission ○ ○ ● Sexuall conta Sexua contact ct bet betwee ween n muco mucous us me memb mbran ranes es Can spread spread to infan infantt during during delivery delivery - administe administerr erythromy erythromycin cin eye ointm ointment ent after after vaginal vaginal deliveries Assessment ○ ○ ○ ○ ○ ○ Purulent dis discharge Fema Fe male le - Vag Vagin inal al bl blee eedi ding ng Male Ma le - sc scro rota tall pain pain and and pe peni nile le swe swelli lling ng Pel elvi vic c and and lo lowe werr bac back k pai pain n Fever Can Ca n lead lead to seri serious ous com compli plicat cation ions s if unt untrea reated ted:: ● Treatment ○ ○ ○ Early treatment can prevent compromising fertility Ceftriaxone Azithromycin ■ ■ ● Males Male s - sp spre read ads s to to upp upper er GU or orga gans ns Female Fem ales s - PI PID, D, sca scarri rring ng of fal fallop lopian ian tub tubes es Risk Fa Factors ○ ○ ○ Unprotexted se sex Sex workers Othe Ot herr STDs STDs (co (comm mmon on wit with h Chl Chlam amyd ydia ia)) Chlamydia ● Sexual contact ○ Can spre Can spread ad to inf infan antt durin during g vagi vagina nall delivery Cont Co ntag agio ious us be befo fore re sy symp mpto toms ms oc occu curr Comm Co mmon on w/ ot othe herr STD STDs s (go (gono norr rrhe hea) a) Mor ore e co common in in fe femal ale es ● ○ Risk Factors ○ ○ ○ Under 25 y.o. Unprotected se sex Mul ulti tip ple part rtn ner ers s Treatment ○ Assessment ○ ○ ○ ○ ○ ● ● Transmission Females ■ PID Vaginal aginal discharge discharge ■ V ■ Pain with sex ■ Dysuria Male ■ Dysuria ■ Penile discharge ● Can spread to eyes ● ● Cause blindness Joint swelling Azithromycin Break Back at…. Hematology & Infectious Disease Sickle cell anemia Sickle Cell Anemia A disorder that causes causes the red blood cells cells to ‘sickle’ and break down. This causes severe pain. It is an inherited disease, and mainly affects the African American American population. If both parents are carriers... ● 25% 25% cha chanc nce e the they y wil willl hav have e the disease (ss). ● 25 25% % cha chanc nce e the they y wil willl not not have the disease (SS). ● 50 50% % ch chan ance ce th they ey wi will ll al also so be a carrier (Ss). If one parent is a carrier, and the other has the disease…. ● 50% 50% cha chanc nce e the they yw wil illl hav have e the disease (ss). ● 50 50% % cha chanc nce e the they y wil willl a als lso o be a carrier (Ss). If one parent has the trait, and the other does not…. ● 100 00% % ch cha anc nce e th the ey wi will ll also be a carrier (Ss). Pathophysiology ● ● Those Thos e with with the the tra trait it hav have e ‘sic ‘sickl kled ed’’ RBCs The Th e sic sickl kled ed ce celllls s are are no nott abl able e to to carry oxygen like they should ○ ● Dec ecre rea ase sed d perf rfu usi sio on Due to Due to the their ir sh shap ape, e, th they ey ca can n get get caught in vessels and cause obstruction Sickle Cell Crisis ● ● ● The decr decrease eased d blood blood flow flow to the tissu tissues es leads leads to to hypoxia, hypoxia, isch ischemia, emia, and infarction. Ther Th ere e is se seve vere re jo join intt pa pain in Sequestration ○ ○ ○ ● Blood pools Often in in the sp spleen Sple Sp leno nome mega galy ly an and d te tend nder erne ness ss Acute Acut e exacerb exacerbation ation can be be caused caused by by hypoxia hypoxia,, exercis exercise, e, high high altitude altitude (due (due to low oxygen), and fever. Assessment ● ● ● ● ● ● Pallor Pain Fatigue Arthralgia Chest pain Res espi pirrat ato ory dis istr tres ess s Interventions ● IV Fluids ○ ○ ● Blo loo od tr transfusion ○ ○ ● This helps helps dilute dilute the blood blood so that that the the sickled sickled cells cells are not so concent concentrate rated d Pro rovi vid des hyd ydra rattio ion n Pro rovi vid des nor norm mal RBCs Helps Hel ps opti optimiz mize e oxyge oxygena natio tion n and and bette betterr perfu perfusio sion n Oxygen ○ Increa Inc rease se oxyg oxygen en to to the the tissue tissues s if the the patie patient nt is hypo hypoxic xic ● Medications ○ ○ Pain man Pain manage agemen mentt - Ana Analge lgesic sics s often often ne neces cessar sary y Hydroxyurea ■ Inc Increa reases ses prod product uction ion of of fetal fetal hemog hemoglob lobin in to reduc reduce e crises crises NCLEX Question You are providing education to your 8 year old patient diagnosed with sickle cell anemia. He has had three crisis events this year. Which of the following points do you enforce with him and his parents to help prevent more sickle cell crises? Select all that apply. a. b. c. d. Drink lo lots of of wa water Perfor Per form m vigo vigorou rous s exer exercis cise e for for 60 min minute utes s a day Avo void id fl flyi ying ng on ai airp rpla lane nes s Callll the Ca the PC PCP P ifif he he bec becom omes es fe febr brile ile.. Answer: A, C, and D A is correct. Hydration is an essential component of preventing a sickle cell crisis, so this is very important education. By drinking lots of water, the boy will increase the volume in his vascular space with w ith fluid, essentially “thinning out” the sickled cells. In other words, they will not be as concentrated anymore. This will help to prevent the sickled cells from snagging on vessels, creating occlusions, and causing a crisis. B is incorrect. While promoting a healthy lifestyle is always important, vigorous exercise is a specific trigger for a sickle cell crisis. This is because during vigorous exercise the tissues have a high demand for oxygen and the sickled cells are unable to deliver a sufficient amount. This results in a crisis. So for this patient, 60 minutes of vigorous exercise every day would not be a good recommendation. C is correct. Avoiding flying on airplanes is good education. In airplanes, you are at a very high altitude where there is much less oxygen. This can be a trigger for a sickle cell crisis because it leads to a high oxygen demand state. D is correct. It is important for the parents par ents to know to call the child’s primary care doctor if he is ill with a fever. Because the body demands more oxygen when it is febrile, fevers are a trigger for sickle cell crises, and must be treated promptly. promptly. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Hematology Disseminated Intravascular Coagulation (DIC) What is DIC? clotting become A serious disorder in which the proteins that control blood clotting overactive. Triggers ● ● ● ● ● Blo loo od tr transfusion Cancer Pancreatitis Liver disease Sev ever ere e ti tis ssue in inju jury ry ○ ○ ● Burns Head injury Preg Pr egna nanc ncy y co comp mpli lica cati tion on Assessment Assess ment Bleeding Ecchymosis Hematomas Hemoptysis Melena Pallor Hematuria Clotting → Where the clot goes ● Lungs/Heart ○ ○ ○ ● Chest pain Dyspnea SOB Legs ○ ○ ○ Pain Redness Warmth ○ ● Brain ○ ○ ○ ○ Lab Findings Treatment ● ● ● ● Determ Dete rmin ine e under underly lyin ing g cause cause and and TREA TREAT T Admi Ad mini nist ster er clo clott ttin ing g fact factor ors s Adm dmin inis iste terr pla plate tele lets ts Ble leed edin ing g pr prec ecau auti tio ons Swelling Headache Speech changes Paralysis Dizziness NCLEX Question The nurse in the Intensive Care Unit notes bleeding from the client’s transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for Sepsis. What should be the nurses immediate next action? a. b. c. d. Assess the client’s hemoglobin and hematocrit level Check the client’s oxygen saturation. Apply pressure to the intravenous site. Call the physician Answer: D Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors. Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should undoubtedly check the client's Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC. Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic patient and the nurse must notify the physician immediately since urgent intervention is needed Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion. Sepsis What is sepsis? ● A sy syste stemic mic inf inflam lammat matory ory rea reacti ction on to an an infec infectio tion. n. Pathophysiology 1. 2. 3. Infect Infe ctio ion n ent enter ers s the the bl bloo oods dstr trea eam m Body Bo dy mou mount nts s an inf infla lamm mmat ator ory y resp respon onse se Inflam Inf lammat matory ory resp respons onse e spread spreads s throug throughou houtt body caus causing ing:: a. b. Vasodilation i. Low BP --> ii. Hypoperfusion iii. Ischemia iv.. Tis iv iss sue damage v. Org rgan an dys ysfu fun nct ctio ion n Increa Inc reased sed cap capilla illary ry mem membra brane ne pe perme rmeabi ability lity i. Third spacing ii. Edema Assessment ● Ele leva vate ted d la lac cti tic c ac acid id ● ● ● ● ● ● Metabolic ac acidosis Leukocytosis Hypotension Tachypnea Tachycardia Febrile ○ ○ Indicates Indica tes body body has swi switch tched ed to to anaer anaerobi obic c metab metaboli olism sm Tissu Ti ssues es are no nott gett getting ing suf suffic ficien ientt oxyg oxygen en Treatment ● Blo lood od cul ultu ture res s fi firs rstt ● Bro roa ad spe spec ctr tru um IV IV ab abx within one hour ● ● IV fluids Vasopressors Integumentary Burns Skin anatomy Epidermis Dermis Hypodermis 1st degree ● ● ● ● ● Mos ostt su supe perrfi fic cia iall bur burn n The sk skin in remai remains ns inta intact; ct; no break break in in integr integrity ity of of epider epidermis mis Red edn nes ess s (er eryt ythe hem ma) No blisters Can Ca n be pa pain infu full to to the the to touc uch h 2nd degree ● ● ● ● ● Par arttia iall thi thic ckne nes ss bur burn n Blisters form Affe Af fect cts s the the ep epid ider ermi mis s and and de derm rmis is Skin is is moist an and re red Thes Th ese e burn burns s are are ve very ry pa pain infu full 3rd degree ● ● ● ● ● ● Ful ulll th thic ick kne nes ss bu burrn Penetr Pen etrate ate all the way fro from m the the epide epidermi rmis, s, to to the the dermis and down into the subcutaneous tissue. Destro Des troy y the the never never end ending ings, s, so so are are not not as pai painfu nfull as 2nd degree burns Appe Ap pear ar re red, d, ta tan, n, or bl blac ack k Are dr dry y an and d le leat ath her ery y Areas of of es eschar 4th degree ● ● ● Full thick thickness ness,, plus plus invo involveme lvement nt of bone and musc muscle le under underneath neath.. Thes Th ese e bur burns ns ar are e dry dry an and d dul dulll Exposed Expo sed tissu tissue e may inclu include de bones bones and muscle muscles s as well as ligamen ligaments ts and and tendons. Types of burns ● ● ● ● ● ● Chemical Electrical Thermal Cold Radiation Friction Chemical ● Burn Bur n occur occurs s when when there there is conta contact ct with with a tox toxic ic subs substan tance ce ○ ○ ○ ● ● Powders Liquids Foods Substa Subs tanc nce e can can be al alka kalin line e or ac acid idic ic Powd Po wder ers s can can caus cause e inha inhala lati tion on inj injur urie ies s Electrical ● ● Burn come Burn comes s from from cont contact act wit with h an ele elect ctric ric cur curren rentt Damages Dama ges more than just the skin skin as as the curr current ent trave travels ls below below the the skin skin ○ ○ ● Iceberg effect ○ ○ ● Muscles Bones There migh There mightt be eve even n more more dam damage age un under der the bur burn n Inju In jury ry is no nott jus justt to to the the su surf rfac ace e Pat atie ient nts s at at ris risk k for for:: ○ ○ ○ ○ Dysrhythmias Fractures Cerv Ce rvic ical al sp spin ine e in inju juri ries es Acut Ac ute e Tub ubul ular ar Ne Necr cros osis is (A (ATN TN)) Thermal ● Burn Bu rn or orig igin inat ates es fr from om a hot hot ob obje ject ct ○ ○ ○ ● ● Steam Fire Liquid Als lso o kno know wn as as a he heat at bur urn n Is th the e mos mostt com commo mon n typ type e of of bur burn n Other ● Cold ● Radiation ○ ○ ○ ● Frostbite Sun burns Burns related to radiation treatment Friction ○ ○ Road rash Abrasions Rule of 9’s Complications of Burn Injuries Inhalation injury ● ● Damage Dama ge to th the e res respi pira rato tory ry sy syst stem em Cau aus sed by by in inha hala lati tion on of of:: ○ ○ ○ ○ ● Smoke Carbon mo monoxide Powd wde ere red d ch che emic ica al Steam One On e of th the e top top ca caus uses es of dea death th in bur burns ns ● ● Upperr air Uppe airwa way y mor more e oft often en in invo volv lved ed Swelli Swe lling ng caus causes es mech mechani anica call obstr obstruct uction ion of the the ● airway Symptoms: ○ ○ ○ Soot in no Soot nose se,, mou mouth th,, spu sputu tum m Singed ha hair Diff Di ffic icul ulty ty spe speak akin ing, g, hoa hoars rse e voic voice e Carbon monoxide poisoning ● ● ● ● ● Colorl Colo rles ess, s, od odor orle less ss ga gas s Hemogl Hem oglobi obin n has has a high higher er aff affini inity ty for for CO CO than than itit does does O2 O2 Instead Inst ead of trans transporti porting ng O2, O2, the the hemog hemoglobin lobin is now now trans transporti porting ng CO CO Pulse ox will will be read reading ing 100%, 100%, but no oxygen oxygen is being being trans transporte ported d out to the the body. Lab La b test test - ca carb rbox oxyh yhem emog oglo lobi bin n ○ ● Pati Pa tien entt has has ne neur urol olog ogic ical al ch chan ange ges: s: ○ ○ ○ ● >15% = CO poisoning Drowsy Drow sy → le leth thar argi gic c → co coma ma Headache Bright red skin Treatment ○ 100% 10 0% Fi FiO2 O2 no nonn-re rebr brea eath ther er ma mask sk Hypovolemic Shock ● ● Increa Incr ease se in ca capi pilla llary ry pe perm rmea eabi bilit lity y Thi hirrd spa pac cin ing g oc occ cur urs s ○ ○ ○ ● ● Plasma moves Plasma moves from from the intra intravascu vascular lar space space,, to the inte interstiti rstitial al space space Sodium Albumin Decreased Decrea sed int intrav ravasc ascula ularr volum volume e = decr decreas eased ed BP BP = hypovolemia Cardiovas Card iovascular cular sys system tem reco recognize gnizes s hypovo hypovolemia lemia - increas increases es HR to to compensate ● ○ Increased HR HR ○ ○ Decrea Decr ease sed d car cardi diac ac ou outp tput ut Decr De crea ease sed d blo blood od pr pres essu sure re Hypovolemic Hypovole mic shock shock leads to decrea decreased sed perf perfusion usion of kidney kidneys s and and renal renal damage Hyperkalemia ● ● ● ● ● Most po Most pota tass ssiu ium m is is sto store red d in th the e cel cells ls Injury Injur y causes causes lysi lysis s of cells cells,, which which then then releas release e potassi potassium um into into bloods bloodstream tream Cau aus ses hy hype perrkal alem emia ia K >5.5 Sig igns ns an and d symp mpto tom ms: ○ ○ ○ ○ ○ ○ Muscle we weakness Cramps Nausea Chest pain Arrhythmias Tal all, l, pe peak aked ed T-w -wav aves es Hyponatremia ● ● ● ● ● ● Sod odiu ium m fol follo low ws wat water er Water Wa ter is leavi leaving ng the intra intravasc vascular ular space space and going going to the inters interstitial titial spac space e Due to incr increas eased ed capi capilla llary ry memb membran rane e perme permeabi abilit lity y Sodium Sod ium follo follows ws this this water water and and the pati patient ent beco becomes mes hypo hyponat natrem remic ic Na < 135 Sig igns ns an and d symp mpto tom ms: ○ Headache ○ ○ Confusion Restlessness ○ ○ ○ Irritability Seizures Coma Emergency Management ● ● ● ● Begins with Begins with the burn burn injury injury and lasts lasts until until the the capillary capillary membr membrane ane permea permeability bility has been restored Usua uall lly y 24 24-4 -48 8 ho hou urs Focu Fo cus s is on flu fluid id rep repla lace ceme ment nt Pat atie ient nt is at ris isk k for for:: ○ ○ ○ Hypovole lem mic sh shock Res esp pir irat ator ory y dis disttre ress ss Comp Co mpar artm tmen entt sy synd ndro rome me Fluid Replacement ● ● ● Crucia Cruc iall in th the e fir first st 24 ho hour urs s Due to to the incre increase ase in in capillary capillary perm permeabili eability ty,, this is when when the patie patient nt is losing losing large volumes of fluid and is at risk for hypovolemic shock. Fluids: ○ ○ Lactated Ringers ■ Ex Expa pand nds s the the in intr trav avas ascu cula larr vol volum ume e Colloids ■ ● ● ● Albumin ● Hel Helps ps pull pull flui fluids ds back back into into the the intra intravas vascul cular ar syste system m Mon onit ito or uri rine ne ou outtpu putt Fluids Flu ids are are titra titrated ted to to ensure ensure adeq adequat uate e UOP UOP (30cc (30cc/hr /hr)) Corr Co rrec ecti tion on of im imba bala lanc nces es ○ Sodi diu um? Pot ota ass ssiu ium m? Parkland Burn Formula 4mL x 20% x 100kg = 8,000 mL LR One half over first 8 hours = 4,000 mL NCLEX Question A nurse nurse is taking care of a client with severe burns. Because of fluid shifting, the nurse knows that the focus of attention is preventing hypovolemic shock. Which is the best intervention to address this? a. b. c. d. Administer dopamine as ordered Apply medical anti-shock trousers Infuse IV fluids are indicated Infuse fresh frozen plasma Answer: C An expected event event during the early po post-burn st-burn period is fluid shifting, where larg large e amounts of plasma fluid leak into interstitial spaces. T To o address the fluid loss, the best intervention would be to administer crystalloid and colloid solutions. Fresh frozen plasma may achieve this, but this is expensive and carries a slight risk of disease transmission. Medical anti-shock trousers trousers are applied when the client is already in hypovolemic shock. It is not used for prevention. Dopamine causes vasoconstriction and raises blood pressure but does not prevent hypovolemia from vasoconstriction burning clients. The correct answer is option C. Options A, B, and D are incorrect. Pressure Injuries What are Pressure Injuries? Injury to skin and underlying tissue resulting from prolonged pressure on the skin The hospital is not reimbursed for pressure injuries caused during a patient's hospital stay. MAJOR emphasis on prevention! Staged in 4 stages: Stage I Stage II Stage III Stage IV Unstageable Prevention bundle Break Back at…. Endocrine Hormone - Not enough steroids → Addison’s disease Glucocorticoids, Too many steroids → Cushing's mineralocorticoids, and sex hormones…. disease STEROIDS Steroids ● ● ● ● Prod Produc uced ed by by th the e adre adrena nall co cort rtex ex Glucocortic ico oid ids s ○ Affect m mo ood ○ Caus Cause e im immu muno nosu supp ppre ress ssio ion n ○ Brea Breakd kdow own n fa fats ts & pro prote tein ins s ○ Inhibit in insulin Min iner eral aloc ocor orti tic coi oids ds - aldosterone ○ Rete Retent ntio ion no off sod sodiu ium ma and nd wate waterr ○ Excr Excret etio ion n of po pota tass ssiu ium m Sex hormones - testosterone, estrogen, progesterone Addison’s Addison’ s Disease What is Addison’s Disease ● ● Adrenocor Adreno cortic tical al insuf insuffic ficien iency cy - not not enough enough ster steroid oids s Decr De crea ease sed d gluc glucoc ocor orti tico coid ids s ○ ○ ○ ○ ● Decr De crea ease sed d mi mine nera ralo loco cort rtic icoi oids ds ○ ○ ○ ● Fatigue Weight loss Hypoglycemia Confusion Loss of sodium Loss sodium and and water water → hypo hyponat natrem remic, ic, fluid fluid volu volume me defic deficit it Retent Ret ention ion of po potas tassiu sium m → hyp hyperk erkale alemic mic Hypotension Dec ecrrea eas sed sex ho horm rmon one es Assessment Treatment ● Think SHOCK SHOCK!! ● ● ● I&O Daily weight Replace steroids ○ ○ ○ ○ IV fl flui uid d ad admi mini nist stra rati tion on Incr In crea ease sed d so sodi dium um in inta take ke Prednisolone Fludrocordisone NCLEX Question A nurse knows that in the event of an Addisonian crisis crisis,, it is most appropriate appropriate to administer which of the following medications intravenously? a. b. c. Insulin Normal saline solution dextrose 5% in water d. dextrose 5% in half-normal saline solution Answer: B One problem of a client in the Addisonian crisis is hyponatremia. The nurse should, therefore, anticipate administering the standard saline solution. Glucose, vasopressors, vasopressor s, and hydrocortiso hydrocortisone ne are also used to treat the Addisonian crisis. It would be inappropriate to administer insulin, dextrose 5% in water, or dextrose 5% in half-normal saline solution for this client. The correct answer is option B, while options A, C, and D are incorrect. i ncorrect. Cushing’s Disease What is Cushing’s Disease? ● ● Exc xce ess of ste tero roid ids s Body has too much much gluco glucocort corticoid icoids, s, minera mineralocor locortico ticoids ids and and sex sex hormone hormones s ○ ○ ○ Glucocorticoid ids s ■ Immuno nosu supp ppre ress ssio ion n ■ Hyperglycemia ■ Mood al alteration ■ Fat redistr redistributi ibution on (excess (excess glucoc glucocortic orticoids oids cause cause lipolys lipolysis is of extrem extremities ities and and lipogen lipogenesis esis in the trunk) Min ine era ralo loco cort rtic icoi oid ds ■ Fluid re retention ■ Sodiu ium m retention ■ Potas assi siu um exc xcre rettio ion n Sex hormones ■ Oily skin/acne Assessment ● ● ● ● ● ● ● ● ● Think extremities Moon faced Truncal obesity Buffalo hump Hyperglycemia Immunosuppressed CHF Weight W eight gain Fluid volume excess Treatment ● Adrenalectomy ● Avoid in infection ○ ○ ○ ○ ○ Remove the gla Remove glands nds sec secret reting ing the exc excess ess hor hormo mone nes s Can re rem move on one e or or bo both Patien Pati entt is im immu muno nosu supp ppre ress ssed ed Hand wa washing Limiting vis visit ito ors Hormone - Not enough ADH → DI Antidiuretic hormone Too much ADH → SIADH (ADH) Antidiuretic Hormone ● ● ● Secreted from the pituitary gland Pituit Pit uitary ary gla gland nd is is in the the brai brain, n, betw between een you yourr eyeba eyeballs lls Be on on the the looko lookout ut for for thes these e issue issues s if a patie patient nt had: had: ○ ○ ○ ● Causes anti - diuresis - holding on to WATER ○ ○ ● Craniotomy Head injury Sinus surgery Only wa Only wate terr is is ret retai aine ned, d, so so sodi dium um!! Incr In crea ease sed d AD ADH H → in incr crea ease sed d wat water er Antidi Ant idiure uretic tic hor hormon mone e = ADH = Vas Vasopr opress essin in Diabetes Insipidus (DI) What is Diabetes Insipidus? ● ● ● ● ● There Ther e is is not not en enou ough gh AD ADH H in in the the bo body dy Without Witho ut ADH to to tell the the body body to hold hold onto onto water water,, the kidney kidneys s produce produce HUGE amounts of urine. This Th is le lead ads s to to flu fluid id vo volu lume me de defi fici citt Hypotension Shock Assessment Lab Values ● Urine = dilute ● Blo lood od = con conce cent ntrrat ate ed ○ ○ ○ ○ ○ Decreased USG Decr De crea ease sed d urin urine e osmo osmola lari rity ty Increased Se Serum Na Na Incr In crea ease sed d seru serum m osmo osmola lari rity ty Serum Hct > 40% Treatment ● ● Mon onit ito or Neu euro ro sta tatu tus s Replace fluids ○ ○ Moni nito tory ry hour urly ly UO UOP P Rep epla lace ce vo volu lum me + MIV IVF F ● ● Vasopressin DDAVP Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) What is SIADH? ● ● ● ● ● The bod The body y is is mak makin ing g too too mu much ch AD ADH H With too much antidiuresis, the kidneys stop excreting water and HOLD ON to it! Decreased UOP Hypervolemia Flu luid id volu lume me ex exc ces ess s Assessment ● Fluid vo volu lum me ex excess ○ ○ ○ ○ ○ ● JVD Edema Wet lung sounds Hypertension Weight gain Anorexia ● ● Nausea Vomiting ● Low serum sodium ○ ○ ○ ○ Irritability Confusion Hallucinations Seiz izu ures (N (Na < 125) Lab Values ● Urin ine e = con onc cen entr trat ated ed ○ ○ ○ ● Increased USG Incr In crea ease sed d ur urin ine e so sodi dium um Incr In crea ease sed d urin urine e osmo osmola lari rity ty Blood = dilute ○ ○ ○ Decreased Se Serum Na Na Decr De crea ease sed d seru serum m osmo osmola lari rity ty Dil ilu utional ane anemia Treatment ● Mon onit ito or seru rum m sod odiu ium m ○ ● ● ● ● Sodi diu um re repl pla ace cem men entt Sei eizu zure re pr prec ecau auttio ions ns Fluid rre estriction Hypertonic s sa alin ine e Demeclocycli lin ne ○ Works Works to reduc reduce e the the responsiv responsivenes eness s of the the collecti collecting ng tu tubule bule cells tto o ADH NCLEX Question A client suddenly develops develops syndrome of inappropriate antidiure antidiuretic tic hormone (SIADH) after undergoing cranial surgery surgery.. Which manifestations should the nurse expect to see from the patient? Select all that apply apply.. a. b. c. d. Edema and weight gain Decreased urine production Hypotension A low urine specific gravity Answers: A and B SIADH is an abnormal release of the antidiuretic hormone, which causes the client to retain water abnormally. abnormally. This leads to manifestations such as edema, weight gain, and low urine output. Excessive urine production, low blood pressure, and a little urine specific gravity are manifestations of Diabetes insipidus. Hormone Thyroid hormone (T3 & T4) Thyroid hormone ● ● ● Produc Prod uced ed by by the the thyr thyroi oid d glan gland d Ther Th ere e are are tw two o typ types es:: T3 T3 and and T4 Thyr Th yroi oid d hor hormo mone nes s = en ener ergy gy Not enough thyroid hormone → hypothyroidism Too much thyroid hormone → hyperthyroidism (Grave’s Disease) Hyperthyroidism What is hyperthyroidism? ● ● ● ● ● Also kn Also know own n as as Gra Grave ves s Dis Disea ease se The Th e body body ha has s too too muc much h thyr thyroi oid d horm hormon one e Dec ecrrea eas sed le lev vel els s of of TS TSH Anterior Anter ior pituita pituitary ry see’s see’s low TSH TSH and and signals signals to to the Thyr Thyroid oid gland gland to secre secrete te more T3 and T4 T3 and and T4 cont continu inue e to be be secr secrete eted d desp despite ite bein being g high high ● The Th e nega negati tive ve fee feedb dbac ack k loop loop is is brok broken en High T4 / Low TSH Treatment ● Anti An tith thyr yroi oid d - me meth thim imaz azol ole e ○ ● Iodine co compounds ○ ● Stop St ops s the the thyr thyroi oid d from from mak makin ing g T3 T3 and and T4 T4 Used Use d to decre decrease ase the the size size and and vascul vasculari arity ty of the the thyro thyroid id gland gland Radi Ra dioa oact ctiv ive e Iod Iodin ine e the thera rapy py ○ ○ Des esttro roys ys th thyr yro oid ce cell lls s Can Ca n cau cause se hy hypo poth thyr yroi oidi dism sm ● Thyroidectomy ○ Remova Rem ovall of all or som some e of of the the thy thyroi roid d glan gland d Hypothyroidism What is hypothyroidism? ● ● ● ● ● The bod body y does does not hav have e enoug enough h thyr thyroid oid hor hormon mone e Increase Incr eased d levels levels of TSH tryin trying g to signal signal the thyroi thyroid d to make make more more T3 and and T4 Thyroi Thy roid d gland gland canno cannott secret secrete e enough enough T3 T3 and T4 despi despite te high high TSH TSH T3 an and d T4 co cont ntin inue ue to be lo low w The Th e nega negati tive ve fee feedb dbac ack k loop loop is is brok broken en Low T4 / High TSH Treatment ● Levothyroxine - thyroid hormone ○ ○ ○ Tak ake e on on an an emp empty ty st stom omac ach h Tak ake e at at the the sa same me ti time me ev ever ery y day day Will Wi ll ta take ke th this is for ore eve verr Hormone - Not enough PTH → Hypoparathyroidism Parathyroid Hormone (PTH) Too much PTH → Hyperparathyroidism Parathyroid Hormone ● ● ● Secret Secr eted ed by th the e para parath thyr yroi oid d glan glands ds Caus Ca uses es ca calc lciu ium m to to be pu pulllled ed ou outt of of the the bones and into the blood. Caus Ca uses es an inc incre reas ase e in ser serum um cal calci cium um.. Hypoparathyroidism What is hypoparathyroidism? ● ● ● The par parath athyro yroid id glan glands ds do do not not secr secrete ete eno enough ugh PTH Ther Th ere e are are lo low w ser serum um ca calc lciu ium m lev level els s Low seru serum m calcium calcium level levels s cause cause high high serum serum phosp phosphor horus us levels levels Assessment Treatment ● Fix Fi x th the e el elec ectr trol olyt yte e im imba bala lanc nces es ○ ○ Cal alci cium um re rep pla lace cem ment Phos osp phor oru us bin ind ders Hyperparathyroidism What is hyperparathyroidism? ● ● ● The par parath athyro yroid id glan glands ds sec secret rete e too too muc much h PTH PTH Ther Th ere e are are hi high gh se seru rum m cal calci cium um le leve vels ls High Hig h serum serum calci calcium um levels levels caus cause e low serum serum phos phospho phorus rus leve levels ls Assessment Treatment ● Part Pa rtia iall parat parathy hyro roid idec ecto tomy my ○ ○ ○ There Ther e ar are e 6 pa para rath thyr yroi oid d gl glan ands ds Taki aking ng out 2 can can dec decrea rease se PTH sec secret retion ion Can cau cause se rebo rebound und hypo hypocal calcem cemia ia if decr decreas eases es too too much much NCLEX Question A patient was admitted to to the ER due to low serum serum calcium leve levels. ls. Upon further examination, he demonstrates carpopedal spasms and reports numbness in his lips and hands. An ECG was taken and revealed a prolonged QT interval. Upon assessment of the client, the nurse should suspect which condition? a. b. c. d. Hyperthyroidism Hypothyroidism Hyperparathyroidism Hypoparathyroidism Answer: D A is incorrect. Patients with Hyperthyroidism display a generalized alm ost all their body gen eralized metabolic excitement in almost systems. They can reveal heat intolerance, warm skin, insomnia, irritability, palpitations, tachycardia, diarrhea, fatigue, and weight loss. B is incorrect. Hypothyroidism results in a general metabolic depression of almost all body systems. The patient may manifest low heart rate, low blood pressure, decreased urine output, constipation, shallow, slow respirations, muscle weakness, diminished deep tendon reflexes, cold intolerance, and sometimes a decrease in body temperature. C is incorrect. Symptoms of Hyperparathyroidism include a serum Calcium level of 10.9 mg/dL or higher. The patient may also display neurological symptoms such as lethargy, fatigue, personality changes, paresthesia, severe stupor, and even coma. GI symptoms would include dyspepsia, nausea, and constipation. D is correct. Symptoms of Hypoparathyroidism mirror that of hypocalcemia. It manifests as numbness and tingling of the lips and hands, tetany, carpopedal spasms (Trousseau s sign), Chvostek’s sign, muscle, and abdominal cramps. ECG analysis may reveal a prolonged QT interval and T-wave abnormalities. Because of low serum calcium, serum phosphorus levels may also be increased. Break Back at…. Hormone - Not enough Insulin → DM, DKA, HHNS Insulin Insulin ● Prod Pr oduc uced ed in th the e pa panc ncre reas as ○ ● ● ● -islets of Langerhan Acts as Acts as the the ‘key ‘key’’ to to tran transp spor ortt gluc glucos ose e from the bloodstream to the cells Allo Al lows ws th the e cel cells ls to us use e glu gluco cose se as fuel Nor orma mall BG BG:: 700-1 110 Too much Insulin → Hypoglycemia Diabetes Mellitus T Type ype I What is Diabetes Mellitus Type I? ● ● ● ● ● ● DMTI Auto Au toim immu mune ne di dise seas ase e - or id idio iopa path thic ic Body Bo dy ha has s des destr troy oyed ed th the e bet beta a cel cells ls of the pancreas that produce insulin Ther Th ere e is lit littl tle e or or no no insu insulin lin in the the bo body dy Ver ery y hig high h leve levels ls of gl gluc ucos ose e in th the e bloodstream No gl gluc ucos ose e can can ge gett to to the the ce cells lls fo forr fuel Assessment Treatment INSULIN ● ● ● ● Basal bo bolus s sy ystem Long Long-a -act ctin ing ga age gent nt gi give ven n onc once e per per day day ShortShort-act acting ing a agen gentt giv given en with with me meals als tto o cov cover er th the e car cars s eat eaten en Regular insulin ○ ● NPH ○ ● Short ac acting Inte In term rme edi dia ate act ctin ing g Glargine ○ Long ac acting Insulin tidbits ● Can mix reg regula ularr and and NPH NPH insul insulin in in in the the same same sy syrin ringe ge ○ ○ ● ● ● Regula Regu larr is is cle clear ar an and d NPH NPH is cl clou oudy dy Draw Dr aw up th the e reg regul ular ar fi firs rstt All lon All long g act actin ing g ins insul ulin ins s are are cl clea earr Never Nev er mix mix long long acti acting ng with with any oth other er typ type e of insu insulin lin Regu Re gula larr insu insulin lin is the the sta stand ndar ard d give given n IV Diabetic Ketoacidosis (DKA) What is Diabetic Ketoacidosis? ● ● ● ● ● There There iis s no ins insuli ulin n to carry carry glu glucos cose e to the cel cells ls Gluc Glucos ose e build builds su up p in th the e bloo blood d (H (Hig igh h BG BG)) Blood beco becomes mes hype hypertoni rtonic, c, causin causing g flui fluid d to shif shiftt into the v vascu ascular lar s space pace.. Kidney Kidneys s wor work k to fi filte lterr this this exc excess ess ffluid luid a and nd gluco glucose se - polyu polyuria ria Cells are n not ot rec receivin eiving g any fluid or glu glucose cose - they are s starv tarving ing - p polydip olydipsia sia & ● ● polyphagia Because Because c cells ells d don’t on’t h have ave a any ny glu glucose cose for e energy nergy,, bre break ak do down wn pr protein oteins s and fat This This p prod roduce uces sk keto etones nes - w whic hich h are are an acid acid ● Caus Causes es a me meta tabo boli lic c acid acidos osis is ○ ○ ○ Kidne Kidneys ys in incre crease ase produ producti ction on of of bicarb bicarb to comp compens ensate ate Kussm Kussmaul aul rresp espira iratio tions ns - to to blow blow off off CO CO2 2 to com compen pensat sate e Hig igh h se seru rum m po pottas assi siu um Assessment Treatment ● Labs ○ ○ ● Hourly Hour ly BG an and d se seru rum m po pota tass ssiu ium m ABGs - evalua evaluate te the the metab metabolic olic acido acidosis sis and and look look for reso resolutio lution n Fluids ○ ○ Monito Moni torr out outpu putt and and pr prev even entt sho shock ck NS used to start ○ ● When BG lowers lowers to 250-30 250-300, 0, D5W D5W added added to to solution solution to to prevent prevent hypo hypoglyce glycemia mia ■ Bl Bloo ood d sug sugar ar sho shoul uld d be lo lowe were red d slow slowly ly ■ Rapi Rapid d drop drop will will cause cause a shift shift of of fluid fluid into into the the cells cells and and cereb cerebral ral edem edema a Insulin ○ ○ Decrea Decr ease se th the e bl bloo ood d su suga garr Drive Dr ive po pota tass ssiu ium m bac back k into into th the e cel celll Diabetes Mellitus T Type ype II What is Diabetes Mellitus Type II? ● ● ● ● There is either not enough insulin, insulin resistance, or bad insulin Commonly found with patients who are overweight. Their body can’t make enough insulin to keep up with the glucose. The increased glucose in the blood suppresses the immune system, causes ● increased bacteria in the blood, and decreases circulation. This is what causes long term damage: ○ Poor wound healing ○ ○ ○ Frequent infections Vision problems problems Kidney problems Assessment Treatment DIET ● ● ORAL AGENTS Low ca Low carb rb - co comp mple lex x ca carb rbs s Proteins & veggies ● EXERCISE ● ● ● ● Eat bef efor ore e ex exer erci cis sin ing g Exer Ex erci cise se wh when en bl bloo ood d sug sugar ar is at its highest Est stab abli lis sh a ro rout utin ine e ● Wor ork k to to dec decre reas ase e the the am amou ount nt of circulating glucose Imp Im pro rove ves s how how the bod ody y produces insulin and uses insulin Metformin INSULIN Hypoglycemia What is Hypoglycemia? ● ● ● When there When there is not not enou enough gh gluc glucose ose in the the bloo bloodst dstrea ream m BG <70 Causes ○ ○ ○ Not enough food Too much insulin Too muc uch h exe xerc rcis ise e Assessment ● ● ● ● ● Cold Clammy Confused Shakey Nervous ● ● ● Nausea Headache Hungry Treatment 1. Hav Ha ve a sn snac ack k - ab abo out 15 grams of carbs a. b. 4-6 oz 4-6 oz of of sod soda/ a/ju juic ice/ e/mi milk lk 8-1 -10 0 pi pie ece ces s of ca cand ndy y 2. Wait 15 minutes, minutes, and check BG again 3. If st stil illl <70 <70,, eat eat an anot othe herr 15 grams of carbs 4. After the BG BG rises, rises, eat a snac snack k with with complex complex carb carb/pro /protein tein to to help help keep the BG up a. Crac Cr acke kers rs wi with th pe pean anut ut bu butt tter er What if the patient is unconscious unconscious?! ?! If IV access → push D50W If no IV → IM Glucagon (catabolic hormone, raises concentration of glucose in the Musculoskeletal Fractures Types of fractures Assessment ● Circulation ○ ○ ○ ○ ● Check Chec k for for perf perfus usio ion n dist distal al to to the the inju injury ry Pulses Skin Sk in te temp mper erat atur ure e & co colo lorr Cap apil illa lary ry re refi fill ll ti tim me Nerve function ○ ○ ○ Any nu numbness? Tingling? Is se sen nsa sati tion on in inta tact ct? ? Treatment ● ● Pain ma management RICE ○ ● Rest Re st,, Ice, Ice, Com Compr pres essi sion on,, Ele Eleva vati tion on Immobilization ○ ○ Cast Splint ○ ○ Brace Monit Mo nitor or the the cast casted ed extr extremi emity ty close closely ly for for perfu perfusio sion!! n!! Compartment syndrome What is Compartment Syndrome? ● There Ther e is in incr crea ease sed d pres pressu sure re wit withi hin na confined space ○ ○ ● Limbs ■ Esp spe eci cial ally ly in a ca cast st!! Abdomen This Th is incr increa ease sed d press pressur ure e comp compro romi mise ses s ● ● circulation With Wi thou outt circ circul ulat atio ion, n, the the dis dista tall tissu tissue e becomes ischemic Tis issu sue e and and ne nerv rve e dam damag age e occ occur urs s Assessment ● ● ● ● ● ● ● ● Extremely painful Limb feels tight Swelling Numbness Tingling Paralysis Dimi Di mini nish shed ed or ab abse sent nt pu puls lses es Dec ecrrea eas sed sen ens sati tion on Treatment ● FASCIOTOMY ○ ○ Must reli Must relieve eve the pre pressu ssure re in the the com compa partm rtment ent Cutt ope Cu open n the the co comp mpar artm tmen entt Rhabdomyolysis What is Rhabdomyolysis? ● Ther Th ere e is in inju jury ry to the the ske skele leta tall musc muscle le ○ ○ ○ ● Burns Trauma Com ompa part rtm ment synd syndro rom me Muscles Muscle s rele release ase the their ir intr intrace acellul llular ar cont content ents s into the blood ○ ○ ○ ○ ● ● Treatment ● Fluids ○ ○ ● NS Hydr Hy drat atio ion n and and fl flus ushi hing ng th the e kid kidne neys ys Diuretics ○ ○ Decreased swe swell lliing Increase UO UOP Myoglobin Creatin iniine Ki Kinase Potassium Phosphorus These Thes e sub subst stan ance ces s bec becom ome e tox toxic ic in circulation Majo Ma jorr kidn kidney ey dam damag age e as the the nep nephr hron ons s try try to filter the toxins out ○ ● Dialysis ○ ● ● Flush out toxins If K too too high high or kidne kidneys ys unab unable le to clea clearr the toxi toxins ns on thei theirr own Bedrest Moni Mo nito torr ele elect ctro roly lyte tes s and and CK ○ Worr Wo rrie ied d abou aboutt high high K?? K?? → TE TELE LEME METR TRY! Y! NCLEX Question A client client that has sustained a sports injury has just finished an arthroscopy on his left knee. The nurse caring for him should FIRST assess the client for which of the following factors? a. b. c. d. Skin and wound integrity Mobility assessment Vascular and skin assessments Circulatory and neurologic assessments Answer: D The nurse should always focus on assessing the client’s; neurological and circulatory status following an arthroscopic procedure. The swelling of the extremity can impair the neurologic and circulatory function of the leg. The nurse can address the other concerns of skin integrity, mobility, and pain once neurologic and circulatory integrity is established. Lunch Break That’s it for Part II!! Back after lunch for Part III! Part III - Specialties Archer Review - NCLEX Rapid Prep Prep Mental Health Anxiety Bipolar Disorder Depression Mental Health Schizophrenia NCLEX topics Eating disorders Alcohol Withdrawal Suicidal ideations Anxiety What is anxiety? ● ● The bo bod dy’s nat atur ural al response to stress A fe feel elin ing g of of fea fearr, wo worr rry y, and nervousness about what’s to come. ● ● Can be normal!! Conc Co ncer erni ning ng if it is ch chro roni nic c and in response to normal life activities. Levels & Management ● Mild ○ ○ ● Nor orm mal & he hea alt lthy hy.. No in inte terv rven enti tion on ne need eded ed.. Severe ○ ○ Needs he Nee help lp to fun unct ctio ion n Anti An ti-a -anx nxie iety ty PRN PRN med medic icat atio ion n ● Moderate ○ ○ ○ ○ ● Sti till ll abl ble e to to fu func ncttio ion n Ensu En sure re sa safe fe en envi viro ronm nmen entt Esta Es tabl blis ish h tr trus ust/ t/ra rapp ppor ortt Enco En cour urag age e exp expre ress ssio ion n of of thou though ghts ts and help problem solve Panic ○ ○ ○ ○ ○ ○ Unabl Una ble e to func ncttio ion n Decream st stimuli Calm environment Mon onit ito or for for se self lf-h -ha arm Daily Da ily an anti ti-a -anx nxie iety ty me medi dica cati tion on Anti-anxiety PRN PRN medication Depression What is Depression? ● ● ● ● “The feel “The feeling ing of seve severe re desp despond ondenc ency y and and dejec dejectio tion” n” A state of of lo low mood Aver ers sio ion n to act ctiv ivit ity y Affec Af fects ts thei theirr thoug thoughts hts,, behav behavior iors, s, and and feel feeling ings. s. Columbia-Suicide Severity Rating Scale Therapeutic management ● Safe environment - assess risk for self harm ○ ○ ● Therapy ○ ○ ● ● ● ● One to One to on one ob obse serv rva ati tion on Remo Re move ve po pote tent ntia ially lly ha harm rmfu full item items s Express feelings Vali alidat date e the their ir fru frustr strati ation on an and d sadn sadness ess Get moving! ADLs Nut utrrit itio ion/ n/hy hydr drat atio ion n Good sl sleep hy hygie ien ne Bipolar Disorder po a so de What is Bipolar Disorder? ● ● A mood disor disorder der where where ther there e is diff difficulty iculty regul regulating ating extr extreme eme emotio emotions. ns. There Ther e a period periods s of mania mania,, periods periods of depres depression, sion, and the the inabilit inability y to self-regulate these emotions. ○ ○ Mania: “A moo Mania: mood d disorder disorder marked marked by hypera hyperactive ctive wildly optim optimistic istic state state”” Depressio Depr ession: n: “The “The feeli feeling ng of of severe severe desp desponde ondency ncy and dejec dejection tion”” Therapeutic Management ● ● ● ● ● ● Man ana age acut ute e epi epis sod ode es Safe environment Calm Ca lm,, contr control olle led, d, focu focuse sed d inter interac acti tion ons s Don’ Do n’tt arg argue ue wh while ile in a man manic ic st stat ate e Provid Pro vide e high-c high-calo alorie rie,, finger finger food food they they can can eat eat on the the go Pro rottec ectt the their ir pr priv iva acy ○ ● ● Appr pro opri ria ate cl clo oth thin ing g Set bo boundaries Medications ○ Antipsychotics ○ Mood stabili liz zers Schizophrenia What is Schizophrenia? ● ● A longlong-term term ment mental al disorder disorder invol involving ving a breakdo breakdown wn in the relatio relation n between between thought, emotion, and behavior behavior.. There Ther e is faulty faulty perc perception eption,, inappropr inappropriate iate action actions s and feelin feelings, gs, withdr withdrawal awal from from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation Assessment Findings ● Delusions ○ ● “False belief “False belief firml firmly y held held to to be true desp despite ite ratio rational nal argu argument ment”” ■ Persecution ■ Jealousy ■ Grandeur Hallucinations ○ “a sensory sensory expe experienc rience e of somet something hing that does not exist exist outsid outside e the the mind” mind” ■ Auditory ■ Olfactory ■ Tactile ■ Visual ■ Gustatory Therapeutic Management ● ● ● ● Provide a safe environment Ask about the delus delusion ion to to unders understand tand what they are expe experienc riencing ing Do not argue about the delusion or hallucination Sta tay y fo focus used ed on rea eali lity ty ● ● ● ● Set limits Decr De crea eati tion on st stim imul ulat atio ion n Don’t Don ’t touc touch h them them when when exp experi erienc encing ing a hal halluc lucina inatio tion n Audi Au dito tory ry ha hall lluc ucin inat atio ions ns ○ ● Are the they y tell telling ing the them m to to do do som someth ething ing? ? PRN me medications NCLEX Question The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric patients around him are getting angry. angry. What is the most appropriate action of the nurse? a. b. c. d. Restrain the client Escort the other clients from the day room Give Haloperidol IM Approach the client calmly accompanied by two other staff Answer: D A is incorrect. Restraining Restraining the client s should hould be the last appr approach oach for the nurs nurse. e. The first intervention should be to talk to the client to remove him from the day room. B is incorrect. The nurse should not try to remove the other clients from the room. The nurse should first remove the client from the place. C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The nurse needs to remove the client from the day before the situation escalates. D is correct. The first intervention is to approach the client calmly and attempt to remove him from the day room. Staff members should not contact the agitated client alone but should be accompanied by other personnel. Eating Disorders Assessment Findings ● ● ● ● ● ● ● ● Low bo bod dy te tem mpe perrat atu ure Bradycardia Hypotension Elec El ectr trol olyt yte e abn abnor orma mali liti ties es Sle lee ep dis distturbances Osteoporosis Amenorrhea Lanugo Assessment Findings ● ● ● ● Labile mood Esophageal var varices Too ooth th en enam amel el br brea eak k dow down n Helplessness Therapeutic Management ● Addr Ad dres ess s me medi dica call is issu sues es ○ ● ● ● Elec El ectr trol olyt yte e im imba bala lanc nces es Provid Prov ide e a sa safe fe en envi viro ronm nmen entt Monito Mon itorr for for sel self-h f-harm arm and sui suicid cidal al ide ideati ations ons Val alid idat ate e th thei eirr fe feel elin ings gs ● Help He lp id iden enti tify fy tr trig igge gers rs an and d avo avoid id NCLEX Question A nurse nurse is assigned to care for a client with anorexia nervosa. Which intervention should the nurse apply following the patient’s meals? a. b. c. d. Instruct the client to get some exercise or go for a walk after meals Restrict client from going to the bathroom for 90 minutes Ask the client to lie down for 2 hours after eating Encourage patient to start an intense exercise program Answer: B The nurse should observe the client while eating and prevent the client from using the bathroom for 90 minutes after meals to break the purging cycle. Exercise is not encouraged until the client has shown adequate weight gain. Until then, training should be done in moderation. There is no need for the patient to lie down after meals. The correct answer is option B, while options A, C, and D are incorrect. Obstetrics OB assessment & testing Labor & Delivery complications Obstetrics Postpartum complications NCLEX topics Newborn complications Antepartum Testing Testing Routine exams done for everyone ● ● ● ● Blo lood od typ ype/ e/R Rh fac acto torr STI testing Glucose ch challenge Urinalysis ● ● ● ● Ultrasound Non ons stre res ss te tes st (N (NST ST)) Group B Strep Kick counts Blood type and Rh Factor ● ● ● Important to know Important know the mother mother's 's blood blood type type and ifif she is Rh posit positive ive or or negative. If the mothe motherr is Rh Rh negative, negative, and the the baby baby is Rh Rh positive positive,, this is conside considered red a ‘set up’ and puts the infant at risk for erythroblastosis fetalis. Further Furt her testi testing ng needed needed if this this is the case case - after after the the baby baby is born born.. ○ ○ ● Dir ire ect Co Coombs te test ■ Pe Perfo rforme rmed d on on the the new newbor born's n's blo blood od sam sample ple Ind In dir ire ect Coo oom mbs te test ■ Pe Perfo rforme rmed d on on the the mo mothe ther’s r’s blo blood od sam sample ple Tre reat atm men entt = Rh Rhog ogam am STI Testing esting Test for STIs including: ● ● ● HIV HPV Herpes ● ● ● Gonorrhea Syphilis Chlamydia ● Trichomoniasis Glucose Challenge 3 hour ho ur Glucose Gl ucose Tolerance Tolerance Test Oral Glucose Tolerance Test ● ● ● ● Done at 28 weeks Moth Mo ther er dr drin inks ks 50 gr gram ams s of of glucose in an oral solution 1 hou hourr lat later er he herr blo blood od su suga garr is checked. If th the e BG BG is is gre great ater er th than an 14 140, 0, the 3 hours glucose test is performed. ● ● ● ● ● ● Done ifif the Done the 1 hou hourr test test is is fail failed ed or or ther there e are other risk factors. It is is done done fas fasti ting ng;; moth mother ers s must must not not eat eat or drink for 8 hours prior to the test. A fa fast stin ing g sug sugar ar is ch chec ecke ked d The Th e mot mothe herr dri drink nks s 100 100 gr gram ams s of of ora orall glucose. Herr BG is rec He reche heck cked ed a 1 hour hour,, 2 hou hours rs,, and 3 hours. A su suga garr grea greate terr than than 140 140 ind indic icat ates es gestational diabetes. Urinalysis ● At each each pre prenat natal al visi visitt urine urine is is dippe dipped d to chec check k for: for: ○ ○ ● ● Glucose Protein Glucose indic Glucose indicates ates gest gestationa ationall diabetes diabetes and needs furt further her work up Protei Pro tein n indica indicates tes pree preecla clamps mpsia ia and and needs needs furth further er work work up Ultrasound ● Each Eac h prena prenatal tal ult ultras rasoun ounds ds ass assess ess the fet fetus us for: for: ○ ○ ○ ○ ● Anatomy If structur structures es dev develo elopin ping g ap appro propri priate ately ly Esti Es tima mate ted d ges gesta tati tion onal al ag age e Bloo Bl ood d flow flow to the the pla place cent nta a and and fe fetu tus s Ultras Ult rasoun ounds ds als also o asse assess ss mat matern ernal al ana anatom tomy: y: ○ ○ Cervix Placenta Nonstress Nonstre ss Test Test (NST) ● ● This test asse assesse sses s fetal fetal wellwell-being being and oxyg oxygenati enation on of of the the placent placenta a Evaluates Evalu ates if there there are chan changes ges in the the fetal fetal heart rate with move movement ment ○ ○ Increase in Increase in fetal fetal heart heart rate with move movement ment = acceler acceleration ation = good good Decrease Decre ase in fetal fetal heart heart rate with move movement ment = decele deceleratio ration n = bad ■ Thi This s is a sign sign that that the fet fetus us will will not not tole tolerat rate e labor labor.. ● ● Results ○ Reactive ■ Ther There e are at at least least two accele acceleratio rations ns of 15 15 beats beats per minu minutes tes for for 15 second seconds s in a 20 minute period. ○ Non-Reactive ■ Ther There e are NOT NOT at least two accele acceleratio rations ns of 15 15 beats beats per per minutes minutes for for 15 second seconds s in a 20 minute period. Furthe Fur therr testi testing ng requ require ired d if res result ult is is non-r non-reac eactiv tive e Group B Strep ● ● ● Tests for the the presen presence ce of group beta stre streptoc ptococcu occus s in the vagina vagina Many wome women n carry carry this this bacteria bacteria and it can put put the infant at risk risk for illnes illness s after after a vagnial delivery Test ested ed with with a simp simple le swa swab b of the vag vagina ina ● Usua Us ualllly y don done e aro aroun und d 34 34 to to 36 we week eks. s. Kick Counts ● ● ● Kick co Kick coun unts ts ar are e per perfo form rmed ed by th the e mother She Sh e is is ins instr truc ucte ted d to to lie lie on he herr lef leftt side for a 2 hour period and count how often she feels the baby kick. She Sh e is in inst stru ruct cted ed to no noti tify fy he herr health care provider for less than 10 kicks felt in a 2 hour period. Extra testing done if needed ● ● ● ● Contra Cont ract ctio ion n st stre ress ss te test st Perc Pe rcut utan aneo eous us umb umbililic ical al bloo blood d samp samplin ling g Alph Al phaa-fe feto topr prot otei ein n sc scre reen enin ing g Chor Ch orio ioni nic c vi vill llus us sa samp mple le ● ● Amniocentesis Nitrazine test Contraction Stress Test ● ● ● ● Prefor Pref orme med d when when the the non non-s -str tres ess s test test is is non-reactive. Pitocin Pitoc in is admin administer istered ed to induc induce e contrac contractions tions and the the baby baby is monit monitored ored to evaluate their response to contractions. Checking Chec king to see see if the the baby will tolera tolerate te labor labor,, or show show signs signs of stress stress.. Results ○ ○ Negative ■ Normal ■ The baby did not have dece decelerat lerations ions in respo response nse to cont contractiv ractives es Positive ■ Bad ■ The baby had decele deceleratio rations ns indicat indicating ing distre distress ss in respo response nse to to contract contractions. ions. Percutaneous Umbilical Blood Sampling ● ● Sample Samp le of of feta fetall bloo blood d obta obtain ined ed from umbilical cord. Bloo Bl ood d can can be te test sted ed fo forr sev sever eral al different things ○ ○ Fetal an anemia Chr hro omoso som mal def defe ect cts s Alpha-fetoprotein screening ● ● This test uses only a samp sample le of the the mother's mother's blood betw between een 16 and 18 18 weeks. weeks. Meas Me asur ures es the the leve levell of alph alphaa-fe feto topr prot otei ein n ○ ● This Th is is is a pro prote tein in rel relea ease sed d by by the the live liverr High Hig h or low leve levels ls of of alphaalpha-fet fetopr oprote otein in can can indic indicate ate ○ ○ ○ ○ ● Neural tub Neural tube e defe defects cts - such such as spi spina na bif bifida ida Down syndrome Chro Ch romo moso soma mall abnor abnorma mali liti ties es Twins (due (due to to the fact ther there e is more more than than one baby baby makin making g the prote protein) in) Not done done on all mothers mothers - done done if one one of these these defec defects ts is susp suspecte ected d or there there is is a history of it in the family. Chorionic Villus Sample ● ● ● ● Chorio Chor ioni nic c villu villus s is the the fet fetal al pla place cent ntal al tissue. This Th is is an in inva vasi sive ve pr proc oced edur ure e where a catheter is inserted through the vagina, into the uterus, and samples of the chorionic villus are taken. Chec Ch ecks ks fo forr man many y dif diffe fere rent nt ge gene neti tic c issues. If in indi dica cate ted, d, don done e bet betwe ween en 11 11 and and 14 weeks. Amniocentesis ● ● This in This inva vasi sive ve pr proc oced edur ure e use uses sa syringe guided by ultrasound to take a sample of amniotic fluid. The Th e amni amniot otic ic flu fluid id is is test tested ed for for gen genet etic ic ● ● and metabolic issues. Can Ca n als also o che check ck fo forr iss issue ues s wit with h the the fetal lungs. Nott don No done e unl unles ess s ind indic icat ated ed.. Nitrazine Test ● ● ● If the the mother mother note notes s fluid fluid leaking leaking from the vagina vagina,, a nitraz nitrazine ine test test can can be performed to evaluate if it is simply vaginal secretions, or amniotic fluid indicated ruptured membranes. Stip is is dipped dipped in the secret secretions ions - color chan change ge indicate indicates s the pH of the the fluid. fluid. Blue Bl ue col color or ind indic icat ates es amn amnio ioti tic c flui fluid. d. NCLEX Question Which of the following are required for a nonstress test to be considered reactive? Select all that apply. apply. a. b. c. Two increas increases es in the fetal fetal heart heart rate rate of 15 15 be beats ats per per minut minute e Two decrea decreases ses in in the the fetal fetal heart heart rate of 15 15 beats beats per per minut minute e Two incre increase ases s in the the fetal fetal hear heartt rate rate for for 1 15 5 secon seconds ds d. Two d decr ecreas eases es in the fet fetal al heart heart rate rate for 15 seco seconds nds Answer: A and C A is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an increase in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement. B is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal fetal distress and a nonreassuring sign. Decelerations would lead to a nonreactive nonstress test. C is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an increase in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement. D is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal fetal distress and a nonreassuring sign. Decelerations would lead to a nonreactive nonstress test. NCSBN Client Need: Topic: Health promotion and maintenance Subtopic: Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. practice . Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Antepartum NCLEX Question Which of the following are invasive procedures not routinely done on all pregnant women? Select all that apply. a. b. Co Cont ntra ract ctio ion n str stres ess s ttes estt Amniocentesis c. d. Nonstress tte est Nitrazine tte est Answer: A and B A is correct. In a contraction stress test, contractions are induced ind uced with oxytocin. This is only done if a nonstress non stress test is nonreactive, or there are other concerns. B is correct. An amniocentesis is a sampling of amniotic fluid that is sent for genetic testing. This is only done if indicated. C is incorrect. A nonstress test is noninvasive and done as routine antepartum testing. D is incorrect. While a nitrazine test is not routinely done on all pregnant women, it is not invasive. This is a testing of the pH of vaginal secretions to determine if they are amniotic fluid and there have been rupture of membranes. This is only done if needed. It is non-invasive. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Antepartum Obstetrical Procedures Induction of Labor ● ● ● ● Using Usin g medi medica cati tion on to to caus cause e labo laborr to beg begin in Can only be done done if the baby is stable stable and a vagin vaginal al deliver delivery y is plann planned ed and and safe. Medica Med icatio tion n used used to stimu stimulat late e contra contracti ctions ons - oxy oxytoc tocin. in. Must monit monitor or contra contraction ctions s while while on oxyto oxytocin; cin; ifif there there are too long long (greate (greaterr than than 1.5 minutes) or too close together (less than 2 minutes apart), the baby is not getting enough oxygen and the oxytocin should be discontinued. Amniotomy ● ● ● Using Usin g a ho hook ok or th the e fin finge gerr to to bre break ak the amniotic sac. “Br Brea eak kin ing g th the e wa wate terr” This Th is he help lps s sti stimu mula late te la labo borr and and ca can n ● ● make pushing more efficient if the mother is fully dilated. Obser Ob serve ve the col color or,, odor odor,, and and condi conditio tion n of the amniotic fluid. Malo Ma lodo doro rous us fl flui uid d can can in indi dica cate te an infection. Episiotomy ● ● ● Forceps-Assisted Delivery ● ● Forcep Forc eps s are are a too tooll use used d ifif the there re is difficulty delivering the head of the baby. Manu Ma nual al pr pres essu sure re us used ed to he help lp pu pullll Done if th Done the e ope openi ning ng is no nott lar large ge enough to accomodate the fetus at the end of a vaginal delivery. An in inci cisi sion on is ma made de in th the e vag vagin ina a to to make the opening larger. This Th is al allo lows ws th the e fet fetus us to ex exit it th the e birth canal. ● ● baby out. Must Mu st be mi mind ndfu full to mo moni nito torr for for injury; laceration to skull of baby or vaginal tissue of mother. Also Al so pu puts ts th the e mot mothe herr at at ris risk k for for PPH Vacuum-Assisted Delivery ● ● ● Anothe Anot herr tec techn hniq ique ue th that at ca can n be be use used d to aid in the delivery of the head of the baby ba by.. Suct Su ctio ion n is is ap appl plie ied d to to the the he head ad of the baby and pulled while the mother pushes. No mo more re th than an th thre ree e att attem empt pts s ○ ● External Version ● ● This is a tec This techn hniq ique ue us used ed wh when en th the e baby is not in an appropriate position for vagnial delivery. We wan wantt the the ba baby by to be ce ceph phal alic ic,, or Called “p “pop of offs” Assess Asse ss sk skul ulll of in infa fant nt an and d mon monit itor or for trauma. ● head down. If th the e bab baby y is is bre breac ach, h, ex exte tern rnal al version can be used to try and more the baby into the cephalic position for a vaginal delivery. Caesarean Section ● If vaginal vaginal deliv delivery ery is not safe, safe, infant infant is is unstable unstable or unable unable to to tolerate tolerate a vaginal vaginal delivery, a caesarean section will be performed to remove the fetus surgically. NCLEX Question Which of the following obstetrical procedures can be used to assist in the delivery of the head of the fetus during a vaginal delivery? Select all that apply. apply. a. b. Amniotomy Forc Forcep eps s ass assis iste ted d del deliv iver ery y c. d. External v ve ersion Vacuu acuum m ass assis iste ted d deli delive very ry Answer: B and D A is incorrect. An amniotomy is the use of a hook hoo k or finger to break the amniotic sac. This helps hel ps stimulate labor but does not assist in the delivery of the head of the fetus. B is correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery. C is incorrect. External version is a technique used when the baby is not in an appropriate position for vagnial delivery. It may help prepare the baby for a vagnial delivery, but does not assist in the delivery of the head of the fetus. D is correct. Vacuum assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk potential reduction Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and delivery Labor and Delivery Complications: Placenta Previa Anatomy Normal Previa Classifications of previa The classification depends on where the placenta is located ● Complete ○ ● Partial ○ ● The pla placen centa ta is com comple pletel tely y cover covering ing the cer cervix vix Part Pa rt of of the the pla place cent nta a cove covers rs the the ce cerv rvix ix Marginal ○ Placen Pla centa ta cov covers ers onl only y the the ed edge ge of the cer cervix vix Complete placenta previa Partial placenta previa Marginal placenta previa Assessment ● ● ● ● Major symp Major symptom tom is PAIN PAINLES LESS S brigh brightt red red bleed bleeding ing The fac factt that that it is is pain painles less s is is very very imp import ortant ant That Th at se sets ts it apa apart rt fr from om an ab abru rupt ptio ion n To as asse sess ss th the e ble bleed edin ing g ○ ○ ○ ● ● Pad coun Pad countt to de dete term rmin ine e the the amo amoun untt Clots Color Ultras Ultr asou ound nd don done e to co conf nfir irm m diag diagno nosi sis s Ultras Ult rasoun ound d will will det determ ermine ine typ type e of pre previa via Nursing Interventions ● ● ● Never ever Never ever perfor perform m a vagina vaginall exam exam if you susp suspect ect a placenta placenta prev previa! ia! Would Wo uld neve neverr want want to to irrit irritate ate the pla placen centa ta or or uteru uterus. s. Cont Co ntin inue ue to mon monit itor or fo forr blo blood od lo loss ss.. ○ Patie Pa tient nt may may have have to stay stay on the the unit unit to be be monit monitore ored d ○ ○ ● Preform pa pad co counts Weigh pads ■ 1 gra gram m = 1 mL mL bl bloo ood d los loss. s. Cesare Ces arean an sec sectio tion n indi indicat cated ed in mos mostt cas cases es Patient Education ● Bed rest ○ ● Bleeding ○ ○ ○ ● This Th is ma may y min minim imiz ize e blo blood od lo loss ss Report Repo rt an any y ble bleed edin ing g tha thatt occ occur urs s Monitor bl blood lo loss Excess Exc essive ive amo amount unts s of bloo blood d loss loss may may need need treat treatme ment. nt. Monitor baby ○ If there there is is excessive excessive bloo blood d loss, loss, perfusio perfusion n to the fetus fetus can be be decrease decreased. d. NCLEX Question You are triaging a new patient in the antepartum unit. They tell you that they started bleeding this morning and were told to come in by their OB. They deny any pain or other symptoms. Which of the following nursing interventions do you anticipate initiating? Select all that apply. apply. a. b. c. d. Bed rest Pad counts Emer Em erge genc ncy y vagi vagina nall deli delive very ry Vaginal ex exam Answer: A and B A is correct. The nurse suspects a placenta previa based off of the clients complaint of painless bleeding. With a placenta previa, bed rest is indicated to prevent further bleeding. This is an appropriate nursing intervention to initiate for both the safety of the mother and fetus and should be done right away. B is correct. Pad counts are a way of monitoring the quantity of blood loss. Because the nurse suspects placenta previa and the patient is reporting vaginal bleeding, pad counts are an appropriate nursing intervention to initiate. When obtaining pad counts, they can be done in two ways. If exact quantity of blood loss is not indicated, the nurse can just count the number of pads saturated with blood. If the health care provider orders strict monitoring, the pads will be weighed to obtain the exact number of milliliters of blood lost. When weighing pads, 1 gram is 1 milliliter of blood lost. Pad counts at a minimum should be initiated for any suspected placenta previa, so this is an appropriate nursing intervention. C is incorrect. An emergency vaginal delivery is contraindicated contraindicated for a patient with suspected placenta previa. previa. Because we believe that the placenta is either partially or fully covering the cervix of this patient, a cesarean section will need to be performed. This may be distressing for some mothers, so be sure to provide education about why this is the safest option for their and their baby’s health. Vagnial deliveries with a placenta previa can cause serious harm to the mother and fetus, and are contraindicated. D is incorrect. Vaginal exams are contraindicated for a patient with a suspected placenta previa. In this patient, we suspect that the placenta is either partially or fully covering the cervix of this patient. That means that if a vaginal exam were to be performed, the hand of the examiner would touch the placenta. We do not want to cause this irritation and exacerbate the bleeding that is already occurring. Vaginal exams are always contraindicated on patients with either confirmed or suspected placenta previa. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and Delivery Break Back at... Labor and Delivery Complications: Abruptio Placentae Anatomy Types ● ● Causes Caus es ma mass ssiv ive e amo amoun unts ts of painful bleeding. Two types ○ ○ ● Incomp Inc omplet lete e is only only part partial ial sepa separat ration ion of of the plac placent enta. a. ○ ○ ● Incomplete Complete Causes Caus es in inte tern rnal al bl blee eedi ding ng Bloo Bl ood d bac backs ks up up beh behin ind d the the pla place cent nta a Comple Com plete te is is when when the the plac placent enta a compl complete etely ly deta detache ches s ○ ○ Causes Caus es ma mass ssive ive ex exte tern rnal al bl blee eedi ding ng Very pa painful Physiology ● ● Once the place Once placenta nta has has detach detached, ed, it is no longe longerr connec connected ted to to materna maternall circulation This Thi s mena mena ther there e is no more more per perfus fusion ion fro from m mom mom to bab baby y ● ● ● ● No per perfus fusion ion mea means ns no oxy oxygen gen or nut nutrie rients nts.. This Thi s is why why an abrup abruptio tion n is consi consider dered ed a MEDIC MEDICAL AL EME EMERGE RGENCY NCY ‘ The ba bab by nee needs ds ox oxy yge gen! n! Stat c-section!! Assessment ● ● ● ● ● ● ● Dark red ble lee eding Int nten ense se ab abdo dom min inal al pa pain in Board Boa rd lik like e abdom abdomen en (du (due e to int intern ernal al ble bleedi eding) ng) Rigid uterus Hypot Hy potens ension ion (Th (Think ink sh shock ock due to blo blood od los loss) s) Mat ate ern rna al tac tachy hyc car ardi dia a Feta Fe tall brad bradyc ycar ardi dia a (fet (fetal al dis distr tres ess! s!!) !) Interventions ● Moni Mo nito torr for for fe feta tall dis distr tres ess s ○ ● Sign Si gns s of of dis distr tres ess? s? St Stat at cc-se sect ctio ion! n! Moni Mo nito torr mat mater erna nall ble bleed edin ing g ○ Abdominal pain ○ ○ ○ ● ● Board lilike ab abdomen Dark Da rk re red d vag vagin inal al bl blee eedi ding ng Change Cha nge in fun fundal dal hei height ght (bl (blood ood in abdo abdome men? n?)) Keep the Keep the BP up wit with h IVF IVF and/ and/or or blo blood od pro produc ducts ts Prepar Pre pare e for for deliv delivery ery - most most lik likely ely cc-sec sectio tion. n. Previa vs. abruptio Previa - painless bleeding Abruption - Painful Painful bleeding NCLEX Question Which of the following signs and symptoms are expected for your patient experiencing abruptio placenta? Select all that apply. apply. a. b. c. d. Painless ble blee eding Dark red bleeding Hypotension Rigid abdomen Answer: B, C, and D A is incorrect. Painless bleeding is NOT a sign of abruptio placenta. Rather, it is a sign of placenta previa. In placenta previa, the placenta is covering the cervix. This causes painless bleeding. In abruptio placenta, p lacenta, the placenta separates from the wall of the womb. This causes a massive amount of very painful dark red bleeding. bleeding . It is important to remember the difference between these two emergencies. Placenta previa presents with painless bleeding, and abruptio placenta presents with painful bleeding. B is correct. Massive amounts of dark red bleeding is a prominent sign of abruptio placenta. This is due to the placenta separating from the wall of the uterus. This massive amount of bleeding causes hypotension as the mother enters hypovolemic shock, and fetal distress as perfusion to the baby decreases dramatically. C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of abruptio placenta. When the mother loses large amounts of blood, her blood pressure will drop. This hypovolemia is treated with IV fluids and/or blood products such as PRBCs. D is correct. A rigid, board-like abdomen is a sign of abruptio placenta. This is also due to massive massive blood loss. As the placenta separates from the wall of the womb blood starts to accumulate in the abdomen, causing it to become rigid, and ‘board-like’. NCSBN Client Need: Topic:: Physiological Integrity Subtopic: Physiological adaptation Topic Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and Delivery Labor and Delivery Complications: Dystocia What is dystocia? “Difficult birth, typically caused by a large or awkwardly positioned fetus, by smallness of the maternal pelvis, or by failure of the uterus and cervix to contract and expand normally.” normally.” (Perry et. al., 2013). Causes ● ● ● Macrosomia Mal alpo pos sit itio ion n of of the the fe fetu tus s Hypo Hy poto toni nic c co cont ntra ract ctio ions ns ● ● Hypert Hype rton onic ic co cont ntra ract ctio ions ns Maternal pelvis Macrosomia Extremely large fetus Greater than 4,000 grams Unable to fit through maternal pelvis Malposition of fetus Fetus is not in proper alignment for maternal pelvis. Incorrect positioning means they will not be putting pressure on the pelvis and therefore not causing dilation and effacement. Maternal anatomy of pelvis plays a role too. Hypotonic Contractions Weak and ineffective i neffective contractions Not able to work efficiently enough to get fetus through maternal pelvis Hypertonic Contractions Contractions are too strong and too fast. So fast, that they are not allowing the uterus time to relax and refill with proper nutrients. Uncoordinated and not effective to cause dilation and effacement. Maternal Pelvis Anatomy of the maternal maternal pelvis can play a role If it is too narrow for the size of the fetus the shoulder can become stuck during delivery (shoulder dystocia). Assessment Mother: ● Extrem Extr eme e pai pain n (es (espe peci cial ally ly with hypertonic Fetus: ● Fetal distress ● ● ● contractions) Unco Un coor ordi dina nate ted d contr contrac acti tion ons s Labo La borr is is not not pr prog ogre ress ssin ing g as as expected. ○ ○ ○ Dilation Effacement Station ● If co cont ntra ract ctio ions ns ar are e to too o strong and too frequent the placenta will not be providing sufficient oxygenation to the fetus. Moni Mo nito torr fet fetal al he hear artt rat rate e for for late decelerations. Interventions ● Moni Mo nito torr for for fe feta tall dis distr tres ess s ○ ● Medications ○ ○ ○ ○ ● ● Notify Not ify the the heal health th care care prov provide iderr for any feta fetall distre distress ss Pain medic ica ations IV Fluids Tocolytics ■ Gi Give ven n for for hy hype pert rton onic ic con contr trac acti tion ons s Oxytocin ■ Gi Give ven n for for hy hypo poto toni nic c con contr trac acti tion ons s Rest betwe between en cont contract ractions! ions! Need to focu focus s during during cont contract ractions. ions. Patients Patie nts with with hypoton hypotonic ic contra contraction ctions s may be encour encouraged aged to to walk to try and get get the contractions into a pattern. Education ● ● Educate the Educate the mother mother abou aboutt the pain she is experie experiencing ncing and her her options options for medication. Positio Pos itionin ning g is impor importan tantt for opti optimal mal oxy oxygen genati ation on to the the fetus fetus ○ Left Le ft si side de ly lyin ing g is is enc encou oura rage ged. d. NCLEX Question Which of the following are causes of dystocia? Select all that apply. a. b. c. d. Hypert Hype rton onic ic co cont ntra ract ctio ions ns Macrosomia Hypo Hy poto toni nic c co cont ntra ract ctio ions ns Bre reec ech h pre prese sen nta tattio ion n Answer: A, B, C, and D A is correct. Hypertonic contractions are contractions that are too strong and too frequent. This is a cause of dystocia. The contractions are not effective in causing dilation and effacement, and do not help labor progress. They are extremely painful. Treatment for mothers experiencing hypertonic contractions would include tocolytics and pain medication. B is correct. Macrosomia is defined as a fetus that is much larger than average; greater than 4,000 grams. Because of the size of these infants, it is difficult for them to fit through the maternal pelvis. This often causes a specific type of dystocia; shoulder dystocia, where the shoulder of the infant essentially becomes stuck behind the pubic bone and causes prolonged and difficult labor. C is correct. Hypotonic contractions are contractions that are very weak and uncoordinated. They are a cause of dystocia. When contractions are weak and uncoordinated they are ineffective in causing dilation and effacement and labor does not progress as expected. Treatment would include oxytocin or helping the mother walk to get her contractions into a pattern. D is correct. Breech presentation is one type of malpresentation that can cause dystocia. When the fetus is not lined up in a cephalic presentation, fitting through the maternal pelvis becomes very difficult and causes dystocia. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and Delivery Labor and Delivery Complications: Preterm Labor Terminology ● Term - A bab baby y born born from from 37-40 37-40 wee weeks ks gest gestati ation on ● Preter Pre term m - A bab baby y born born betw between een 20 and and 37 37 week weeks s Preter Pre term m labor labor Any labo laborr occuri occuring ng betwe between en 20 and and 37 week weeks s ● Viability Viab ility - The The thresh threshold old at at which which an an infant infant can can survi survive ve outside outside the womb womb ○ ● PROM PR OM - Prem Premat atur ure e Rupt Ruptur ure e of Me Memb mbra rane nes s ○ ● Abou Ab outt 20 20 wee weeks ks ge gest stat atio ion n Ruptur Rup ture e of the mem membra branes nes bef before ore lab labor or begi begins. ns. PPROM PPR OM - Prete Preterm rm Prem Prematu ature re Rupt Rupture ure of Memb Membran ranes es ○ PROM that occur occurs s before before the the 37th 37th week week of gest gestation ation,, or prema premature turely ly.. Assessment ● ● ● Important to determi Important determine ne if it is true labor labor,, or ‘fals ‘false’ e’ labor labor.. Many wome women n experien experience ce Braxton Braxton Hick Hicks s contrac contractions tions in their their second second and third third trimester, but these are not indicative of true labor. Asse As sess ssme ment nt of tr true ue la labo borr ○ ○ ○ ○ ○ Contra Cont ract ctio ions ns at at regu regula larr inte interv rval als. s. Cont Co ntra ract ctio ions ns of of incr increa easi sing ng int inten ensit sity y Pelvic pain Lower back pain Rup uptu ture re of mem memb bra rane nes s Interventions ● ● Try to stop labor! If at all possib possible, le, we we want want contrac contractions tions to stop stop so so that that the pregn pregnancy ancy can continue and the baby can be born at a normal gestational age. ● Ways to to st stop la labor: ○ ○ ○ ● ● ● Tocolytics ■ Terbutaline ■ Magnesium Su Sulf lfa ate Bedrest Fluids Must moni Must monitor tor bot both h moth mother er and bab baby y clos closely ely Evaluate Evalu ate the the mothers mothers cont contract ractions ions and and their their frequen frequency cy,, and how the the fetus fetus is tolerating the contractions. If PRO PROM M or PPR PPROM OM mon monito itorr clos closely ely for inf infect ection ion.. Education ● ● Most impor important tant educa educationa tionall point point for mother mothers s is what what the the signs signs and symp symptoms toms of true labor are, so that they know when to call their doctor doctor.. Tea each ch mot mothe hers rs to to call call the their ir OB OB for: for: ○ ○ ○ ○ ● Rup uptu ture re of mem memb bra rane nes s Reg egu ula larr co contr tra act ctio ions ns Contracti Cont ractions ons that that become become strong stronger er and more more frequen frequentt with walking walking (Braxt (Braxton on Hicks Hicks will fade fade away with walking) Back pain Once preterm Once preterm labor has begun, begun, educ educate ate mother mothers s about about tocoly tocolytics tics and the the importance of bedrest. NCLEX Question Which of the following are symptoms of true labor? Select all that apply apply.. a. Contra Con tracti ctions ons tha thatt diss dissipa ipate te wit with h wal walkin king g b. c. d. Contracti Contra ctions ons tha thatt come come in regu regular lar int interv ervals als Lower back pain Cont Co ntra ract ctio ions ns of of cons consis iste tent nt inte intens nsit ity y Answer: B and C A is incorrect. Contractions that fade away with activity, a change in position, or rehydration are not a sign of true labor. These are more likely Braxton Hicks contractions, which do not indicate labor. They are ‘practice contractions’ for the uterine muscle. True contractions will not fade with activity, come in regular intervals, become closer together as time goes on, and become more intense as time goes on. B is correct. Contractions that come in regular intervals are a sign of true labor. You You should educate mothers to seek care for contractions that come in regular intervals, and become stronger and closer together with time. These contractions also will not go away with a change in position or activity. C is correct. Lower back pain is in fact a sign of true labor. Both lower back pain and pelvic pain indicate true labor, and mothers should be educated to seek treatment when such treatments present. ‘False’ labor, or braxton hicks, do not present with these symptoms. They are much weaker than contractions, and typically subside with a change in position or by going on a short walk. D is incorrect. Contractions of consistent intensity indicate braxton hicks, or ‘false’ labor. labor. When a mother mothe r is in true labor, her contractions will increase in intensity over time. Education should be provided on the difference between braxton hicks and true labor so that mothers know when to call their OB and seek treatment. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Labor and Delivery Complications: PROM Definition The rupture of membranes before labor begins. “Rupture of membranes” is when the amniotic sac breaks - when someone says their water broke this is what they mean. This is supposed to happen after labor starts. With the amniotic sac intact there is a buffer between the uterus and the infants preventing contractions. The lack of this can stimulate contractions. Assessment ● Whenever When ever the membran membranes es rupture rupture,, always always assess assess the color color amoun amountt and odor odor.. ○ ○ ○ Should be clear Shou Sh ould ld no nott hav have e a fo foul ul od odor or Can be just just a sma smallll amoun amountt of flui fluid d up to to a few few hundr hundred ed mLs. mLs. ○ ● If the mem membran branes es are yello yellow w, green, green, malodor malodorous, ous, etc… etc….. Worry Worry about about infectio infection!! n!! ● Infection is Infection is the major conc concern ern with with PROM, PROM, so so that that is what what your your assess assessment ment with focus on. Temperature ● ● WBCs CRP Interventions ● Nitrazine te test ○ ○ ○ ● Mon onit ito or for for in infe fec ctio ion n ○ ○ ○ ○ ● pH test test that that differe differentiat ntiates es amnioti amniotic c fluid fluid from from urine urine or othe otherr secretio secretions. ns. Strip Str ip will will turn turn blu blue e if the flu fluid id is is amni amnioti otic c fluid fluid This Th is will will con confi firm rm rup ruptu ture re of of memb membra rane nes s Temperature WBCs CRP Anti An tibi biot otic ics s if in indi dica cate ted d Fetal monitoring ○ Heart rate ○ Decelerations NCLEX Question Which of the following statements is true regarding premature rupture of membranes (PROM)? Select all that apply. a. PROM is when when the the membr membranes anes rupt rupture ure befor before e 37 week weeks s gestati gestation. on. b. c. d. Membran Membr anes es are are expect expected ed to rupt rupture ure befo before re labor labor begi begins ns A prior priority ity nursing nursing inter interventi vention on with with PROM PROM is is to monito monitorr for infec infection tion.. When obser observing ving the the fluid after after ruptur rupture e of membran membrane, e, it should should be clear clear and witho without ut odor odor. Answer: C and D A is incorrect. PROM stands for Premature Rupture of Membranes. This is defined as the rupture of membranes (or “water breaking”), before labor begins. This term is not related to at what gestation the membranes rupture. If the membranes rupture before 37 weeks gestation, the correct terminology is PPROM. This stands for Preterm Premature Rupture of Membranes. The Preterm part of this acronym is what refers to the membranes rupturing before 37 weeks gestation. B is incorrect. It is not expected that the membranes will rupture before labor begins. In a normal delivery, there is rupture of membranes after the mother has begun having regular contractions, dilating, and effacing. When the membranes do rupture before labor has started, it is called PROM, or premature rupture of membranes. C is correct. A priority nursing intervention with PROM is is to monitor for infection. When the membranes are ruptured before labor labor begins, the baby is then exposed to bacteria and pathogens of the outside world. These germs can enter the birth canal and infect both the mother and the infant. One of the most important observations you must make is of the color, odor, consistency, and amount of the amniotic fluid when the rupture of membranes occurs. Any discolored or malodorous fluid may indicate an infection. After the rupture of membranes occurs, the nurse should monitor the mother's temperature, WBC count, CRP CRP,, and other markers of infection. D is correct. It is very important to assess the color, odor, consistency, consistency, and amount of fluid when rupture of membranes occurs. If the fluid is green or yellow and malodorous, it is indicative of infection. If the fluid is brown or black it is indicative of meconium passing in utero. The expected finding of amniotic fluid is a clear fluid with no odor. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care . Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and Delivery Postpartum Complications: Postpartum Hemorrhage What is it? Why is it important Postpartum hemorrhage is the major loss of blood (hemorrhage) after a vaginal delivery. Can occur immediately after the delivery, up until 2 weeks after delivery (delayed postpartum hemorrhage) It is one of the major causes of maternal mortality! Almost 3% of women in the US will experience PPH to some degree!! More info: http://www.pphproject.org/maternal-morbidity-mortality.asp Risk factors for PPH ● ● ● Twins or or tr triplets Macrosomic fetus Preeclampsia ● ● ● ● ● Prolonged labor Precipitous labor Use Us e of of forc forceps eps or vac vacuum uum dur during ing del delive ivery ry Placenta pr previa Abruptio pl placenta Causes ● Uterine atony ○ ○ ○ ○ ● Inju In jury ry to th the e bi birt rth h ca cana nall ○ ● Could Coul d be due due to malpres malpresenta entation tion of of the fetus fetus,, use of of forceps forceps or or vacuum, vacuum, or a large fetu fetus s Rete Re tent ntio ion n of of the the pl plac acen enta ta ○ ● This is the ina This inabil bility ity of the the ute uterus rus to con contra tract ct Typica ypically lly after after birth, the the uterus uterus contract contracts s to clamp clamp down on on all of the the blood blood vessels vessels and stop stop the bleeding If the the uterus uterus does does not not contra contract, ct, or or ‘clamp ‘clamp down’ down’ hemor hemorrhag rhage e will will occur. occur. This Th is is is the the mo most st co comm mmon on ca caus use e of of PPH PPH If the entire entire placen placenta ta is not expell expelled ed within within 30 minute minutes s of delivery delivery,, the mother mother is at at risk for PPH PPH Ble lee eding di disorders ○ ○ DIC Mothe Mo thers rs on loven lovenox ox or warfa warfarin rin for for pre-ex pre-exist isting ing cond conditi itions ons.. Definitions ● 2 types of PPH ○ ○ Early - Occur Early Occurs s in the fir first st 24 24 hour hours s post post del delive ivery ry Late Lat e - Occur Occurs s after after the fir first st 24 24 hours hours pos postt delive delivery ry ● To qualify qualify as as PPH, PPH, the mother mother must lose 500 500 ml of of blood blood if she she had a SVD and 1,000 ml of blood if she had a cesarean section. Assessment ● Boggy uterus ○ ○ ● Blood loss ○ ○ ○ ● This is is a uterus uterus that is not cont contractin racting g to clamp down on the the blood blood vessels vessels The fun fundus dus will will feel feel sof softt instea instead d of hard hard as as it shoul should. d. Pad coun counts ts - most PPH patie patients nts are are satura saturating ting pads every 15 minut minutes es Pudd Pu ddle le of bl bloo ood d in in the the be bed d If they they try try to stand stand up for for the the first first time time there there could could be a huge huge gush gush of blood Shock Shoc k - if there there is is large large amounts amounts of blood blood loss loss leadi leading ng to hypo hypovolem volemia ia ○ ○ ○ ○ ○ Decreased LOC Pale Diaphoretic Hypotensive Tachycardic Interventions ● Fundal massage ○ ○ Mass ssag age e th the fun fundu dus s - hard! Warn Wa rn the moth mother er this this will hurt, hurt, but but you must must do it to get get the uter uterus us to contr contract act and and stop stop the ○ ● Esti Es tima mate ted d Blo Blood od Lo Loss ss (E (EBL BL)) ○ ○ ○ ● bleeding. Ever Ev ery y 15 15 min minut utes es at a min minim imum um Weigh Weig h pad pads s to to est estim imat ate e the the lo loss ss 1 g = 1 mL Moni Mo nito torr hemo hemogl glob obin in and and hem hemat atoc ocri ritt Mediations ○ ○ ○ Oxytocin Meth thyl yle erg rgon ono ovi vin ne Blood products NCLEX Question Which of the following conditions are considered a risk factor for women to experience postpartum hemorrhage? Select all that apply. a. b. c. d. Microcephaly Dystocia Placenta previa Sing Si ngle letton pr preg egna nanc ncy y Answer: B and C A is incorrect. Microcephaly is a newborn complication where the newborn is born with a head smaller than average. This is not a risk factor for a woman to experience postpartum hemorrhage. If you selected this answer, a nswer, you may have gotten it confused with macrosomia macrosomia,, a condition where the infant is larger than average, specifically greater than 4,000g. This is a risk factor for postpartum hemorrhage. B is correct. Dystocia, a prolonged and difficult d ifficult labor, labor, is a risk factor for postpartum hemorrhage. Prolonged labor specifically can dramatically increase the risk for postpartum hemorrhage. hemorrhag e. C is correct. Placenta previa is a risk factor for postpartum hemorrhage. In placenta previa, the placenta is covering the cervix of the mother rather than sitting in the fundus of the uterus as it should be. This puts the mother at risk for postpartum hemorrhage. D is incorrect. A singleton pregnancy, pregnancy, or a pregnancy with only one fetus does not pose a risk for postpartum hemorrhage. The risk factor for postpartum hemorrhage hemorrha ge is with multiples; such as twins or triplets. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Labor and Delivery Newborn Complications: Meconium Aspiration Meconium Meconium is the first stool of the newborn. It is a sticky, black, tar-like substance. It can be passed in utero before delivery, or after the fetus is born. Meconium passed in utero is sometimes a sign that the fetus is in distress. Aspiration Aspiration is when a substance, such such as food or fluids, is inhaled and passes into the lungs via the trachea instead of into the stomach stomach via the esophagus. Meconium Aspiration When the meconium is passed before delivery, the fetus is at risk for meconium aspiration. The aspiration can occur in utero, or just after delivery when the infant takes their first breath and starts to cry. Meconium in the lungs causes very serious illness; pneumonia, pulmonary hypertension, and sepsis are all common. These infants become critically ill very quickly. Assessment If meconium aspiration is suspected, pertinent assessment will include: ● Res espi pirrat ato ory sta tatu tus s: ○ ○ ○ ○ Acc cce ess ssor ory y musc scle le use Breath sounds Grunting Nasal flaring Assessment to to determine if meconium has been passed passed in utero: ● Visi Vi sibl ble e mec mecon oniu ium m in fl flui uid/ d/on on in infa fant nt ● ● ● Discolore Discol ored d or or fou foull smel smelling ling amn amniot iotic ic flu fluid id Disc Di scol olor orat atio ion n of of the the co cord rd Discol Dis colora oratio tion n of of the the nails nails/to /tonge nge on the inf infant ant Interventions Very Ve ry quick action is essential to the outcome. ● Suction Suct ion immedia immediately tely after birth - before before they take their first breat breath. h. ● ● Intubation ECMO NCLEX Question You are called to the delivery of an infant that is 41 weeks gestation, and they suspect meconium in the amniotic fluid. After the birth, which of the following signs would help you confirm a meconium delivery? Select all that apply. a. b. c. d. Brown Brow n ti ting nged ed am amni niot otic ic fl flui uid d Thick, Thi ck, whi white te subs substan tance ce coa coatin ting g the the newbo newborn rn Vigorous cr cry Brown Bro wn dis discol colora oratio tion n of of the the inf infant ant's 's nai nails ls Answer A and D A is correct. If the amniotic fluid is tinged brown, it is a good indication that meconium was passed prior to delivery. B is incorrect. A thick, white substance coating the newborn is known as vernix caseosa. This is a normal substance and serves to moisturize the newborn's skin. C is incorrect. A vigorous cry is a good sign in a newborn. This alone is not an indicator ind icator of meconium aspiration. If there is meconium in the fluid and then the infant starts to cry vigorously it can then lead to meconium aspiration. D is correct. Brown discoloration of the infant's nails, umbilical cord, or tonge can all indicate meconium aspiration. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Newborn Newborn Complications: Jaundice Terminology ● Jaundice - eleva Jaundice elevated ted bilirubi bilirubin n level level resulting resulting in yellowing yellowing of the scle sclera, ra, skin, skin, and and mucous membranes. ● Bilirubin Biliru bin - wast waste e product product produ produced ced durin during g breakdo breakdown wn of red blood blood cells cells.. ○ Unconjugated (indirect) - The heme that is released from hemoglobin in the process of red blood cell breakdown is converted to unconjugated bilirubin. It is transported to the liver. ○ Conjugated (direct) - Unconjugated bilirubin is converted converted to conjugated conjugated bilirubin in the liver. liver. It is excreted in the stool. Lab Values Depend on the age of the infant i nfant - specifically their hours of life! ● Total ○ ● Unconjugated ○ ● 0.8-12 mg/dL 0.2-0.7 mg mg/dL Conjugated ○ 0.1-0.4 mg mg/dL Why do we see jaundice so often in newborns? Their livers are immature! In utero the placenta does the job of removing bile from circulation because the fetal liver isn’t functioning yet. Sometimes it takes a bit for their livers to start removing the bilirubin themselves. Pathological Jaundice Jaundice that occurs within the first 24 hours of life. Serum bilirubin will be compared to normal value based on hours of life. Jaundice appearing in the first 24 hours indicates some problem or disease process that needs addressed. Could be an issue with the liver, or an ABO incompatibility Physiological Jaundice Jaundice that appears on day 2 or 3 of life. l ife. This is expected and not considered pathologic unless other issues arise. This is simply due to the normal transition from the placenta removing bilirubin, to the infant's liver doing the work. Followed up outpatient with pediatrician. Kernicterus Kernicterus is a type of brain damage that can result from high levels of bilirubin bili rubin in the blood. Complications of kernicterus: ● ● ● ● ● Cerebral palsy Hearing loss Pro rob ble lems ms wit ith h vis visio ion n Proble lem ms wi with te teeth Inte In tell llec ectu tual al dis disab abil ilit itie ies s Kernicterus is completely preventable! We must monitor for signs and symptoms of jaundice early and treat promptly promptly.. Assessment Skin Sclera Mucous membranes Treatment - phototherapy ● ● ● ● Helps Help s bre break ak do down wn bi bilir lirub ubin in so it may may be excreted in the feces. Must Mu st ens ensur ure e the the eyes eyes an and d geni genita tals ls are are covered. Moni Mo nito torr the the lev level el an and d dis dista tanc nce e fro from m the light if overhead therapy being used. Doub Do uble le,, trip triple le,, and and quad quadru rupl ple e ther therap apy y depending on severity. NCLEX Question Which of the following statements is true regarding jaundice in newborns? a. Jaundi Jau ndice ce withi within n the firs firstt 24 hours hours of of life life is physi physiolo ologic gic.. b. c. d. Unconjugated Unconjug ated biliru bilirubin bin has has been conv converted erted to conjugat conjugated ed bilirubi bilirubin n in the the liver liver and is ready to be excreted in the stool. Assessing Asse ssing a newborn newborn for jaundic jaundice e involve involves s inspectio inspection n of the the skin, skin, scler sclera, a, and and mucous membranes. When treat treating ing a jaund jaundice ice infant infant with phot photother otherapy apy,, importan importantt nursing nursing considerations are to ensure their eyes and genitals are covered. Answer: C and D A is incorrect. Jaundice within the first 24 hours of life is pathologic. This means that there is some other disease process or condition causing the jaundice that needs to to be investigated. Physiologic Physiologic jaundice is is noted 2-3 days after birth and is simply simply due to the normal normal process of the infant’s infant’s liver taking over the processing of bilirubin. B is incorrect. Conjugated bilirubin has been converted to conjugated bilirubin in the liver and is ready to be excreted in the stool, not unconjugated. Unconjugated bilirubin is the waste product that is released when the heme is released from hemoglobin in the process of red blood cell breakdown. It is transported to the liver to be converted into conjugated bilirubin. C is correct. When performing an assessment on an infant suspected to have jaundice, the most important thing to do will be to assess the skin, sclera, and mucous membranes. When bilirubin levels are high, there will be a yellow tinge to these areas due to high levels of the bilirubin pigment in the blood. Jaundice usually starts in the face and forehead area, so begin your assessment there. The sclera and mucous membranes are an easy location to appreciate the yellow discoloration, especially in a patient with darker skin. D is correct. When treating a jaundice infant with phototherapy phototherapy,, important nursing considerations are to ensure their eyes and genitals are covered. The phototherapy light will help break down the bilirubin in the blood so that it may be excreted in the infants stool, but the light can be harmful to their eyes and genitals. Nurses should ensure these areas are covered with an eye mask and a diaper. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L. , & Wilson, D. (2013). Maternal child nursing care. care. Elsevier Health Sciences. Subject: Maternal and Newborn Health Lesson: Newborn Break Back at... Pediatrics Congenital Heart Defects Cleft lip/palate Omphalocele Pediatrics NCLEX topics Intussusception Epiglottitis RSV/Bronchiolitis Cystic Fibrosis Cerebral palsy Congenital Heart Defects Overview Definition ● ● Abnormali Abnorm alitie ties s in in the the str struct ucture ure of the hea heart rt Occur Occ ur during during the the very very beginnin beginning g of gestat gestation ion - the the heart heart is form formed ed by the 8th 8th ● week of gestation! Commonly Comm only occu occurr with with chromo chromosoma somall abnormal abnormalities ities and syndr syndromes omes such as: ○ ○ ○ ○ Trisomy 21 Trisomy 18 Turners sy syndrome DiG iGeo eorg rge e sy synd ndro rom me Congenital Heart Defects 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Atrial Atri al Se Sept ptal al De Defe fect ct (A (ASD SD)) Ven entr tric icul ular ar Se Sept ptal al De Defe fect ct (V (VSD SD)) Atri At riov oven entr tric icul ular ar ca cana nall Pate Pa tent nt Du Duct ctus us Ar Arte teri rios osus us (P (PDA DA)) Tet etra ralo logy gy of Fal allo lott Tri ric cus usp pid at atrres esia ia Coar Co arct ctat atio ion n of of the the ao aort rta a Aortic stenosis Pulmonic st stenosis Tran ranspo sposit sition ion of the gre great at art arteri eries es (TG (TGA) A) Tru runc ncus us ar arte teri rios osus us Hypop Hy poplas lastic tic Lef Leftt Hea Heart rt Syn Syndro drome me (HL (HLHS) HS) Foramen ovale An opening between the right and left atrium present present in fetal circulation circulation Ductus arteriosus An opening between the pulmonary artery and aorta present present in fetal circulation. Assessment ● ● Murmurs Tachycardia Left sided heart failure ● Tachypnea Right sided heart failure ● ● ● ● ● Diaphoresis Dec ecrrea eas sed ur urin ine e out outpu putt Fatigue Pallor Cyanosis ● ● ● Clubbing Hypotension Prol Pr olon onge ged d cap capil illa lary ry re refi fill ll ● ● ● ● ● ● Dyspnea Grunting Retrations Nasal flaring Cough Wheezing ● ● ● ● ● Weight gain Enlarged liliver Edema Ascites JVD Interventions ● ● ● ● Sur urg gic ica al in inte terrven enti tion ons s Rep epa air vs. pal palli lia ati tion on Car ardi diac ac ass ssis istt dev devic ice es Phar Ph arma maco colo logi gic c in inte terv rven enti tion ons s ○ ○ ○ ○ Digoxin ■ Cardiac gl glycoside Ace-inhibitors ■ Antii-h hypertensive Diuretics ■ He Help lp wi will ll fl flui uid d vol volum ume e ove overl rloa oad d Beta-blockers ■ Decrease HR NCLEX Question Which of the following heart sounds would the nurse expect to auscultate in her patient diagnosed with heart failure? Select all that apply. a. b. c. d. S1 S2 S3 S4 Answer: A, B, and C A is correct. The nurse would expect to hear an S1 heart sound in her patient with heart failure. S1 is a normal heart sound caused by the closing of the mitral and tricuspid valves. This heart sound should still be auscultated in a patient with heart failure. B is correct. The nurse would expect to hear an S2 heart sound in her patient with heart failure. S2 is a normal heart sound produced by the closure of the aortic and pulmonic valves. This heart sound should still be auscultated in a patient with heart failure. C is correct. The nurse would expect to hear an S3 heart sound in her patient with heart failure. This is an abnormal heart sound also known as a ventricular gallop. It occurs after S2 with the opening of the mitral valve, and is caused by a large amount of blood hitting a compliant left ventricle. Because this abnormal heart sound is associated with a large amount of blood, it is related to fluid volume overload. We see fluid volume overload in heart failure patients whose hearts are not effectively moving blood forward. That is why S3 is heart in patients with heart failure. D is incorrect. The nurse would not expect to hear an S4 heart sound in her patient with heart failure. S4 is also known as an “atrial gallop” it occurs before S1 when the atria contract to force blood into the left ventricle. It is caused by a stiff, noncompliant left ventricle. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Atrioventricular canal Definition Opening between the septum of the atria and the ventricles. Classification: acyanotic with increased pulmonary blood flow flow.. Sunt: left to right Associated disorders: disorders: Trisomy Trisomy 21 Repair Repair needed in infancy Patches to close ASD and VSD, rebuilding of tricuspid and mitral valves. NCLEX Question Which of the following signs would the nurse expect to find on her assessment of the patient with an atrioventricular canal? Select all that apply. a. b. c. d. Murmur Cyanosis Capi Ca pill llar ary y ref refil illl of of 4 sec secon onds ds Weight loss Answer: A and C A is correct. The nurse would expect to auscultate a murmur for a patient with an atrioventricular canal. In this patient, there is an ASD and as VSD. The higher pressures on the left side of the heart lead to blood shunting from the left side to the right side. This passing of blood from the left to right side of the heart creates the ‘whoosh’ sound that we know as a murmur. B is incorrect. Atrioventricular canal defect is an acyanotic defect with increased pulmonary blood flow. The nurse would not expect this patient to be cyanotic. Blood comes back to the heart and enters the atrium. The hole between the top two chambers allows oxygenated and deoxygenated blood to mix in the atrial component, and the hole between the bottom two chambers allows oxygenated and deoxygenated blood to mix in the ventricular component. oxygenated and deoxygenated blood is pumped to the lungs at high pressure instead of just deoxygenated, and oxygenated blood is pumped to all parts of the body by the aorta. Because it is only oxygenated blood being pumped to the body by the aorta, it is an acyanotic defect. C is correct. A capillary refill time of 4 seconds is is prolonged, and the nurse would expect to find this in her patient with an atrioventricular canal. This indicates poor perfusion due to heart failure. D is incorrect. Weight gain rather than loss would be expected in a patient with an atrioventricular canal. This patient will likely experience heart failure due to their defect, causing blood to back up in the body as the right ventricle struggles to move it forward into the lungs. This backup of blood causes edema, fluid retention, and weight gain. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subect: Pediatrics Coarctation of the Aorta Definition Congenital cardiac condition characterized by a constriction of the descending aorta. Classification: Ventricular outflow obstruction Shunt: left to right (IF a VSD or ASD is also present!!) present!!) Associated disorders: disorders: Turner Turner syndrome syndrome (45X) Repair Specific findings ● Upper extremities ○ ○ ○ ○ ● Bounding pu pulses Hypertensive Warm Pink Lower extremities ○ ○ ○ ○ Wea eak k or or ab abse sent nt pul ulse ses s Hypotensive Pale Cool NCLEX Question Which of the following assessment findings would lead the nurse to believe her patient could have a coarctation of the aorta? Select all that apply. apply. a. b. c. d. +1 rad radia iall puls pulses es an and d +3 fe femo mora rall puls pulses es Pale, Pal e, cool cool feet feet and leg legs s with with warm warm pin pink k hands hands and arm arms s Hype Hy pert rten ensi sive ve brac brachi hial al bloo blood d press pressur ure e Hypo Hy pote tens nsiv ive e poplit poplitea eall blood blood pres pressu sure re Answer: B, C, and D A is incorrect. In coarctation of the aorta, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper up per body is abundant, but b ut hardly any can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses, and increased upper extremity pulses. So the nurse would expect to palpate bounding +3 or +4 pulses in the radial pulse, but weak +1 or even absent femoral pulses. This is all due to the stricture in the aorta preventing blood flow from getting to the lower extremities. B is correct. Pale, cool feet and legs with warm pink hands and arms would be expected in a patient with coarctation of the aorta due to the stricture in the aorta preventing blood flow from getting to the lower extremities. C is correct. A hypertensive hypertensive brachial blood pressure would be expected in a patient with coarctation of the aorta due to the stricture in the aorta preventing blood flow from getting to the lower extremities. D is correct. A hypotensive hypotensive popliteal blood pressure would be expected in a patient with with coarctation of the aorta due to the stricture in the aorta preventing blood flow from getting to the lower extremities. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Pulmonic Stenosis Definition Stenosis of the pulmonary valve. The leaflets are thickened and stiff preventing blood from flowing into the pulmonary artery. Classification: Acyanotic Acyanotic with ventricular outflow obstruction defects Shunt: none Associated disorders: disorders: Noonan syndrome syndrome Repair ● Ca Card rdia iac c cat cathe hete teri riza zati tion on ○ Balloon Balloo n valvul valvuloplas oplasty ty to “open “open up” the steno stenotic tic pulmo pulmonary nary valv valve. e. ● Open he heart su surgery ○ Valv lve e rep epla lac cem emen entt Specific findings ● Ca Card rdio iome mega galy ly - en enla larg rged ed he hear artt ● Righ Rightt ve vent ntri ricu cula larr hy hype pert rtro roph phy y ● Ri Righ ghtt at atri rial al hy hype pert rtro roph phy y ● Murmur ○ Systol Systolic ic murmu murmurr - abnorma abnormall flow/ba flow/backck-flo flow w across across the the stenose stenosed d pulmonary valve ● Heart failure NCLEX Question Which of the following signs and symptoms would be expected in an infant diagnosed with pulmonary stenosis? Select all that apply. a. Murmur b. Tachycardia c. Cyanosis d. Poor feeding Answer: A and D A is correct. In an infant with pulmonary stenosis, the nurse will be able to auscultate a murmur during systole. This is due to the abnormal flow and backflow of blood across the stenosed pulmonary valve. B is incorrect. The nurse does not expect the infant with pulmonary stenosis to be tachycardic unless something else is also going on. Pediatric patients will become tachycardic if their cardiac output is decreasing, such as in shock or heart failure, to maintain their blood pressure. But this question does not say that the infant is experiencing anything other than pulmonary stenosis. C is incorrect. Pulmonary stenosis is an acyanotic heart defect. Blood enters the right atrium, flows through the tricuspid valve into the right ventricle, and then struggles to flow through the stenosis pulmonary pu lmonary valve into the pulmonary artery artery.. The right ventricle must work harder to push this blood forward, and becomes hypertrophied due to the extra workload. Once blood pushes past this stenosed valve however, it follows a normal flow through the left side of the heart: it becomes oxygenated in the lungs, returns to the left atria through the pulmonary veins, passes through the mitral valve into the left ventricle, passes through the aortic valve into the aorta, and is distributed to the body. It is only oxygenated blood being distributed to the body, therefore it is an acyanotic defect and the nurse would not expect the infant to be cyanotic. D is correct. In an infant with pulmonary stenosis, the nurse would expect poor feeding. Due to the stenosed pulmonary valve, the right side of the heart will have to work much harder to pump blood into the pulmonary artery and to the lungs. The lungs will have less blood flow, and there will be increased metabolic demands due to the increased workload on the right side of the heart. This will make it difficult for the infant to feed. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Basic care, comfort Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Tetralogy of Fallot Definition Congenital malformation involving four distinct heart defects: Pulmonary stenosis, right ventricular hypertrophy, hypertrophy, VSD, and overriding aorta. Classification: Cyanotic with decreased pulmonary blood flow Shunt: Right to left Associated disorders: 22q11 22q11 deletion syndrome Tet Spells ● ● Hypoxi Hypo xic c spel spells ls tha thatt occu occurr in TOF TOF.. Begins Beg ins wit with h irrit irritabi ability lity and hyp hyperp erpnea nea and fol follow lowed ed ● by a prolonged period of intense cyanosis leading to syncope. Thou Th ough ghtt to be be seco second ndar ary y to a sp spas asm m of the the infundibulum of the outflow tract, or a drop in systemic vascular resistance (SVR). ● A dro drop p in SVR SVR inc increa reases ses the rig right ht to to left left shunt shunt and decreases pulmonary blood flow. Tet Spell Interventions Comfort and calm Knee-to-chest position Supplemental oxygen Sedation - morphine Volume Sodium bicarbonate Propranolol Phenylephrine Increases the SVR, which decreases R-->L shunting to increase pulmonary blood flow. Treatment ● Alprostad Alpro stadilil administ administered ered to keep keep PDA open until until surger surgery y can be performe performed. d. ○ Keepi Ke eping ng the the PDA PDA open open allo allows ws more more pulmo pulmonar nary y blood blood flow flow ● ● ● ● If mild mild - can can go home home and gro grow w until until read ready y for for surge surgery ry If critica critically lly ill ill with seve severe re hypoxia hypoxia - surgery surgery is require required d in the the neonatal neonatal perio period. d. Ideall Ide ally y, compl complete ete rep repair air arou around nd 6 mont months hs of of age. age. Can be earl earlier ier dep depend ending ing on sign signs s and and symp symptom toms. s. Repair 1. Pulmonary Pulmonary steno stenosis sis repa repaired ired by rese resectin cting g the the infundi infundibular bular musc muscle le 2. Pat atc ch clos losure of VSD 3. Pulmo Pulmonary nary artery artery is opene opened d and a patch patch placed placed to open open up the outflow outflow trac tractt obstruction. NCLEX Question Which of the following statements about the heart defect tetralogy of fallot are true? Select all that apply. a. There There is is no per perman manent ent rep repair air for tetr tetralo alogy gy of of fallot fallot.. b. In tetralo tetralogy gy of of fallot, fallot, the right ventri ventricle cle is enlarge enlarged d due due to pulm pulmonary onary stenosis. c. Tetr etralo alogy gy of of fallot fallot is an an acyan acyanoti otic c heart heart def defect ect d. Mor Morphi phine ne may may be give given n to the the child child exp experi erienc encing ing a tet spel spell. l. Answer: B and D A is incorrect. There is a total repair for tetralogy of fallot. It is usually completed around 6 months of age, unless the child's status requires intervention sooner. In this surgery, the pulmonary stenosis is repaired by resecting the infundibular muscle. There is a patch closure of VSD, and the pulmonary artery is opened and a patch placed to open up the outflow tract obstruction. This stops right to left shunting, and allows blood to easily flow to the lungs. B is correct. In tetralogy of fallot, the right ventricle is enlarged due to pulmonary stenosis. The pulmonary stenosis makes it very hard for the right ventricle to pump blood out to the lungs. This puts an extra workload on the right side of the heart, and therefore causes the muscle of the right ventricle to hypertrophy. TOF, deoxygenated blood from the right side of C is incorrect. Tetralogy of fallot is a cyanotic heart defect, not acyanotic. In TOF, the heart shunts through the VSD and to the overriding aorta, where it is distributed to the body. This distribution of deoxygenated blood causes cyanosis. D is correct. Morphine may be given to the child experiencing a tet spell. This intervention calms the child, decreases pulmonary vascular resistance, therefore increasing blood flow to the lungs to increase oxygenation and relieve the tet spell. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Tricusp ricuspid id Atresia Definition Absence of tricuspid valve. There is a hypoplastic RV and a right ventricular outflow tract obstruction. There must be a PFO or ASD for circulation Classification: Cyanotic with decreased pulmonary blood flow Shunt: Right to left Associated disorders: disorders: Treatment ● Alprostad Alpro stadilil administ administered ered to keep keep PDA open until until surger surgery y can be performe performed. d. ○ ● ● Keepi Ke eping ng the the PDA PDA ope open n allo allows ws more more shu shunti nting ng Mild case Mild cases s can can be be treat treated ed in in the the cardi cardiac ac cat cath h lab lab If critica critically lly ill ill with seve severe re hypoxia hypoxia - surgery surgery is require required d in the the neonatal neonatal perio period. d. Repair ● ● Usualllly Usua y follo follows ws a sing single le-v -ven entr tric icle le rout route e Ther Th ere e are are th thre ree e sta stage ged d sur surge geri ries es ○ ○ ○ ● ● Norwoo Norw ood d - so soon on af afte terr bir birth th Bidi Bi dire rect ctio iona nall Glen Glenn n - 4-6 4-6 mo mont nths hs old old Fon Fo nta tan n - 2-3 2-3 ye year ars s ol old d Pulmon Pulm onar ary y ar arte tery ry ba band ndin ing g BT shunt NCLEX Question While providing care to an infant diagnosed with tricuspid atresia, the LPN knows it is important to decrease their cardiac demands. Which of the following are appropriate nursing interventions? Select all that apply. apply. a. b. c. d. Small, Smal l, fr freq eque uent nt fe feed edin ings gs Clusterin ing g ca cares Decrea Dec reasin sing g stimul stimulati ation on such such as ligh lights ts and and noise noise from from alarms alarms Main Ma inta tain in the their ir tem tempe pera ratu ture re bel below ow 34C 34C Answer: A, B, and C approp riate way to decrease the infant's cardiac demands. This ensures that A is correct. Small, frequent feedings is an appropriate too large of feedings don’t place increased stress on the infant, and that they do not become too hungry and irritable, as crying increases their cardiac demands as well. B is correct. Clustering cares is an appropriate way to decrease the infant's cardiac demands. Clustering cares involves completing your assessment, checking vitals, administering any necessary medications, feeding, and anything else that the infant needs all around the same time instead of spreading them out. This will promote rest and leave optimal time for the infant to sleep, therefore decreasing their cardiac demands. C is correct. Decreasing stimulation such as lights and noise from alarms is an appropriate way to decrease the infant's cardiac demands. This will promote rest and decrease their cardiac demands. D is incorrect. The nurse should not maintain the infants temperature below 34C. This is hypothermic, and will result in increased cardiac demands as the infant’s body and heart work harder to warm them up. The nurse should maintain euthermia, or a normal body temperature, to lower cardiac demands. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Transposition of the Great Arteries Definition A switch of the the aorta and pulmonary artery. artery. The aorta is coming off of the RV and the pulmonary artery is coming off of the LV. Creates two parallel and separate tracks. Classification: Cyanotic with increased pulmonary blood flow Shunt: left to right Associated disorders: disorders: none Repair Balloon atrial septostomy - Creation of ASD to allow shunting in the unprepared TGA patient. Arterial switch NCLEX Question The LPN is discussing transposition of the great arteries with a family whose 2 day old son just received this diagnosis. Which of the following statements by the father indicates to the nurse that he understands his son’s condition? Select all that apply. a. b. c. d. “Instead of the “Instead the pulmonar pulmonary y artery artery attaching attaching to to the right right ventricle ventricle like like it should, should, it is attach attached ed to the left ventricle. And the aorta is attached to the right ventricle instead i nstead of the left ventricle.” “Oxygenat “Oxyg enated ed blood blood from from the lungs is recirculat recirculating ing on the right right side side of my my son’s son’s heart, heart, and and deoxygenated deoxygenate d blood is re-circulating on the left side.” “Instead “Inst ead of the the pulmonar pulmonary y artery artery attaching attaching to to the left left ventricle ventricle like itit should, should, it is attache attached d to the right ventricle. And the aorta is attached to the left ventricle instead of the right ventricle.” “Oxygenat “Oxyg enated ed blood blood from from the lungs is recirculat recirculating ing on the left left side side of my my son’s son’s heart, heart, and and deoxygenated deoxygenate d blood is re-circulating on the right side.” Answer: A and D A is correct. This correctly explains transposition of the great arteries. In a healthy heart, the pulmonary artery attaches to the right ventricle and the aorta to the left ventricle. In transposition of the great arteries they are switched. B is incorrect. This statement would not indicate that the father understands transposition of the great arteries. This incorrectly explains the pattern of blood flow present in transposition of the great arteries. This LPN should reinforce that the right side of the heart is recirculating deoxygenated blood and the left side of the heart is recirculating oxygenated blood. C is incorrect. This statement would not indicate that the father understands transposition of the great arteries. In a healthy heart, the pulmonary artery attaches to the right ventricle and the aorta to the left ventricle. In transposition of the great arteries they are switched. The father has this reversed, and the LPN should reinforce education on transposition of the great arteries with him. D is correct. This correctly explains the pattern of blood flow present in transposition of the great arteries. This father understands that the right side of the heart is recirculating deoxygenated blood and the left side of the heart is recirculating oxygenated blood. NCSBN Client Need: Topic: Health promotion and maintenance Subtopic: Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Total Anoma Anomalous lous Pulmon Pulmonary ary Venous Return Definition Drainage of the pulmonary veins into the right atrium instead of the left atrium. Can be total or partial (there are 4 pulmonary veins). Classification: Cyanotic with increased pulmonary blood flow Shunt: right to left/mixing Associated disorders: disorders: ASD Repair NCLEX Question Which of the following statements about total anomalous pulmonary venous return (TAPVR) are true? Select all that apply. a. b. c. d. In TAPVR, TAPVR, there there is too much blood blood flow to to the body body,, and not enoug enough h blood blood flow to the lungs. Leftt ventri Lef ventricul cular ar hype hypertr rtroph ophy y can occu occurr with with TAPV TAPVR. R. Atrial Atr ial sep septal tal def defect ects s are are com common mon in TAPV APVR. R. Surger Sur gery y for TAPV APVR R is done done in in the fir first st 6 mont months hs of of life. life. Answer: C A is incorrect. In TAPVR, TAPVR, there is far too much blood flow to the lungs, not too little. The pulmonary veins, which usually bring oxygenated blood back to the left atrium, drain blood into the right atrium. This means that the right atrium ends up receiving body deoxygenated blood from the body and oxygenated blood from the lungs to send to the lungs. B is incorrect. Right ventricular hypertrophy may end up occurring with TAPVR, but not left. This is because there is increased blood flow and therefore a higher workload on the right side of the heart. This is because the pulmonary veins, which usually bring oxygenated blood back to the left atrium, drain blood into the right atrium. This means that the right atrium ends up receiving body deoxygenated blood from the body and oxygenated blood from the lungs to send to the lungs. This extra blood forces the right ventricle to work harder and is what can lead lea d to right ventricular hypertrophy. C is correct. An atrial septal defect is very common in children with TAPVR. TAPVR. In fact, an ASD can actually help the child child with TAPVR TAP VR because it allows blood to shunt from the right atrium across the ASD to the left atrium and then out to the body bod y. Children without an atrial septal defect have a much lower chance at survival. D is incorrect. Surgery for TAPVR is usually done in the first 2 months of o f life. Infants who are critically ill will require surgery immediately. If their ASD is allowing sufficient blood flow to the body, the surgeon may elect to wait up to 2 months to allow the child to grow. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Cardiac Hypoplastic Left Heart Syndrome Definition Disorder including 4 components: mitral stenosis or atresia, aortic stenosis or atresia, coarctation, and a hypoplastic left ventricle. Classification: Cyanotic with increased pulmonary blood flow Shunt: left to right Associated disorders: disorders: Turner Turner syndrome syndrome (45X), Trisomy Trisomy 18 (Edwards (Edwards syndrome), syndrome), Repair NCLEX Question Which of the following defects are part of the diagnosis Hypoplastic Left Heart Syndrome (HLHS)? Select all that apply. apply. a. b. c. d. Atreti Atre tic c mi mitr tral al va valv lve e Hypo Hy popl plas asti tic c righ rightt vent ventri ricl cle e Atre At reti tic c tric tricus uspi pid d valv valve e Hypo Hy popl plas asti tic c lef leftt ven ventr tric icle le Answer: A and D A is correct. HLHS is a disorder including 4 components: mitral stenosis or atresia, aortic stenosis or atresia, coarctation, and a hypoplastic left ventricle. An atretic mitral valve is part of the diagnosis. B is correct. There is not a hypoplastic right ventricle in HLHS. Instead there is a hypoplastic left ventricle. C is correct. There is not an atretic tricuspid valve in HLHS. There is mitral stenosis or atresia, and aortic stenosis or atresia, but the tricuspid valve is intact and functioning. D is correct. HLHS is a disorder including 4 components: mitral stenosis or atresia, aortic stenosis or atresia, coarctation, and a hypoplastic left ventricle. A hypoplastic hypoplastic left ventricle is part of the diagnosis. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Risk potential reduction Reference: Hockenberry Hockenberry,, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Break Back at... Cleft lip and Cleft Palate Cleft Lip A congenital abnormality where there is a slip, or gap, in the upper lip on one or both sides. Cleft Palate A congenital abnormality where there is a split, split, or gap, in the hard hard palate (the roof of the mouth) Assessment ● Visible defect ● ● ● ● ● Monito Moni torr res respi pira rato tory ry st stat atus us Airway pa patency Nutritional sta status Weight gain Hydration Complications ● ● ● ● ● ● ● Fee eedi ding ng dif iffi ficu cult ltie ies s Weight loss Failure to thrive Spee Sp eech ch an and d lan langu guag age e del delay ays s Hearing issues Ear infections Aspiration Management ● Sur urg gic ica all lly y cor corrrec ecte ted d ○ ○ ● Pre re--op oper era ati tiv ve car are e ○ ○ ○ ● Cleftt lip Clef lip fi firs rstt at at 3 6 mo mont nths hs of ag age e Cleft Cle ft pal palate ate sec second ond at 6-2 6-24 4 mon months ths of age Prone po posit itio ion nin ing g Moni nito torr for for asp spir ira ati tion on Asse As sess ss airw airway ay pa pate tenc ncy y fre frequ quen entl tly y Pos ostt-op oper erat ativ ive e car care e ○ ○ ○ ○ ○ Positio Posit ion n up upri righ ghtt fo forr fe feed edin ings gs Protect su suture liline Elbow Elbo w restraint restraints s to avoid avoid toddler toddler putting putting things things in the the mouth mouth that that would would comprom compromise ise the sutures No har hard d food foods, s, str straw aws, s, pac pacif ifie iers rs,, etc. etc. No or oral al or na nasa sall suc sucti tion onin ing g Feedings ● ● ● ● ● ● Specializ Specia lized ed bottl bottle e to facil facilita itate te a good good suct suction ion/la /latch tch Smal Sm all, l, fr freq eque uent nt fe feed edin ings gs Upright position Burp Bu rp fre frequ quen entl tly y - will will sw swal allo low w a lot lot of of air air May tak take e long longer er to fee feed d than than oth other er chi childr ldren en Mon onit ito or for for as aspi pirrat atio ion n ○ At risk for fee feedin ding g to to go go out out of the their ir nose nose.. NCLEX Question While assisting the intra-disciplinary team with interventions for a toddler who has just had a cleft palate repair, repair, the nurse knows which of the following are appropriate? Select all that apply. a. b. c. d. Pacifier Pacifi er with with oral oral sucro sucrose se to redu reduce ce posto postoper perati ative ve pain pain Elbo El bow w re res str trai ain nts Spec Sp ecia iali lize zed d bot bottl tle e for for fe feed edin ings gs Pron Pr one e po pos sit itiion onin ing g Answer: B and C A is incorrect. It is not appropriate to offer a toddler who is postoperative from a cleft palate repair a pacifier. This is because there is an incision with sutures in the palate of the mouth, and placing an object there could compromise the site. If the sutures break, the surgical site could open back up. B is correct. Applying elbow restraints is an appropriate intervention for a toddler who has just had a cleft palate repair. Toddlers are often putting things in their mouths, and pulling on things. It is a priority to protect their sutures, and we do not want the toddler to be able to pull out the sutures or put anything in their mouth that would compromise the suture line. Therefore, elbow restraints are often needed and an appropriate intervention. C is correct. Providing specialized bottles to the toddler who has completed their cleft palate repair will be very important for helping them establish feedings. It will be difficult for them to get good g ood suction on a normal nor mal bottle, so specialized ones are needed. D is incorrect. While prone positioning is appropriate for the infant with cleft palate pre-operatively, we will want to position them upright after surgery. This will facilitate the initiation of feeds and prevent p revent aspiration. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Endocrine Omphalocele What is omphalocele? ● ● ● Congen Cong enit ital al ab abno norm rmal alit ity y wh wher ere e the abdominal contents protrude through the umbilicus while remaining in the peritoneal sac. Occu Oc curs rs du duri ring ng we week eks s 9-1 9-10 0 of of gestation. Usua uall lly y dia diag gno nos sed on a prenatal ultrasound. Assessment ● Visible defect ● ● ● Som ome e inf infan ants ts ha have ve on only ly the omphalocele Some also have cardiac defects Lung size can be be affected Complications ● Hypothermia ● Dehydration ● Sepsis Surgical repair Management Pre-op ● ● ● ● ● Keep exp Keep expos osed ed int intes esti tine nes s mois moistt Cove Co verr wit with h ste steri rile le ga gauz uze e soa soake ked d in saline IV fluids IV antibiotics Thermoregula lattion Post-op ● ● ● ● Parenteral feeds Tro roph phic ic fe feed eds s sta start rted ed ent enter eral ally ly very gradually Monitor weight Ver ery y lo long ng ho hosp spit ital al st stay ay NCLEX Question The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate? a. b. c. d. “Stop, “Sto p, yo you’ u’ll ll ki kill ll yo your ur ba baby by!! !!”” “Thatt is a nice “Tha nice,, tight tight swaddle swaddle.. It will will really really help sooth your new baby” baby” “May I help help you? you? We will will need need to be be careful careful with with their their intestin intestines, es, we do not want the swaddle to push them back inside.” “Swadd “Sw addlin ling g is not not allowe allowed d for thes these e babies babies,, please please stop stop.” .” Answer: C A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to promote the parent bonding with their infant, and phrases like this will scare the parent and make them afraid to touch the baby, which is not therapeutic. B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their exposed intestines and could push them back inside of the baby, which we do not no t want. C is correct. This is a therapeutic statement. It educates the parent p arent about the need to swaddle the baby only very loosely, and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby. D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed intestines, but if it is done loosely and a nd avoids placing pressure on the defect it can certainly be done. Telling Telling the parent to stop will not promote bonding and decrease their interaction with the baby. The nurse should educate the parent on the necessary precautions when traveling and help them develop a positive relationship with their new baby baby.. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Gastrointestinal Intussusception What is Intussusception? ● ● ● Occurs when one part Occurs part of the the intestin intestine e slips slips inside inside the other other intes intestine tine “Telescoping” Often Ofte n occurs occurs wher where e the the small small intesti intestine ne and and large large intes intestine tine meet meet.. Assessment ● Red Re d cu curr rran antt je jell lly y st stoo ools ls ● ● ● ● ● Cycli lic cal abd bdom omin inal al pain Nausea Vomiting Gree een, n, bil ilio ious us em eme esi sis s Sau aus sag agee-s shap aped ed ma mas ss in abdomen Treatment ● Enema Enem a to to att attem empt pt to pu push sh th the e intestine back out ○ ○ ○ ● Air enema Hydrostatic en enema Barium enema If su succ cces essf sful ul a su surg rgic ical al re repa pair ir is needed. Management Pre-op Post-op ● ● ● ● Monitor stool NPO IV fluids IV antibiotics ● ● ● Mon onit ito or bow bowel el fu fun ncti tion on Infe In fect ctio ion n is is com commo mon n com compl plic icat atio ion n ○ Mo Moni nito torr te temp mps, s, WB WBCs Cs,, CR CRP P Slo low wly ad advance di diet NCLEX Question Which of the following symptoms should the nurse monitor for in her patient suspected of intussusception? Select all that apply. apply. a. b. c. d. Red cu Red curr rran antt je jell lly y st stoo ooll Hematemesis Palp Pa lpab able le,, saus sausag agee-sh shap aped ed mas mass s in RUQ RUQ Steatorrhea Answer: A and C A is correct. Red currant jelly stool is a classic finding of intussusception. When the bowel telescopes into another portion of the intestine, it causes intestinal obstruction and subsequently red currant jelly stools. B is incorrect. Hemateme Hematemesis, sis, or bloody vomiting, is not an expected finding in intussusception. We would expect vomiting of gastric contents, and possibly green bile if there is an obstruction. C is correct. Palpable, sausage-shaped sausage-shaped mass in RUQ RUQ is a classic finding of intussusception. intussusception. This is due to the physical telescoping of the intestine and the mass can sometimes be felt on palpation. D is incorrect. Steatorrhea is the passage of oily, pale, foul-smelling stool. It indicates fat malabsorption and can be a sign of Celiac disease, but would not be present in a patient with intussusception. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Endocrine Pediatrics Epiglottitis What is epiglottitis? ● Infl In flam amma mati tion on of th the e ep epig iglo lott ttis is ● Epiglottis ○ ● ● Inflam Infl amma mati tion on re rest stri rict cts s the the ai airw rway ay Cau aus sed by by an an inf infec ecti tion on ○ ● ● A leaf-sh leaf-shaped aped flap flap in the the throat throat that that prevents prevents food food from from entering entering the the windpipe windpipe and and the lungs. It stands open during breathing, allowing air into the larynx l arynx Bacterial Haemop Haem ophi hilu lus s infl influe uenz nzae ae typ type eb Med edic ical al eme merrge gen ncy Assessment ● ● ● ● ● ● ● ● Fever Dif iffi fic cul ulty ty swa swall llo owi wing ng Drooling Stridor Tripoding No cough Change in LOC Che herrry re red epi epigl glot otti tis s The 4 D’s of epiglottitis ● Dysphagia ● Dysphonia ● Drooling ● Distress Treatment ● ● ● ● ● ● ● IV antibiotics Humid idif ifie ied d ox oxygen Intu In tuba bati tion on and and mec mecha hani nica call vent ventila ilati tion on Keep the child calm No in inte terv rven enti tion ons s unt untilil ai airw rway ay is secure Do no nott irr irrit itat ate e the the th thro roat at ○ ○ NO ton ong gue depr pres esso sorr NO ora rall th the erm rmom ome ete terr ○ NO ass asse ess ssin ing g the the thr hro oat NPO Education ● Hib Hib vac vacci cine ne ha has s rred educ uced ed in inci cide denc nce e ● ● Tripod po position Avoid su supine ● ● Encour Encourage age par parent ents s to to vacc vaccina inate te to pre preven ventt When to call 911 ○ Trouble swallowing, breathing, and talking Straining the neck forward (trying to open the airway) Drooling (when it becomes too painful to swallow) A harsh raspy sound sound when inhaling inhaling (stridor), a sign that the airways airways are blocked Blue, purple, or gray skin or lips ○ ○ Trouble waking up to awake or arouse or unresponsive Trouble breathing ○ ○ ○ ○ NCLEX Question The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C HR: 188 RR: 46 O2: 82 % Which of the following is the priority nursing action at this time? a. b. Keep the chil Keep child d calm calm and call call for for emerg emergenc ency y airway airway equi equipme pment nt Obtain IV access c. d. Assess the thr Assess throat oat for a cher cherry ry red epi epiglo glotti ttis s Place Pla ce the the child child on on a high high flow flow nasal nasal cann cannula ula at at 100% 100% FiO2 FiO2 Answer: A A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious for this medical emergency. In addition, this patient is already showing signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and airway is always the priority! B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment. C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect that airway before assessing the throat. . D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this intervention addresses the ‘C’ in your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their airway, a irway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child their airway could spams and obstruct completely making it impossible to intubate them. That is why keeping the child calm and calling for emergency airway equipment is the priority in epiglottitis patients. NCSBNClientNeed: Topic:Physiological Integrity Subtopic:Risk potentialreduction : , ., , . , . RSV/Bronchiolitis What is bronchiolitis? ● Infl In flam amma mati tion on of th the e bro bronc nchi hiol oles es 17. ’ 1 . . , : . ● Bronchioles ○ ○ ● Smalle Smal lest st br bran anch ches es of th the e air airwa way y Lead to alveoli Alveoli ○ ○ Air sacs Loca Lo cati tion on of ga gas s exch exchan ange ge in the the lu lung ngs s ● Thic Th ick k mu mucu cus s cl clog ogs s up th the e ● bronchioles Lea Le ads to de dec crea eas sed ga gas s exchange in alveoli ○ ○ Air trapping Coll lla apsed alv alve eoli Overview ● ● Most com Most commo mon n in chi child ldre ren n unde underr 2 year years s old old Seasonal ill lln ness ○ ● Caus Ca usat ativ ive e agen agentt usua usuall lly y vira virall ○ ● ● Most co com mmon in in win winte terr Resp Re spir irat ator ory y Syn Syncy cyti tial al Vir Virus us (RS (RSV) V) Very contagious Worst on on da days 44-6 Assessment ● Cough ● ● Fever Incr In crea ease sed d wor work k of of bre breat athi hing ng ○ ● ○ Retractions ■ Subcostal ■ Intracostal ■ Tracheal tug Nasal flaring ○ ○ Head bobbing Tachypnea ● Hypoxia ○ ○ ○ ○ ● Circu Circ umor ora al cy cya anos osis is Mottling Dela De laye yed d ca capi pill llar ary y re refi fill ll Decreased SpO2 Changes in in be behavior ○ ○ Irritability Lethargy ○ Poor fe feeding Lung sounds ○ ○ Crackles Wheezing Treatment Supportive treatment ● Oxygenation ○ ○ ● Nasall cann Nasa cannul ula a - hig high h flow flow nas nasal al can cannu nula la Alw lwa ays humid idif ifie ied d Fluid & Nutrit itio ion n ○ ○ ○ NGT Enteral feedings IVF ● Antipyretics ● Analgesics Nursing Considerations ● Contin Con tinue ue to to monit monitor or resp respira irator tory y statu status s for for chang changes es ○ ○ ● Work of bre Work breath athing ing - impro improvin ving? g? Wo Worse rsenin ning? g? Cont Co ntin inuo uous us pu puls lse e oxi oxime metr try y Main Ma inta tain in ai airw rway ay at al alll tim times es ○ ○ ○ Semi fow Semi fowle lers rs pre prefe ferr rred ed po posi siti tion onin ing g Keep Ke ep ne neck ck ext exten ende ded d to to ope open n air airwa way y ■ Shoulder roll Suct ctio ion n ava vail ila abl ble e Education ● Inf nfec ecti tion on pr prev even enti tion on ○ ○ ● Dro rop ple lett pre reca cau uti tio ons Isol Is olat ate e fro from m oth other ers s as as abl able e at at hom home e Prevention ○ Paliviz Paliv izum umab ab fo forr at at ris risk k pat patie ient nts s ■ Synagis ■ Premature in infants ■ CF ■ Trisomy 21 NCLEX Question The nurse is assigned to care for a 18 month m onth old diagnosed with bronchiolitis. She was born at 32 weeks gestation, but has no other past medical history. history. Which of the following does the nurse anticipate including in the plan of care? a. b. c. d. Ceftri Ceft riax axon one e ad admi mini nist stra rati tion on Humi Hu midi difi fied ed oxy oxyge gen n admi admini nist stra rati tion on Cont Co ntac actt pre preca caut utiion ons s IV fluids Answer: B and D A is incorrect. Bronchiolitis is usually caused by a viral infection, most commonly respiratory syncytial virus (RSV). Ceftriaxone is an antibiotic, and antibiotics will not no t be effective against viral infections for they are not supported in the treatment of bronchiolitis. B is correct. Treatment of bronchiolitis will be primarily symptom management. Many children will require oxygen administration as the mucous in their bronchioles lessens gas exchange in the alveoli. Oxygen administration should be humidified to prevent drying out the mucous membranes. C is incorrect. Contact precautions are not sufficient for bronchiolitis. This infection is likely caused by a respiratory virus such as RSV and spread through droplets in the air, so droplet precautions will be necessary. This will include a gown, gloves, and mask when the nurse enters the room. Frequent handwashing is also key to preventing the spread of this infection. D is correct. Due to the increased work of breaking that bronchiolitis br onchiolitis causes, IV fluid administration may be necessary in the treatment of bronchiolitis if the patient is unable to meet their fluid requirements through PO intake. An isotonic crystalloid solution will be used to ensure en sure the patient remains hydrated until they can safely take PO fluids again. NCSBN Client Need: Topic: Physiological Physiological Integrity Subtopic: Basic care, comfort Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Cystic Fibrosis What is Cystic Fibrosis? ● ● ● Autoso Auto soma mall re rece cess ssiv ive e di diso sord rder er Mutati Mut ation on leads leads to a build buildup up of exce excessi ssive ve mucus mucus in the airw airways ays Mucu Mu cus s lea leads ds to ai airw rway ay ob obst stru ruct ctio ion n Pathophysiology ● Mucu Mu cus s is bo both th exc exces essi sive ve an and d ver very y thic thick k ● Cause Cau ses s mecha mechanic nical al obstr obstruc uctio tions ns thro through ughout out the the body body ○ ○ ○ ○ Bronchi Small intestines Pancreatic ducts Bile ducts Testing ● Newborn sc screenin ing g ○ ○ ● Sweat ch chloride te test ○ ○ ● Meconium ileus ■ Meco Meconium nium is is thicker thicker and and stickier stickier than than normal, normal, creat creates es a blockage blockage and first first stool stool doesn’t doesn’t pass. Test for for elevate elevated d levels levels of immuno immunorea reacti ctive ve trypsi trypsinog nogen en ■ Sub Substan stance ce normally normally prod produced uced by by the pancre pancreas as and relea released sed into into the the small small intestine intestine Sweat is coll Sweat collect ected ed and and analyz analyzed ed for for increas increased ed level levels s of chlori chloride de Swea eatt ta tast ste es sa salt lty y Genetic te testing ○ ○ DNA analyzed Mutation pr present Assessment ● Respiratory ○ ○ ○ ● ● Excessive mu mucus Freq Fr eque uent nt re resp spir irat ator ory y inf infec ecti tion ons s Hypoxemia ■ Clubbing ■ Cyanosis ■ Barrel chest ○ ● ● Diabetes Integumentary ○ ○ Gastroin inttestinal ○ ○ ○ ○ Endocrine Salt lty y ta tast stin ing g sw swe eat Elev El evat ated ed ch chlo lori ride de in sw swea eatt Reproductive ○ Male les s ar are e in infe fert rtil ile e In Inte obst stru ion n Mtest ecstin oinal nial umob ilile uruct s ctio Large, Lar ge, bu bulky lky,, froth frothy y, foul foul smel smellin ling g stool stool Fatt so Fa solu lubl ble e vi vita tami min n de defi fici cien ency cy ■ ADEK ■ Malnutrition ■ Failure to thrive Treatment ● Air irw way clearance ○ ○ ● Monitor fo for Tre reat at wi with th IV an anti tibi biot otic ics s Prevent! Monito Moni torr wor work k of of bre breat athi hing ng Oxygen as as ne needed Promote nutrition and growth ○ ○ ○ ○ Res espi pirrat ato ory sup uppo porrt ○ ○ ● Che hest st ph phys ysio iotthe hera rap py Vest th therapy Resp Re spir irat ator ory y in infe fect ctio ions ns ○ ○ ○ ● ● High calorie, high protein diet Increased fluid intake Monitor serial weights Pancreatic enzymes ■ Give within 30 min of eating every meal and snack ■ Sprinkle capsules on food ■ Fat soluble vitamin replacement ● Bronchodilators NCLEX Question The nurse is working in the normal newborn nursery. When she observes which of the following signs, she would suspect cystic fibrosis and notify the healthcare provider for further testing? a. b. c. d. Steatorrhea Hyperhidrosis Meconium IlIleus Barrel chest Answer: C A is incorrect. Steatorrhea are stools that are bulk bulk,, frothy frothy,, and foul smelling. They are caused by the excretion of abnormal quantities of fat in the stool. This does occur in cystic fibrosis, but would not be present yet in a newborn just being diagnosed. B is incorrect. Hyperhidrosis is a medical condition in which a person p erson sweats excessively and unpredictably. This is not a sign of cystic fibrosis in the newborn. The newborn with cystic fibrosis will have elevated levels of chloride in their sweat, causing it to taste salty, but they will not sweat excessively excessively.. C is correct. Meconium Ileus is very frequently the first sign of cystic fibrosis in a newborn. It is a bowel obstruction that occurs when the infant’s first stool is thicker and stickier than usual, causing a blockage in the ileum. D is incorrect. Barrel chest is a long term complication of cystic fibrosis, but not a sign that would be present at birth in the newborn. Barrel chest refers to a broad, deep chest that is large and cylindrical. It occurs when the patient has been suffering from hypoxemia due to cystic fibrosis for a prolonged period of time. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatric Lesson: Respiratory Cerebral Palsy What is Cerebral Palsy? ● ● ● A mot motor or disa disabili bility ty that that app appear ears s in earl early y child childhoo hood d Affects Aff ects the child’ child’s s ability ability to move, move, and and maintain maintain balan balance ce and and postur posture e It is the mos mostt common common perm permane anent nt phys physica icall disabi disabilit lity y in kids kids Pathophysiology Damage Dam age to area areas s of the bra brain in that that con contro troll movem movement ent ○ ○ ○ ● Cerebellum Motor co cortex Basal ganglia Causes: ○ ○ ○ Anoxia Meningitis TBI ○ Intr In trac acra rani nial al he hemo morr rrha hage ge Assessment ● ● ● Abnormal mov movements Poor muscle tone Abnormal po postures ○ ● Contractures Chro Ch roni nic c res respi pira rato tory ry in infe fect ctio ions ns Break Back at... Oncology Oncology Leukemia Lymphoma NCLEX topics Leukemia Terminology ● ● ● ● Mal alig igna nan nt - can anc cero rous us Blas Bl asts ts - Imm Immat atur ure e whi white te bl bloo ood d cel cells ls Lym ympho phoid id - tissu tissue e that that makes makes lymph lymphocy ocytes tes;; lymph lymph tiss tissue ue Myel My eloi oid d - ti tiss ssue ue of th the e bon bone e mar marro row w Leukemia ● ● ● A malign malignant ant prog progress ressive ive disea disease se in which the bone marr marrow ow prod produces uces increased numbers of immature or abnormal leukocytes. These suppress the production of normal blood cells, leading to anemia and other symptoms. “Blood cancer” There Ther e are are tons tons of abnor abnormal, mal, under underdeve developed loped WBCs - this this is what is causing causing the symptoms. Classifications ● Acut Ac ute e Lym Lymph phoc ocyt ytic ic Le Leuk ukem emia ia (AL (ALL) L) ○ ○ ○ ○ ● The immat immature ure cells cells that that the the body body is prod producing ucing too many many of of are lymph lymphoid oid cells. cells. Most Mo st co comm mmon on in 2 to to 5 ye year ar ol olds ds Tre reat atab able le an and d mor more e com commo mon n 85% 85 % su surv rviv ival al rat ate. e. Acut Ac ute e Mye Myelo loge geno nous us Le Leuk ukem emia ia ○ ○ ○ The immat immature ure cells cells that that the the body body is prod producing ucing too many many of of are myelo myeloid id cells. cells. Poor ou outcomes 27 % survival rate Pathophysiology ● ● ● ● ● Abundance of of bla blas sts These The se und underd erdeve evelop loped ed cel cells ls ca can’t n’t fun functi ction on Immunity Immu nity is suppre suppressed ssed sinc since e these these immatu immature re WBCs WBCs are not not functio functioning ning Excess Exc essive ive bla blasts sts sup suppre press ss the bon bone e marr marrow ow Other Ot her cell cells s in the the blood blood begi begin n to die die due to the the exces excess s of blas blasts ts ○ ○ ○ RBCs → anemia Plat Pl atel elet ets s → ina inabi bili lity ty to cl clot ot WBCs → infection Diagnosis ● ● Bone ma Bone marr rrow ow bi biop opsy sy is di diag agno nost stic ic The results show: ○ ○ ○ ○ Hig igh h bla blast sts s pe perc rce enta tage ge Low platelets Low RBCs High or low WBCs Assessment ● ● ● ● ● ● ● Weight loss Fever Infections Arthralgia Pallor Fatigue Bleeding ● Bruising Side effects of treatment ● ● ● ● ● ● ● ● Infection Bleeding Nausea Vomiting Loss of appetite Weight loss Ulcers Alopecia Interventions ● Treatment ○ ○ ○ ○ ● Chemotherapy Steroids Radiation Bone Ma Marr rro ow tra transp spla lant nt Management ○ ○ Neutro Neut rope peni nic c pr prec ecau auti tion ons s Antibiotics ○ ○ ○ Antiemetics Enteral nu nutrition Bloo Bl ood d pr prod oduc uctt ad admi mini nist stra rati tion on NCLEX Question The nurse is taking vital signs on her patient with a diagnosis of ALL. ALL. His temperature is 38.7C. What is the nurse's first priority? a. b. c. d. Place coo Place cooll washc washclot loths hs on the the pati patient ent’s ’s hea head. d. Cont Co ntin inue ue wit with h her her asse assess ssme ment nt Obtain Obt ain int intrav raveno enous us acc acces ess s on on the the pat patien ient. t. Asse As sess ss th the e pat patie ient nt’s ’s pe perf rfus usio ion. n. Answer: C A is incorrect. Placing cool washcloths on the patient’s head is not the priority, there is a better answer. This would only need to be done if the patient was at risk for seizures due to an incredibly high body temperature. The temperature of 38.7C does not warrant cooling measures, and the nurse has another immediate priority given the patients immunosuppression and her suspicion of an infection. B is incorrect. It is not appropriate for the nurse to simply continue with her assessment. She suspects an infection in her patient who is immunocompromised. Another answer has an immediate priority that the nurse must do. C is correct. It is the priority action to establish intravenous access on this patient. This patient has a diagnosis of ALL, so the nurse knows that he is immunocompromised. He is very susceptible to infections, and with a fever of 38.7C she has a high index of suspicion for an infection. Broad spectrum IV antibiotics will need to be started right away, therefore it is the priority for the nurse to start an IV. D is incorrect. Assessing the patient’s patient’s perfusion has nothing to do with the nurses suspicion of an infection. She should immediately establish IV access for the administration of antibiotics. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Infection control and safety Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Oncology Lymphoma Lymphoma ● ● ● Cancer Canc er of th the e lym lymph phat atic ic sy syst stem em Affe Af fect cts s th the e ly lymp mpho hocy cyte tes s Impair Imp airs s the the bod body’ y’s s natu natural ral imm immune une res respon ponse se Classifications ● Hodgkin’s ○ ○ ○ ● Localiz Loca lized ed,, sin singl gle e gro group up of no node des s Reed Re ed-S -Ste tern rnbe berg rg ce cells lls ar are e pre prese sent nt Extr Ex tran anod odal al inv invol olve veme ment nt not not co comm mmon on Non-Hodgkin’s ○ ○ ○ ○ Multip Mult iple le lym lymph ph no node des s are are in invo volv lved ed Reed Re ed-S -Ste tern rnbe berg rg cel cells ls are are not not pre prese sent nt Extr Ex tran anod odal al in invo volv lvem emen entt is co comm mmon on Most Mo st co comm mmon on ty type pe of lym lymph phom oma a Assessment ● ● ● ● ● ● ● Painle Pain less ss sw swel elliling ng of ly lymp mph h nod nodes es Fatigue Fever Night sweats Infections Weight loss Enla En larg rged ed li live verr of sp sple leen en Interventions ● Treatment ○ ○ ○ ● Chemotherapy Radiation Lym ymp ph nod ode e re rem mova vall Management ○ ○ ○ ○ Neutro Neut rope peni nic c pr prec ecau auti tion ons s Antibiotics Antiemetics Enteral nu nutrition Part IV: Wrap Up Prep rep Archer Review - NCLEX Rapid P Prioritization ABC’s ● Airway ● Breathing ● Circulation ○ ○ ○ ○ ○ Foreign body in the airway Obstruction Edema Goal is a patent airway No patent airway? ■ Intubate ■ Trach ○ ○ ○ ○ ○ Adequate respirations ■ RR is sufficient ■ Shallow? Bilateral breath sounds Good air entry Breathing insufficient? Breathe for them. ■ BMV ○ ○ ○ Are they getting good blood flow to their tissues. Providing oxygen to organs Good pulses Brisk cap-refill ○ ○ ○ W Warm arm skin color Appropriate Insufficient circulation? ■ Fluids ■ Pressors Stability Most stable to least stable Unstable ● ● ● ● ● ● ● ● Changing condition Acute Unexpected Recently admitted New onset Newly diagnosed Critical lab values Hemorrhage Stable ● ● ● Chronic Expected findings Ready for discharge ● ● ● Consistent Consistent lab vitalvalues signs Unchanging The Nursing Process Delegation The five rights of delegation ● ● ● ● ● Right task Right cir circumstance Right Person Rig ight ht com omm mun unic icat atio ion n Right su supervisio ion n Right task ● ● ● ● Can thi Can this s tas task k be de dele lega gate ted? d? Is it withi within n the scope scope of an LPN, LPN, or an unlicen unlicensed sed assist assistive ive perso personnel nnel such such as as a nursing assistant? Is itit a low ri risk ta task? Is itit withi within n the the scope scope of prac practic tice e of the the RN RN to dele delegat gate? e? Right circumstance ● What Wh at is go goin ing g on on wit with h tha thatt pat patie ient nt? ? ○ ● Are the they y stable stable? ? If unst unstab able le - RN RN should should not not dele delega gate! te! How abo about ut wit with h the the per person son you you’re ’re del delega egatin ting g to? to? ○ How Ho w muc much h tra train inin ing g do do the they y hav have? e? ○ How many many patien patients ts do they they have have - are they able able to comp complete lete the the task task you’re you’re delegat delegating ing to them? ○ Do you fee feell comfo comforta rtable ble del delega egatin ting g this this tas task? k? Right person ● ● ● ● ● Who ar Who are e yo you u de dele lega gati ting ng to to? ? Do the they y hav have e the the appr approp opri riat ate e trai traini ning ng? ? Do the they y have have exp exper erie ienc nce e with with thi this s take take? ? Are the they y comp compete etent nt in in the the task task you are del delega egatin ting? g? Shou Sh ould ld yo you u del deleg egat ate e to an LP LPN N or or an an UAP UAP? ? Right communication ● ● ● ALWAYS expl ALW explain ain wha whatt you you are are deleg delegati ating! ng! What Wh at do yo you u exp expec ectt the them m to to do? do? Do you you exp expect ect the them m to follo follow w up and and repo report rt bac back k to you? you? Right supervision ● ● The RN should should alway always s ensure ensure the task task was comp completed leted prope properly rly.. Accountab Acco untability ility is not tran transfer sferred red to to the perso person n you are delegati delegating ng to, the RN RN is ultimately responsible!! Unlicensed Assistive Personnel (UAP) Scope of practice YES ● Ambulating ● Turning ● Bathing ● Intake and output ● Oral care ● Toileting ● Feeding ● Vital signs ● Weights ● Linen change NO IVss ● IV ● Administering medication ● Delegate any task LPN Scope of practice YES NO ● Duties depend on the state, the facility, and also the LPN’s ● training. ● ● ● ● ● Ambulating ● ● ● ● ● Turning Bathing Oral care Toileting Feeding Vital signs Weights Gathering data Taking care of stable patients Registered Nurse scope of practice ● ● ● ● ● ● ● ● Assessment Evaluation Teaching Education All medications Blo loo od tr transfusions Inv nvas asiv ive e pr proc oced edur ures es Dev evel elop opin ing g car care e pla plans ns ● ● ● ● ● Teaching and education Assessment Planning Evaluation Interpreting data Taking care of unstable patients Testing Strategies Eliminate what you KNOW is wrong first. ● Rea Read d each each ans answer wer cho choice ice ind indivi ividua dually lly ● If you you know know it is is wron wrong, g, mark mark it out. out. ● If part part of the answ answer er is wrong, wrong, the the WHOLE WHOLE answer answer is wrong wrong.. Mark it out! Group drug classes together and remember what their names look like. You ou don’t need to memorize every every drug from ● Y your Davis Drug Guide. ● Study the major groups from the pharmacology crash course and learn what the names sound/look like. ● -pam = anti-anxiety agent ● -ptyline = TCA ● -pril = ACE inhibitor ● -lol = beta blocker blocker ● -mycin = antibiotic ● -cillin = penicillin abx ● -azole = antifungal ● -mide = loop diuretic Don’t pick an answer if you don’t know what it means. ● If I have haven't n't hear heard d of it no no one els else e has eit either her ● You are are a br bran and d new new nurs nurse! e! ● Th The e NCLE NCLEX X know knows s tha that! t! Know the WHY behind signs and symptoms ● Th Think ink thro through ugh WHY WHY some somethi thing ng is happ happeni ening. ng. ● Pol Polyur yuria ia  flu fluid id volu volume me defi deficit cit  shoc shock k ● Heart Heart failure failure  pump pump not movin moving g blood forwa forward rd  decrea decreased sed blood blood flow flow to kidneys  decreased UOP  fluid retention ● Hypo Hypoxia xia  not not enough enough oxygen oxygen to the the tissues tissues  not not enough enough oxygen oxygen to to the brain brain  anxious patient/change in LOC Think like a NEW nurse! The NCLEX expects you to have 2 weeks of nursing knowledge. They DO NOT expect you to know everything. They DO expect you to keep your patient safe. ALW AL WAYS protect the patient Safety first This test is to protect the public Assume the worst worst - fix the problem. problem. If there is a question about it there is something to worry about. Pick the least invasive option first. ● Nonp Nonpharm harmacolo acologic gic inter intervent ventions ions befo before re medic medication ation.. ● Non Non-op -opioi ioid d analg analgesi esic c befor before e opioi opioid d ● PT PT/O /OT T be befo fore re su surg rger ery y Only call the healthcare provider if there is nothing that YOU the nurse can do for your patient. ● If there there is an immed immediate iate interv interventio ention n YOU can take take to help, help, do that that first! first! ● Prolapsed Prolapsed umbilic umbilical al cord – priority priority is lift the prese presenting nting part part of the fetus fetus off off the cord, NOT call the HCP. For priority questions, pick the answer most likely to kill your patient. Pain doesn’t kill your patient. Hypoxia kills. Acidosis kills. Respiratory distress kills. SOME arrhythmias kill. VT, VT, VF, VF, asystole = fatal If the answer puts work off on someone else, it is wrong. ● YO YOU U sho shoul uld d be do doin ing g the the work work.. ● “Sa “Save ve for the nex nextt shif shift” t” = wron wrong g If the answer ignores what a patient is saying, it is wrong. ● Pa Pati tien entt foc focus used ed an answ swer ers s ● Al Alwa ways ys lilist sten en to to the the pati patien entt ● Alway Always s take take the patie patient’s nt’s conc concerns erns seri seriously ously ● Us Use e the therap rapeut eutic ic com commun munica icatio tion n Select all that apply - treat each answer choice as a true or false question. They are all independent of each other. ● All of the ans answer wers s coul could d be rig right. ht. ● On Only ly on one e cou could ld be ri righ ght. t. Don’t freak out when you get a question on a topic you don’t know. It’s gonna happen! ● Th Thin ink k back back to wha whatt you you DO DO kno know w ● Rem Rememb ember er the the WHYs WHYs behind behind sign signs s and sym sympto ptoms ms ● Eli Elimin minate ate wha whatt you you kno know w is is wron wrong g ● Pi Pick ck th the e kil kille lerr an answ swer er

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