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Ready to Pass - Nclex practices tip
Nursing Concepts IV (Brookdale Community College)
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TABLE OF CONTENTS
Disclosure Statement
ZĞǀŝĞǁŽƵƌƐĞKďũĞĐƟǀĞƐ
About NCLEX
ϭϬƐƐĞŶƟĂůdŽŽůƐ
YƵŝĐŬƌĞĨĞƌĞŶĐĞŐƵŝĚĞŽĨĞƐƐĞŶƟĂůĨĂĐƚƐ
Normal Lab values
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ŽŵŵŽŶƌĞƐƉŝƌĂƚŽƌLJŵĞĚŝĐĂƟŽŶƐ
Overview of pharmacology
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2
3
4
11
17
29
50
78
121
139
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ƐƐĞŶƟĂůEƵƌƐŝŶŐ^ŬŝůůƐΘdĞĐŚŶŝƋƵĞƐ
Alphabet list
Mneumonics
DĂƚĞƌŶĂůͬEĞǁďŽƌŶĂƌĞƐƐĞŶƟĂů&ĂĐƚƐ
ŽŵŵŽŶŵĂƚĞƌŶŝƚLJŵĞĚŝĐĂƟŽŶƐ
WĞĚŝĂƚƌŝĐEƵƌƐŝŶŐƐƐĞŶƟĂů&ĂĐƚƐ
WƐLJĐŚŽƐŽĐŝĂů/ŶƚĞŐƌŝƚLJƐƐĞŶƟĂů&ĂĐƚƐ
ŽŵŵŽŶŵĞŶƚĂůŚĞĂůƚŚŵĞĚŝĐĂƟŽŶƐ
WƌĂĐƟĐĞYƵĞƐƟŽŶƐ
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140
141
143
144
147
160
161
178
190
191
210
Graphics: Louise Martin and Rebecca Rivera
MAR 18
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About NCLEX
The NCLEX® is designed to determine whether you meet the minimal standard to practice as a nurse.
NCLEX® is an integrated exam, which means the subjects are all mixed together.
The test follows the April 2016 NCLEX® RN/April 2017 LPN plan. Questions are drawn from four categories
including but not limited to the topics listed below. The following test plan structure is copyright of the
National Council of State Boards of Nursing, Inc. All Rights Reserved.
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A. Management of Care – 51/31(Coordinated Care)
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•
Advance Directives
•
Establishing Priorities
•
Advocacy
•
Ethical Practice
•
Case Management
•
Informed Consent
•
Client Care Assignment
•
Information technology
•
Client Rights
•
Legal Rights and Responsibilities
•
Collaboration with Interdisciplinary Team
•
Performance improvement
•
Concepts of Management & Supervision
•
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•
Referrals Process
•
Consultation
•
Resource Management
•
Continuity of Care
•
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Delegation and Supervision
•
Supervision
(Quality Improvement)
B. Safety and Infection Control51/31
Protecting clients and health care personnel from environmental hazards.
•
Accident/Injury Prevention
•
Medical and Surgical Asepsis
•
Disaster Planning/Internal & External Plans
•
Reporting of Incident/Event/Irregular
•
Emergency Response Plan
•
Error Prevention
•
Safe Use of Equipment
•
Ergonomic principles
•
Security Plan
•
Handling Hazardous & Infectious Materials
•
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•
Home Safety
•
Least Restrictive Restraints/Safety Devices
Occurrence/Variance
Precautions
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II. Health Promotion and Maintenance- 51/31
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knowledge of expected growth and development principles, prevention and/or early detection of
health problems, and strategies to achieve optimal health.
•
Aging Process
•
Health and wellness
•
Ante/Intra/Postpartum and Newborn Care
•
Health Promotion Programs
•
Community Resources
•
Health Screening
•
Data Collection Techniques
•
High Risk Behaviors
•
Developmental Stages and Transitions
•
Human sexuality
•
Disease Prevention
•
Immunizations
•
Expected Body Image Changes
•
Lifestyle Choices
•
Family Planning
•
Principles of Teaching & Learning Self Care
•
Family Systems
•
Techniques of Physical Assessment*
•
Growth and Development
III. Psychosocial Integrity- 51/31
Providing and directing nursing care that promotes and supports the emotional, mental, and social
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with acute or chronic mental illness.
•
Abuse/Neglect
•
Psychopathology
•
Behavioral Interventions
•
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•
Chemical & Other Dependencies
•
Sensory/Perceptual Alterations
•
Coping Mechanisms
•
Situational Role Changes
•
Crisis Intervention
•
Stress Management
•
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•
Substance Use Disorders
Health/Cultural Awareness
•
Support Systems
•
End of Life Care and Concepts
•
Suicide/Violence Precautions
•
Family Dynamics
•
Therapeutic Communications
•
Grief and Loss
•
Therapeutic Environment
•
Mental Health Concepts
•
Unexpected Body Image Changes
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IV. Physiological Integrity
A. Basic Care and Comfort: 51/31
Providing comfort and assistance in the performance of activities of daily living.
•
Alternative and Complimentary Therapies
•
Nutrition and Oral Hydration
•
Assistive Devices
•
Palliative/Comfort Care
•
Elimination
•
Personal Hygiene
•
Mobility/Immobility
•
Rest and Sleep
•
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B. Pharmacological and Parenteral Therapies: 51/31
Managing and providing care related to the administration of medications & parenteral therapies.
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Parenteral/Intravenous Therapy
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Pharmacological Agents/Actions
•
Blood and Blood Products
•
Pharmacological Interactions
•
Central Venous Access Devices
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Pharmacological Pain Management
•
Dosage Calculations
•
Total Parenteral Nutrition
•
Expected Actions/ Outcomes
•
Medication Administration
•
C. Reduction of Risk PotentiaO51/31
Reducing the likelihood that clients will develop complications or health problems related to
existing conditions, treatments or procedures.
•
Potential for Complications from Surgical
•
Diagnostic Tests
•
Laboratory Values
•
Monitoring Conscious Sedation
•
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•
Potential for Alterations in Body Systems
•
Therapeutic Procedures
•
Potential for Complications of Diagnostic
•
Vital Signs throughout the life span/ changes/
Procedures and Health Alterations
abnormalities
Tests/Treatments/Procedures
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conditions.
D. Physiological Adaptation:51/31
•
Alterations in Body Systems
•
Medical Emergencies
•
Fluid and Electrolyte Imbalances
•
Pathophysiology
•
Hemodynamics
•
Radiation Therapy
•
Illness Management
•
Unexpected Response to Therapies
•
Infectious Diseases
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ABOUT THE EXAM
•
•
•
•
The test is computer based; you will be required to use a mouse to select the correct answer.
There is an on screen calculator available to calculate medication dosages.
Once a question is answered you will not be allowed to change it.
NCLEX® is a computer adaptive test which means it adjusts based on the answers you provide
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correctly but easier questions if you do not. It is very important that you do not guess. It is better
to take more time to answer correctly than to choose answers randomly. At times, content
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process. Always select the answer believed to be correct. Exams vary in length in order to
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•
Six hours are allotted for the RN exam to complete a minimum of 75 to a maximum of 265
questions. Of these items, 15 are pretest items that are not scored. The LPN exam allots
5 hours and has 85 to 205 questions. There are 25 pretest items on the NCLEX PN exam.
However you should stick to the rule of allowing 1 minute per question. The analysis level
questions may require more than one minute in order to synthesize all of the information given.
The length of an exam is not an indication of a pass or fail result. The computer will stop when
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passing standard or the candidate has run out of time.
When you run out of time before reaching the
maximum amount of items, the computer has not been able to decide whether you passed or failed with 95% certainty and has
to use an alternate rule. If you have not answered the minimum amount of items, you fail.
•
If you have at least answered the minimum amount of items, the computer reviews your last 60 ability estimates:
•
If your last 60 ability estimates were above the passing standard, you pass.
•
If your ability dropped below the passing standard, even once, during your last 60 items, you fail.
Types of Questions:
Ordered response
Multiple Response
Multiple Choice
Fill in the Blank
Hot Spot/Graphic
Chart exhibit
Audio
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ESSENTIAL TEST-TAKING
TECHNIQUES
Critical Thinking Is the Key
To Successfully Answering NCLEX® Questions!
1:
ĞƚĞƌŵŝŶĞǁŚĂƚƚŚĞƋƵĞƐƟŽŶŝƐasking.
2:
/ĚĞŶƟĨLJƚŚĞtopicŽĨƚŚĞƋƵĞƐƟŽŶ͘
3:
Determine the relevanceŽĨƚŚĞĨĂĐƚƐĂďŽƵƚƚŚĞĐůŝĞŶƚ͘&ŽƌĞdžĂŵƉůĞ͕ƚŚĞĐůŝĞŶƚŵĂLJŶŽƚďĞƚŚĞƉĞƌƐŽŶǁŝƚŚƚŚĞ
ŚĞĂůƚŚƉƌŽďůĞŵʹŝƚŵĂLJďĞƚŚĞƐƉŽƵƐĞ͕ĂƌĞůĂƟǀĞ͕ŽƌĂŵĞŵďĞƌŽĨƚŚĞŚĞĂůƚŚĐĂƌĞƚĞĂŵ͘
4:
RephraseƚŚĞƋƵĞƐƟŽŶ͕ŝĨƉŽƐƐŝďůĞ͘
5:
ŽŶŽƚread ŝŶƚŽƋƵĞƐƟŽŶƐ͘
6:
^ĞůĞĐƚƚŚĞďĞƐƚŽƉƟŽŶ ĂŌĞƌĞůŝŵŝŶĂƟŶŐŝŶĐŽƌƌĞĐƚĐŚŽŝĐĞƐ͘
ǀŽŝĚĂďƐŽůƵƚĞǁŽƌĚƐ;Ăůů͕ĞǀĞƌLJ͕ŶĞǀĞƌ͕ĂůǁĂLJƐ͕ŽŶůLJͿ͘
7:
&ŽĐƵƐŽŶƚŚĞlast lineŽĨƚŚĞƋƵĞƐƟŽŶ͕ĂƐŝŶǀĂƌŝĂďůLJǁŚĂƚƚŚĞƋƵĞƐƟŽŶŝƐĂƐŬŝŶŐǁŝůůďĞĨŽƵŶĚƚŚĞƌĞ͘
8:
>ŽŽŬĐĂƌĞĨƵůůLJĨŽƌ facts about the client,ĨŽƌĞdžĂŵƉůĞ͕ĂŐĞ͕ŐĞŶĚĞƌ͕ŵĞĚŝĐĂůŚŝƐƚŽƌLJ͕ŵĞĚŝĐĂƟŽŶƐ͕ƉƐLJĐŚŽůŽŐŝĐĂů
ƐƚĂƚƵƐ͘dŚĞƐĞǁŝůůƉƌŽǀŝĚĞĐůƵĞƐĂƐƚŽǁŚĂƚƚŚĞƋƵĞƐƟŽŶŝƐƌĞĂůůLJĂƐŬŝŶŐ͘
9:
ŽŶŽƚĂŶƐǁĞƌƋƵĞƐƟŽŶƐďĂƐĞĚŽŶLJŽƵƌƉĞƌƐŽŶĂůĞdžƉĞƌŝĞŶĐĞƐ͘ƌŝƟĐĂůƚŚŝŶŬŝŶŐƌĞƋƵŝƌĞƐƚŚĂƚLJŽƵƚŚŝŶŬƉƵƌƉŽƐĞĨƵůůLJ
ǁŝƚŚŽƵƚĐŽŵĞĚŝƌĞĐƚĞĚŐŽĂůƐ͘zŽƵƌƚŚŝŶŬŝŶŐŵƵƐƚďĞĂŝŵĞĚĂƚŵĂŬŝŶŐũƵĚŐŵĞŶƚƐďĂƐĞĚŽŶƐĐŝĞŶƟĮĐĞǀŝĚĞŶĐĞ
ƌĂƚŚĞƌƚŚĂŶƚƌĂĚŝƟŽŶŽƌŐƵĞƐƐŝŶŐ͘E>yΠŝƐďĂƐĞĚŽŶƚĞdžƚŬŬŶŽǁůĞĚŐĞŶŽƚŝŶĚŝǀŝĚƵĂůǀĂƌŝĞĚĞdžƉĞƌŝĞŶĐĞƐ͘
YƵĞƐƟŽŶƐ ŽŶ ĚĞůĞŐĂƟŽŶ ƐŚŽƵůĚ ďĞ ĂŶƐǁĞƌĞĚ ǁŝƚŚ ŐƌĞĂƚ ĐĂƌĞ͘ EĞǀĞƌ ĚĞůĞŐĂƚĞ ƚŚĞ ĂƐƐĞƐƐŵĞŶƚ ƉŽƌƟŽŶ ŽĨ ƚŚĞ
10: nursing process or tasks that involve complex procedures.
ŽŶ͛ƚďĞƚŽŽŚĂƐƚLJƚŽĐŚŽŽƐĞ͞EŽƟĨLJƚŚĞŚĞĂůƚŚĐĂƌĞƉƌŽǀŝĚĞƌ͟ĂƐƚŚĞĂŶƐǁĞƌ͘/ƐƚŚĞƌĞƐŽŵĞĂĐƟŽŶ͕ƐŽŵĞƉĂƌƚŽĨ
11: ƚŚĞŶƵƌƐŝŶŐƉƌŽĐĞƐƐƚŚĂƚLJŽƵĐĂŶƉĞƌĨŽƌŵďĞĨŽƌĞĐĂůůŝŶŐƚŚĞƉŚLJƐŝĐŝĂŶ͍
12:
ZĞĂĚĞǀĞƌLJǁŽƌĚŝŶƚŚĞƋƵĞƐƟŽŶĂŶĚĞĂĐŚŽĨƚŚĞĂŶƐǁĞƌĐŚŽŝĐĞƐ͕ůŽŽŬŝŶŐĨŽƌŬĞLJǁŽƌĚƐ͘<ĞLJǁŽƌĚƐŝŶƚŚĞ
ƐƚĞŵŽĨƚŚĞƋƵĞƐƟŽŶǁŝůůƉƌŽǀŝĚĞĐůƵĞƐĂƐƚŽƚŚĞƚLJƉĞŽĨƌĞƐƉŽŶƐĞLJŽƵĂƌĞƐĞĞŬŝŶŐ͘WůĞĂƐĞƐƚƵĚLJƚŚĞĨŽůůŽǁŝŶŐ
ŬĞLJǁŽƌĚƐĂŶĚůŽŽŬĨŽƌƚŚĞƐĞŝŶƚŚĞƋƵĞƐƟŽŶƐƚĞŵ͘dŚĞŶƌĞƉŚƌĂƐĞƚŚĞƋƵĞƐƟŽŶƚŽĮŶĚŽƵƚǁŚĂƚŝƚŝƐƌĞĂůůLJ
ĂƐŬŝŶŐ͘
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Remember PAIN
PRIORITY/ FIRST: This indicates that you must determine the most essential response.
Tools helpful to answering these questions include:
1. The developmental phases of Erkison (if age is designated)
2. The theorist Orem (Universal Self Care Needs)
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$%&¶V DLUZD\EUHDWKLQJFLUFXODWLRQ
6. Time
7. Expected/unexpected
8. Safety
9: Disaster & triage
ANTICIPATE:
or most appropriate, correct, expected, should, include, instruct, will reinforce. These all
indicate you are looking for a correct or expected response.
INTERVENE:
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LQHႇHFWLYH QRWLI\ WKH KHDOWK FDUH SURYLGHU DOO LQGLFDWH WKDW \RX DUH ORRNLQJ IRU DQ LQFRUUHFW RU XQH[SHFWHG
response.
NEXT: may imply you are currently in one phase of the nursing process and must proceed to the next one.
Remember ADPIE (Assessment, Diagnosis, Plan, Intervention, Evaluation).
PREPARING FOR THE EXAM
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* Practice time management: allow 1 – 1.5 minutes per question.
* A positive attitude is essential for success!
* Develop a study plan and remain focused.
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* Avoid distractions.
* Insure adequate rest, as sleep deprivation can prevent you from focusing.
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SAMPLE QUESTION
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for the client who has a:
A.
B.
C.
D.
Uric acid level of 10.3 mg/dL
Ammonia level of 95 mg/dL
Albumin level 3.1 g/dL
Calcium 12 mg/dL
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values are abnormal and need follow up, which of the previous choices would take priority? Knowledge of
normal lab values will help you to select the most appropriate response.
Note: The correct answer is (b). High ammonia levels will lead to hepatic encepholapathy and brain
damage. This client would take priority.
SAMPLE QUESTION
The nurse is teaching a client about crutch walking. Which of the following statements, if made by the client,
indicates an understanding of teaching?
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& ³,GRQRWDSSO\SUHVVXUHXQGHUP\DUPZKHQ,XVHP\FUXWFKHV´
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7KHSKUDVH³XQGHUVWDQGLQJRIWHDFKLQJ´LQGLFDWHV\RXDUHORRNLQJIRUa correct statement, that is, one choice
is true, while the other three are incorrect. Knowledge of ambulation with crutches will allow you to select
the correct or true statement. (OLPLQDWHDOOWKHIDOVHRULQFRUUHFWFKRLFHV¿UVW
Note: (c) is true, and the other three are false. Therefore, (c) is correct.
Schedule your test within 1 month after course completion!!
For information on scheduling or rescheduling your exam:
* National Council of State Boards of Nursing:
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ESSENTIAL
TOOLS
11
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TOOL # 2
ERIKSON’S THEORY OF DEVELOPMENT
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does not.
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should be considered in order to select the correct response.
AGE/STAGE
PSYCHOSOCIAL CRISIS
TASK
1. Infancy (0 - 18 months)
Trust vs. Mistrust
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
dƌƵƐƚŝŶƉĞŽƉůĞĂŶĚŚŽƉĞĂďŽƵƚƚŚĞ
ĨƵƚƵƌĞ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ŝĸĐƵůƚLJƌĞůĂƟŶŐƚŽƉĞŽƉůĞ͖
ƐƵƐƉŝĐŝŽŶ͖ĨĞĂƌŽĨƚŚĞĨƵƚƵƌĞ
2. Toddler (18 months to 3 years)
ƵƚŽŶŽŵLJǀƐ͘^ŚĂŵĞΘŽƵďƚ
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞŶƐĞŽĨƐĞůĨĐŽŶƚƌŽůĂŶĚĂĚĞƋƵĂĐLJ͖
ǁŝůůƉŽǁĞƌ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
&ĞĂƌŽĨŝŶĚĞƉĞŶĚĞŶĐĞ͕ƐĞǀĞƌĞƐĞůĨͲ
ĚŽƵďƚ
3. Pre School (3 - 6 years)
/ŶŝƟĂƟǀĞǀƐ͘'Ƶŝůƚ
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ďŝůŝƚLJƚŽŝŶŝƟĂƚĞŽŶĞ͛ƐŽǁŶ
ĂĐƟǀŝƟĞƐ͖ƐĞŶƐĞŽĨƉƵƌƉŽƐĞ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞŶƐĞŽĨŝŶĂĚĞƋƵĂĐLJŽƌŐƵŝůƚ͘
4. School Age (6 - 12 years)
Industry vs. Inferiority
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ŽŵƉĞƚĞŶĐĞ͕ĂďŝůŝƚLJƚŽůĞĂƌŶĂŶĚ
ǁŽƌŬ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞŶƐĞŽĨŝŶĨĞƌŝŽƌŝƚLJ͕ĚŝĸĐƵůƚLJůĞĂƌŶŝŶŐ Develops social, physical and school skills
ĂŶĚǁŽƌŬŝŶŐ͘
5. Adolescence (12 - 20 years)
/ĚĞŶƟƚLJǀƐ͘ZŽůĞŽŶĨƵƐŝŽŶ
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞŶƐĞŽĨƉĞƌƐŽŶĂůŝĚĞŶƟƚLJ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ŽŶĨƵƐŝŽŶĂďŽƵƚƐĞůĨ͕ŝĚĞŶƟƚLJ
ĞǀĞůŽƉƐƐĞŶƐĞŽĨŝĚĞŶƟƚLJ
ƐƵďŵĞƌŐĞĚŝŶƌĞůĂƟŽŶƐŚŝƉƐŽƌŐƌŽƵƉ
ŵĞŵďĞƌƐŚŝƉƐ
6. Early Adulthood (20 - 35 years)
/ŶƟŵĂĐLJǀƐ͘/ƐŽůĂƟŽŶ
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ďŝůŝƚLJƚŽůŽǀĞĚĞĞƉůLJĂŶĚĐŽŵŵŝƚ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ŵŽƟŽŶĂůŝƐŽůĂƟŽŶ͖ĞŐŽĐĞŶƚƌŝĐŝƚLJ
7. Middle adulthood (35 -65 years)
'ĞŶĞƌĂƟǀŝƚLJǀƐ͘^ƚĂŐŶĂƟŽŶ
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ďŝůŝƚLJƚŽŐŝǀĞĂŶĚĐĂƌĞĨŽƌŽƚŚĞƌƐ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞůĨͲĂďƐŽƌƉƟŽŶ͖ŝŶĂďŝůŝƚLJƚŽŐƌŽǁĂƐ
ĂƉĞƌƐŽŶ
8. Later (65 years to death)
Integrity vs. Despair
^ƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
^ĞŶƐĞŽĨŝŶƚĞŐƌŝƚLJĂŶĚĨƵůĮůůŵĞŶƚ
hŶƐƵĐĐĞƐƐĨƵůZĞƐŽůƵƟŽŶŽĨƌŝƐŝƐ
ŝƐƐĂƟƐĨĂĐƟŽŶǁŝƚŚůŝĨĞ
ƩĂĐŚŵĞŶƚƚŽƚŚĞƉƌŝŵĂƌLJĐĂƌĞŐŝǀĞƌ
Gains some basic control of self and
environment
ĞĐŽŵĞƐƉƵƌƉŽƐĞĨƵůĂŶĚĚŝƌĞĐƟǀĞ
ƐƚĂďůŝƐŚĞƐŝŶƟŵĂƚĞďŽŶĚƐŽĨůŽǀĞĂŶĚ
friendship
&ƵůĮůůƐůŝĨĞŐŽĂůƐƚŚĂƚŝŶǀŽůǀĞĨĂŵŝůLJ͕ĐĂƌĞĞƌ͕
and society, volunteering
>ŽŽŬƐďĂĐŬŽǀĞƌŽŶĞ͛ƐůŝĨĞĂŶĚĂĐĐĞƉƟŶŐŝƚƐ
meaning
13
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722/
THE NURSING PROCESS
This process consists of the following, in this order:
1: Assessment 2: Diagnosis (Analysis)
3: Planning
4: Implementation
5: Evaluation
1. ASSESSMENT:
Words that mean to assess: Check, Look, Ask, Monitor, Inspect, Evaluate , Observe &/$0,(2
1. Assessment is done primarily by the RN.
2. BUT the LPN must understand this process because the LPN collects data, a critical role in assessment.
7\SHVRIGDWDWREHFROOHFWHG
• History taking
• Objective data: observable, measurable (vital signs)
• 6XEMHFWLYHGDWDV\PSWRPVH[SHULHQFHGE\FOLHQW ³0\WKURDWKXUWV´
• Data collected from the chart
&RQ¿UPGDWDFROOHFWHG
5.Communicate information received in the assessment.
2. DIAGNOSIS (ANALYSIS):
1. Identify actual or potential health care needs and/or problems based on your assessment.
2. Interpret the data: validate, organize and determine if there is a need for more data collection.
,QWKLVSKDVHWKHQXUVHXVHVGDWDWRIRUPXODWHDnursing diagnosis.
DETERMINE CLIENT’S UNIQUE NEEDS
3. PLANNING:
1.This is done to provide client care consistently and appropriately.
2. Ask yourself the following questions: What is the priority?
How does this determine the client’s needs?
+RZZLOOWKLVD௺HFWWKHFDUHWKHFOLHQWLVJHWWLQJ"
7KLVLVZKHQWKHQXUVHGHWHUPLQHVJRDOVIRUPXODWHVRXWFRPHFULWHULDGHYHORSVDSODQRIFDUHDQG
collaborates with other health care professionals (the Interdisciplinary approach).
4: IMPLEMENTATION:
To begin to do something...and then doing it!!
1. Prepare:RUJDQL]HFOLHQW¶VFDUHJDWKHUHTXLSPHQWDQGH[SODLQSURFHGXUHVWRWKHFOLHQW
2. Counsel and Teach:GLUHFWHGDWWKHFOLHQWWKHLUIDPLO\PHPEHUVVLJQL¿FDQWRWKHUVDQGRWKHUPHPEHUV
of the health care team.
Perform:IROORZSURFHGXUHVLQIHFWLRQFRQWURODQG26+$JXLGHOLQHVPRQLWRUFOLHQW¶VUHVSRQVHWRFDUH
given.
4. After Care is Performed: make client comfortable, and then replace any equipment no longer needed.
5. Record and Report: document everything accurately.
7KH/31UHSRUWV¿QGLQJVWRWKH51
51UHSRUWVDEQRUPDO¿QGLQJVWRWKHKHDOWKFDUHSURYLGHU
5: EVALUATION:
1. Has the need been met?
2. Compare actual outcome with expected outcome.
5HHYDOXDWHWKHSUREOHPOLVWZLWKWKHUHVWRIWKHKHDOWKFDUHWHDP
TIP: ACTIVE CLIENT PROBLEMS TAKE PRIORITY OVER POTENTIAL PROBLEMS!
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TOOL #4
TOOL # 8
REMEMBER THE ABC’s
THERAPEUTIC COMMUNICATION:
A. Remember to establish a patent airway
for your client.
B. Be sure your client is breathing.
C. Check to see if your client has good
circulation.
Do not wait until there is a crisis to assess
for ABC’s!!
1. Remember
to
utilize
therapeutic
communication: choose the response that
DOORZV WKH FOLHQW WR H[SUHVV KLV QHHGV
fears or concerns.
2. BUT, mental health questions may be handled
GLႇHUHQWO\ )RU H[DPSOH LI DQ 51 VXVSHFWV
suicide is an issue for her/his client, then direct
questioning is required (e.g., “Do you feel like
\RXZDQWWRKXUW\RXUVHOI"´
In mental health cases, reality orientation may
TOOL #5
EXPECTED / UNEXPECTED
1. Determine what the stem of the question
is asking.
,IRIWKHFKRLFHVJLYHQDUHFRUUHFWRU
DUH H[SHFWHG ¿QGLQJV WKHQ \RX VKRXOG
FKRRVHWKHXQH[SHFWHG¿QGLQJ
,IRIWKHFKRLFHVJLYHQDUHLQFRUUHFWRU
DUH XQH[SHFWHG ¿QGLQJV WKHQ \RX VKRXOG
FKRRVHWKHH[SHFWHG¿QGLQJ.
*Distinguish between chronic conditions
vs acute conditions!
TOOL #6
TIME
The client most recently admitted is not
DOZD\VVHHQ¿UVW
TOOL # 7
REMEMBER SAFETY:
&KHFNWKHFOLHQW¿UVWWKHQWKHHTXLSPHQW
also be called for.
TOOL # 9
OREM’S THEORY OF NURSING
The nurse must be concerned with the
following
UNIVERSAL HEALTH CARE NEEDS:
1. AIR: oxygen, airway, temperature.
2. WATER:GHK\GUDWLRQÀXLGYROXPHH[FHVV
3. FOOD: malnutrition, feeding concerns.
4. ELIMINATION: proper evacuation of bladder
and bowel.
5. REST: sleep, comfort and freedom from
pain (not always a low priority).
6. SOCIALIZATION: the right balance of
solitude and social interaction must be
struck.
7. HAZARDS: safety must be provided for.
Remember: AWFERS
15
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TOOL # 10
DISASTER NURSING / TRIAGE:
PRIORITY #1
PRIORITY #2
PRIORITY #3
PRIORITY #4
IMMEDIATE
RED
DELAYED
YELLOW
MINIMAL
GREEN
EXPECTANT
BLACK
Treatment is needed
in hours to days.
Client may be moved
away from the triage
area.
Injuries are intensive!
Chances of survival
are unlikely.
Give comfort, separate
from others but do not
abandon
May require immediate
Life-threatening
injuries survivable with attention, but can
sometimes wait for
minimal intervention.
hours.
• Chest wounds
• Airway obstruction
• Abdominal wounds
• Shock
without evidence of
• Pneumothorax
hemorrhage
• QG UGGHJUHH
• Soft tissue injuries
EXUQVWR±RI
(muscles, ligaments
the body
tendons)
Key Words:
$Q[LHW\
Apprehension
Restlessness
Confusion
Change in LOC
•
•
•
•
•
(1st sign of increased
•
Genitourinary injury
•
Eye injury
•
CNS injuries
•
•
•
•
•
Upper extremity
fracture
Minor burns
Sprains
Small lacerations
ZLWKRXWVLJQL¿FDQW
bleeding
Psychological
disturbance
•
•
•
•
•
•
ICP)
Penetrating head
wounds
Burns in excess of
RIWKHERG\
surface area (BSA)
Seizures or vomiting
within 24 hours of
exposure to radiation
Profound shock with
multiple injuries
agonal respirations
Absent pulses,
absent blood
SUHVVXUH¿[HG dilated pupils
In the event of a disaster, the nurse may be required to discharge clients to make room for incoming victims:
¿UVWGLVFKDUJHFOLHQWVWKDWDUHDPEXODWRU\ZKRQHHGPLQLPDOFDUH
FOLHQWVUHTXLULQJDVVLVWDQFHDUHQH[W$UUDQJHPHQWVVKRXOGEHPDGHIRUFRQWLQXLW\RIFDUHDWKRPHRUH[WHQGHG
care facility.
DO NOT discharge clients who are unstable or require nursing care unless they are in imminent danger.
16
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ESSENTIAL
FACTS
WORDS OF WISDOM..........
A wise person would not attempt a job without tools and the proper
equipment.
Why should you?
Consistent studying to understand CONCEPTS is essential.
You cannot memorize answers and questions from previous exams!
...You cannot cram to understand...
17
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WHAT IS YOUR ROLE?
THE ROLE OF AN RN:
1. Assess clients.
2. Initiate, evaluate and update the plan of care and clinical pathways.
Care for the most critical and unstable clients, for example:
• Fresh post-operative clients
• Clients with a change in condition who need assessment
• Admissions • Discharges • Transfers
$VVHVVDYDLODEOHVWDႇDQGWKHLUMREGHVFULSWLRQV
5. Perform the most complex procedures, for example:
• Starting IV’s
• Interpreting EKG’s
• Correlating lab values
6. Collaborate with other departments and disciplines (the Interdisciplinary Approach).
'LUHFWDQGVXSHUYLVHWKH/31¶VDQGRWKHUDQFLOODU\VWDႇLH8QOLFHQVHG$VVLVWLYH3HUVRQQHO 8$3¶V 8. Act as a client advocate.
THE ROLE OF AN LPN:
1. Provide care to clients in stable condition under the supervision of an RN or other health care
provider.
2. Perform basic therapeutic, preventative care and rehabilitative procedures, for example:
• Sterile dressing changes • Urethral catheter and NGT insertion • Application of restraints
Assist RN with unstable and complex clients. Continuity of care plan and clinical pathway.
4. 6XSHUYLVH8$3¶VDVZHOODVGHOHJDWHDQGVXSHUYLVHRWKHU/31¶VZLWKLQWKHLUVFRSHRISUDFWLFH LPN’S ARE USUALLY NOT ALLOWED TO:
1. Perform triage, patient assessment, case management or independently develop the nursing care
plan.
2. Perform mental health teaching.
Administer IV chemotherapy (however bladder installation of chemotheray is permissible).
4. Perform central line or venous port procedures or IV push medications (except saline or Heparin
ÀXVKHV QRWHWKHVHVNLOOVFDQEHGRQHLQDQRXWSDWLHQWFKURQLFKHPRGLDO\VLVVHWWLQJ
5. Administer blood transfusions UNLESS they have satisfactorily completed a transfusion training
SURJUDPPHHWLQJFULWHULDVSHFL¿HGE\WKH'HSDUWPHQWRI+HDOWKDQGWKH6WDWH(GXFDWLRQ'HSDUWPHQW
A RN must be present for supervision.
THE ROLE OF A CNA (UAP):
1. 3URYLGHURXWLQHQRQVNLOOHGFDUHVXFKDVEHGEDWKVEHGPDNLQJURXWLQHYLWDOVLJQVHQHPDV
oropharyngeal suctioning, apply clean dressings (they may not change dressings), CPR.
UAP’S ARE NOT ALLOWED TO:
Administer medications, tracheal suctioning or trache care, administer O2, deliver NGT or PEG
feedings, insert urinary catheters, perform sterile or invasive procedures, assess evaluate or problem
solve, develop a nursing care plan
TIP: DELEGATION AND SUPERVISION ALONG WITH COLLABORATION CONCEPTS MUST BE
CONSIDERED WHEN SELECTING ANSWER CHOICES!
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LEADERSHIP AND PROFESSIONAL ISSUES
TYPES OF LEADERS:
Laissez-faire:2ႇHUVOLWWOHLIDQ\JXLGDQFH
Autocratic / Authoritarian: Strict. Makes all of the decisions. Uses punishment and coercion.
Democratic:&RQVXOWVZLWKVWDႇ3URPRWHVSDUWLFLSDWLRQDQGPDMRULW\UXOH
PROFESSIONAL ISSUES:
• Chain of command
• 'HOHJDWLRQWR8$3¶V
• Taking verbal orders
• (ႇHFWLYHFRPPXQLFDWLRQXVH6%$5 6LWXDWLRQ%DFNJURXQG$VVHVVPHQW5HFRPPHQGDWLRQ
• 'RFXPHQWDWLRQVKRXOGEHGRQHXSRQFRPSOHWLRQRIFDUH
DELEGATION: DO NOT DELEGATE WHAT YOU CAN E A T
1. The RN should never delegate the assessment portion of the nursing process.
2. The RN or LPN should never delegate the teaching or evaluation phase of patient care.
7KH51LVXOWLPDWHO\UHVSRQVLEOHIRUDOOWDVNVGHOHJDWHGWR8$3¶V
4. Be aware of the competence and job description of those to whom you delegate.
&RPPXQLFDWHHႇHFWLYHO\
6. The nurse must be sure to follow up on all tasks that were delegated.
7. If criticism is necessary, provide privacy.
8. Document unsafe practices and procedures.
0DQDJH\RXUWLPHHႇHFWLYHO\
RIGHTS OF DELEGATION
TASK
CAN YOU DELEGATE THIS TASK?
CIRCUMSTANCE
HOW COMPLEX IS THE PATIENT? WHAT IS THE
SKILL LEVEL OF THE STAFF MEMBER?
PERSON
IS THIS PERSON COMPETENT?
COMMUNICATION
DID YOU GIVE CLEAR DIRECTIONS?
SUPERVISION/ FEEDBACK
DID YOU MONITOR, EVALUATE, AND PROVIDE
FEEDBACK?
19
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LEGAL CONSIDERATIONS:
The nurse client relationship is a legal status that occurs whenever a nurse renders care to another person.
Once this relationship occurs, the law automatically imposes certain legal responsibilities upon the nurse.
7KHQXUVHVKRXOGQHYHUFDUU\RXWDSURYLGHU¶VSUHVFULSWLRQZKLFKGLUHFWVKHUKLPWRFRPPLWDQDFWZKLFKWKH\
know, or should know is unlawful.
TERMS TO KNOW:
VERACITY: Adherence to the truth.
LIABILITY: The obligation one incurs or might incur through acting or failing to act.
MALPRACTICE:,PSURSHUXVHRIRQH¶VSURIHVVLRQDOGXWLHVDIDLOXUHWRPHHWFDUHVWDQGDUGVWKDWFDXVHV
harm to another person.
NEGLIGENCE: The failure to provide care that a reasonable person would perform in similar
circumstances.
LIBEL: Defamation by written or printed words or pictures.
SLANDER: Defamation of character by speech.
ACTS OF OMISSION OR COMMISSION: Doing wrong by not acting; doing wrong by acting.
BENEFICENCE:7RGRJRRG([DPSOHVRIEHQH¿FHQWDFWLRQVUHVXVFLWDWLQJDGURZQLQJYLFWLPHQFRXUDJLQJ
smoking cessation.
NON MALEFICENCE:7RGRQRKDUP([DPSOHRIDQRQPDOH¿FHQWDFWLRQVWRSSLQJDPHGLFDWLRQWKDWLV
shown to be harmful.
ASSAULT: To threaten to touch.
BATTERY: Touching someone without consent.
TORT: A wrongful act, whether intentional or accidental, from which injury occurs to another.
FALSE IMPRISONMENT:
:KHQIRUH[DPSOHDFOLHQWLVPDGHWREHOLHYHWKH\FDQQRWOHDYHDEHGURRPRUÀRRU$OVRWKHXQDXWKRUL]HG
use of physical (e.g., lap tray) or chemical (e.g., sedatives). HINT: Authorized physical restraints must be
FKHFNHGHYHU\PLQXWHV GHSHQGLQJRQDJHQF\SROLF\ DQGUHOHDVHGHYHU\KRXUVLQRUGHUWRSURYLGH
ROM exercises and comfort measures.
INFORMED CONSENT:
This must be obtained from a client or their health care proxy for any invasive procedure. It is obtained by
WKHKHDOWKFDUHSURYLGHU SK\VLFLDQ ZKLOHWKHQXUVH¶VUROHLVWRLQVXUHWKHFRQVHQWLVVLJQHGDQGLQWKHFKDUW
prior to the procedure. (Assent = Consent)
INVASION OF PRIVACY:
(YHU\RQH LQ WKH PHGLFDO WHDP PXVW PDLQWDLQ WKH SULYDF\ RI WKH FOLHQW¶V PHGLFDO UHFRUG DV ZHOO DV KHU
his personal, physical privacy, for example, close the curtain or door when the client would otherwise be
exposed. Minimize the computer screen. The nurse has the legal duty to report to public health agencies
gunshot wounds, suspected child or elder abuse, and certain communicable diseases.
20
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MORE ABOUT LEGALITY
1. GOOD SAMARITAN LAW:
This act protects those persons who choose to aid others who are ill or injured from liability. It does not
cover gross negligence.
2. INCIDENT REPORTING:
Reports unusual occurrences and deviation from care standards. Facilities use the document to evaluate
care, determine potential risks or discover system problems that might have contributed to the error.
3. HARRISON NARCOTIC ACT OF 1941:
7KLVDFWFODVVL¿HGFHUWDLQKDELWIRUPLQJGUXJVDVQDUFRWLFVDQGEHJDQWRUHJXODWHWKHP,WZDVODWHUUHSODFHG
by the Comprehensive Drug Abuse Prevention and Control Act of 1970.
&RQWUROOHGVXEVWDQFHVVWRUHGLQORFNHGV\VWHPGLVSRVHRIXQXVHGQDUFRWLFVLPPHGLDWHO\ZDVWHPXVWEH
witnessed; document immediately and accurately
4. ADVANCE DIRECTIVES: $OVRFDOOHG02/67LQVRPHVWDWHV 0HGLFDO2UGHUIRU/LIH6XVWDLQLQJ7UHDWPHQW
ZULWWHQLQVWUXFWLRQVUHFRJQL]HGXQGHUVWDWHODZWKDWDUHUHODWHGWRWKHSURYLVLRQRIFDUHDSHUVRQZLVKHVWR
have when she/he cannot make decisions themselves.
Living will: Prepared by a competent adult and gives health care directions in the case when that per
son is unable to make decisions on their own.
'XUDEOHSRZHURIDWWRUQH\KHDOWKFDUHSUR[\: Documents that specify who will make your health
care decisions if you cannot.
Advanced care medical directive:&RPSHWHQWFOLHQWFRQVXOWVZLWKKHDOWKFDUHSURYLGHUDQGVSHFL¿HV
WKHNLQGRIPHGLFDOFDUHWKH\GRGRQRWZDQWLQVSHFL¿FVFHQDULRV
5. EMANCIPATED MINOR:
$FKLOGLVIUHHGIURPSDUHQWDOFXVWRG\DQGFDQEHFRPHDQ³DGXOW´LQPDQ\ZD\V:KHQDPLQRUPDUULHVRU
joins the armed forces (with parental consent and permission from the courts), she/he becomes
emancipated from her/his parents.
6. HIPAA: The Health Insurance Portability and Accountability Act
3URWHFWVWKHFRQ¿GHQWLDOLW\RIDSDWLHQW¶VKHDOWKFDUHLQIRUPDWLRQ,WUHTXLUHVSK\VLFLDQVQXUVHVKRVSLWDOVDQG
other health care providers to inform clients how their health care information is used and/or disclosed.
7. ORGAN DONATION:
• Health care provider determines if organ is suitable before approaching family.
• 2UJDQVVKRXOGEHUHPRYHGZLWKLQRQHKRXURIWKHFOLHQW¶VGHDWK
• Each hospital has its own protocol regarding organ donation.
• Donor must be kept on life support until the organs are removed.
• 1H[WRINLQFORVHVWOLYLQJUHODWLYHPDNHVGHFLVLRQVZKHQFOLHQWFDQQRW
8. UTILIZATION REVIEW:
'HWHUPLQHVHႇHFWLYHQHVVRIVHUYLFHVLQDKHDOWKFDUHIDFLOLW\ZKLFKLVUHODWHGWRFOLHQWV¶OHQJWKRIVWD\7KH
process compares requests for medical services to treatment guidelines that are deemed appropriate for such
services.
9. AUDIT REVIEW:
Review of charts along with direct assesment to determine causes of hospital acquired infections or deviations
from care standards.
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21
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RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH
RELIGION
BELIEFS AND PRACTICES
JUDAISM (ORTHODOX)
•
•
Autopsy: Only in special
circumstances
•
•
•
‡
•
•
•
‡
Visits to dying are a religious duty
A witness must be present at death to protect family and commit
soul to God
Torah and psalms read, prayers recited
Conversation is kept to minimum
Someone should be with body from death to burial usually within
24 hours
%RG\PXVWQRWEHWRXFKHGIURPWRPLQXWHVDIWHUGHDWK
Circumcision done on day 8 after birth ceremony called Briss
Medical personnel do not touch or wash body unless death
occurs on Jewish Sabbath; then care given by nurse with gloves
Water is removed from the room
0LUURUVPD\EHFRYHUHGDWIDPLO\¶VUHTXHVW
HINDUISM
•
Autopsy: Permitted
•
Priest ties thread around neck or wrist of deceased and pours
water in the mouth
Only family and friends touch the body
BUDDHISM
•
•
•
Buddhist priest present at death
Last rites are chanted at bedside
May prefer same sex wash body
•
•
•
•
Before death, Koran read, prayers said
Dying confesses sins, asks family to forgive
Only family members touch or wash body
$IWHUGHDWKERG\LVWXUQHGWRZDUGV0HFFD6RXWKHDVW
ROMAN CATHOLIC
Autopsy: Permitted
•
Sacrament of Sick administered to severely ill, those near death,
or newly dead
CHRISTIAN SCIENTIST
•
•
No ritual performed before or after death
No surgical procedures; no autopsy
•
•
No ritual performed before or after death
Baptism done after the age of 8
•
•
•
No ritual performed before or after death
Clergy ministers through counsel and prayer
No blood or blood products accepted
EPISCOPALIAN
Autopsy: Permitted
•
Last rites optional
LUTHERAN
Autopsy: Permitted
•
Last rites optional
Autopsy: Personal Preference
ISLAM (MUSLIM)
Autopsy: Only for medical or legal
reasons
Autopsy: Unlikely
CHURCH OF CHRIST (MORMON)
Autopsy: Permitted
JEHOVAH’S WITNESS
Autopsy: Only if required by law
WESTERN ORTHODOX CHRISTIAN
•
Autopsy: Not encouraged
ASIAN AMERICANS
Autopsy: Permitted
•
•
•
•
•
Last rites mandatory and given by ordained priest
Value silence
Touching is unacceptable with the opposite sex
+HDGLVFRQVLGHUHGVDFUHGGRQRWWRXFKWKHKHDG
Believe in yin (dark, cold) & yang (bright, hot); do not mix hot and
cold
They prefer warm—considered good for wellness
22
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RELIGIONS AND DIETARY PRACTICES
7TH DAY ADVENTISTS
(CHURCH OF GOD)
•
•
$OFRKROFRႇHHWHDSURKLELWHG
Some groups prohibit meat. Pork is prohibited.
BAPTISTS
•
$OFRKROSURKLELWHGFRႇHHWHDGLVFRXUDJHG
BUDDHISM
•
•
Alcohol and drug use discouraged.
Some sects are vegetarian.
ROMAN CATHOLICISM
•
•
•
Avoid meat on Ash Wednesday and Good Friday.
During Lent, fasting is optional, meat on Fridays is discouraged.
Children and the ill are exempt from fasting.
•
CHURCH OF JESUS CHRIST OF •
LATTER DAY SAINTS (MORMON) •
•
HINDUISM
•
•
•
•
•
ISLAM
JEHOVAH’S WITNESS
PENTECOSTAL
(ASSEMBLY OF GOD)
RUSSIAN ORTHODOX
Beef and veal prohibited, limited meat consumed.
Many individuals are vegetarians.
)DVWLQJRFFXUVRQVSHFL¿FGD\VRIWKHZHHNGHSHQGLQJRQZKLFK
god a person worships.
Children are exempt from fasting.
Fasting can be complete abstinence to one meal a day.
•
•
•
Pork is prohibited as is any meat not ritually killed.
Alcohol and drugs are avoided.
During Ramadan (9th month of Mohammedan year) fasting is
practiced during the daytime.
•
•
Food to which blood has been added is prohibited.
&DQFRQVXPHÀHVKWKDWKDVEHHQGUDLQHGRIEORRG
•
•
•
•
•
•
•
Orthodox believers adhere to dietary Kosher rules.
Meats that are allowed come from animals that are vegetable
HDWHUVFORYHQKRRIHGDQGULWXDOO\VODXJKWHUHG
)LVKZLWKVFDOHVDQG¿QVDUHDOORZHG FDQKDYHZKLWH¿VKKDOLEXW
haddock, canned tuna, sardines, salmon).
Sea scavengers, such as shrimp, are not allowed.
The combination of meat and milk is prohibited.
24 hour fasting is observed on Yom Kippur.
Pregnant women are exempt from fasting.
During Passover Week, only bread that is unleavened is permitted.
•
•
•
Alcohol is prohibited.
Avoid food to which blood has been added.
Some individuals avoid pork.
•
Meat and dairy are abstained from on Wednesday, Friday and
during Lent.
During Lent, all animal products are abstained from.
Fasting is practiced during Advent.
The ill or pregnant are exempt from fasting.
•
JUDAISM
$OFRKROFRႇHHDQGWHDSURKLELWHG
Limited consumption of meat.
Avoid spices.
)DVWLQJLVGRQHRQWKH¿UVW6XQGD\RIHDFKPRQWK
•
•
•
23
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HERBAL REMEDIES AND MEDICAL IMPLICATIONS
HERBAL REMEDY / USES
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
MEDICAL IMPLICATIONS
ALOE VERA
7RSLFDODQWLLQÀDPPDWRU\IRUEXUQVDEUDVLRQV
Helps with tissue injury
ECHINACEA
%ORRGSXUL¿HUWKDW¿JKWVFROGVLQIHFWLRQVDQG
cancer
GINSENG
Anemia
Hypertension
Benign Prostatic Hypertrophy
SAINT JOHN’S WORT
Wound healing
Menstrual disorders
Diuretic
Depression
KAVA KAVA
Decrease anxiety and stress
GINKO BILOBA
Improves blood circulation
Improves attention span
7DNHVZHHNVWRVHHUHVXOWV
GINGER
Reduces morning sickness, nausea
Used to treat burns
GARLIC
May decrease cholesterol, BP and glucose levels
+DYHDQWLEDFWHULDODQGDQWLIXQJDOSURSHUWLHV
May improve circulation
SAW PALMETTO
6XSSRUWVKHDOWKRISURVWDWH LPSURYHVXULQHÀRZ
$QWLLQÀDPPDWRU\
Prevents hair loss
VALERIAN ROOT
Calms neuro system
Promotes sleep
Used for headaches, anxiety, nervousness
BLACK COHOSH
Used for menstrual and menopausal symptoms
Used as a sedative, and diuretic
5HGXFHVEORRGSUHVVXUHKRWÀDVKHVQLJKW
sweats, and mood changes
FEVER FEW
Used for migraine headaches and arthritis.
LICORICE
Used for peptic ulcer, GERD, weight loss,
eczema, canker sores
•
If ingested, may cause GI upset. May increase
Digoxin level; Avoid with kidney disorders
•
•
•
•
•
•
Avoid with ragweed allergy
&RQWUDLQGLFDWHGLQEUHDVWIHHGLQJZRPHQ
children, immunocompromised
Caution with HTN, DM, clotting disorders
$YRLGZLWK&RXPDGLQ PD\ĹHႇHFW
0D\LQFUHDVHHႇHFWRIVWLPXODQWV
Hold for 7 days before surgery
•
•
•
•
Avoid sunlight, antidepressants
Avoid with HTN, and with immunosuppression
Avoid foods containing tyramine
'HFUHDVHVHႇHFWRI&RXPDGLQ
•
,QFUHDVHVHႇHFWVRI%DUELWXUDWHV
•
•
•
•
•
•
•
•
•
•
•
•
Contraindicated in pregnant women & children
$YRLG&RXPDGLQ PD\ĹEOHHGLQJ
,QFUHDVHVHႇHFWRI0$2,¶V$YRLG'LODQWLQ
+ROGIRUKRXUVEHIRUHVXUJHU\
May cause CNS depression, cardiac arrhythmias
Contraindicated with gallbladder disease
May increase bleeding with Coumadin
Caution with DM, antihypertensives, and cardiac
medications
0D\DႇHFWEORRGFORWWLQJEORRGVXJDUOHYHOV
Avoid DM medications
May increase bleeding with Coumadin
Hold for 7 days before surgery
•
•
No drug interactions.
May cause stomach discomfort.
•
May increase sedation when used with: ETOH,
barbiturates, sleeping pills, muscle relaxants &
benzodiazepines
•
Overdose may cause N/V, headache, dizziness,
tremors, reduced heart rate
Contraindicated with CHF, pregnancy
$ႇHFWVXVHRIKRUPRQHUHSODFHPHQWWKHUDS\
contraceptives, cardiac medications
•
•
•
•
•
•
•
,QFUHDVHVHႇHFWRI&RXPDGLQ
Contraindicated in pregnancy
Contraindicated in heart disease
May increase blood pressure
Avoid with ACE inhibitors, steroids, digoxin
24
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MISCELLANEOUS KEY POINTS
COUMADIN
Kthe risk of bleeding when taken with:
$Chamomile
$Clove $Dong Quai
$Ginger $Ginseng $Fever Few $Licorice
LWKHHႇHFWRI&280$',1!
Saint John’s Wort
Clients should AVOID THE SUN with the following:
(Other phrases: avoid the beach, wear long sleeves, wear sunglasses, wear a wide brimmed hat)
•
Thorazine (chlorpromazine)
•
Retin A (retinoic acid)
•
Bactrim (trimethoprim)
•
Griseofulvin (grifulvin)
•
Exopthalmus (bulging eyes)
•
6DLQW-RKQ¶V:RUW
•
Lupus
•
'XUDJHVLF3DWFK IHQWDQ\O IROGDQGÀXVKWRGLVSRVH
•
&LSUR FLSURÀR[DFLQ
•
9LDJUD VLOGHQD¿OFLWUDWH
•
Glucotrol (glipizide)
•
3DFHURQH DPLRGDURQH GLVFRORUVWKHVNLQEOXHJUD\
•
Benadryl (dipenhydramine)
•
Tetracycline: do not give to pregnant women or children under eight as it stains the teeth
•
'RQ4XDLWUHDWVPHQVWUXDOFUDPSVPHQVHVDVPXVFOHUHOD[DQWEORRGSXUL¿HUPDQDJHV
HTN (avoid with bleeding & clotting disorders)
•
Diuretics (Loops & thiazides)
TIP: REMEMBER TO USE YOUR 10 TOOLS AS A THEORETICAL FRAMEWORK FOR
ASSISTING WITH YOUR DECISION MAKING!
25
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MEDICATION CALCULATIONS
Microdrip = 60 gtts/ml
REMEMBER:
Standard IV Set = 15 gtts/ml
Blood Administration = 10 gtts/ml
9ROXPH LQPO [JWWIDFWRU HJJWWVPO
Time in Minutes
7RDGPLQLVWHUPORI,9ÀXLGLQKRXUVXVLQJDPLFURGULS set, how many drops/minute will you administer?
1.Calculate an IV Infusion:
Sample Question: 500 (volume) x 60 (gtt factor) JWWVPLQ(rounded up from 62.5)
8 hours x 60 minutes (time in minutes)
Answer:
2. Calculate Parenteral Medications:
Desire = order, prescription, want, give, administer
Have = on hand, available
'HVLUHG$PRXQW[7RWDO9ROXPH
Total Amount of Drug on Hand
Sample Question:
You have on hand Benadryl 50 mg / 2 ml.
The prescription reads: Give Benadryl 25 mg IM STAT.
Answer:
25 mg (desired amount) x 2 (total volume) = 1 ml
50 (total amount of drug on hand)
3. Calculate Oral Medications:
Sample Question:
Desire = order, prescription, want, give
Have = on hand, available
The prescription reads: Administer Albuterol 6 mg po, tid.
On hand is Albuterol 2 mg tablets.
Answer:
GHVLUHGDPRXQW WDEV.
2 (dosage on hand)
4. Calculate Critical Care Medications:
Desire X Volume X Weight (kg) X Minutes
Have
Sample Question: Answer:
7KHSUHVFULSWLRQUHDGV$GPLQLVWHU'RSDPLQHPFJNJPLQ
On hand: Dopamine 800mg in 250 ml D5W
The client weighs: 80 kg
The IV should run at ___________ml/hr
PFJ;PO;NJ;PLQXWHV
800mg
Convert mcg to mg........... PJ;PO;NJ;PLQXWHV
800mg
The IV should run at 4.5ml/hr
26
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Volume
Weight
1 tsp
1 cup
1 tbsp
1 pint
1 oz.
1 quart
5 ml
240 ml
15 ml
473 ml
30 ml
946 ml
15 –16 gtts
15-16 minims = 1 ml
Sample Question Answer:
1 mg
1,000 mcg
1 gr
60 mg
1gm
1,000 mg = 1ml
1 kg
2.2 Ibs
1L
1 kg = 1,000 ml
,IDFKLOGZHLJKVOEVKRZPXFKGRWKH\ZHLJKLQNJ"
2.2 lbs = OEV [ [ NJ
1 kg
x kg
SAMPLE QUESTION
Prescription reads: Administer Drug A 4mg/kg every 8 hours intravenously
On hand: 100mg in 50ml Normal Saline
The client weighs: 286 lbs
How many ml/dose_____________
ANSWER:
&RQYHUWOEVWRNJ· NJ
0XOWLSO\NJ;PJ PJ
Use formula D X V
520 X 50 = 260ml/dose
H
100
%RG\0DVV,QGH[ %0, 0HDVXUHVERG\IDWEDVHGRQKHLJKWDQGZHLJKW.
BMI =
weight in pounds
(Height in inches) X (Height in inches)
;
BMI < 18
= Under Weight
< 18.5
= Thin for Height
+HDOWK\:HLJKW
2YHUZHLJKWIRU+HLJKW
! 2EHVLW\
%RG\6XUIDFH$UHD %6$ 7KHVXUIDFHDUHDRIWKHERG\H[SUHVVHGLQVTXDUHPHWHUV.
BSA = Weight in kilograms X Height in centimeters
1 kg = 2.2 lbs
1inch = 2.54cm
27
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MATH PRACTICE QUESTIONS
1. A nurse is preparing to administer Ringers Lactate 600 ml IV over 8 hours. The drop factor is
15 gtt/ml. The nurse should deliver how many gtt/min? Round to a whole number _____gtt/min
2. A nurse is preparing to administer Pepcid (famotidine) 20 mg IV over 15 minutes. The drug
available is 20 mg/100 ml. The nurse would be correct to set the infusion pump at _____ml/hr
$QXUVHLVUHYLHZLQJSUHVFULSWLRQV7KHSUHVFULSWLRQUHDGVDGPLQLVWHU&HIWD]LGLPHPJNJ
orally every 8 hours to a child who weighs 22 pounds . The drug is available in 100 mg/ml
suspension. The nurse should administer ________ml/dose
$QXUVHLVSUHSDULQJWRJLYHR[\FRGRQHK\GURFKORULGHJPSRHYHU\KU7KHDPRXQW
available is 15mg/tab. How many tab(s) should the nurse administer per dose? ______tabs
5. A nurse is teaching a client on correct use of Azithromycin. The prescription reads, give one
dose 500 mg orally. The drug available is 250 mg / tab. How many tablets should be given?
_____tab(s)
6. A nurse is preparing to administer Rocephin (ceftriaxone) 2 gm IM x 1 dose. The amount
DYDLODEOHLVJPPO+RZPDQ\POVKRXOGWKHQXUVHDGPLQLVWHU"'RQRWURXQGBBBBBPO
7. A nurse is preparing to administer 5,000 mcg of Vitamin B12 (methylcobalmin) SQ x 1 dose.
The amount available is 10 mg/ml. How many ml should the nurse administer? ______ml
$FOLHQW¶VWRWDOKRXULQWDNHVKRXOGQRWH[FHHGP/7KHSHULSKHUDO,9LVUXQQLQJDW
mL/hr. The client is also receiving Cefazolin 500 mg IVPB in 50 mL D5W q6h and Azithromyin
PJLQPO':,93%GDLO\+RZPXFK32ÀXLGPD\WKHFOLHQWKDYH"BBBBBBBP/
6DUDKGULQNVFXSVRIZDWHUPORIEURWKFXSRISXUHHGFKLFNHQDQGR]RIWHD+HU
total oral intake is _________ml
10. A nurse is to administer Keppra (levitiracetam) po. The maximum dose is 1.5 gm per day
WREHJLYHQLQHTXDOO\GLYLGHGGRVHVHYHU\KRXUV7KHDPRXQWDYDLODEOHLVPJWDE
How many tab(s) should the nurse administer? ______tab(s)
11. A nurse is preparing to administer Theophylline 160 mg PO q6h. The medication available is
Theophylline 80 mg / 15 ml. How many mL/dose? _______mL
$SUHVFULSWLRQLVZULWWHQWRLQIXVHPO'H[WURVH,9RYHUKRXUV7KHGURS)DFWRULV
JWWPO7KHQXUVHZRXOGEHFRUUHFWWRVHWWKHÀRZUDWHWRBBBBBJWWPLQ5RXQGWRDZKROH
number
$SUHVFULSWLRQRIPO5/WRLQIXVHDWPOKRXULVRUGHUHG7KHGURSIDFWRULVJWWPO
7KHÀRZUDWHVKRXOGEHFDOFXODWHGDWBBBBBBJWWPLQ5RXQGWRDZKROHQXPEHU
14. The nurse is preparing a prescription of Regular Insulin 10 units/hr IV. The bag available
contains Insulin 25 Units in 100ml NS. How many ml/hr will the client receive? _______ml
[www.dosagehelp.com]
Detailed answers Page 218
1. .19 gtts/min
2. 400 ml/hr
PO
4. 2 tabs
5. 2 tabs
PO
7. 0.5ml
PO
9. 1080 ml
10. 1tab
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28
PO
12. 5 gtts / min
JWWVPLQ.
14. 40 ml/ hr
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CBC (COMPLETE BLOOD COUNT)
Hematocrit (HCT)
Female
Male
Hemoglobin (HGB)
g/dL Female
g/dL Male
White Blood Cell Count (WBC)
FHOOVPP
Red Blood Cell Count (RBC)
PLOOLRQP/
Platelet Count
ȝ/
B Lymphocytes
T Lymphocytes:
&'VLJQL¿HV$,'6
with increased risk for opportunistic infection. HIV kills
&'FHOOVZKLFKUHVXOWVLQDVLJQL¿FDQWO\LPSDLUHGLPPXQHV\VWHP
URINALYSIS
Normal Color
<HOORZ6WUDZ
Child
6SHFL¿F*UDYLW\
pH
CHEMISTRY: ADULT
Sodium
mmol/L
Chloride
mmol/L
Glucose
mg/dL
Potassium
mEq/L
BUN
mg/dL
Creatinine
mg/dL
Carbon Dioxide
mmol/dL
Calcium
mg/dL
Amylase
U/L
Increased in pancreatitis
Lipase
U/L
Increased in pancreatitis
Magnesium
mg/dL
Ammonia
mg/dL
Uric Acid
mg/dL
Albumin
g/dL
Alkaline Phosphatase
.$8G/
ALT
IU/L
AST
IU/L
Bilirubin Totals
mg/dL (Adult Normal)
1.2 mg/dL (Adult Critical)
mg/dL (Newborn Normal)
15 mg/dL (Newborn Critical)
Increased in dehydration and renal dysfunction
Decreased with kidney & liver disorders & decreased protein
**Requires treatment usually phototherapy**
HgbA1c
Levels > 8% indicate poor diabetic control with need for education
regarding adherence to regimen or changes in therapy**
29
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CHEMISTRY: CHILD
Glucose
mg/dL
Calcium
mg/dL
Billirubin
mg/dL
Platelets
ȝ/
BLOOD CULTURE
•
2 bottles collected (anaerobic / aerobic) blood drawn from 2 seperate sites; must be venipuncture
•
Do not draw from IV lines
•
Clean skin
•
Collect sample before starting antibiotics
NORMAL BLOOD GAS...Remember ROME / RAMS
pH
±
PaO2
80 – 100
mmol/L
PaCO2
±
mmol/L
HCO
mmol/L
SaO2
ACID - BASE IMBALANCES
pH
PaCO2
HCO3
Respiratory Acidosis
†
45 mmHg
N/A
Respiratory Alkalosis
7.45
† mmHg
N/A
Metabolic Acidosis
†
N/A
† 22 mEq/L
Metabolic Alkalosis
7.45
N/A
26 mEq/L
SAMPLE QUESTIONS
Label the acid – base imbalances:
1. pH = 7.20, CO2 = 64, HCO = 26 ______________________
2. pH = 7.50, CO2 +&2 BBBBBBBBBBBBBBBBBBBBBB
S+ &22 +&2 = 18 ______________________
Compensation occurs when the body’s processes counterbalance to bring the pH within normal limits!
$16:(565HVSLUDWRU\$FLGRVLV0HWDEROLF$ONDORVLV0HWDEROLF$FLGRVLV
30
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LIPIDS (CHOLESTEROL): Test is done fasting.
TOTAL
< 200 mg/dL
HDL KLJKGHQVLW\OLSLGV PJG/
LDL ORZGHQVLW\OLSLGV PJG/
COAGULATION PROFILE:
37
VHFRQGV
D377 VHFRQGV
377 VHFRQGV
,15 7KHWKHUDSHXWLFUDQJHLVRQO\ZKHQWKHFOLHQWLVRQDQWLFRDJXODQWWKHUDS\
7KH37377UDQJHVKRXOGEHWLPHVWLPHVWKHFRQWUROZKHQRQPHGLFDWLRQ
MEDICATION THERAPEUTIC LEVELS:
$FHWDPLQRSKHQ
PJ/8VHZLWKFDXWLRQZLWKOLYHUGLVHDVH0D[LPXP'RVHJPGD\
7R[LFLW\66N/V, RUQ pain, jaundice, coagulation abnormalities
/LWKLXP
±P(T/0RQLWRU1D+\SRQDWUHPLDĹrisk of toxicity.
7R[LFLW\66N/V, blurred vision, drowsiness, slurred speech, arrthymias, renal
toxicity
'LODQWLQ
PFJP/6LGHHႇHFWVGLVFRORUHGXULQHJLQJLYDOK\SHUSODVLD
(phenytoin)
7R[LFLW\66 rapid eye movements, slurred speech, coordination problems
7KHRSK\OOLQH
±PFJP/6LGHHႇHFWVLQFOXGHWDFK\FDUGLDDQGSDOSLWDWLRQV
7R[LFLW\66 N/V, anorexia, palpitations, sinus tachycardia
'LJR[LQ
PJ/PRQLWRUHOHFWURO\WHV²K\SRNDOHPLDK\SRPDJQHVHPLDDQG
hypercalcemia predispose clients to Digoxin toxicity.
7R[LFLW\66N/V/D, anorexia, blurred vision, halos around the light
0DJQHVLXP6XOIDWH±PJG/$UHÀH[LDLVDVLJQRIWR[LFLW\STOP THE INFUSION!!
7R[LFLW\66CNS depression
*HQWDP\FLQ XJPO&DXVHVRWRQHXURDQGQHSKURWR[LFLW\
7R[LFLW\66WLQQLWXVEDODQFHGLႈFXOW\YLVXDOGLVWXUEDQFHVUHQDOG\VIXQFWLRQ
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Vital Signs
Vital signs must be assessed:
1. on admission
2. as per M.D. order
with any change of health status
4. with chest pain or any abnormal sensation
5. before and after administration of preoperative medications; after surgery or invasive
diagnostic procedures
6. EHIRUHDQGDIWHUDGPLQLVWUDWLRQRIEORRGDQGEORRGSURGXFWVRUPHGLFDWLRQVWKDWDႇHFW
cardiovascular or respiratory function
7. EHIRUHDQGDIWHUDQ\QXUVLQJLQWHUYHQWLRQWKDWDႇHFWVWKHFDUGLRYDVFXODURUUHVSLUDWRU\
system
Vital signs include temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP),
and pain assessment, SaO2 is done as indicated.
)DFWRUV$ႇHFWLQJ9LWDO6LJQV
Vitals Across the Lifespan
Age
Pulse Rate
Respiratory Rate
Blood Pressure
Before birth
140 – 160
–
–
Newborn
130 – 150
30 – 60
73/55
Infant
110 – 130
24 – 30
Preschool
90 – 110
20 – 24
85–90/50–60
School age
80 – 90
18 – 20
90–110/60
Adolescent
70 – 90
16 – 20
110–130/70
Adult– > 18
50 – 100
16 – 20
120–129/80– 84
Older adult >70
60 – 100
15 – 20
90/55
diastolic
32
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NORMAL FLUID INTAKE AND OUTPUT
INTAKE:
1,500 – 2,500 ml over 24 hours.
OUTPUT:
1,500 – 2,500 ml over 24 hours.
INSENSIBLE LOSS:
500 – 1,000 ml / day
NORMAL FLUID FOR COLOSTOMY / ENEMA:
500 – 1,000 ml
AMNIOTIC FLUID:
500 – 1,000 ml
9$*,1$/'(/,9(5<1250$/%/22'/266
±PO&6(&7,21PO
REMEMBER!!!
Minimum urine output is 0.5 - 1 ml/kg/hour (adult) 2ml/kg/hour (child).
7KHPRVWDFFXUDWHLQGLFDWRURIÀXLGORVWRUJDLQHGLVWEIGHT!
1,000 ml = 1 kg = 2.2 lbs
BASIC ASSESSMENT
1. Obtain history:
Subjective Data:
What the client tells you; history of current illness, pain, aggravating / relieving factors.
Objective Data:
Things that can be assessed by the examiner: name, age, gender, vital signs, diet, activity level,
medications (prescribed or illicit), alcohol intake, cigarettes smoked.
ALWAYS ASSESS CLIENT FROM HEAD TO TOE
REMEMBER TO INCLUDE:
HEAD
Shape and symmetry of face. Condition of hair and scalp
(e.g., thinning, balding, alopecia, etc)
EYES
Appearance of sclera, color of conjunctiva, appearance of pupils
(They should be equal in size, round and regular in shape, and react to light and
accommodation) PERRLA
EARS
Presence of drainage, hearing aids, pain, hearing disturbances
NOSE
Drainage, sense of smell, nasal congestion
THROAT
Presence of dentures
Oral hygiene
Oral mucosa (should be pink, moist)
Tracheal alignment
Presence of jugular venous distention (JVD)
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PAIN ASSESSMENT
1. Use a pain scale from 0 – 10, 0 = no pain, 10 = worst pain.
2. For a child or a client with a language barrier, use faces or OUCHER scale:
no pain
moderate pain
worst pain
3LHFHVRISDLQRUFRORUVFDOHFDQDOVREHXVHG
4. Assess PQRST:
P: What provokes the pain?
Q: What is the quality of the pain? (e.g., sharp, dull, stabbing).
R: Does the pain radiate? (does it move around)
S: What is the severity of the pain?
HJVFDOHIURPDVVRFLDWHGVLJQV V\PSWRPVVXFKDVGLDSKRUHVLV
tachycardia, SOB)
T: What was the time of onset (constant, intermittent?)
5. Nursing implications:
Pain Relief:
• Reposition patient
• Rest and relaxation techniques
• Analgesics as per health care provider prescription
• 2௺HUUHDVVXUDQFHDOORZFOLHQWWRH[SUHVVIHDUVDQGFRQFHUQV
• Distraction techniques: deep breathing, imagery, massage, eliminate stimuli, music
therapy, biofeedback (non pharmacological comfort measures)
5HPEHUWRQRWLI\WKH+HDOWK&DUH3URYLGHULIWKHUHDUHVLJQL¿FDQWFKDQJHVLQFOLQLFDO¿QGLQJVLHIHYHU
FKDQJHLQ%3OLPESDLQRUVZHOOLQJ
TIP *Emphasize prioritization of care on systemic client concerns i.e. sepsis vs. localized concerns.
34
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NEUROLOGICAL ASSESSMENT
1. Assess Mental Status:
alert
disoriented
confused
stuporous
comatose
1RWHDSSHDUDQFHDVVHVVVSHHFKDႇHFWPRWRUIXQFWLRQ
1RWHFRJQLWLYHGH¿FLWVRULIFOLHQWKDVWURXEOHKHDULQJRUVSHDNLQJ
4. RAPID NEUROLOGICAL ASSESSMENT: (performed on admission or on an emergent basis).
0 absent, no response
1 (+) weaker than normal
2 (++) normal
VWURQJHURUPRUHEULVNWKDQQRUPDO
4 (++++) hyperactive
*Note: 1 and 3 may be normal for some individuals.
THE GLASCOW COMA SCALE
7KH*ODVFRZ&RPD6FDOHLVXVHWRPHDVXUHDFOLHQW¶VEDVHOLQHGDWDLQWKUHHDUHDV
Eye opening
Motor response
Verbal response
2. The highest score is 15
$VFRUHEHORZ
normal neurological function.
coma is present.
7KHORZHVWVFRUHLV
deep coma is present.
THE SCALE ITSELF
Assess the client in each area and assign a numerical score as per the scale. Then add up
the three numbers to arrive at the total score. Whatever the total is, the three numerical sign
SRVWVLQDERYHZLOOLQGLFDWHDEURDGGHVFULSWLRQRIWKHFOLHQW¶VQHXURORJLFDOVWDWXV.
EYE OPENING
MOTOR RESPONSE
VERBAL RESPONSE
Spontaneous 4
7RVRXQG 7RSDLQ
1RUHVSRQVH
Obeys commands
/RFDOL]HVSDLQ
1RUPDOÀH[LRQ
$EQRUPDOÀH[LRQ
Extension
No response
Oriented
5
&RQIXVHGFRQYHUVDWLRQ ,QDSSURSULDWHZRUGV
,QFRPSUHKHQVLEOHVRXQGV No response
1
6
2
1
35
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THE BRAIN AND NERVOUS SYSTEM
(DFKOREHRIWKHEUDLQKDVDVSHFL¿FIXQFWLRQ
Frontal lobe
Voluntary muscle movements, motor areas for control of speech, controls personality, behavioral functions,
intellectual functions i.e. memory, judgment and problem solving, autonomic functions and cardiac and
HPRWLRQDOUHVSRQVHV'DPDJHWRWKHIURQWDOOREHFRXOGOHDGWR%URFD¶VDSKDVLD H[SUHVVLYHDSKDVLD Temporal lobe
Controls taste, hearing, smell
and the interpretation of spoken
language.
Parietal lobe
Coordinates and interprets sensory
Information from the opposite side
of the body.
Occipital lobe
Interprets visual stimuli.
Temporal arteritis: LQÀDPPDWLRQDQGGDPDJHWRWKHEORRGYHVVHOVWKDWVXSSO\WKHKHDGDUHD
Signs and Symptoms: headache, thrombosis, excessive sweating, fever, malaise, jaw pain with chewing
and muscle aches.
RX: Corticosteroids
LEFT-BRAIN / RIGHT-BRAIN
:KHQFHOOVLQDSDUWRIWKHEUDLQORRVHWKHLUEORRGVXSSO\DFRUUHVSRQGLQJVLGHRIWKHERG\LVDႇHFWHG
Remember!
'DPDJHWRRQHVLGHRIWKHEUDLQZLOOH[KLELWGH¿FLWVRQWKHRSSRVLWHVLGH FRQWUDODWHUDO RIWKHERG\
LEFT-SIDED BRAIN DAMAGE
RIGHT-SIDED BRAIN DAMAGE
Slow, cautious behavior
Quick, impulsive behavior
Speech problems, aphasia
Short attention span
Trouble following verbal commands
Neglects left side
Apraxia (impaired motor function)
Easily distracted
Trouble performing simple tasks
5LJKWVLGHGKHPLSOHJLD
/HIWVLGHGKHPLSOHJLD
Dandy Walker Syndrome -congenital malformation of 4th ventricle of the brain. Results in increased ICP.
Associated with other disorders of the CNS. Treatment: placement of a VP shunt. Management of S/S.
36
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NERVE
FUNCTION
TEST
I.
OLFACTORY
Smell (sensory)
Identify familiar odors
II.
OPTIC
Vision (sensory)
Snellen eye chart
III.
OCCULOMOTOR
Most eye movements, constricts
pupils, keeps upper lid open
III, IV, VI test together, Check for ptosis
of lid. Assess ocular movements
IV.
TROCHLEAR
Eye movements inward, downward
Note any eye deviation
V.
TRIGEMINAL
Facial, scalp, teeth (sensation), jaw,
chewing movement
Close jaws tightly, Touch forehead,
cheeks, chin, and cornea with cotton.
7HVWVHQVLWLYLW\WRVXSHU¿FLDOSDLQ
(sharp/dull), and temperature (hot/cold)
VI.
ABDUCENS
Eye movements, lateral
See III, IV
VII.
FACIAL
)DFLDO±PRYHPHQWWDVWHVHQVRU\
Observe for facial symmetry: whistle,
smile, raise eyebrows; Test taste
discrimination on front of tongue
Hearing (cochlear), balance
(vestibular)
Check Weber, Rinne, check balance
VIII. ACOUSTIC
Taste of posterior, tongue, pharynx,
IX.
GLOSSOPHARYNGEAL swallowing, salivating, sensation of
ear, raises palate, controls pharynx
7DVWHGLVFULPLQDWLRQRQSRVWHULRURI
WRQJXHFKHFNJDJUHÀH[
X.
VAGUS
Taste, palate, sensation of pharynx,
,OOLFLWJDJUHÀH[QRWHKRDUVHQHVVLQ
larynx, ear, talking, swallowing
voice, Observe rise of uvula when
parasympathetic stimulation to heart
SDWLHQWVD\V³$KKK«´
& abdominal viscera
XI.
SPINAL ACCESSORY
Movements of head, neck and
shoulders
Shrug shoulders against resistance.
Turn head against opposing pressure of
the examiners hand
XII.
HYPOGLOSSAL
Movements of the tongue
Protruded tongue, it should be midline
EXAMPLE OF A DISEASE AFFECTING A CRANIAL NERVE:
TRIGEMINAL NEURALGIA:
TKLVGLVHDVHFDXVHVDVSHFL¿FW\SHRIIDFLDOSDLQ
Trigeminal Neuralgia
which occurs in sudden, intense, paroxysmal
HSLVRGHV $ႇHFW LV XQLODWHUDO DQG FRQ¿QHG WR
the area innervated by the trigeminal nerve
(5th cranial nerve).
• 5th cranial nerve
• frequent eye care
• good oral hygiene
• frequent dental visits
• avoid hot & cold liquids
• wear glasses outdoors to protect
Priority nursing diagnosis: Pain
eye from dust & particles
Treatment:: pain management
Tegretol (carbamazepine), Dilantin
(phenytoin), Elavil (amitriptyline)
37
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LUNG ASSESSMENT
Inspection – 5HVSLUDWRU\ UDWH UK\WKP V\PPHWULFDO ULVH DQG IDOO RI FKHVW ZDOO UHVSLUDWRU\ HႇRUW XVH
RIDFFHVVRU\PXVFOHVQDVDOÀDULQJVWHUQDOVXEVWHUQDOUHWUDFWLRQVREYLRXVLQMXU\RUFRQWXVLRQUDVKRU
erythema.
Palpation – Pain, tenderness, crepitus, tracheal deviation
Percussion –'XOOQHVV LQGLFDWHVSRVVLEOHKHPRWKRUD[SQHXPRQLDRUHႇXVLRQ W\PSDQ\ DLU¿OOHGDVLQ
pneumothorax), resonance (normal lung sounds), hyperresonance (indicates possible pneumothorax, or
emphysema)
Auscultation – DVVHVVHVIRUQRUPDOOXQJVRXQGVVKRXOGEHFOHDUDQGHYHQPRVWO\YHVLFXODUORXGHU
RQLQVSLUDWLRQ6WDUWDWWKHWRSRIOXQJ¿HOG DSH[ ZRUNGRZQWRZDUGVEDVHRIOXQJVDOWHUQDWLQJIURPOHIW
to right, anterior to posterior.
Abnormal Lung Sounds
Crackles (rales): heard on inspiration in the lower bases, it cannot be relieved by coughing.
Ronchi: Coarse, gurgling sound. Heard on expiration over trachea and bronchi, it can be relieved by
coughing.
Wheezes: +LJKSLWFKHGVTXHDN\VRXQG+HDUGWKURXJKRXWOXQJ¿HOGVXVXDOO\
on expiration. Cannot be relieved by coughing.
Stridor: high pitched sound heard on inhalation and exhalation. Indicates narrowing of upper airway or
obstruction. ***THIS SOUND REQUIRES IMMEDIATE INTERVENTION***
ABDOMINAL ASSESSMENT
Inspection: Skin, distention, presence of scars, obesity, herniations.
Auscultatation: %RZHOVRXQGVK\SHUHYHU\VHF1RUPDOHYHU\VHFK\SRHYHU\PLQXWH
Percussion: Dullness:RYHUVROLGRUJDQVOLYHUTympany: RYHUDLU¿OOHGRUJDQVERZHOV
Resonance: over lungs
Flatness: over muscle or bone
Palpation: pulsation, masses, tenderness, rigidity,
NOTE 1:
Always work from area of least pain towards area of most pain.
A pulsatile abdominal mass may indicate an ABDOMINAL AORTIC ANURESYM.
NOTE 2:
%RDUGOLNHDEGRPHQLQGLFDWHVEOHHGLQJLQWRDEGRPHQLHSODFHQWDDEUXSWLRQRUSODFHQWDSUHYLDSHULWRQLWLV
38
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EXTREMITY ASSESSMENT
Grip: Should be equal bilaterally. Assess push pull strength of feet.
Distal sensory/motor:3UHVHQFHDEVHQFHRIGLVWDOSXOVHVFDSLOODU\UH¿OOPRWRUPRYHPHQW
Nail beds: note clubbing or cyanosis
Range of Motion: note any limitations
Deep Vein Thrombosis (DVT): 'RUVLÀH[WKHIRRWIRUSUHVHQFHRIFDOISDLQQRWHSUHVHQFHRISDLQYHQRXV
distention, warmth and localized tenderness. NEVERPDVVDJHDႇHFWHGH[WUHPLW\
Edema:FKHFNIRUGHSHQGHQWRUQRQGHSHQGHQWHGHPD/RFDOL]HGRUGLႇXVH
Intermittent claudication: pain with ambulation that is relieved by rest.
SKIN ASSESSMENT
Color: Pallor, jaundice, redness, cyanosis
Temperature: Coolness, warmth
Moisture: Diaphoresis, excessive dryness
Turgor: Poor skin turgor may indicate dehydration
Edema: Edema of extremities (bilateral or unilateral), sacrum; dependent side if bed bound
Lesions: Presence of or type of skin lesions
Stages of skin breakdown (Decubitus ulcers)
Stage I:
,QWDFW1RQEODQFKLQJHU\WKHPLFDUHD
Stage II:
Interruption of epidermis, dermis or both;
appears as an abrasion, blister or crater
Stage III:
Full thickness crater involving damage &/or necrosis down to, but not penetrating the fascia
Stage IV:
Full thickness crater, similar to stage III, but penetrating the fascia,
with involvement of muscle, bone, tendon, joint
Negative pressure wound dressing±UHPRYHVÀXLGIURPWKHDUHDDQGKHOSVZRXQGVWRKHDOIDVWHUE\
SXOOLQJWKHHGJHVWRJHWKHUDQGDOORZV¿OOLQJIURPWKHERWWRPXSZLWKJUDQXODWLRQWLVVXH)RDPLVDSSOLHG
to the wound. A wound drain is attached and covered with a trasparent dressing. The pump is attached to
WKHZRXQGGUDLQ2QFHWKHSXPSLVWXUQHGRQLWFDXVHVDYDFXXPHႇHFWZKLFKSURYLGHVDVHDOWRSURPRWH
KHDOLQJ PP+JDVSUHVFULEHG Surgical wounds are changed daily. Chronic wounds are changed three times per week.
39
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COMMON PREFIXES
AND
THEIR MEANINGS
COMMON WORD
ROOTS
a
without
infra
beneath
ab,abs
away from
inter
between
ad
towards
intra
within
alb
white
MX[WD
beside
allo
other
meso
middle
ambi
both
meta
after
anph
both
milli
one• thousanth
an,ana
without
mono
single
ante
before
multi
many
anti
oppose, against
neo
new
auto
self
nan
all, wide
bi
two
pan
all
bio
life
para
beside
brady
slow
per
through
circum
around
peri
around
con
together or with
poly
many
contra
against, opposed
post
after
dys
GLႈFXOWSDLQ
pre
before, in front of
ecto
outside
primi
¿UVW
endo
within
pseudo false
epi
above or over
retro
backward
eu
good
rube
red
H[
out or away from
semi
half
hemi
half
sub
beneath
homeo
likeness
supra
above
homo
same
tachy
fast, rapid
hydro
water
trans
across, through
hyper
above, high, excessive
tri
three
hypo
ORZRUGH¿FLHQW
ultra
beyond
idio
IURPRQH¶VVHOI
uni
one
im
not
[HUR
dry
abdomin/o
acetabul/o
aden/o
adip/o
adrenio
aer/o
angi/o
anter/o
abdomen
acetabulum
gland
fat
adrenal gland
air
vessel
front
arthr/o
arteri/o
blast/o
bronch/i
broncho
calc/o
calcane/o
cardi/o
joint
artery
embryonic
bronchus
bronchus
calcium
heel bone
heart
40
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Subcutaneous injections:
average size client 45°
obese client 90° angle
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DIABETES: ESSENTIAL FACTS
*Native Americans,Hispanics & African Americans at highest risk
Type1 ,''0 PRVWSUHYDOHQWLQFKLOGUHQDQGQRQREHVHDGXOWV7KHUHLVOLWWOHRUQRLQVXOLQ
production by the beta cells or the islets of Langerhans.
Type II 1,''0 0RVWFRPPRQLQREHVHDGXOWVROGHUWKDQ\HDUVRIDJH7KHUHLVDSDUWLDO
decrease of insulin production and or cell resistance to insulin.
Insulin is required for transport of glucose across cell membrane. Decreased insulin results in
hyperglycemia.
Random glucose > 200 + S/S or Fasting glucose![ '0
Gestational DM GTT > 135
Clinical
Manifestations
Hypoglycemia
Diabetic Ketoacidosis
(DKA)
Hyperglycemic
Hyperosmolar Nonketonic
Coma (HHNK)
Onset
Type I
Too much insulin or too little
food
Rapid (within minutes)
Type I
$EVHQFHRUGH¿FLHQF\RI
insulin
Slow (about 8 hours)
Type II
Uncontrolled DM or oral
hypoglycemic drugs
Slow (hours to days)
Appearance
Symptoms of fainting
Appears ill
Appears ill
Respirations
Normal
Breath odor
Pulse
Blood Pressure
Normal
Tachycardia
1R(ႇHFW
Rapid and deep
Shortness of breath
Kussmaul
Fruity due to acetone
Tachycardia
Decreased Blood Pressure
Rapid and deep
Shortness of breath
Absence of Kussmaul
Normal
Tachycardia
Decreased Blood Pressure
Hunger
Hunger
Anorexia
Metabolic Acidosis
Hunger
Thirst
None
Increased
Cause
Vomiting
Eyes
Headache
Nausea, vomiting rare
Staring, Double Vision
Common
Pallor
Skin
Perspiration
Chilling sensation
Twitching common
Muscle action
Unsteady gait
Pain in abdomen None
Confusion
Erratic
Mental status
Change in mood
Unable to concentrate
Treatment
Administer glucose
PO, IV, sub q, IM
Likely
Appear sunken
Occasionally
Increased
Dehydration
Likely
Visual loss
Occasionally
Hot
Dry
Hot
Dry
Twitching absent
Twitching absent
Common
Malaise
Drowsy
Confusion
Coma
Common
$GPLQLVWHU,9ÀXLGVDQGRU
insulin
Confused
Dull
Coma
$GPLQLVWHU,9ÀXLGVDQGRU
insulin
42
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Insulin Chart
TimeCourse
5DSLGDFWLQJ
Agent
Onset
Peak
Duration
Indications
Lispro (Humalog)
Aspart (Novolog)
Apidra (insulin glulisine)
PLQ 1h
PLQ PLQ
PLQ K
K
K
K
Used for rapid
reduction of
glucose level, to
treat postprandial
hyperglycemia and
to prevent nocturnal
hypoglycemia
Short acting
Regular
Humalog R
Novolin R
Iletin II Regular
òK
K
K
Usually administered
before a meal. May
be taken alone or
in combination with
longer acting insulin.
,QWHUPHGLDWH
acting
NPH (neutral protamine Hagedorn) K
Humulin N
K
Iletin II Lente
Iletin II NPH
Novolin L (Lente)
Novolin N (NPH)
8OWUDOHQWH ³8/´ K
K
K
K Usually taken after
food
K
K
K
**DO NOT MIX
Long acting
Very long acting Lantus (glargine)
1h
**DO NOT MIX
Levimir (insulin detimir)
*Discard open refrigerated vials of Insulin after 28 days.
Used primarily to
control glucose level
Used for basal dose
Continuous 24h
QD at bedtime
(no peak)
*Insulin detemir lasts 42 days
6HTXHQFHIRUPL[LQJWZR,QVXOLQVLQRQHV\ULQJH
•
Wash hands, then inspect the insulin
•
Roll cloudy insulin gently * Do not shake
•
Draw up amount of air equal to the dose of cloudy (intermediate or long acting) insulin & inject it into the
cloudy insulin vial (be sure the needle does not touch the solution)
•
Draw up amount air equal to dose of clear (regular) insulin and inject into clear insulin vial
•
Withdraw insulin from the clear bottle then withdraw
•
3ODFHV\ULQJHLQFORXG\YLDOSXOOEDFNRQWKHSOXQJHUXQWLOWKHV\ULQJHLV¿OOHGZLWKWKHDPRXQWHTXDOWR
the total amount
Somogyi phenomenon:
Manifests as glucose peaks and valleys. Caused by increased insulin resulting in hypoglycemia; usually
occurs at night. Symptoms:
• nightmares
• sweating
• headache
• ketonuria
Treatment: check blood glucose 1–2 times/ night, adjustment of insulin dosage & time, & or a bedtime snack.
Dawn phenomenon: Hyperglycemia in the morning, usually between 2:00 am and 8:00 am.
Treatment: Increase insulin and avoid a bedtime snack.
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• Complications of Diabetes Mellitus (K.N.I.V.E.S.)
Kidney disorders Neuropathy Infection Vascular changes
Eye damage
Skin lesions
• Females experiencing recurrent vaginal yeast infections should be tested for:
• Type II Diabetes Mellitus
• HIV infection
REMEMBER
glucose is high
• Hot and dry
• Wet and clammy
give hard candy
:KDWLVWKHUHODWLRQVKLSEHWZHHQGLHWLQVXOLQDQGH[HUFLVH"
Fill in the blanks with the words increase or decrease:
A client that took too much insulin will need to ______________food
A client that exercises three times a day may need to ___________insulin
A client that missed a meal may need to ________________insulin
FACTS ABOUT ORAL HYPOGLYCEMIC AGENTS
• Prescribed for treatment of type 2 Diabetes
‡7HDFKDYRLG$OFRKRO
• *clients on oral medications may require Insulin therapy during times of illness or stress
LHSRVWRSHUDWLYHO\ UHODWHGWRLQFUHDVHJOXFRVHOHYHOVDVERG\¶VUHVSRQVHWRVWUHVV
THE AGENTS
Hold for 24 hours before and 48 hours after contrast dye
Glucophage (metformin) May cause lactic acidosis
Contraindicated with kidney disease
Glucotrol (glipizide)
*LYHPLQXWHVEHIRUHPHDOVWHDFKDYRLGVXQOLJKW
Take with meals, contraindicated in pregnancy.
Diabeta (glyburide)
6LGH(ႇHFWVSKRWRVHQVLWLYLW\DSODVWLFDQHPLD
Take with meals.
6LGH(ႇHFWVGL]]LQHVVRUZHDNQHVVEOXUUHGYLVLRQKHDGDFKHQDXVHDDQG
Amaryl (glimepiride)
vomiting, dark urine
Avandia (rosiglitazone)
Monitor liver enzymes; contraindicated with CHF & MI
Actos (pioglitazone)
6WDUOL[ (nateglinide)
May cause cough, SOB, seizures
Prandin (repaglinide)
Precose (acarbose)
$EGRPLQDOSDLQGLDUUKHDLQFUHDVHG/)7¶V
Onglyza (saxagliptin)
URI, UTI, headache, pancreatitis, abdominal pain, drowsiness, weakness.
Administered once a day
Januvia (sitagliptin)
Byetta (exenatide)
Injectable – to treat type II DM; helps the pancreas to produce insulin more
HႈFLHQWO\$GPLQLVWHUWLPHVGDLO\PLQXWHVEHIRUHPHDOVLWPXVWEHWDNHQ
on an empty stomach.
6LGH(ႇHFWVSDQFUHDWLWLVK\SRJO\FHPLDUHQDOLPSDLUPHQWQDXVHDYRPLWLQJ
diarrhea
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Infection Control Essentials
Standard PrecautionV±DUHXVHGIRUWKHFDUHRIDOOFOLHQWV±WRSUHYHQWGLUHFWFRQWDFWZLWKDOOERG\ÀXLGV
Standard precautions routinely practiced by health care providers include:
:KHQLQFRQWDFWZLWKDOOERG\ÀXLGV
Be sure to wash hands after removing gloves.
Wash Hands and Don Gloves
Use mask/eye protection/ face shield: If the threat of a splash is eminent.
Don Gowns: To protect skin and clothing during procedures that may involve splashing.
TRANSMISSION BASED PRECAUTION PROCEDURES
Airborne Precautions
Droplet Precautions
Contact Precautions
6XUJLFDO PDVN ZLWKLQ IHHW RI WKH
Gloves and gown
patient
13DUWLFXODWH5HVSLUDWRU0DVN
Negative pressure
Private room
Keep door closed
Patient wears surgical mask during
transport
Limit transport
Private room
Private room
Patient wears surgical mask during
transport
Limit transport
Remove gloves and gown before
leaving room
:+,&+',6($6(6:+,&+35(&$87,216"""
AIRBORNE PRECAUTIONS
Used for clients with suspected or
FRQ¿UPHG LQIHFWLRQV WUDQVPLWWHG
by airborne droplets with nuclei <
5 microns.
• Measles (Rubeola)
• Varicella (Chicken Pox)
• Tuberculosis
• SARS (Severe Acute Respiratory
DROPLET PRECAUTIONS
Used for clients with suspected or
FRQ¿UPHG LQIHFWLRQV WUDQVPLWWHG
by large particle droplets.
• Meningitis
• Bacterial Pneumonia (PNA)
• Epiglottitis
• Pertussis • RSV for 24 hrs
• Mumps
• Ebola
• Rubella (German Measles)
• HIB
+DHPRSKLOXVLQÀXHQ]DW\SH%
• Group A Strep (Scarlet &
Rheumatic fever)
• Diptheria (Pharyngeal)
CONTACT PRECAUTIONS
Used for clients with suspected or
FRQ¿UPHG LQIHFWLRQV WUDQVPLWWHG E\
direct or indirect contact.
• &ORVWULGLXP'L௻FLOH
• Herpes Simplex Virus
• Klebsiella Pneumonia
• MRSA
• VRE
Syndrome)
• RSV
• Smallpox
• Rotavirus
• H1N1 • Ebola
• Herpes Zoster (shingles)
• Herpes Zoster (shingles) • Infected pressure ulcers
Disseminated disease in any
• Major skin wound/burn infection
patient. Localized disease in
• SARS
immunocompromised
• Adeno Virus • Fifth’s Disease • Vaccinia (cow pox)
Skin Infections:
NOTE* ,QIHFWLRQFRQWUROVKRXOGEHQRWL¿HGHYHU\WLPHDSDWLHQW • Impetigo (Group A strep)
• Pediculosis
with a communicable disease is seen and not admitted.
• Scabies
• Varicella
*Also, Do not cohort post-op patients with anyone • Diptheria (cutaneous)
Viral Hemorrhagic Infections:
H[SHULHQFLQJ QDXVHD YRPLWLQJ GLDUUKHD RSHQ ZRXQGV
• Ebola
chest drainage or infections.
• Viral conjunctivitis
45
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MORE ABOUT INFECTION CONTROL....
1. Chain of Infection – hand washing is essential to
break the chain
2. Medical Asepsis = Clean technique
A. STANDARD PRECAUTIONS:
USED FOR ALL CLIENTS regardless of diagnosis
ZKHQLQFRQWDFWZLWKEORRGERG\ÀXLGVHFUHWLRQV
excretion, non intact skin and mucous membranes.
Hand washing and personal protective equipment
are essential.
B. TRANSMISSION BASED PRECAUTIONS
Airborne; Droplet; Contact
I.
Airborne Precautions particles < 5 microns
• Private room (negative pressure with at least 6 exchanges per hour)
• Door must be kept closed
• 0DVN 1 WREHZRUQDWDOOWLPHVZKLOHLQWKHFOLHQW¶VURRP
• Limit transport; mask the patient if transport is needed
II. Droplet Precautions
• 3ULYDWHURRP3DWLHQWVDႇHFWHGZLWKVDPHRUJDQLVPPD\VKDUHDURRP
• 0DLQWDLQIHHWGLVWDQFHEHWZHHQSDWLHQWVDQGYLVLWRUV
• 0DVNWREHZRUQZKHQZRUNLQJZLWKLQIHHWRISDWLHQW
• Limit transport; mask the patient if must transport
III. Contact Precautions
Direct (contact with client’s skin) or indirect (contact with contaminated surfaces)
• Private room – or cohort with same organism
• Gown and glove upon entering room
• Change gloves after contact with infective material
• Don personal protective equipment using correct sequence:
Gown, mask or respirator, goggles then gloves
Remove personal protective equipment using correct technique: (GERM)
1. Remove gloves
2. Remove goggles or face shield (handle by headband or earpiece)
5HPRYHgown (inside out)
4. Remove mask (front of mask is contaminated DO NOT TOUCH). Wash hands.
• Do not touch anything in environment after hand washing.
• Limit transport of patient.
• Dedicate use of patient care equipment to this patient only; leave equipment in the room.
• (QWHULFSUHFDXWLRQV±*,WUDFWLHFORVWULGLXPGLႈFLOHWR[LQ
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3. Surgical Asepsis
Sterile technique, free from all pathogens and their spores
4. Disinfection
Destruction of pathogens
5. Sterilization
Destruction of all microbes
6. Antiseptic
Inhibits microbial growth
7. Heat sterilization
A. moist heat steam under pressure (autoclave) or boiling objects in water
B. dry heat
A. gamma rays used to sterilize food and drugs
8. Radiation
B. ultraviolet light used to inhibit the microbial population of air in operating
rooms, nurseries and laboratories
%LRORJLFDO7R[LQV XVHGLQZDUIDUH
$QWKUD[±Standard precautions (Cipro or Doxycycline)
Botulism – Standard precautions
• Caused by clostridium botulinum toxin
• $ႇHFWVWKHQHUYHVFDXVLQJUHVSLUDWRU\IDLOXUHDQGSDUDO\VLV
• Food bourne (canned foods, aluminum foil wrapped baked potato)
• 6\PSWRPVDSSHDUVWRKRXUVDIWHUH[SRVXUH XSWRGD\V
• 6LJQV 6\PSWRPV GLSORSLD GURRSLQJ H\HOLGV VOXUUHG VSHHFK GLႈFXOW\ VZDOORZLQJ
weak muscles and constipation
• Treatment: antitoxin
Pneumonic Plague – 'URSOHWSUHFDXWLRQVFDXVHGE\\HUVLQLDSHVWLV6WDUWDQWLELRWLFWKHU
apy within 24 hours. Streptomycin, Gentamicin or Tetracycline
West Nile Virus • • • • • • 6WDQGDUGSUHFDXWLRQV7HDFKHOLPLQDWHVWDQGLQJZDWHU
Handling Hazardous Wastes: nurses should be familiar with the material safety data
sheet (MSDS) for the facility. It contains data on each substance in the facility that is
FRQVLGHUHGKD]DUGRXV,WLQFOXGHVLQIRUPDWLRQRQVDIHKDQGOLQJRIVSLOOV¿UVWDLG
interventions, and protective equipment for the management of hazards.
Read labels: use all materials solely for their intended purpose; always use required PPE;
contact biohazard department when appropriate.
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BURNS
$EXUQLVGDPDJHWRWKHERG\¶VWLVVXHVFDXVHGE\KHDWFKHPLFDOVHOHFWULFLW\VXQOLJKWRUUDGLDWLRQ,WUHVXOWV
LQDK\SHUPHWDEROLFVWDWHFDXVLQJSURWHLQDQGOLSLGEUHDNGRZQZKLFKDႇHFWVZRXQGKHDOLQJ7KHFOLHQW¶V
FDORULFLQWDNHZLOOQHHGWREHLQFUHDVHG»WRWLPHVWKH%05 EDVDOPHWDEROLFUDWH ZLWK±JPNJ
of body weight of protein daily. High metabolic rates increase the rate of infection.
DEPTH OF BURNS
• 6XSHU¿FLDO±FDXVHVOLJKWHSLGHUPDOGDPDJHUHVXOWLQJLQUHGQHVVDQGSDLQ
•
Deep partial thickness – cause necrosis of epidermal and dermal layers.
•
)XOOWKLFNQHVV±QHFURVLVWKURXJKDOOWKHVNLQOD\HUVZLWKGHVWUXFWLRQRIQHUYH¿EHUV
•
(VFKDU KDUGOHDWKHUOLNHWLVVXH GHYHORSV7KHVHSDWLHQWVGRQRWIHHOSDLQ
TYPES OF BURNS
• Thermal – hot objects, frostbite (rewarm area as rapidly as possible)
• Electrical – electrical current
• Chemical – acid, alkaline liquids
• Radiation – sunburn, external radiation beams
BURN ASSESSMENT
Rule of the Palm: 7KLVPHWKRGXVHVWKHSDWLHQW¶VKDQGVL]HWRHVWLPDWHWKHSHUFHQWRI%6$RI
VPDOOEXUQV RUOHVV 7KHVXUIDFHDUHDRIWKHSDWLHQW¶VSDOPHTXDOVDSSUR[LPDWHO\
Rule of Nines:7KLVPHWKRGGLYLGHVWKH7%6$LQWRVHJPHQWVWKDWDUHPXOWLSOHVRI
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GOALS OF CARE FOR A BURN PATIENT *No pain relief until V/S are stable
•
Priority: maintain a patent airway – may require intubation; supplemental O2
•
Prevent or correct hypovolemic shock
0RQLWRU96±LQFUHDVHG+5GXHWRGHFUHDVHGFDUGLDFRXWSXWGHFUHDVHG%3GXH
to increased capillary permeability
,QVHUWODUJHERUHDQJLRFDWK,9ÀXLGUHSODFHPHQWZLWK5LQJHU¶V/DFWDWH
3DUNODQG¶VIRUPXODFDOFXODWHVÀXLGUHTXLUHPHQWVLQDKRXUSHULRG
7%6$[:W NJ [P/ JLYHòRIWRWDOYROXPHLQKUVQGòRYHUQH[WKUV
&DOFXODWLRQRIÀXLGUHTXLUHPHQWLVVWDUWHGIURPWKHWLPHRIWKHEXUQUDWKHUWKDQWKH
WLPHRISUHVHQWDWLRQ,ISUHVHQWDWLRQLVGHOD\HGÀXLGPD\QHHGWREHJLYHQPRUH
rapidly.
$GPLQLVWHUEORRGDQGEORRGSURGXFWVDVSUHVFULEHG
6WULFW, 2GDLO\ZHLJKWVLQGZHOOLQJFDWKHWHU
•
&RUUHFWPHWDEROLFDFLGRVLV±,9ÀXLGV1D+ Bicarbonate
•
Prevent infection – Give Tetanus injection prophylactically; cover the wound with sterile or
clean dressings; Sterile dressing changes; Antibiotic therapy; Protective isolation
•
Maintain nutritional status – high calorie, high protein diet, TPN; calorie count, I&O
•
Restore skin integrity – skin grafts; Jobst stockings
•
Prevent contractures – ROM exercises, proper positioning and alignment
•
Prevent other complications – Curling’s Ulcer – stress ulcer associated with severe burns
7UHDWPHQW+%ORFNHUV 3HSFLGIDPRWLGLQH DQGRU33,¶V SURWRQSXPSLQKLELWRUV3UHYDFLG
lansoprazole)
•
Restore function as much as possible – Rehab (occupational therapy, physical therapy, and
VSHHFKWKHUDS\ LQWHUGLVFLSOLQDU\DSSURDFK
•
5HHVWDEOLVKVRFLDODQGHPRWLRQDOHTXLOLEULXP
%XUQVIURPWKHZDLVWXSDLUZD\LVWKHSULRULW\IURPWKHZDLVWGRZQÀXLGDQGHOHFWURO\WH
management is the priority. ***
MEDICATIONS
•
0RUSKLQH6XOIDWHWRFRQWUROSDLQ16$,'¶VVRPHWLPHVXVHG
•
Silvadene (silver sulfadiazene)
•
Sulfamylon (mafenide acetate) no dressing with this med
•
6LOYHU1LWUDWHNHUDWRO\WLFDJHQW EUHDNVGRZQNHUDWLQ 0D\FDXVHK\SRNDOHPLDK\SRQDWUHPLD
hypochloremia
•
Garamycin (gentamicin sulfate) oto, neuro and nephrotoxic – monitor BUN & Creatinine
49
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PHYSIOLOGICAL
INTEGRITY
TIP: When prioritizing patient care remember to select life saving measures over preserving a limb!
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PHYSIOLOGICAL INTEGRITY
I. Health Promotion and Illness Prevention
A. PREVENTION
Primary prevention: 3UHYHQWVGLVHDVHLHLPPXQL]DWLRQVSURWHFWLYHGHYLFHVFDUVHDWVKHOPHWV
needle exchange programs.
Secondary prevention: Early detection, screening & diagnostic tests i.e. self breast exam,
mammogram, colonoscopy, testicular self exam
Tertiary prevention: Palliative care, rehab, comfort, hospice
B. SCREENING TESTS
Angiography (cerebral, pulmonary, renal, coronary)
•
;UD\RIWKHEORRGYHVVHOVXVLQJFRQWUDVWG\H
•
DVVHVVIRUDOOHUJ\WRLRGLQHVKHOO¿VKRUG\HDVVHVVNLGQH\IXQFWLRQKROGPHWIRUPLQ
•
LQFUHDVHÀXLGVDIWHUWHVW
Bronchoscopy
•
visualization of the bronchus
•
before exam – provide oral hygiene, postural drainage, NPO for 6 to 8 hours
•
DIWHUH[DP±FKHFNIRUJDJUHÀH[LFHFROODUIRUVZHOOLQJREVHUYHIRUVXEFXWDQHRXVHPSK\VHPD
(Crepitus): indicates air leakage/ perforation; frequent swallowing indicates bleeding.
X- ray
•
no metals or jewelry
•
instruct client to keep still
•
assess females for pregnancy
Fasting Glucose Level
•
>126 two times used to diagnose DM (Diabetes Mellitus)
•
VKRXOGEH! *HVWDWLRQDO'LDEHWHV
Intra-venous pyelogram (IVP)
•
dye injected to assess for blockage in kidneys, ureters, and bladder
•
132KRXUVEHIRUHWHVW
•
DIWHUWHVWLQFUHDVHÀXLGV
Bladder Scan
•
ultrasound to assess condition of the bladder and for presence of residual urine
•
SDLQOHVVPLQXWHVLQOHQJWK
24 Hour Urine Collection
•
1st urine should be discarded
•
refrigerate specimen / place on ice
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Amniocentesis
•
•
•
DVVHVVIHWDOKHDUWWRQHGXULQJDQGDIWHUWKHWHVW QRUPDO P/UHPRYHG
can indicate gender, congenital abnormalities, neural tube defects, gestational age
5KIDFWRU/6UDWLRIRUOXQJPDWXULW\VKRXOGEHUDWLR
Thoracentesis
•
•
•
•
•
•
UHPRYDORIÀXLGRUDLUIURPSOHXUDOVSDFH
needle inserted on exhalation
place client in orthopenic position to perform procedure
LISDWLHQWFDQQRWVLWRQWKHLURZQSODFHRQXQDႇHFWHGVLGH
after test assess for respiratory distress–shock, pallor, diaphoresis
PD[LPXPÀXLGZLWKGUDZDO/
Paracentesis
•
•
•
•
•
•
EHIRUHSURFHGXUHFOLHQWPXVWYRLG¿UVW
check weight
check abdominal girth BID
LQFUHDVH+2%±GHJUHHVWRDOORZÀXLGWRSRROSRVLWLRQVXSLQHZLWK+2%VOLJKWO\HOHYDWHG
for withdrawal
post – monitor I&0, abdominal girth; priority follow up – blood in urine
PD[LPXPÀXLGZLWKGUDZDO±/
Barium enema
•
•
•
•
•
before procedure give enemas/laxatives until colon is clear of stool
clear liquid diet the night before the procedure
NPO 8 hours before the test
DIWHUWKHSURFHGXUHDGPLQLVWHUÀXLGVOD[DWLYHVRUVXSSRVLWRULHVWRH[SHOEDULXP
Teach: expect constipation & clay colored stools
C. NUTRITION
•
Foods high in Sodium (Na+): celery, processed foods, condiments, canned foods, smoked
meats, tomato juice, pickles, butter.
Increase salty snacks in clients with Burns, Lithium therapy, Addison’s disease, and
Cystic Fibrosis (BLAC)
•
)RRGVKLJKLQFDOFLXP &D GDLU\SURGXFWVJUHHQOHDI\YHJHWDEOHVNDOHEURFFROL¿VK FDQQHG
ZLWKERQHVVDUGLQHV ZKLWHEHDQVRUDQJHVUDLVLQVQXWVVHVDPHVHHGVTake with Vitamin
D to increase absorption VXQOLJKWFRGOLYHURLOHJJVPLONIDWW\¿VKVDOPRQVDUGLQHVWXQD
oatmeal, mushrooms).
•
Foods high in potassium (K+): apricots, melons, citrus fruits, potato, spinach, raisins (dried
IUXLWV UDZYHJHWDEOHVQXWVEDQDQDVJUDLQVNLZL¿JVDYRFDGRSXPSNLQSHDVFUDQEHUULHV
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Foods high in Iron: JUHHQOHDI\YHJHWDEOHVRUJDQPHDWVWRIXSRXOWU\DQG¿VK
Take with Vitamin C to increase absorption
VEGETARIAN DIET
DAIRY
EGG
MEAT
Lacto-ovo
+
+
-
Lacto-vegetarian
+
-
-
Ovo-vegan
-
+
-
Pesco-vegetarian
+
-
Only Fish
Partial/semi vegetarian
+
+
Avoid selected meats
*Vegans- eliminate all animal products & dairy
Nutrition
Carbohydrate: major source of food energy
• Grains, nuts, fruit
Protein: needed for tissue building
• Found in meats, chicken, beans, legumes, tofu, eggs
Fat: insulation, energy, carry fat soluble vitamins
• Fat soluble vitamins include A, D, E, K (water soluble: B & C)
• Found in egg yolk, liver, butter, cheese, margarine
• Decrease in clients with cardiovascular and cardiac disease
Normal Values
CHO: 4 kcal/gm
Example:
Protein: 4 kcal/gm
Fat: 9 kcal/gm
The client had a 24 hour dietary intake of 200 gm CHO, 100 gm protein and
50 gm of fat.
What is the total caloric intake for the day?
ANS: 1650 calories
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VITAMINS – necessary for normal cellular functions of the body
Vitamin B1
•
•
Vitamin B3
•
•
•
Vitamin B6
•
•
•
Vitamin B9
•
•
Vitamin B12
•
•
•
% 7KLDPLQH ± JLYHQ WR DOFRKROLFV DQG WR SUHYHQW EHULEHUL VV ZDONLQJ GLႈFXOWLHV
parasthesias of hands and feet, loss of muscle function)
)RXQGLQJUDLQVPHDW¿VKQXWVOHJXPHV
% 1LDFLQJLYHQWRGHFUHDVHFKROHVWHURO WULJO\FHULGHV
'H¿FLHQF\FDXVHVSHOODJUD VVGLDUUKHDGHUPDWLWLVGHPHQWLDGHDWK
Found in mushrooms, tuna, chicken breast, asparagus, halibut, salmon
B6 = Pyridoxine
Increase with INH(Isoniazid) to decrease peripheral neuropathy
)RXQGLQPHDW¿VKSRWDWRHVYHJHWDEOHV
% )ROLF$FLGJLYHQSUHQDWDOO\WRSUHYHQWQHXUDOWXEHGHIHFWV
)RXQGLQRUJDQPHDWVJUHHQOHDI\YHJHWDEOHV¿VKDQGSRXOWU\
B12 = Cyanocobalamin–needed for normal neurological function
'H¿FLHQF\FDXVHVSHUQLFLRXVDQHPLD
Found in brewer’s yeast, citrus fruit, dried beans, green leafy vegetables, nuts, organ
meats
Vitamin A
•
•
•
•
Good for mucous membranes and night vision
'H¿FLHQF\FDXVHVQLJKWEOLQGQHVVDQGKDLUORVV7R[LFLW\ OLYHUGDPDJH &16HႇHFWV
Bile necessary for absorption
)RXQGLQ¿VKOLYHUHJJ\RON\HOORZDQGGDUNJUHHQYHJHWDEOHV
•
•
•
Necessary for synthesis of collagen & neurotransmitters, assists with wound healing
'H¿FLHQF\FDXVHV6FXUY\ VVLUULWDELOLW\EOHHGLQJJXPVOHJSDLQ
Found in citrus fruits, green leafy vegetables, strawberries, peppers
•
•
•
Required for the proper function of many organs in the body. It is also an antioxidant
2YHUGRVH66QDXVHDVWRPDFKSDLQGLDUUKHDKHDGDFKHIDWLJXHEOXUUHGYLVLRQ
)RXQGLQVXQÀRZHUVHHGVDOPRQGVROLYHVSDSD\DGDUNJUHHQYHJHWDEOHV ZKROH
grains
Vitamin C
Vitamin E
Vitamin K
• Necessary for clotting
• Found in green vegetables, cabbage, liver and organ meats
Omega 3 fatty acids
• Good for cardiovascular health, diabetes mellitus, immune function, joint health
LQÀDPPDWLRQ FDQFHUDQGFRJQLWLYHDQGEHKDYLRUDOIXQFWLRQ
• Found in salmon, herring, mackerel, anchovies, sardines, tuna, halibut, plant and nut oils
54
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'LHW0RGL¿FDWLRQV
Progression
Bland Diet
Low Residue
•
•
•
•
•
•
Clear liquid – full liquid – soft – regular
Helps to heal gastric mucosa
Decrease spices
Used after bowel surgery, prior to bowel exam, for internal radiation
$YRLGQXWVVHHGV VWUDZEHUULHV PLONIRRGVKLJK¿EHU JUDLQV
&URKQ¶VGLVHDVH
Tube Feedings
• Place the client in the semi fowlers position
• Measure from the tip of the nose, to the tip of the earlobe to the zyphoid process
• $VVHVVIRUSODFHPHQWHYHU\IRXUKRXUVZLWKGUDZÀXLGWRFKHFNS+RUOHVVLQGLFDWHVJDVWULFFRQWHQWV
9DOXHVJUHDWHUWKDQLQGLFDWHVLQWHVWLQDOFRQWHQWV ÀXLGPXVWEHUHSODFHG Insertion of air while listening
for air over the stomach is not a reliable method to assess placement.
• Residuals greater than 150 ml should be reported
• ;UD\ PRVWGH¿QLWLYH PHWKRGWRGHWHUPLQHSODFHPHQW
PPN: Peripheral Parenteral Nutrition
TPN: Total Parenteral Nutrition
Peripheral: peripheral vein is used
Central Line – long term/ Jugular – less than 4 weeks
7HPSRUDU\VXSSOHPHQW GD\V
Finger sticks Q 6 hours – prone to hyperglycemia
Never stop abruptly/ taper may cause hypoglycemia
Piggy back with lipids only
Change tubing daily, XVHD¿OWHU
Change dressing every other day using sterile technique
,I731XQDYDLODEOHDGPLQLVWHU'H[WURVHXQWLODYDLODEOH
Celiac Disease:
• Formerly called (Sprue)
• Avoid foods containing gluten
• Avoid barley, rye, oat, wheat (BROW)
• &DQKDYHULFHFRUQVR\ÀRXUSLVWDFKLRV
• High protein, high calorie diet
PKU : Phenylketonuria Diet:
•
•
•
•
•
Avoid phenylalanine (amino acid that cannot be metabolized)
$YRLGDUWL¿FLDOVZHHWHQHUVEUHDGPHDW¿VKSRXOWU\FKHHVHQXWVHJJVOHJXPHV
*XWKULHWHVWSHUIRUPHGYLDKHHOVWLFN,IGRQHHDUOLHUWKDQKRXUVWHVWPXVWEHUHSHDWHGLQ
days
For infants – lofenolac formula is used (low protein, low amino acids)
Can cause brain damage/mental retardation
Low Purine Diet (Gout: Increase Uric Acid)
•
•
•
$YRLGRUJDQPHDWVKHOO¿VKOREVWHUSHDVEHDQVQXWVRDWPHDOZKHDWVDUGLQHVDQFKRYLHVDOFRKRO
mushrooms
(JJVDQGFKRFRODWHDUH2.±HQFRXUDJHÀXLGV±/GD\
%HQH¿FLDOIRRGVEODFNEHUULHVWRIXVR\EHDQVVDOPRQ
Medications:
•
•
•
Colcrys (CROFKLFLQH 0D\GHFUHDVH9LWDPLQ%DEVRUSWLRQGLDUUKHDXVHGXULQJDFXWHH[DFHUEDWLRQ
Zyloprim (Allopurinal)– Bone marrow depression, arthralgias
Benemid (Probenicid) –nausea, rash, constipation
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Safety – Fire safety
Rescue/remove those in immediate danger
AODUPRWKHUVE\DFWLYDWLQJWKH¿UHDODUP
CRQ¿QHWKH¿UH
E[WLQJXLVKWKH¿UHLIVPDOORUHYDFXDWH
7RXVHD¿UHH[WLQJXLVKHU:
Pull the pin
ALPORZDWWKHEDVHRIWKH¿UH
STXHH]HWKHKDQGOH6WDQGDSSUR[LPDWHO\WHQIHHWIURP¿UH
Sweep the hose from side to side
Important Positions for Various Conditions
Laminectomy:
•
log roll; post op: place in supine position
Tube inserted in GI tract: •
right side
Enema:
•
OHIWVLGHO\LQJLQVHUWWXEHLQFKHV FP GRQRWKDQJHQHPDEDJ
JUHDWHUWKDQLQFKHV FP ,IFUDPSLQJRFFXUVORZHUWKHEDJ
Amputation:
ORZHUH[WUHPLW\
•
•
elevate stump 1st 24 hours only
elevate the bed not just the stump; to prevent contractures; place client in
prone position several times daily
Cast:
•
elevate part
Compression bandages
•
•
reduces edema and pain
wrap limb distal to proximal
Gastric resection:
Avoid dumping syndrome
• lie down after eating
• do not drink with meals
• Vitamin B12 replacement necessary
Liver biopsy:
•
•
SUHSURFHGXUHSODFHRQOHIWVLGHHOHYDWHULJKWDUPPD\DOVREHSODFHGVXSLQH
post procedure: place on right side with a small pillow to decrease bleeding
Pneumonectomy:
•
SODFHRQRSHUDWLYHVLGHSRVWRS
Respiratory Distress:
Mastectomy:
• high fowlers/orthopneic position
DO NOT ABDUCT
• causes strain on suture line
• elevate arm on pillow (same side as operative breast)
• exercises: wall climbing, rope turning, broom lifting, hair combing
Retinal Detachment:
•
•
•
Venous:
lay on AFFECTED side
any other eye surgery lay on UNAFFECTED side
keep legs elevated (V)
Arterial:
•
Radical Neck Dissection: •
keep legs dependent (A)
DႇHFWHGVLGH
Kidney Biopsy:
•
•
•
pre procedure: position prone
KROGDVSLULQZHHNVSULRUWRSURFHGXUH
post procedure: position supine; hematuria and pain expected for a few
days after
Hip Surgery:
ABDUCT
• use abduction pillow between legs to immobilize & prevent dislocation
• never cross legs or bend over
• XVHDUDLVHGWRLOHWVHDWXVHDUDLVHGKLJKFKDLU
• OD\RQXQDႇHFWHGVLGH
56
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II. Perioperative Nursing
•
•
•
•
•
Types of surgery Reasons performed
([DPSOHV
Diagnostic
Determine cause of symptoms
Biopsy, exploratory laparotomy
Curative
Removal of diseased part
Appendectomy
Restorative
Strengthen weakened areas
Correct deformities
Rejoin a separated area
Herniorrhaphy
Mitral valve replacement
Palliative
Relieve symptoms without curing disease
Sympathectomy
Cosmetic
Improve appearance
Rhinoplasty
,WLVWKHUHVSRQVLELOLW\RIWKHVXUJHRQWRREWDLQFRQVHQWIRUWKHVXUJHU\DQGWRH[SODLQEHQH¿WVULVNVDQG
possible complications.
Preoperative teaching should include instructions for deep breathing and coughing exercises, leg
exercises, and options for pain management.
Diagnostic and laboratory tests should include: CBC, BUN, EKG, Electrolytes, HCG (for females),
XULQDO\VLVKLVWRU\DQGSK\VLFDODQG&KHVW[UD\
7KHFOLHQWVKRXOGEH132KRXUVSULRUWRVXUJHU\$QHQHPDRUOD[DWLYHPD\EHJLYHQWKHQLJKW
before surgery of the GI tract. Conduct a timeout immediately before starting an invasive procedure.
Conscious sedation used for minor procedures (extensive suturing, endoscopy, cardiac catheterization,
bone reduction) to minimally depress the level of consciousness. Patient can cooperate during the
procedure but may have partial amnesia afterwards. Versed (midazolam) or propofol may be used.
Common Post Operative
Complications include:
• Atelectasis (collapsed alveoli)
• Hemorrhage of the wound
• Thrombophlebitis
• Wound infection
• Dehiscence (separation of the wound)
• Evisceration (wound contents are expelled)
• Urinary tract infection
Risk factors include:
• Obesity
• Poor nutrition
• Steroid therapy
3UHH[LVWLQJFRQGLWLRQV:
• Diabetes Mellitus
• Cardiac
• Respiratory
• Neurological disorder
Tubes and Drains
Jackson Pratt, Hemovac, Penrose
• 8VHGSRVWRS
• 5HPRYH EORRG ÀXLGV IURP WKH ZRXQG WR SUHYHQW
infection
• Promote wound healing
Nasogastric
• Used to decompress the stomach
• Levine: (1 lumen) low intermittent suction
• Salem Sump: (2 lumens) continuous or intermittent
suction
• *Monitor drainage for consistency, color and amount
Sengstaken–Blakemore
• Used to treat esophageal varicies (medical emergency)
• 'HÀDWHJDVWULFEDOORRQHYHU\WRKRXUV± OXPHQV • Keep scissors at the bedside
Miller Abbott
• Used for intestinal suction and decompression
Percutaneous Endoscopic, Gastrostomy (PEG tube)
• Used for long term feeding
• Not necessary to check for placement
57
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III. Circulatory Function and Disorders
A. Anatomy and physiology review
B. Risk factors related to the development of peripheral vascular disease:
• Smoking
• Exposure to cold
• Obesity
• Immobility
• Hypertension
• DM
C. Peripheral vascular disease assessment:
Check for 6 p’s
1. Pain
2. Paresthesia
3. Pulselessness
4. Paralysis
5. Pallor
6. Poikliothermia
Arterial Ulcers
Venous Ulcers
•
/RZHUOHJDႇHFWHG
•
$QNOHWRNQHHDႇHFWHG
•
Secondary to PVD, DM
•
Secondary to obesity, age, pregnancy, DVT
•
Pallor and pain with leg elevation
•
Painless
•
Ulcers are distal to the loss of blood supply •
$ႇHFWVPHGLDODQGODWHUDODVSHFWRIWKHPDOOHROXV
•
Pale, yellow or gray wound base
•
Ruddy or red wound base
•
Skin tight and shiny with hair loss
•
Regular wound margins
•
Irregular wound margins
•
Keep legs dependent
•
Elevate legs
•
Decreased or absent peripheral pulses
•
Presence of peripheral pulses
Metabolic Syndrome X - a group of risk factors that increase the risk for heart disease and other health
problems such as diabetes and stroke. People with metabolic syndrome are twice as likely to develop heart
GLVHDVHDQG¿YHWLPHVDVOLNHO\WRGHYHORS'LDEHWHV0HOOLWXV
• Increased B/P 135/85 or higher
• Increased fat around the waist (over 35 inches female, over 40 inches male)
• Increased glucose level
• High triglyceride level
• Decreased HDL or Increased LDL
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D. Arterial vs. Venous disorders – smoking contributing factor
Arterial Disorders: NHHSH[WUHPLWLHVGHSHQGHQW GRZQ
Signs & Symptoms:
• intermittent claudication
• cold
• edema
• diminished pulses
Treatment:
• Vasodilators
• Analgesics
• Anticoagulants
• Anticholesterol Agents
• Smoking cessation
• Keep extremities warm
•
7UHQWDO SHQWR[LI\OOLQH GHFUHDVHVYLVFRVLW\RIEORRGXVHGWRLPSURYHEORRGÀRZLQFOLHQWVZLWK
circulatory problems to reduce aching, cramping & tiredness in the hands and feet
6LGH(ႇHFWVGURZVLQHVVGL]]LQHVVKHDGDFKH7DNHZLWKPHDOV
1. Thromboangitis obliterans (Buerger’s disease):
9HVVHORFFOXVLRQRFFXUVFRPPRQO\LQPDOHV\UROGV
2. Raynaud’s disease:
$UWHULDOVSDVPVRIWKH¿QJHUVFRPPRQO\LQIHPDOHVEHWZHHQWHHQ\HDUVDQGDJH
7DVNVWKDWLQYROYHUHSHWLWLYH¿QJHUPRYHPHQWVLQFUHDVHWKHULVNV EXWFKHUSLDQLVWW\SLVW
3. Arteriosclerosis Obliterans (occlusive arterial disease):
)RXQGLQPDOHV\HDUVROG
4. Aneurysm:
6DFIRUPHGE\GLODWLRQRIDQDUWHU\0DOHVDUHDWKLJKHVWULVN
'[;UD\DRUWDJUDSK\VRQRJUDSK\7UHDWPHQWVXUJHU\RUEHWDEORFNHUVLIWKHDQHXU\VPLVVPDOO
9HQRXV'LVRUGHUVHOHYDWHH[WUHPLWLHV
1. Thrombophlebitis,QÀDPPDWLRQRIWKHYHVVHOZDOOZLWKIRUPDWLRQRIDFORW
7UHDWPHQWDQWLFRDJXODQWWKHUDS\, warm packs, surgery
2. Varicose veins:
Dilated veins.
Risk factors: obesity, pregnancy, heart disease, thrombophlebitis, excessive sitting or standing.
7UHDWPHQWYHLQOLJDWLRQRUVFOHURWKHUDS\
3RVWRSFDUHHODVWLFEDQGDJHV±UHPRYHHYHU\KRXUVIRUVKRUWSHULRGV&RXPDGLQ ZDUIDULQ decrease foods high in vitamin K (green vegetables, organ meat) while on this medication
59
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(
•
•
•
•
•
•
+\SHUWHQVLRQ³7KHVLOHQW.LOOHU´
Risk factors:
Age
Race (African Americans at highest risk)
Family history
Diabetes mellitus
Cigarette smoking/ ETOH
Ĺcholesterol
Primary hypertension: no known cause
Secondary hypertension: caused by another
condition i.e pheochromoytoma (hypersecretion
of the adrenal medulla)
Categories of Blood Pressure
Symptoms:
• Early morning headaches
• Nosebleeds
• Fatigue
• SOB on exertion
Normal
3UHK\SHUWHQVLRQ
Stage 1 hypertension
Stage 2 hypertension
6WDJHK\SHUWHQVLRQ
Recommended Life Style Changes:
•
•
•
•
•
•
•
•
•
•
•
•
Avoid smoking and alcohol
Decrease sodium
Increase exercise
Reduce stress
Less than 120/80
160 & above/100
180/110
Treatment:
Beta Blockers
Calcium Channel Blockers
ACE inhibitors
Angiotensin II Receptor Blockers
Diuretics
Alpha Blockers
Vasodilators
Lipid Lowering Agents
IV. Cardiac Function and Disorders
A. Anatomy and physiology review
P wave:
Atrial depolarization
(contraction)
QRS wave:
Ventricular depolarization
(contraction)
T wave:
Ventricular repolarization
(relaxation)
EKG PAPER
Small block: 0.04 secs
An increased potassium level will result in an increased T wave
Big Block: 0.20 secs (or 5 small
blocks)
1 Second: 25 small boxes or 5
big blocks
1 minute: 1500 small blocks or
ELJEORFNV
A decreased potassium level will result in a decreased T wave
*Signs of hypokalemia include: • Anorexia • Nausea • Vomiting • Faint pulse • Muscle weakness
6LJQVRIK\SHUNDOHPLDLQFOXGH‡0XVFOHZHDNQHVV‡'HFUHDVHGXULQHRXWSXW‡'HSUHVVHGUHÀH[HV respirations • EKG changes • Decreased heart contractility
•
•
•
•
•
Normal Sinus Rhythm:ESP
PR Interval: 0HDVXUHVWLPHLWWDNHVIRUWKHLPSXOVHWRJHWIURPWKHDWULDWRWKHYHQWULFOHVVHFV
QRS Interval:0HDVXUHVWKHWLPHLWWDNHVIRUWKHYHQWULFOHVWRFRQWUDFWVHFV VPDOOEORFNV
QT Interval: 0HDVXUHVGHSRODUL]DWLRQDQGUHSRODUL]DWLRQWLPHRIWKHYHQWULFOHVVHFV DERXW
small blocks)
ST segment: &RPSOHWLRQRIYHQWULFXODUGHSRODUL]DWLRQVHFRQGV
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C. Disorders
61
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)LOOLQWKHEODQN&DUGLDF
7KHQRUPDO35LQWHUYDOLVBBBBBBBBBBBBBBBVHFRQGVRUBBBBBBBBBBBBBBER[HV
7KHQRUPDO456LQWHUYDOLVBBBBBBBBBBBBBBBVHFRQGVRUBBBBBBBBBBBBBBER[HV
7KHQRUPDO47LQWHUYDOLVBBBBBBBBBBBBBBBVHFRQGVRUBBBBBBBBBBBBBBER[HV
4. One small box =____________seconds
Answer Key
VHFRQGVRUER[HV
OHVVWKDQVHFRQGVRUER[HV
OHVVWKDQVHFRQGVRUER[HV
4. 0.04 seconds
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A. Diagnostic Tests
•
•
•
CK- MB:
5LVHVKRXUVDIWHUDQ0,
Peaks in 24 hours
TroponinULVHVLQKRXUVDQGPD\EHHOHYDWHGIRUZHHNV EHVWLQGLFDWRURIDQ0,
•
•
•
Pulmonary artery Pressure Monitoring: (Swan Ganz)
Measures pressure in the right atrium, pulmonary artery and left ventricle
Normal is 15 mm/Hg. Pressure is increased with left sided heart failure
Used to evaluate left ventricular and overall cardiac function
•
•
•
•
Central venous pressure reading (CVP):
Measures pressure in the right atrium
Normal 5 to 10 – used to monitor hydration status
An increase indicates over hydration
$GHFUHDVHLQGLFDWHVÀXLGYROXPHGH¿FLW
•
•
•
•
Cardiac Catheterization:
NPO 6 to 8 hours prior to test
$VVHVVIRUDOOHUJ\WRODWH[G\HVKHOO¿VKRULRGLQH
3RVWSURFHGXUHPRQLWRUIRUEOHHGLQJ KHPDWRPD GHFUHDVHGSXOVHV FKHFNWKH3¶V Keep leg extended 4 to 6 hours after test
•
•
•
•
Muga Scan :
Ejection fraction study
Radioactive tags injected
&DPHUDWDNHVSLFWXUHVRIWDJJHG5%&¶V
Avoid with pregnancy
•
•
•
•
•
•
•
Thallium Scan (stress test):
Dye injected which acts as a tracer
Cameras take pictures of the heart
$UHDVWKDWDSSHDUGDUNLQGLFDWHLQDGHTXDWHEORRGÀRZ
Other types of stress tests: H[HUFLVH WUHDGPLOO IRUPLQXWHV$GHQRVLQHRU/H[LVFDQ
UHJDGHQRVRQ LQMHFWLRQ LQFUHDVHV EORRG ÀRZ WKURXJK WKH DUWHULHV RI WKH KHDUW GXULQJ D
cardiac nuclear stress test in clients unable to exercise adequately
Holter Monitor:
Painless 24hr EKG
Teach: do not get wet
Keep a diary of activities
Transesophageal Echocardiogram – (TEE):
• Detects blood clots, tumors, and valve problems
• WRPLQXWHSURFHGXUH
• 7XEHLVVZDOORZHGHQGLVSRVLWLRQHGLQWKHHVRSKDJXVEHKLQGWKHKHDUW
• 7KHKHDUWLVH[DPLQHGIURPGLႇHUHQWDQJOHV
Pre procedure: • NPO 6 hrs
• Place client on the left side
• IV sedative, throat anesthetic
Post procedure:
•
•
132;KRXUVRUXQWLOJDJUHÀH[UHWXUQV
No driving for 12 hours
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CONGESTIVE HEART FAILURE (CHF)
SRU6SUHVHQWĹ%13 EW\SHQDWULXUHWLFSHSWLGH OHYHO RIGHT SIDED HEART FAILURE (Body)
Signs include: jugular neck vein distention, edema of the hands and lower extremities, abdominal distention,
GI distress.
LEFT SIDED HEART FAILURE (Lung)
Signs include: coughing, wheezing, dyspnea, frothy sputum
Treatment: Low Na+ diet, Aspirin, Lasix (furosemide), Lanoxin (digoxin) – slows and strengthens heart beat
– take on empty stomach, monitor apical pulse for 1 minute, monitor electrolytes.
6LGHHႇHFWV: diarrhea, vision changes, arrhythmias
ANGINA
Inadequate oxygenation to the heart causing pain
(relieved with rest and or nitroglycerin sublingual 1 tab
HYHU\PLQXWHVIRUGRVHV
MYOCARDIAL INFARCTION (MI)
2FFOXVLRQRIEORRGÀRZZLWKQHFURVLVRIDYHVVHOZLWKLQ
the heart (not relieved with rest).
Treatment: MONA (morphine, oxygen, nitrates, aspirin)
PULMONARY EDEMA
)OXLG ZLWKLQ WKH OXQJVVLJQV LQFOXGH UHVWOHVVQHVV
tachypnea, dyspnea, crackles
Treatment: Oxygen, diuretics, narcotics, vasodilators
CORONARY ARTERY DISEASE
Atherosclerosis (narrowing of arteries from deposition of fatty plaque) which causes decreased oxygenation
and tissue perfusion. May contribute to CHF, hypertension, and myocardial infarction.
PERICARDITIS
,QÀDPPDWLRQRIWKHSHULFDUGLXPXVXDOO\IROORZLQJDQLQIHFWLRQ0D\DFFRPSDQ\+,95KHXPDWLF)HYHU7%
May also be caused by MI or radiation therapy to the chest. Common in men 20 to 50 years old.
Signs and SymptomsFKHVWSDLQVKDUSVWDEELQJEDFNSDLQIHYHUFKLOOVSHULFDUGLDOIULFWLRQUXEGLVWDQWPXႉHG
heart sounds, crackles.
DXFKHVW[UD\HFKRFDUGLRJUDP&7VFDQKHDUW05,/DEVWURSRQLQ$1$&UHDFWLYHSURWHLQ(657%VFUHHQ
rheumatoid factor
Treatment:16$,'¶VFROFKLFLQHDQWLELRWLFVVWHURLGVGLXUHWLFVSHULFDUGLRFHQWHVLV
CARDIAC TAMPONADE
&RPSUHVVLRQRIWKHKHDUWFDXVHGE\EORRGRUÀXLGDFFXPXODWLRQLQWKHVSDFHEHWZHHQWKHP\RFDUGLXPDQGWKH
pericardium. May be caused by pericarditis.
Signs and Symptoms: shortness of breath, feeling faint or light headed, anxiety, coughing related to pressure
RQWKHWUDFKHDGLVWHQGHGQHFNYHLQVGLVWDQWPXႉHGKHDUWVRXQGVSHULFDUGLDOIULFWLRQUXE
Treatment – pericardiocentesis
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D. Related pharmacology
Antiarrhythmics:
Used for the prevention and treatment of cardiac arrythmias. The major goal is to restore NSR
Cardizem (diltiazem): Tx. of HTN, angina, tachycardia, DWULDO¿EULOODWLRQ39&¶V
6LGHHႇHFWVSHULSKHUDOHGHPDEOXUUHGYLVLRQK\SRWHQVLRQSDOSLWDWLRQVK\SHUJO\FHPLD
Adenocard (adenosine): Tx. of supraventricular tachycardia, aWULDO¿EULOODWLRQYHQWULFXODUWDFK\FDUGLD
6LGHHႇHFWVVKRUWQHVVRIEUHDWKK\SRWHQVLRQSDOSLWDWLRQVGL]]LQHVV
Xylocaine (lidocaine hydrochloride): Tx. of ventricular tachycardia, YHQWULFXODU¿EULOODWLRQ
6LGHHႇHFWVFRQIXVLRQGURZVLQHVVEUDG\FDUGLDDEVHQWJDJUHÀH[
Calan, Isoptin (verapamil): Tx. of HTN, angina,DWULDO¿EULOODWLRQWDFK\FDUGLD
6LGHHႇHFWV&+)EUDG\FDUGLDWDFK\FDUGLDSHULSKHUDOHGHPDDQHPLDWUHPRUV
Pronestyl (procainamide): Tx. of ventricular tachycardia
6LGHHႇHFWVYHQWULFXODU¿EULOODWLRQWKURPERF\WRSHQLDQHXWURSHQLDDQHPLDK\SRWHQVLRQEUDG\FDUGLD
Pacerone, cordarone (amiodarone): 7[RIDWULDO¿EULOODWLRQYHQWULFXODU tachycardia, V-Fib, PVC’s
6LGHHႇHFWVEUDG\FDUGLDVLQXVDUUHVW&+)SHULSKHUDOQHXURSDWK\KHSDWRWR[LFLW\SKRWRVHQVLWLYLW\EOXHJUD\
skin discoloration
Rythmol (propafenone): Tx. of tachycardia, DWULDO¿EULOODWLRQ
6LGHHႇHFWVGL]]LQHVVQDXVHDHGHPD85,WDVWHFKDQJHVG\VSQHD±PRQLWRUHOHFWURO\WHV
7DPERFRU ÀHFDLQLGH 7[RIWDFK\FDUGLDDWULDO¿EULOODWLRQ39&¶V
6LGHHႇHFWVGL]]LQHVVKHDGDFKHZHDNQHVVFRQVWLSDWLRQ\HOORZLQJRIVNLQDQGH\HV
Client teachingUHSRUWDQNOHHGHPDZHLJKWJDLQFKHFNSXOVHUHJXODUO\FDXWLRQSDWLHQWWRDYRLGGULYLQJRU
other activities requiring alertness
Nursing interventionsFKHFNDSLFDODQGUDGLDOSXOVHEHIRUHDGPLQLVWUDWLRQ2EVHUYHIRUWKHUDSHXWLFHႇHFW
(normal vital signs, adequate urine output).
Medication titration for cardiac meds: Titration is the process of gradually adjusting the dose of a medication
until optimal results are reached.
Example: Cardizem (diltiazem) or Nipride (nitroprusside)
E. Treatment
Pacemakers: EDWWHU\ OLIH \HDUV 7HDFK WR
avoid contact sports, avoid areas of high voltage,
wear med alert bracelet. Client should also be
taught to take apical pulse for one full minute &
have pacemaker checked at regular intervals.
ICD: ,PSODQWDEOH&DUGLRYHUWHU'H¿EULOODWRUVHQGV
shock to the heart when abnormal beat is occuring.
Signs of malfunction include:ĻSXOVHEHORZVHW
rate, hiccups, dizziness, SOB, weakness, chest
pains, fainting
Cardioversion: timed electrical current delivered
during QRS complex to terminate a dysrhythmia
SODQQHG XVHMRXOHVYLWDOVLJQV
'H¿EULOODWLRQ used in an emergency to treat
YHQWULFXODU ¿EULOODWLRQ DQG SXOVHOHVV 9WDFK XVH
MRXOHV
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9,QÀDPPDWLRQDQG,QIHFWLRQ
A.$QDWRP\DQGSK\VLRORJ\UHYLHZ&RPSRQHQWVRIWKHLPPXQHV\VWHPERQHPDUURZ:%&¶VO\PSKRLG
tissue (thymus gland, spleen, lymph nodes, tonsils, adenoids)
B. Mononucleosis (Kissing disease) (Epstein Barr virus):
• Signs include: fever, sore throat, cervical lymphadenopathy, malaise, headache, nausea, and
abdominal pain.
• 4 to 6 week incubation period.
• Transmitted by direct intimate contact, infected blood and oral secretions. Standard precautions.
C. Autoimmune disorders
Systemic Lupus Erythematosus:
&KURQLFDQGSURJUHVVLYHDXWRLPPXQHGLVRUGHUWKDWDႇHFWVWKHYDVFXODUDQGFRQQHFWLYHWLVVXHRIPXOWLSOH
RUJDQV7KHUHLVQRNQRZQFXUH,WLVFKDUDFWHUL]HGE\ZHLJKWORVVDEXWWHUÀ\UDVKRQWKHIDFHMRLQWSDLQ
IHYHUPDODLVHDQHPLDDQGSKRWRVHQVLWLYLW\,WDႇHFWV\RXQJEODFNIHPDOHVSUHGRPLQDQWO\
Precipitating factors include; sunlight, pregnancy and stress.
Treatment:$6$16$,'¶VVWHURLGV3ODTXHQLO K\GUR[\FKORURTXLQH PD\EHXVHGWRGHFUHDVH
LQÀDPPDWLRQ)UHTXHQWH\HH[DPVDUHHVVHQWLDOZLWKWKLVPHGLFDWLRQ
7HDFKDYRLGVXQDYRLGVWUHVVĹUHVW H[HUFLVH
Sclerodoma:DႇHFWVFRQQHFWLYHWLVVXHWKURXJKRXWWKHERG\6\PSWRPVLQFOXGHWLJKWVNLQG\VSKDJLD
edema of the extremities, joint contractures and brittle nails.
Teach client to sit up after eating. Treatment is supportive (tertiary).
Lyme disease:
• Caused by the bite of a deer tick, common in MA, CT, NJ & RI
• 7KH¿UVWVLJQLVHU\WKHPD
• 6NLQOHVLRQVVWDUWGD\VDIWHUWKHELWH
• Begins as a bump (macule or papule), then the lesion expands with a
ULEEHGERUGHUDQGDFOHDUFHQWHU EXOO¶VH\HUDVKHU\WKHPDPLJUDQV
• /DEWHVWVLQFOXGHFRPSOHWHEORRGFRXQW &%& HU\WKURF\WHVHGLPHQWDWLRQUDWH (65 QRUPDO
FHUHEURVSLQDOÀXLGWHVW &6) DQG/\PHVHURORJ\
• 7UHDWPHQW9LEUDP\FLQ GR[\F\FOLQH RU$PR[LO DPR[LFLOOLQ LIGLDJQRVHGHDUO\ZLWKLQGD\VRI
WKHELWH/RQJWHUPWUHDWPHQW±5RFHSKLQ FHIWULD[RQH VLGHHႇHFWLVDIXUU\WRQJXH
D. Diagnostic tests
• Antinuclear antibodies test (ANA): may be positive with Lupus
• Erythrocyte sedimentation rate:PD\EHHOHYDWHGZLWKVHYHUHDQHPLD/XSXVRUDQ\LQÀDPPDWRU\
process.
• C– reactive protein:LQFUHDVHVZLWKDFXWHLQÀDPPDWRU\UHVSRQVH
E. Transplants: Prograf (tacrolimus), Neoral (cyclosporine), Sandimmune (cyclosporine) May be given
to prevent rejection of the new organ
)/DWH[DOOHUJ\ clients with a latex allergy should avoid: kiwi, chestnut, pineapple, strawberries,
grapes, papaya, peaches, tomato, avocado, rye, wheat, melon, hazelnut, plums, cherry, banana,
¿JVSRWDWR
+RVSLWDOSURGXFWVLQFOXGHEORRGSUHVVXUHFXႇWRXUQLTXHWVFDUGLDFFDWKHUL]DWLRQWXELQJFDWKHWHUV
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VI. Blood Function and Disorders
A. Anatomy and physiology review
Blood Type
A
Blood administration:
B
AB
O
Major blood types
1. A
2. B
Can Receive
A,O
B,O
A, B, AB, O universal recipient
O universal donor
3. AB
4. O
Key points for blood administration:
•
Baseline vital signs are always needed
•
$<±W\SHWXELQJZLWK¿OWHULVQHFHVVDU\
•
An RN must always be present
•
7KHEORRGLVYHUL¿HGZLWKQXUVHVSUHVHQW
•
The safest blood to administer in an emergency if the blood type is unknown is O negative
•
The only IVF to run with blood is Normal Saline
•
If there is a blood transfusion reaction, immediately STOP the transfusion!
•
Common signs of transfusion reactions include:
• Flank pain
• Chills
• Hives
• Elevated temperature
• Tachycardia
B. Disorders
Sickle Cell Anemia:
Priorities in sickle cell crisis include oxygenation, hydration and pain relief (Morphine).
Patients should avoid high altitudes. Client is at risk for priapism (prolonged erection of the penis).
7HDFKWRGULQN/LWHUVGD\/LWHUVLQFULVLV
Pernicious Anemia:
Lack of intrinsic factor, VIT B12 injections IM monthly for life.
Diagnosed using the Schilling Test
S/P gastrectomy clients also require vitamin B12 replacement.
•
Aplastic Anemia: malfunctioning bone marrow
•
Hypochromic Anemia: LURQRUYLWDPLQGH¿FLHQF\
•
Hemolytic Anemia: excessive RBC destruction
•
Clotting Disorders: Idiopathic Thrombocytopenic Purpura, Hemophilia, DIC (Disseminated
Intravascular Coagulation): implement bleeding precautions
67
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BLEEDING PRECAUTIONS: RANDI
RAZORS ELECTRIC
ASPIRIN NO!
NEEDLES: SMALL GAUGE
DECREASE STICKS
INJURY PREVENTION
Implement with:
•
•
•
•
•
Anticoagulants
Liver disease
Decreased platelets
Thrombolytics
Bleeding disorders
Bleeding Assessment:
BEEP
Bruising
Ecchymosis
Epistaxis
Petechiae
3RO\F\WKHPLD9HUD H[FHVV5%&¶6:%&¶V 3ODWHOHWV • Common clients of Jewish descent
• Signs and Symptoms: dizziness, headache, blurred vision, hypertension
• 7UHDWPHQWLQFOXGHVLQFUHDVHGÀXLGVDQGSKOHERWRP\WRUHPRYHH[FHVV5%&¶6
Thalassemia:
• $OVRNQRZQDV&RROH\¶VDQHPLD
• Common in clients of Mediterranean descent
• Goal is to maintain normal hgb level, bone marrow transplant may be necessary
• Signs: anemia, pallor, increased size of liver and spleen
• Treatment is supportive: folic acid, blood transfusion, genetic counseling
68
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VII. Respiratory Function and Disorders
A. Anatomy and physiology review
B. Diagnostic tests.
Sputum Specimen
•
Deep breath and cough
•
Oral hygiene – rinse mouth
•
Morning specimen from deep
•
Sterile container
•
$YRLGUHGÀXLGV
•
Do not begin antibiotics before collecting culture
Bronchoscopy-ÀH[LEOHOLJKWHGVFRSHLQWREURQFKXV
•
Informed consent
•
NPO after midnight
•
$VVHVVUHVXOWRIEORRGVWXGLHV±FRDJXODWLRQSUR¿OH
•
Remove dentures/eyeglasses
•
Atropine, sedative
•
Topical anesthesia
•
O2, suction/ resuscitation equipment at bedside
Post procedure
•
Vital signs monitored until stable
•
132XQWLOJDJUHÀH[UHWXUQV
•
6HPLIRZOHUVSRVLWLRQ
•
Monitor respiratory status/ bronchospasms
•
'LႈFXOW\EUHDWKLQJ±QRWLI\0'
•
Crepitus: SQ Emphysema (bubbling under the skin): indicates perforation of bronchus
•
Monitor patient for bleeding: frequent swallowing = bleeding
•
Teach to expect blood streaks but not copious amounts of blood
69
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Pulmonary Angiography
• Diagram of pulmonary tree
• Informed consent
• &KHFNDOOHUJ\WRG\HVKHOO¿VK
• NPO 8 hours prior
• Teach not to cough during test
• Emergency equipment at bedside
Post procedure
• Vital signs
• Do not do B/P on the extremity used
• 0RQLWRUQHXURYDVFXODUVWDWXV 3¶V
• ,QFUHDVHÀXLGV
• Assess for edema at injection site
• Check insertion site for bleeding and hematoma
Thoracentesis5HPRYDORISOHXUDOÀXLGDQGRUDLUIURPSOHXUDOVSDFH
• Informed consent
• Vital signs prior
• &KHVW;UD\8OWUDVRXQG
• Place patient in orthopneic position
Post procedure
• Vital signs
• Monitor respiratory status
• Apply pressure dressing to puncture site
• Check for bleeding at insertion site
• Check for crepitus
• Assess for signs of pneumothorax, air embolism, respiratory distress
Lung Biopsy- analyzes tissue; cytologic exam i.e. cancer/ sarcoidosis
• ,GHQWL¿HVSXOPRQDU\OHVLRQV±7%SOHXUDOHႇXVLRQ
• Informed consent
• NPO
Post procedure
• Vital signs
• Pressure dressing
• Monitor drainage/blood
• Signs of respiratory distress, pneumothorax, air embolus
• &KHVW;UD\
70
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ABG
• Determine acid/base balance
• 3ULRUWR$%*FKHFN$OOHQWHVWDUWHULHVDUHRFFOXGHGWRWHVWEORRGVXSSO\WRWKHKDQG,IWHVW
is positive (delayed blood return to the hand) arterial puncture should not be attempted.
• Avoid suctioning prior to doing ABG – after drawing ABG place on ice
• 3UHVVXUHWRSXQFWXUHVLWHPLQXWHV DUWHU\ ORQJHULIRQDQWLFRDJXODQWWKHUDS\
3XOVHR[LPHWU\
• QRUPDOOHDGSODFHGRQ¿QJHUWRHIRUHKHDGRUHDUOREH
• Inaccurate reading could be due to poor perfusion – nail polish, temperature, hypothermia:
ZDUPXSWKHH[WUHPLW\
Chest PT (physiotherapy SHUFXVVLRQDQGYLEUDWLRQWRORRVHQVHFUHWLRQVLQWKHOXQJV
• 'RQHZLWK&\VWLF)LEURVLV&23'SQHXPRQLDSRVWRSSDWLHQWV
• 3HUIRUPKRXUEHIRUHPHDOVRUKRXUVDIWHUWRSUHYHQWUHJXUJLWDWLRQ%HVWWLPHLVHDUO\
morning
• If patient complains of pain – stop PT
• Give bronchodilator before treatment
• Good oral hygiene following
• Contraindicated:EURQFKRVSDVPV3DJHW¶VGLVHDVHULEIUDFWXUHFKHVWLQMXU\FKHVWLQFLVLRQ
pathological fractures, bleeding disorders
&DUERQPRQR[LGHSRLVRQLQJ – colorless and odorless may be fatal;
• 6LJQV V\PSWRPVPLPLFVWKHÀXKHDGDFKH19ZHDNQHVV62%
• 7UHDWPHQW±JHWIUHVKDLU&KHFN$%*DQG&%&*LYH22 in ER
2[\JHQ7KHUDS\
• Given as supplement when blood O2 is decreased
• Requires a prescription–considered medication
• 2L without HCP prescription as immediate intervention
• Can be harmful too much can cause blindness – baby
• Delivered via nasal cannula, mask, or tent. (Mask delivers higher concentation of O2 than
cannula)
6LJQV V\PSWRPVRIR[\JHQGH¿FLW
• 5HVWOHVVQHVV VWVLJQ QDVDOÀDULQJWDFK\FDUGLDWDFK\SHQDSDOORUG\VSQHDXVHRI
accessory muscles (neck, chest, abdomen), wheezing
• R.A.T (early signs: restlessness, anxiety, tachycardia)
• B.E.D (late signs: bradycardia, extreme restlessness, dyspnea)
Tests:
$%*3XOVHR[LPHWU\FKHVW;UD\SXOPRQDU\IXQFWLRQWHVW
Complication:
• Knocks out respiratory drive in patient with COPD (NEVER GIVE HIGH FLOW O2)
• 3UHYHQWGU\LQJRIPXFRXVPHPEUDQHVGU\LQJFDQFDXVHEOHHGLQJXVHDKXPLGL¿HU
71
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SUCTIONING
0D\ EH QHFHVVDU\ IRU UHPRYLQJ VHFUHWLRQV FOLHQWV ZLWK DQ LQHႇHFWLYH FRXJK UHÀH[ RU VLJQV RI
hypoxia. Limit suctioning to less than 15 seconds to avoid hypoxia. Suction pressure should be set
WRPP+J
• Oropharyngeal: aseptic technique is acceptable. A Yankauer catheter is usually used. Use
surgical asepsis for all other suctioning.
•
•
Nasopharygeal: DÀH[LEOHFDWKHWHULVXVHGWKHVL]HLVVHOHFWHGEDVHGRQWKHVL]HRIWKHFOLHQW¶V
nares and the viscosity of secretions.
Endotracheal: performed through a tracheostomy or endotracheal tube.
Mechanical Ventilation and causes of alarms
**High Pressure Alarm** (Obstruction)
• Excess secretions; client needs to be suctioned
• Tube is kinked
• Displacement of tube
• Bronchospasm – causes increased resistance
• Coughing / wheezing
• Biting of tube
• Fighting the ventilator
Low Pressure Alarm (Leak)
• Tube is disconnected
• Air leak
• /RZFXႇSUHVVXUH QRWLQÀDWHGHQRXJK
• The client stops breathing spontaneously
Surgical interventions
TracheostomyDWHPSRUDU\RUSHUPDQHQWRSHQLQJLQWKHWUDFKHD
• Surgical incision
• Protects airway
Post op
• Maintain patent airway
• Assess presence of bilateral breath sounds (unilateral indicates lung collapse)
Complications
• Dislodged tube – secure trache ties, (velcro)
• Increased secretions – can lead to obstruction: suction, humidify air
• Pneumothorax
• %OHHGLQJ±ZLWKJORYHGKDQGDVVHVVUHDURISDWLHQW¶VQHFNIRUSRROLQJRIEORRG
• Prevent Infection–sterile technique during suctioning
• (URVLRQRIWUDFKHDOZDOOOHDGLQJWR¿VWXODNHHSWKHFXႇGHÀDWHG
Person with a laryngectomy needs a permanent tracheostomy. Nursing priority: establish a means of
SRVWRSFRPPXQLFDWLRQ SDSHUDQGSHQFLOÀDVKFDUGVHWF
Teach: No swimming, wear medical alert bracelet
72
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Pneumothora[
• ,QFUHDVHDLUÀXLGLQSOHXUDOVSDFH
• Increase thoracic pressure
• Decrease vital capacity
(the amount of air you can take in forcibly)
6LJQV V\PSWRPV
Dyspnea, tachycardia, tachypnea, chest pain
VKDUS DEVHQW EUHDWK VRXQGV RQ DႇHFWHG VLGH RU
hyperresonance, decreased chest expansion on
DႇHFWHG VLGH VXEFXWDQHRXV HPSK\VHPD WUDFKHDO
GHYLDWLRQWRXQDႇHFWHGVLGH WHQVLRQSQHXPRWKRUD[ ,IRSHQZRXQG±VXFNLQJVRXQGKHDUGIURPFKHVWPHGLDVWLQDOVKLIWWRZDUGVXQDႇHFWHGVLGH
Nursing Intervention:
• High fowlers position ‡&KHVW;UD\ • Monitor vital signs
• Dressing over open wound
2
• O as prescribed
• Prepare for chest tube placement
Chest Tube
Returns negative pressure to the lung space (pleural), removes
ÀXLGDLUSURPRWHVUHH[SDQVLRQRIWKHOXQJ
Pleur-Evac
'LVSRVDEOHV\VWHPIROORZVERWWOHV\VWHPV
Water seal system acts as a one way valve to prevent air and liquid
from moving back into chest cavity.
CHAMBER 1
CHAMBER 2
CHAMBER 3
&ROOHFWVÀXLGGUDLQLQJIURPFOLHQW Serves as a water seal.
Is the suction control. Suction
,QWHUPLWWHQWEXEEOLQJÀXFWXDWLRQ VHWDWFPDVSUHVFULEHG
are normal with inhalation and
Nurse should see gentle
exhalation. Excessive bubbling/
continuous bubbling.
continuous = air leak. If there
DUHQRÀXFWXDWLRQVDVVHVV lung
sounds & call MD. There may
be obstruction or the lungs have
UHH[SDQGHG
• Monitor respiratory status
• Maintain dry, sterile, occlusive dressing
• Chest tubes: label bottle with date and time, tell patient to expect pain when they cough.
• Drainage > 100ml/hr is excessive – Notify MD
• Have clamp at the bedside for an emergency – never clamp unless the system breaks
• If tube disconnects – place tip in sterile water until the system can be replaced
• 7ZRFKHVWWXEHVRQWKHVDPHVLGHWRSGUDLQVDLUERWWRPÀXLG
5HPRYDO RI FKHVW WXEH KDYH SDWLHQW LQKDOH WKHQ H[KDOH
+ROG H[KDODWLRQ IRU WXEH UHPRYDO 9DOVDOYD PDQHXYHU SODFH
RFFOXVLYH 9DVHOLQH GUHVVLQJ WR WKH VLWH 3ODFH RQ XQDႇHFWHG
side. Obtain Chest X-ray.
73
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D. Disorders
COPD: emphysema and, chronic bronchitis
• Chronic obstructive pulmonary disease
• &KURQLFDLUÀRZOLPLWDWLRQOLPLWHGDLUÀRZLQWRDQGRXWRIOXQJV
• 3DWLHQW¶VGULYHWREUHDWKH±ORZ322 JLYH»/R[\JHQRQO\
• Alveoli – site of gas exchange; respiratory acidosis when CO2 is trapped
• Increased incidence in cigarette smokers, occupational exposure to fumes or chemicals,
genetics
• Risk for Cor pulmonale (Right sided heart failure)
SignV 6\PSWRPV:
• SOB/hypoxia
• Easily fatigued
• Wheezing/crackles
• Recurrent cough and URI
• Increased sputum production
• Barrel chest (emphysema)
• +\SHUFDSQLD5HVSLUDWRU\DFLGRVLV
• Skin color dusky to cyanotic (chronic bronchitis)
• No cyanosis (emphysema)
Teaching/ Nursing interventions
• Assess respiratory status
• Pursed lip breathing and deep breathing exercises
• Smoking cessation
• Avoid exposure to cold
• ,QÀXHQ]DYDFFLQH±FKHFNIRUHJJDOOHUJ\
• Pneumonia vaccine
• Avoid milk: increases mucous, high calorie, high protein, low CHO diet
• ,QFUHDVHÀXLGVXQOHVVFRQWUDLQGLFDWHG
• Increase rest periods
• +XPLGL¿HGDLU
• Suction as necessary
Related pharmacology
• Atrovent (ipratropium bromide), Spiriva (titropium inhaled)
• Ventolin (albuterol) – short acting; rescue inhaler
• Serevent (salmeterol) long acting. Teach–take BID
• Symbicort (budesonide/formoterol) (long acting B2/corticosteroid), not used with acute episodes
• Steroids: oral, inhaled, IV – Deltasone (prednisone), Beclovent (beclomethasone), Solumedrol
(methylprednisolone)
6LGHH௺HFWVSRRUZRXQGKHDOLQJ &XVKLQJ¶V6\QGURPH GHFUHDVHGLPPXQHUHVSRQVHLQFUHDVHÀXLG
retention, hyperglycemia, mood swings, weight gain, oral thrush
• Antibiotics (prophylactic)
TIP: When selecting answers, choose the client with an acute condition over chronic!
&23'LVQRWDOZD\V¿UVW,IWKHFKURQLFFOLHQWLVLQH[DFHUEDWLRQWKH\DUHWKHSULRULW\!74
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Pneumonia
•
,QÀDPPDWLRQLQIHFWLRQRIOXQJ
Causes:
•
•
Aspiration
Bacterial
•
•
Mycoplasma
Viral
•
•
Fungal
Protozoan infections
Bacterial pneumonia requires isolation until 24 hours after starting
antibiotics – viral does not need isolation
Common organisms:
Staphylococcus aureus, staphylococcus pneumoniae, HIV – PCP.
Signs & Symptoms:
•
•
•
•
•
Fever
• Tachypnea
Chills
• Night sweats
Dyspnea
• ,QFUHDVHG:%&¶V
Pleural pain
• Diaphoresis
Productive cough (with rust colored, blood tinged or greenish sputum)
Diagnosis:
•
•
•
&KHVW;UD\
• CBC
ABG
• Pulse oximetry
Sputum culture (before starting antibiotics)
Treatment:
•
•
•
Antibiotics as prescribed
Chest PT
Antipyretic
•
•
O2 as prescribed
,QFUHDVHÀXLGV
/HJLRQQDLUH¶V'LVHDVHVSUHDGWKURXJKFRQWDPLQDWHGZDWHU
Risk factors: COPD & immunosuppression
Treatment: Erythromycin, Tetracycline, Quinolones, Zithromax (azithromycin) or Rifampin
Asthma
• &KURQLFLQÀDPPDWRU\GLVHDVHZLWKEURQFKRFRQVWULFWLRQ
• Mucosal edema with increased mucous production
Signs & Symptoms:
•
•
Tachycardia
Tachypnea
•
•
Apprehension/restlessness
Wheezing and night time cough
Diagnosis:
•
•
History and physical
Pulmonary function tests
•
•
ABG
Allergy testing
Nursing intervention/ teaching:
• Avoid known triggers
• Bronchodilators
• +LJKIRZOHU¶VSRVLWLRQ
• ,QFUHDVHÀXLGLQWDNHHOLPLQDWHPLON
• NOAH – Nebulizer, Oxygen, Antibiotic, Hydrocortisone
• Prophalytic medication: Albuterol (B2 agonist
that opens airway) should be kept with them at all
times for rescue.
• 0RQLWRUSHDNÀRZPHDVXUHVKRZZHOODLUPRYHVRXWRIOXQJV
• Teach zone management:
Green:3()LVRIQRUPDO±DVWKPDLVZHOOFRQWUROOHG
Yellow:3()LVRISHUVRQDOEHVW±DVWKPDLVÀDULQJXS
Red:3()LVRISHUVRQDOEHVW±DVWKPDLVVHYHUHHPHUJHQF\FDUHQHHGHG
75
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Teach correct MDI technique
1.
2.
4.
5.
6.
7.
8.
Remove the cap and hold inhaler upright.
Shake
Tilt the head back slightly and exhale
2SHQPRXWK+ROGLQKDOHULQFKHVIURPPRXWKRULQWKHPRXWK
making a seal
Press down on MDI to release the medicine
%UHDWKHLQVORZO\IRUVHFRQGV
Hold the breath for 10 seconds
Exhale slowly through pursed lips.
Medications
• %HFORYHQW EHFORPHWKDVRQH VWHURLG LQKDOHUV ± ULQVH PRXWK DIWHU XVH FDQ FDXVH RUDO WKUXVK
)ORYHQW ÀXFLWDVRQH
)ORQDVH ÀXFLWDVRQHSURSLRQDWH ±XVHGLQDOOHUJLFUKLQLWLV$]PDFRUW WULDPFLQRORQH
• Prednisone (p.o.) Solumedrol (methylprednisolone) (IV)
• $GYDLU± ÀXFLWDVRQHVDOPHWHURO ORQJDFWLQJ%FRUWLFRVWHURLG±GRQRWXVHGXULQJH[DFHUEDWLRQ
• Symbicort –(budesonide/formoterol) – not used with acute episodes
• Brethine (terbutaline)– also used in labor (premature contractions)
• Intal (cromlyn Na+) – long acting – prevents histamine release from the mast cells
• Singular (montelukast) – daily, usually at night
• $FFRODWH ]D¿UOXNDVW ±PJ%,'7DNHRQDQHPSW\VWRPDFK
Pulmonary Embolism
•
•
Thrombus – stationary
(PEROXVPRELOH
•
•
Life threatening
Result of thrombophlebitis/ DVT
Signs & Symptoms:
•
•
•
•
Dyspnea
Pleuritic chest pain
Tachycardia
Tachypnea
•
•
•
•
Anxious
Cough
Restlessness
Hemoptysis
Risks
•
•
•
Prolonged bedrest
Surgery
Long plane rides
•
•
•
Pregnancy
Obesity
CHF
Diagnosis:
•
•
•
•
•
•
&KHVW;UD\
VQ scan: looks at lungs when breathing in (measures if lungs are
being perfused)
&%& WKURPERF\WRVLV EORRGWHVWIRU'GLPHU±LIQHJDWLYHLWUXOHV
out the diagnosis
PT & PTT
EKG
ABG
$VVHVVIRU+RPDQ¶VVLJQ
•
•
•
•
•
Bedrest
O2
)RZOHU¶VSRVLWLRQ
Heparin or Coumadin (warfarin)
Thrombolitic drugs (streptokinase)
•
Nursing Intervention:
76
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TB (Tuberculosis)
•
•
•
0\FREDFWHULXPDFLGIDVWEDFLOOXV
Spread by droplet nuclei
Lodges high in lungs (highly O2 concentrated)
Risks:
•
•
•
Malnutrition
Large crowded living conditions
Poor socioeconomic status
Signs & Symptoms:
•
•
•
•
•
•
Can be asymptomatic
• Anorexia
Dyspnea
• Fatigue/malaise
Low grade temperature
• Pallor
Pleuritic chest pain
• Weight loss
Night sweats
Chronic productive cough– purulent sputum / hemoptysis
Diagnosis:
&KHVW;UD\‡%URQFKRVFRS\
6SXWXPIRU$)% $FLG)DVW%DFLOOXV QHJDWLYH$)%VSHFLPHQVWRGLVFRQWLQXH
isolation
• 33'±7%WHVWJDXJHWXEHUFXOLQV\ULQJHUHVXOWVUHDGLQKRXUV
,QGXUDWLRQ PP QRUPDO
PP HTXLYRFDO
PP (Note: 15mm or more is positive in patients without risk factors older than
4 years of age, 10 mm is positive in patients age 4 or less)
> 5 mm induration = + in HIV
‡ 4XDQWLIHURQ 7% *ROG ,QWXEH WHVW PHDVXUHV LPPXQH UHVSRQVH WR 7%
bacteria in the blood. It cannot determine is person has latent or active
7%0RUHVSHFL¿FWKDQ33'
Note : + PPD does not mean automatic isolation- further assessment needed
Nursing Interventions:
•
•
•
•
•
•
•
5HVSLUDWRU\LVRODWLRQ±ZHHNVDIWHUVWDUWLQJPHGLFDWLRQ
Airborne precautions – N 95 mask
Teach to cover mouth and nose when coughing and sneezing
Dispose contaminated tissue into paper bag – good hand washing
Mask patient for transport
,QFUHDVHÀXLGVSURPRWHSURSHUQXWULWLRQ
O2 as prescribed
Medication:
•
,1+ LVRQLD]LG 6(SHULSKHUDOQHXULWLVKHSDWRWR[LFLW\*,XSVHWDYRLG
Dilantin (phenytoin)– increased risk of toxicity. Avoid foods with Tyramine
B6 Pyridoxine: prescribed with INH to prevent peripheral neuropathy
5LIDPSLQGLVFRORUVXULQHFRQWDFWOHQVHVRUDQJH19WKURPERF\WRSHQLD
Streptomycin S.E. 8th cranial nerve damage
77
*Drugs may be given in combination to decrease the risk of resistance
•
•
•
Alcoholics
IV drug users
Immune dysfunction
•
•
•
•
•
•
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3OHXUDO(ႇXVLRQ
•
•
•
$FFXPXODWLRQRIÀXLGLQSOHXUDOVSDFH
3DLQRQLQVSLUDWLRQSOHXULWLFFKHVWSDLQ
Dyspnea on exertion
Treatment:
•
•
•
•
•
Dry nonproductive cough
0HGLDVWLQDOVKLIWDZD\IURPÀXLG
Monitor breath sounds, treat underlying cause
Antibiotics
&KHVW;UD\WKRUDFHQWHVLVFKHVWWXEHSODFHPHQW
Sleep Apnea
•
Characterized by episodic upper airway obstruction that occurs at night
Risks:
•
•
Obesity
ETOH
•
•
Sleeping pills
0HQDႇHFWHGPRUHWKDQZRPHQ
Signs & Symptoms:
•
•
Loud snoring
Daytime drowsiness with delayed reaction time
Diagnosis:
•
Sleep Study
Treatment:
•
•
•
•
•
CPAP (continuous positive airway pressure)
Dental appliances
Anatomical surgery
Weight loss may be helpful
Children – tonsillectomy
Complication:
•
Cor Pulmonale
Common Respiratory Medications
Bronchodilators
1. Adrenergic Bronchodilators: relaxes and opens the airway
A. Epinephrine: fast onset within 5 minutes lasts up to 4 hours given sub q. in an emergency. Drug may
be repeated 20 minutes after initial dose.
Epi pen:DXWRLQMHFWLRQV\VWHPFDQEHDGPLQLVWHUHGE\VHOILQMHFWLRQLQWRWKHPLGGOHDVSHFWRIWKHWKLJK
&RPPRQ FDXVHV RI DQDSK\OD[LV LQFOXGH IRRGV SHDQXWV HJJV PLON ZKHDW VKHOO¿VK PHGLFDWLRQV
(penicillin, sulfa drugs, anesthetics), and insect stings.
'RVDJHPJRU(SLSHQ-UPJ
C. Proventil,Ventolin (albuterol): given via MDI or nebulizer. Teach client use as rescue medication in
acute bronchospasm. Use with caution in patients with cardiovascular disease and MAO inhibitors.
S.E. tachycardia, palpitations, headache
D. Serevent (salmeterol): long acting, given daily BID even if not symptomatic, do not use in acute
EURQFKRVSDVPRQVHWPLQXWHV
E. Brethine (terbutaline): long acting agent
6(QHUYRXVQHVVWUHPRUVDOVRXVHGWRLQKLELWSUHPDWXUHXWHULQHFRQWUDFWLRQV SUHWHUPODERU
78
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2. Xanthine Bronchodilators
A. Theophylline: prevention and treatment of bronchospasm.
• Aminophylline - I.V.
• Theo-Dur (theophylline) P.O.
6LGHHႇHFWVQDXVHDYRPLWLQJWUHPRUVLQVRPQLDWDFK\FDUGLDSDOSLWDWLRQVQHUYRXVQHVV
7HDFKWDNHRQHPSW\VWRPDFKLQFUHDVHÀXLGLQWDNH XQOHVVFRQWUDLQGLFDWHG DQGGRQRWFUXVKRU
FKHZ$YRLGFDႇHLQH±PD\LQFUHDVHVLGHHႇHFWV
1XUVLQJ0RQLWRU$%*¶V DFLGEDVHEDODQFH DQGÀXLGDQGHOHFWURO\WHEDODQFH
* Not indicated for the initial treatment of acute episodes of bronchospasm
3. Leukotriene Inhibitors
• Singular (montelukast sodium): give at night
• Accolate (zafrilucast) : BID
4. Steroids:GHFUHDVHLQÀDPPDWLRQDQGRSHQVDLUZD\
Nursing Implications for client’s taking respiratory medications
Client Assessment
1. Vital signs, note respiratory rate, depth, and character, skin, color, s/s of hypoxia (restlessness is an
early sign, also called thrashing), ABG, auscultate lungs noting adventitious breath sounds.
2.Assess precipitating and relieving factors of bronchospasm, note frequency and severity of attacks,
ZKDWLVSDWLHQW¶VEDVHOLQHUHVSLUDWRU\VWDWXVEHWZHHQDWWDFNV
$VVHVVIRUUHVSLUDWRU\GLVWUHVV QDVDOÀDULQJXVHRIDFFHVVRU\PXVFOHVWULSRGLQJ K\SR[LDFRXJK
sputum, exercise intolerance, medications, drug therapy.
B. Nursing Interventions
1. Accurate administration of medication – 10 rights (see page 121).
2. 2EVHUYHIRUWKHUDSHXWLFHႇHFWV UHOLHIRIV\PSWRPV 2EVHUYHIRUDGYHUVHHႇHFWV
• Cardiac: arrhythmias, palpitations, tachycardia,
• CNS: agitation, insomnia, headache, restlessness, seizures, tremors
• GI: anorexia, diarrhea, nausea and vomiting
• Respiratory: cough
4. (QFRXUDJHRUDOLQWDNHRIÀXLGV XQOHVVFRQWUDLQGLFDWHG 5. Encourage deep breathing and coughing, postural drainage, chest PT (as ordered).
6. Teach client to avoid known triggers of bronchospasm.
7. 7HDFKLPSRUWDQFHRIVPRNLQJFHVVDWLRQDQGDYRLGDQFHRIFDႇHLQH
8. 8VHFDXWLRQZKLOHGULYLQJRURSHUDWLQJPDFKLQHU\XQWLOHႇHFWVRIPHGLFDWLRQLVNQRZQ
**Do not give beta blockers to asthmatics ie. Inderal (propanolol), Corgard (nadolol).
Beta Blockers cause hypotension and bradycardia which increases oxygen consumption.
ASA, NSAID’s, and Ace Inhibitors should also be avoided with asthma.
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VIII. Fluid and Electrolyte Balance
A. Physiology review
%&RPSRVLWLRQRIERG\ÀXLGV
a. Intracellular
b. Extracellular
1. Interstitial
2. Intravascular
)OXLGYROXPHGH¿FLW dehydration = hypovolemia
Treat the underlying cause. Strict I&O, IVF replacement, antipyretics, antidiarrheal agents
)OXLG9ROXPHH[FHVV RYHUK\GUDWLRQ K\SHUYROHPLD
7UHDWXQGHUO\LQJFDXVH±ÀXLGDQGVRGLXPUHVWULFWLRQGLXUHWLFV
C. Normal electrolyte values (may show slight variances by institution)
P(T/
PJG/
Na+
Ca++
PPRO/
Cl
HCO
P(T/
K+
PO4
P(T/
PJG/
Mg+
P(T/
C. Venous Access Devices- Peripheral lines, PICC, Epidural, Tunneled, Implanted
Peripheral lines: device used to access veins, the tip is distal to a central vein.
• 3HULSKHUDOYHQRXVDFFHVVGHYLFHXVHGIRUDQDGXOWRUJDXJH
• 0LGOLQHEHVWIRUFOLHQWVZLWKOLPLWHGSHULSKHUDOYHLQVWKDWQHHGDQH[WHQGHGSHULRGRIDFFHVV weeks).
• 0LGFODYLFXODUFDWKHWHUVFDQEHXVHGWRPRQWKVEHVWVXLWHGIRUDGPLQLVWHULQJ,9ÀXLGVDQG,9
PHGLFDWLRQVKRUWWHUP
Central Venous Access Devices- placed by MD into jugular or subclavian vein above the heart.
• ,PSODQWHGSRUW 3RUW$&DWK • 3,&&SHULSKHUDOO\LQVHUHGFHQWUDOFDWKHWHU'RQRWWDNH%3RUGUDZEORRGRQWKHOLPEZLWKWKHOLQH
• May be used for IVF & blood, TPN, monitoring CVP, administering medications & chemotherapy,
obtaining blood samples, hemodialysis or for long term use when peripheral veins are inaccessible.
Complications
• ,Q¿OWUDWLRQÀXLGLQIXVLRQRXWVLGHRIWKHYHLQTreatment: warm or cold compresses, elevate the limb.
• 3KOHELWLVLQÀDPPDWLRQRIWKHYHLQTreatment: warm, moist compresses, antibiotics, eliminate cause.
ExtraYDVDWLRQLQ¿OWUDWLRQRIDYHVLFDQWGUXJ LHFKHPRWKHUDS\DJHQWVDQWLELRWLFVHOHFWURO\WHV
DQWLHPHWLFVRUYDVRSUHVVRUV FDQOHDGWRQHFURVLVGLV¿JXUHPHQWDQGORVVRIIXQFWLRQ
Treatment: stop the infusion, use syringe to aspirate remaining drug in the line, inject antidote into
s.c. tissue if appropriatee, remove the catheter (as ordered), notify MD, elevate arm, ice or warm
FRPSUHVV PRVWUHTXLUHLFHIRUPLQXWHVWLPHVSHUGD\IRUKRXUV ‡$LUHPEROLVPDLUHQWU\LQWROLQH3RVLWLRQFOLHQWRQWKHOHIWVLGHLQWUHQGHOHQEXUJSRVLWLRQ*LYH22. 80
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D. Signs and symptoms of abnormal values
Imbalance and Causes
Signs and Symptoms
Nursing Interventions
HYPONATREMIA
Loss of Sodium
• *DVWURLQWHVWLQDOÀXLGORVV
• Sweating
• Use of diuretics
Gain of Water
• Drinking water
• Excess IV D5W (dextrose in water)
• SIADH
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HYPERNATREMIA
/RVVRIÀXLGV
• Insensible water loss
• (Hyperventilation or fever)
• Diarrhea
Water deprivation
([FHVVVDOWLQWDNH
• IV administration of saline solutions
• Excessive use of table salt
• Diabetes Insipidus
• Heat Stoke
• Thirst
• Dry, sticky mucous
membranes
• Tongue red, dry, swollen
• Weakness
• Postural hypotension
• Dyspnea
Severe hypernatremia:
• Fatigue, restlessness
• Decreasing LOC
• Disorientation
• Convulsions
• Monitor intake and output
• Monitor mental status
(e.g., restlessness disorientation)
• Monitor lab results
• (QFRXUDJHÀXLGDVSUHVFULEHG
• Restrict intake of salt and foods high in
sodium
HYPOCALCEMIA
• Surgical removal of the parathyroid
glands
Conditions such as:
• Hypoparathyroidism
• Acute pancreatitis
• Hyperphosphatemia
• Thyroid cancer
• Inadequate Vitamin D intake
• Malabsorption
• Hypomagnesemia
• Alkalosis
• Sepsis
• Alcohol abuse
• Numbness and tingling of
the extremities and around
the mouth
• Muscle tremors, cramps;
untreated can progress to
tetany and convulsions
• Cardiac dysrhythmias:
decreased cardiac output
• Positive Trousseau’s sign
• Positive Chvostek’s sign
• Confusion
• Anxiety
• Closely monitor respiratory and
cardiovascular status
• Initiate safety precautions to protect a
confused client
• Administer oral or parental calcium
supplements as prescribed
• During IV administrations closely monitor
cardiac status and ECG
HYPERCALCEMIA
• Prolonged immobilization
Condition such as:
• Hyperparathyroidism
• Malignancy of the bone
• Lethargy
• Weakness
• Depressed deep tendon
UHÀH[HV
• Anorexia
• Nausea, vomiting
• Constipation
• Polyuria
• Hypercalciuria
• Flank Pain secondary to
urinary calculi
• Dysrhythmas, possible
heart block
• Pathological fractures
• Increase client movement and exercise
• (QFRXUDJHRUDOÀXLGVDVSHUPLWWHGWR
maintain dilute urine
• Teach clients to limit intake of food and
ÀXLGKLJKLQFDOFLXP
• ,QFUHDVH¿EHULQGLHWWRSUHYHQW
constipation
• Protect a confused client; monitor for
SDWKRORJLFIUDFWXUHVLQFOLHQWVZLWKORQJ
term hypercalcemia
• (QFRXUDJHLQWDNHRIDFLGDVKÀXLGV HJ
prune or cranberry juice) to counteract
deposit of calcium salt in the urine.
• Assess clients receiving digitalis
for digitalis toxicity. Hypercalcemia
increases the risk of toxicity
Lethargy
Confusion
Anxiety
Muscle twitching
Abdominal cramps
Anorexia
Nausea, vomiting
Headache
Seizures, coma
Assess signs and symptoms
Monitor intake and output
Monitor lab results
Assess client closely for injury risk
Institute safety precautions
(QFRXUDJH IRRG DQG ÀXLG KLJK LQ VRGLXP
XQOHVVFRQWUDLQGLFDWHG HJ,9)16
table salt, bacon, ham, processed cheese)
• Limit water intake as indicated.
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Imbalance and Causes
Signs and Symptoms
Nursing Interventions
HYPOKALEMIA
Loss of potassium
• Vomiting and gastric
suction
• Diarrhea
• Heavy perspiration
• 8VHRISRWDVVLXPZDVWLQJ
drugs (e.g., diuretics)
• Poor intake of potassium
(as with debilitated clients,
alcoholics, anorexia
nervosa)
•
•
•
•
• Monitor heart rate and rhythm
• Monitor clients receiving digoxin closely,
because hypokalemia increases risk of
digitalis toxicity.
• Give oral potassium as prescribed with food
RUÀXLGWRSUHYHQWJDVWULFLUULWDWLRQ
• Administer IV potassium solutions at a
UDWHQRIDVWHUWKDQP(TKQHYHU
administer undiluted potassium IV.
• IV potassium: monitor for pain and
LQÀDPPDWLRQDWWKHLQMHFWLRQVLWH7HDFK
FOLHQWDERXWSRWDVVLXPULFKIRRGV7HDFK
clients how to prevent excessive loss of
K+ (e.g. through abuse of diuretics and
laxatives).
•
•
•
•
•
•
•
Muscle weakness
Leg cramps
Fatigue
Lethargy
Anorexia
Nausea, Vomiting
Decreased bowel sounds
Decreased bowel motility
&DUGLDFG\VUK\WKPDLV±39&¶V
9WDFK9¿E
'HSUHVVHGGHHSWHQGRQUHÀH[HV
ABGs may show Alkalosis
7ZDYHÀDWWHQLQJ67VHJPHQW
Depression on ECG ; prominent
U waves
HYPERKALEMIA
Decreased potassium
H[FUHWLRQ
• Renal failure
• Potassium sparing
diuretics
• High Potassium intake
• Excessive use of salt
substitutes
• Potassium shift as in burns
•
•
•
•
•
Diarrhea
Irritability
Confusion
Cardiac dysrhythmias or arrest
0XVFOHZHDNQHVVDUHÀH[LD
DEVHQFHRIUHÀH[HV
• Paresthesias and numbness in
extremities
• Peaked T wave, widened QRS
on ECG
• Closely monitor cardiac status and ECG
• Administer Kayexalate (sodium
polystyrene), diuretics and other
medications such as glucose and insulin as
prescribed.
• Hold potassium supplements and K+ sparing
diuretics
• Monitor serum K+ levels carefully; a rapid
drop may occur as potassium shifts into the
cells
• Teach clients to avoid foods high in
potassium and salt substitutes.
HYPOMAGNESEMIA
• Excessive loss from the
gastrointestinal tract
• Nasogastric suction
• 'LDUUKHD¿VWXODGUDLQDJH
• /RQJWHUPXVHRIFHUWDLQ
drugs (e.g., diuretics,
aminoglycoside antibiotics)
• Neuromuscular irritability with
tremors
• ,QFUHDVHGUHÀH[HV
• Convulsions
• Cardiac arrhythmias
• Tetany
• Psychosis
• Positive Chvostek’s sign
• Positive Trousseau’s sign
• Assess clients receiving digitalis for digitalis
toxicity. Hypomagnesemia increases the
risk for toxicity.
• Protect patient from injury, seizure
precautions
HYPERMAGNESEMIA
Conditions such as:
• Renal impairment
• DKA
• Dehydration
• Hypothyroidism
• $GGLVRQ¶VGLVHDVH
• Use of antacids/laxatives
containing magnesium
• Neuromuscular depression;
cardiac muscle depression
(arrhythmia, asytole)
• Weakness
• Nausea, vomiting
• CNS depression: lethargy,
hypotension, bradycardia
• Initiate safety precautions
• Monitor B/P, pulse and respirations closely
• Administer Calcium Gluconate as
prescribed
• Teach patients with renal disorders to avoid
preparations containing Mg+
Wilson’s Disease - is a rear inherited disorder that causes too much copper to accumulate in the
liver, brain and other vital organs.
S/S: fatigue, jaundice, easy bruising, edema of the legs, ascites, problems with speech, swallowing or
physical coordination
7UHDWPHQW&KHODWLQJDJHQWV3HQLFLOODPLQHVLGHHႇHFWVERQHPDUURZVXSSUHVVLRQPRQLWRU&%&
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Imbalance and Causes
Signs and Symptoms
Nursing Interventions
METABOLIC ACIDOSIS
• Renal failure
• Diabetes Mellitus
• Loss of bicarbonate i.e. diarrhea
• Excessive infusion of chloride
FRQWDLQLQJ,9ÀXLGV
pH < 7.35 NaHCO3 < 22
• Monitor LOC
• Strict intake and output
• Administer IV sodium bicarbonate
as prescribed.
• Treat underlying problem
• METABOLIC ALKALOSIS
• ([FHVVLYHDFLGORVVWKURXJKWKH
GI tract
• Vomiting
Gastric suction
• Excessive use of potassium
wasting diuretics
• Excessive adrenal corticoid
hormone
• Cushing's syndrome
• Hyperaldosteronism
• Excessive bicarbonate intake from
DQWDFLGVSDUHQWHUDO1D+&2
• pH > 7.45 NaHCO3 > 26
• Decreased respiratory rate and
depth
• Dizziness
• Hypokalemia
• Circumoral paresthesias
• Numbness and tingling of the
extremities
• Tetany
• Monitor intake and output
• Monitor vital signs, especially
respiration and LOC
• $GPLQLVWHU,9ÀXLGVDVSUHVFULEHG
• Treat underlying problem
RESPIRATORY ACIDOSIS
• Acute lung conditions that
LPSDLUDOYHRODUJDVH[FKDQJH
• Pneumonia
• Acute pulmonary edema
• Aspiration of foreign body
• 1HDUGURZQLQJ
• Chronic lung disease (e.g. asthma,
F\VWLF¿EURVLVRUHPSK\VHPD • Overdose of narcotics or sedatives
that depress respiratory rate and
depth
• %UDLQLQMXU\WKDWDႇHFWVWKH
respiratory center
pH < 7.35 PaCO2 > 45
• Increased pulse
• Increased respiratory rate
• Headache
• Dizziness
• Confusion
• Decreased LOC
• Convulsions
• :DUPÀXVKHGVNLQ
• Hyperkalemia
Chronic:
• Weakness
• Headache
• Monitor respiratory status and lung
sounds
• Prepare for mechanical ventilation
as necessary
• Administer pulmonary therapy
measures such as inhalation
therapy, bronchodilators and
antibiotics as prescribed
• Percussion and postural drainage
(chest PT)
• 0RQLWRUÀXLGLQWDNHDQGRXWSXW
• Monitor vital signs and ABGs
• Administer narcotic antagonists
(Naloxone) as indicated
• ,QFUHDVHÀXLGV/GD\
RESPIRATORY ALKALOSIS
Hyperventilation due to:
• Extreme anxiety
• Elevated body temperature/fever
• Over ventilation with a mechanical
ventilator
• Hypoxia
• Salicylate overdose
pH > 7.45 PaCO2 < 35
• Complaints of shortness of breath,
chest tightness
• /LJKWKHDGHGQHVVZLWKFLUFXPRUDO
paresthesias
• Numbness and tingling of the
extremities
• 'LႈFXOW\FRQFHQWUDWLQJ
• Tremulousness
• Blurred vision
• Hypokalemia
• Monitor vital signs and ABGs
• Assist client to breathe more slowly
• Help client breathe in a paper bag
or apply a rebreather mask (to
inhale CO2)
• Lethargy
• Confusion
• Headache
• Weakness
• Nausea, vomiting
• Hyperkalemia
• .XVVPDXO¶VUHVSLUDWLRQV
(rapid, deep respirations)
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IX. The Client with Pain
A. Pathophysiology of pain
Most pain caused by damage to nerves or tissue. Nerve signal travels up the spinal cord to
the brain.
B. Acute vs. chronic pain
• Acute pain lasts from one second to 6 months serves as a warning signal
• Chronic pain > 6 months • • • serves no useful purpose
C. Assessment of pain
• assess the P.Q.R.S.T of pain (provoke, quality, radiation, severity, time)
‡SHUFHSWLRQDQGFXOWXUDOLQÀXHQFH
• anxiety level
D. Pharmacological approaches
• Nonnarcotic analgesics used for mild to moderate pain, temperature reduction and treat
PHQWRILQÀDPPDWRU\GLVRUGHUV
1. Salicylates:
• Aspirin
‡'RORELG GLÀXQLVDO
6LGHHႇHFWV*,EOHHGLQJ±WDNHZLWKIRRGRUPLON
Toxicity: tinnitus, hyperventilation, vomiting, double vision
2. Acetaminophen
‡7\OHQROPD\EHDGPLQLVWHUHGSR,9RUVXSSRVLWRU\0D[LPXPGDLO\GRVHPJ
• • • Antidote• • Mucomyst (acetylcysteine)
1RQVWHURLGDODQWLLQÀDPPDWRU\GUXJV 16$,'¶6
• Motrin (ibuprofen)
• Naprosyn (naproxen), Anaprox (naproxen sodium)
• Indocin (indomethacin)
• Celebrex (celecoxib)
6LGHHႇHFWV*,EOHHGLQJWDNHZLWKIRRGRUPLONWHDFKSDWLHQWWRPRQLWRUVWRROIRUEORRG
drowsiness
• Teach: avoid operating machinery, hold before surgery
Remember:'L௺HUHQWLDWHEHWZHHQDQ³H[SHFWHG´FOLHQW¿QGLQJYVDQHPHUJHQF\RU
deterioration!
Look for signs of an exacerbation in client’s current condition!
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• Narcotic analgesics: used for moderate to severe pain (acute or chronic) and sedation
• Roxanol (morphine)
• Demerol (meperidine)
• Dilaudid (hydromorphone)
‡'XUDJHVLF IHQWDQ\O GLVSRVHRISDWFKHVE\IROGLQJVWLFN\HGJHVWRJHWKHUWKHQ
ÀXVKWKHPGRZQWKHWRLOHW‡'RORSKLQH PHWKDGRQH 6LGHHႇHFW&16GHSUHVVLRQ
• Antidote: Naloxone
•
$GMXYDQWVSRWHQWLDWHVWKHHႇHFWVRIQDUFRWLFRUQRQQDUFRWLFDQDOJHVLFV
Has own analgesic properties:
• Vistaril, Atarax (hydroxyzine)
Duragesic (fentanyl): adjuvant to anesthesia
• Teach may cause drowsiness or fatigue • Avoid hazardous activities
• Avoidance of heat from fever or environment
• May increase release resulting in toxicity
• NO: sunbathing, hot tubs, saunas, heating pads, or electric blankets
•
•
•
Patient Controlled Analgesia (PCA): allows the patient to control their own narcotic
analgesic.
Drug of choice: Morphine
Goal is to achieve more steady state of analgesia compared to prn medications.
Nursing Management:
‡0RQLWRUSDWLHQW¶VOHYHORIFRQVFLRXVQHVVYLWDOVLJQVDQGSDLQOHYHOIUHTXHQWO\
•
Peripheral Nerve Catheter: is used to relieve pain at the site of surgery. Catheter is placed
under the skin near the nerves to cause numbness at the surgical site. It provides
FRQWLQXRXVORFDODQHVWKHVLD,WFRXOGODVWIRUXSWRGD\VDIWHUWKHSURFHGXUH
E. Non pharmacological approaches
•
TENS (transcutaneous electrical nerve stimulation): battery operated unit that sends a
mild electrical current along the skin, blocking pain sensation
Nursing: • Do not place electrodes over incision site, broken skin, or eyes
• Contraindicated in client with a pacemaker
• Provide skin care daily—wash skin with soap and water daily, air dry
• ([HUFLVH
•
3URPRWHUHVWDQGUHOD[DWLRQ
• Teach relaxation techniques i.e. rhythmic breathing, guided imagery, music therapy,
biofeedback
• Positioning of body parts, immobilization, heat and cold application; massage
F. Evaluation:ZKDWLVWKHSDWLHQW¶VUHVSRQVHWRWKHLQWHUYHQWLRQV"5HDVVHVVPHQW
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85
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X. The Client with Cancer
A. Physiology of cancer
• Cancer occurs when cells become abnormal and grow without control
B. Prevention and early detection
Cancer’s seven warning signs
Cancer’s seven safeguards
Change in bowel or bladder habits
Lung:'RQ¶WVPRNHFLJDUHWWHV
A sore that does not heal
Colorectum: Have a proctoscopic exam as part of a
Unusual bleeding or discharge
regular checkup after age 40.
Thickening or lump in breast or elsewhere
Breast: Practice monthly breast self exam.
IQGLJHVWLRQRUGLႈFXOW\LQVZDOORZLQJ
Uterus: Have a Pap test as part of a regular checkup.
Obvious change in wart or mole
Skin: Avoid exposure to the sun.
Nagging cough or hoarseness
Oral: Have a regular mouth exam by MD or dentist
Complete body: have an overall physical yearly or at
\HDULQWHUYDOV
C. Tumors
Benign Tumors: non cancerous, do not spread to other parts of body
Malignant Tumors: can metastasize and are life threatening
D. Guidelines for cancer related screening
TEST OR EXAM
SEX
AGE (YEARS)
RECOMMENDATION
2QFHHYHU\\HDUV%HJLQQLQJ
years after sexual activity begins.
No later than age 21
Papanicolaou test
Female
> 18; under 18 If
sexually active
3HOYLF([DP
Female
Over 18
%UHDVWVHOIH[DP
Female
Over 20
%UHDVW3K\VLFDO([DP
Female
Over 40
(YHU\\HDUV
Yearly
Mammogram
Female
One baseline mammogram
(YHU\\HDUV
Stool guaiac slide test
Male & Female
Over 50
Yearly
'LJLWDOUHFWDOH[DP
Male & Female
Over 40
Yearly
6LJPRLGRVFRSLF([DP
Male & Female
Over 50
(YHU\\HDUV
After 2 negative, 1 year apart
7HVWLFXODU([DP
Male
Over 15
Perform after warm shower
Yearly
Monthly
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E. Diet/nutritional considerations
Diet
Some evidence suggests that the development
of colorectal cancer may be associated with a
diet that is high in fat and calories.
F. Common types
ANTI CANCER DIET
• Low fat
• +LJK¿EHU
• Whole grains
• Raw fruits
• High calcium
• Raw vegetables
LEUKEMIA
• ALL (Acute Lymphocytic Leukemia)
• Most common form of childhood cancer
• 5HVXOWVLQDQHPLD GHFUHDVHG5%&¶V
• Increased risk of infection (increased immature
:%&¶V
• Increased risk for bleeding (decreased platelets)
HIGH ANTIOXIDANTS
• Berries
• Apricots
• Prunes
• Cereals
• Vegetables
• Nuts
• Seeds
• Clove
• Oregano
• Cinnamon
Risk Factors:
Smoking, viruses, chemicals, radiation
Signs/Symptoms:
Fever, bruise easily, generalized weakness, bone pain
Treatment :
Chemotherapy, radiation therapy
HODGKIN’S DISEASE
Malignant neoplasm of lymphoid with a proliferation of
lymphocytes
Cause: unknown – prevalent in adolescents (males)
Risk Factors:
Epstein Barr virus, HIV, chemicals, radiation
* There is no link for Hodgkins to smoking, ETOH, diet or exercise
Major symptom: enlarged nodes in lower cervical region; fever, pruritis, night sweats
Diagnosis: presence of Reed Sternberg cells in the blood
NON HODGKIN’S LYMPHOMA
7XPRURIO\PSKDWLFWLVVXHFRQWUROLVGLႈFXOWDႇHFWVDOODJHJURXSV
Risk Factors:
Gender (men), Epstein Barr virus, HIV, Hepatitis C, autoimmune disease, chemicals, radiation
Treatment: chemotherapy, radiation and surgery
WILM’S TUMOR
Malignant tumor of the Kidney; occurs in childhood and older white men
Signs/ symptoms: blood in urine, parent reports presence of abdominal mass
Teach1HYHUSDOSDWHPDVVSDOSDWLRQPD\FDXVHUXSWXUH
Treatment: nephrectomy; chemotherapy and radiation
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BREAST CANCER
Risk factors:
• Family history
• Early menarche
• ETOH use
• Advanced age
• Nulliparity
• Late menopause
• Obesity
• Personal history of breast cancer
• Use of estrogen & progesterone
• First child late in life
• High socioeconomic status
Treatment:
• Chemotherapy and Radiation
• Surgery
‡7DPR[LIHQPD\EHSUHVFULEHGIRU\HDUV
DYRLG&RXPDGLQ ZDUIDULQ PD\LQFUHDVHHႇHFW
Monitor PT/INR. Separate antacids by 2 hours)
‡0HJDFH PHJHVWURO WUHDWVEUHDVWDQGHQGRPHWULDOFDQFHU
(also used to prevent loss of appetite and severe weight loss with AIDS patients)
LUNG CANCER
Primary risk factors:
• Cigarette smoking
• Exposure to asbestos or other carcinogens
Signs & Symptoms:
• Chronic cough
• SOB
• Hemoptysis
• Weight loss
Diagnosis: Biopsy, sputum cytology, PET scan
Treatment:
• Chemotherapy, radiation, surgery
BLADDER CANCER
Risk factors:
• Smoking
• Diet (high fat, fried meats)
• Exposure to rubber
• Gender (older white males)
• Living in urban areas
Signs/Symptoms:
• Low back pain
• Dysuria
• Polyuria
• Hematuria
Treatment:
• Chemotherapy, radiation, surgery
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COLON CANCER
&RPPRQLQ\HDUROGV
Risk Factors
‡5LVNLQFUHDVHVZLWKDJH
‡5DFHDIULFDQDPHULFDQ
‡,QÀDPPDWRU\ERZHOGLVHDVH
‡6PRNLQJ
‡(72+
‡/RZ¿EHUKLJKIDWGLHW
‡'LDEHWHV
‡2EHVLW\
Signs & Symptoms:
• Bowel changes, abdominal pain
• Weight loss
• Pallor
• Assess stool for occult blood
'LDJQRVLVEDULXPHQHPDFRORQRVFRS\GRQHXQGHUFRQVFLRXVVHGDWLRQSODFHLQOHIWODWHUDOSRVLWLRQ
during procedure.
Treatment: chemotherapy, radiation, surgery
SKIN CANCER
The most common form of cancer in the U.S.
Risk Factors:
• Sun exposure
• Fair skin
• Heredity
• Age over 50
Teach:
• Change in color, size, itching
• Suspicious skin or Nevi (mole) changes need further evaluation
• Avoid the sun and tanning salons
• Mole assessment: Asymmetry, Border, Color, Diameter, Evolution
Treatment: chemotherapy, radiation, surgery
MULTIPLE MYELOMA
• Malignant overgrowth of plasma cells and malignant tumor growth in bone
• Interferes with RBC, WBC, and platelet production
• Common in older men
Subjective: • bone pain • low back pain • progressive weakness
Objective:
• DQHPLDSODWHOHWGH¿FLHQF\ZHLJKWORVVFDFKH[LDLGLRSDWKLFERQHIUDFWXUHV
• positive Bence Jones protein in blood & urine
• precipitation of protein, calcium, and uric acid in the urine
Nursing Diagnoses: Pain, risk for injury
Implementation:
• Pain control
• ,QFUHDVHÀXLGVWRSUHYHQWUHQDOGDPDJH
• High nutrient dense foods (boost, nutriment)
• Immune stimulant nutrients (selenium, vitamin A, C, E, protein)
Treatment: chemotherapy, radiation, steriods, stem cell transplantation
89
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G. Therapeutic techniques:
•
•
•
Bone marrow transplant:UHVWRUHVWKHERQHPDUURZ¶VDELOLW\WRSURGXFHKHDOWK\FHOOVPDMRUULVNRILQIHFWLRQ
Surgery
Internal radiation: also referred to as brachy therapy
Females:
• Flex and extend legs to promote circulation
• Deep breathing and coughing exercises
• Low residue diet (decrease bowel movements)
• Catheter (keep bladder empty)
• Report nausea, vomiting, elevated temperature
• Opioids, muscle relaxants, sedatives may be used
0DOHV
‡,IEHLQJWUHDWHGIRUSURVWDWH&$VHHGVDUHLPSODQWHG
• Client returns home after procedure
• Avoid contact with pregnant women and infants for 2 months
• Strain urine for seeds
• Instruct on condom use with sexual intercourse for 2 weeks after implantation to
catch seeds that may pass through urethra
•
•
• Absolute bed rest
• Head of bed 15 degrees
• Elastic stockings
• Avoid pericare
• Report profuse discharge
• Keep items in easy reach
([WHUQDOUDGLDWLRQ+LJKHQHUJ\EHDPVWRDႇHFWHGDUHDalso referred to as tele therapy
• Avoid pressure, trauma or infection to site
‡:DVKDႇHFWHGDUHDZLWKSODLQZDWHUDQGSDWGU\
• Teach to avoid exposure to heat, cold & sunlight
Chemotherapy: Drugs used to kill cancer cells, normal cells may be damaged
‡6LGHHႇHFWVLQHYHU\ERG\V\VWHP
• Nadir: lowest point
‡3DQF\WRSHQLDRFFXUVGD\VDIWHUVWDUWLQJFKHPRWKHUDS\
‡0XFRVLWLVXOFHUDWLRQRIWKHPRXWKVHFRQGDU\WRFKHPRWKHUDS\5LQVHPRXWKZLWKZDWHUVDOW
baking soda or peroxide.
‡,I,9LQ¿OWUDWHVWKHWUHDWPHQWPD\EHWRDGPLQLVWHUDQDQWLGRWH
Tumor lysis syndrome:
Complication of cancer treatment, metabolic disturbances caused by the breakdown products of dying cancer cells
Results in
• Hyperkalemia
• Hyperphosphatemia,
• Increased uric acid in blood and urine,
• Hypocalcemia – leads to acute uric acid nephropathy and acute renal failure
‡7UHDWPHQW$OORSXULQRO,9ÀXLGVPRQLWRUHOHFWURO\WHV
Superior Vena Cava Syndrome
Results from obstruction of the SVC by a tumor ie hodgkins, non hodgkins or lymphoma
Signs and symptoms: • Facial edema & periorbital edema
• Distended veins in neck & chest, headaches, seizures
• 0HGLDVWLQDOPDVVRQFKHVW[UD\
• Treatment: radiation and chemotherapy
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XI. Metabolic and Endocrine Function and Disorders
A. Pathophysiology
Gland
Pituitary
Endocrine System Imbalances
Hyposecretion
Hypersecretion
'ZDU¿VP
3LWXLWDU\DGUHQDOLQVXႈFLHQF\
7K\URLGGH¿FLHQF\
Hypoprolactinemia
Diabetes insipidus
Hyperpituitarism
Acromegaly
Gigantism
3LWXLWDU\&XVKLQJ¶VV\QGURPH
Hyperprolactinemia
SIADH (syndrome of inappropriate ADH secretion)
Hyperthyroidism
Graves disease
Thyroid
Hypothyroidism
Cretinism
Myxedema
Parathyroid
Hypoparathyroidism
Hyperparathyroidism
$GUHQDO&RUWH[
$GGLVRQ¶VGLVHDVH
$GUHQDO&XVKLQJ¶VV\QGURPH
Adrenal medulla
Pancreas
Pheochromocytoma
Diabetes Mellitus
Hypoglycemia
B. Disorders
1. Pituitary Gland Disorders
Anterior Pituitary
a. Growth hormone excess: • Acromegaly (adult) • Gigantism (child)
Diagnosis: ‡ĹVHUXP+&*
‡;UD\
‡&7VFDQ
‡05,
Treatment: • Hypophysectomy: monitor ICP & CSF drainage
• Complication: increased ICP, Bleeding, meningitis
• Patient will need glucocorticoid replacement for life
E*URZWKKRUPRQHGH¿FLW‡'ZDU¿VP VKRUWVWDWXUH
Treatment: • Synthetic hormone injections • Limb lengthening surgery
Complications:
• Developmental delay
• Spinal pressure
• Crowded teeth
• Kyphosis or lordosis
Posterior Pituitary
c. Anti Diuretic Hormone (ADH): secreted by posterior pituitary
• SIADH: ADH Excess
(Syndrome of inappropriate antidiuretic hormone)
Signs/ Symptoms:
• Headache • Fatigue • Hyponatremia
• Decreased urine output
‡,QFUHDVHGVSHFL¿FJUDYLW\
5;+\SHUWRQLFVROXWLRQ'16GLXUHWLFV'HPHFORF\FOLQHDQWLELRWLFXVHGWRLQFUHDVHZDWHULQWKHXULQH
surgery
G'LDEHWHV,QVLSLGXV ',$'+'H¿FLW
Signs/ Symptoms:
‡3RO\GLSVLD ‡3RO\XULD ‡'HFUHDVHGVSHFL¿FJUDYLW\
RX: Replace ADH:
• Vasopressin (petressin)
• Desmopressin (DDAVP) - intranasally
91
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2. Thyroid Disorders
Hyperthyroidism: • Graves disease
• Exopthalmus
• Goiter
• Hyperthroidism
Hypothyroidism:
Normal thyroid function test levels:
7PFJGO
7QJGO
76+PO8/
• Myxedema (adult)
• Cretinism (infant)
HYPOTHYROIDISM
HYPERTHYROIDISM
O = Slow / COLD
Hyper = Fast / HOT
77D Low
TSH D High
77D High
Weight increase (metabolism slow)
Weight loss (metabolism fast)
Constipation
Diarrhea
Slurred speech
Insomnia
Sluggish
Mood swings
Depression
Palpitation
Bradycardia
Tachycardia
Cold
Hot
TSH D Low
Brittle nails, hair loss, menstrual disturbances
Scanty menstruation
(more frequent/lasts longer)
Dry skin
Complication: Thyroid Storm = emergency
Treatment:
Treatment:
‡3URSDFLO SURS\OWKLRXUDFLO378
• 6\QWKURLG OHYRWK\UR[LQH V\QWKHWLF7
‡7DSD]ROH PHWKLPD]ROH LQKLELWVV\QWKHVLVRI
(hold for pulse greater than 110)
thyroid hormone
Teach: it takes 1 week to work,
• SSKI (saturated solution of potassium iodide)
take early in the morning
‡/XJRO¶V6ROXWLRQ
• &\WRPHO OLRWK\URQLQHVRGLXP V\QWKHWLF7
‡5DGLRDFWLYH,RGLQH , (requires 72 hours isolation)
• Thyroidectomy
Post op: • Trache set
Myxedema Coma: Decreased cardiac output
• Oxygen
due to bradycardia and decreased stroke
• Suction & Ca+ Gluconate at bedside
volume
7;PRQLWRU(.* ÀXLGVWDWXVJLYH,9ÀXLGV
'RSDPLQHUHSODFHKRUPRQH,9OHYRWK\UR[LQH Thyroid Storm: control temp, IVF, electrolyte
replacement, hydrocortisone, propranolol
treat hypothermia
(blocks the action of thyroid hormone on the cells)
92
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+\SRWK\URLGLVP &UHWLQLVP0\[HGHPD
Hair loss
Intolerance to cold
Hyperthyroidism (Graves Disease)
Receding Hairline
Intolerance to heat
Dull-blank expression
Bulging eyes
Muscle aches & weakness
Lethargy
Anorexia
Constipation
Extreme fatigue
Apathy
Facial & eyelid
edema
Thick tongueslow speech
Dry skin
(coarse & scaly)
Brittle nails & hair
Late Clinical Manifestations
Subnormal Temp / Bradycardia / Weight Gain
Cardiac Complications
Enlarged Thyroid
Goiter
Fine/ straight hair
Facial blushing
Warm skin
Weight loss
KSystolic B/P
Muscle wasting
KDiarrhea
Tachycardia
Restless, fatigue
Tremors
Menstrual changes
(Amenorrhea)
Localized edema
3. Parathyroid Disorders: controls calcium and phosphate metabolism
a. Hyperparathyroidism
‡9RQ5HFNOLQJKDXVHQ¶V'LVHDVHK\SHUVHFUHWLRQRIWKHSDUDWK\URLGJODQG
• Hypercalcemia
Signs/ Symptoms: • GI disturbance • Constipation • Bone pain • Renal stones • Joint pain
Rx: Observation, IV Fluids or surgery
b. Hypoparathyroidism:
• Hyposecretion of the parathyroid gland
‡3RVLWLYH7URXVVHDXVLJQ
• Muscle twitching
Rx: Replace calcium and vitamin D
Signs/ Symptoms:
• Hypocalcemia
‡3RVLWLYH&KHYRVWHN¶VVLJQ‡7HWDQ\
• Brittle nails
• Paresthesias
4. Adrenal disorders
a. Pheochromocytoma tumor of adrenal medulla (inner portion) causes hypersecretion
• Severe hypertension
• Headache
• Hyperglycemia
• Hyperhydrosis
• Hypermetabolism
Treatment:
• Regitime (phentolamine) at bedside for blood pressure management
• Nipride (nitroprusside)
• Surgical removal of tumor or gland
‡$YRLGFDႇHLQH
• Promote rest
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'LVRUGHUVRIWKH$GUHQDO&RUWH[ RXWHUFRYHULQJ
ADDISON’S DISEASE
CUSHING’S DISEASE
$GUHQDOLQVXႈFLHQF\ $&7+GH¿FLW
Adnenocorticol (ACTH excess)
SIGNS
• Bronze skin discoloration
• Muscle weakness
• Lethargy, fatigue
• Dizziness
• Vomiting and diarrhea
• Weight loss
• GI disturbance
• Mood swings
• Headache
• Hypertension
• Weight gain
‡%XႇDORKXPS‡0RRQIDFH
• Easy bruising
• Purple striae
• Metabolic alkalosis
• Pathological fractures
• Pendulous abdomen
DECREASED
Blood pressure
Sodium Chloride
Hypoglycemia
WBC (eosinophils)
Potassium*
Magnesium
INCREASED
Potassium*
Magnesium
Leukocytosis
Calcium
TREATMENT
• Quiet environment
• Increase sodium in diet
• Decrease potassium in diet
• Daily weight
‡)RUFHÀXLGV
Observe for signs of Addisonian
Crisis:
• Severe hypotension
• Shock
• Weakness
• Vasomotor collapse which may lead
to death
• Treat with bed rest and IV Cortisone
• Teach patient to carry injectable
cortisone at all times and wear medic
alert bracelet
Temperature
HCT
Facial hair in women (hirsuitism)
Gynecomastia
Glucose
5%&¶V
Sodium
• Provide comfort
• Decrease sodium in diet
• Increase potassium in diet
• Monitor glucose
• Observe mood changes
• Intake and output
• Increase protein
• Decrease calories
• Surgery
• Radiation
Medications:
• Cytadren (aminoglutethimide)
• Hormone replacement
RELATED PHARMACOLOGY
6WHURLGVXVHGWRVXSSUHVVLQÀDPPDWLRQ
$GYHUVHHႇHFWV,QVXႈFLHQF\ $GGLVRQ¶V
([FHVV &XVKLQJ¶V
94
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Fill in the blanks with the most appropriate response based on information related to
common Endocrine Disorders:
ACTH excess_________________________________
Hypothyroidism in an infant______________________
Treatment for hypothyroidism_____________________
ADH Excess___________________________________
$&7+'H¿FLWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Hypersecretion of the adrenal medulla__________________
Constipation, cold, bradycardia_______________________
,QFUHDVHG76+GHFUHDVHG77BBBBBBBBBBBBBBBBBBBBBB
Hunger, confusion, perspiration _______________________
Hyposecretion of the pancreas___________________________
+¶VBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
_________________
Decreased sodium, weight loss, increased potassium, bronze skin color ___________________
7HVWIRUGLDEHWLFFRQWURORYHUDZHHNSHULRGLQGLFDWHVJRRGFRQWURO
__________________________________________________________
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XII. Gastrointestinal Function and Disorders
A. Review of anatomy and physiology
B. Diagnostic tests • purpose, description, nursing implications
1. Radiological exams
2. Barium enema:
• Give a laxative or enema post procedure
• Expect clay colored stool for up to 72 hours
(QGRVFRSLFVWXGLHV
132KRXUVEHIRUHWKHSURFHGXUH
132XQWLOJDJUHÀH[UHWXUQV
4. Sigmoidoscopy: administer an enema before the procedure
5. ERCP (Endoscopic retrograde cholangiopancreatography)
• Fluroscopy & X• ray used to diagnose problems in the liver,
gallbladder, bile ducts, and pancreas
‡132KRXUVSUHSURFHGXUHFKHFNIRUDOOHUJLHVWRLRGLQH VKHOO¿VKPXOWLSOHSRVLWLRQFKDQJHVUHTXLUHGGXULQJSURFHGXUH
3RVWSURFHGXUHPRQLWRUIRU&16GHSUHVVLRQVHGDWLRQJLYHQ
C. Common Problems related to GI tract
1. Nausea and vomiting
&RQVWLSDWLRQGHFUHDVHQXPEHURIVWRROVKDUGGLႈFXOWWRH[SHO
feces
'LDUUKHDIUHTXHQWORRVHZDWHU\VWRROV
D. Disorders
1. Hiatal hernia: client may complain of dysphagia and heartburn
Nursing Interventions: small frequent meals, antacids, elevate the
HOB. Remain in upright position for 2 hours after meals
2. Stomatitis:LQÀDPPDWLRQRIWKHPRXWK
3. Gastritis:LQÀDPPDWLRQRIWKHVWRPDFK
4. GERD:JDVWURHVRSKDJHDOUHÀX[GLVHDVH
5[33,¶V SURWRQSXPSLQKLELWRUV +DQWDJRQLVWV
7HDFKDYRLG(72+WRPDWRHVFRႇHHVSLF\RUIDWW\IRRGVFDUERQDWHGEHYHUDJHVFKRFRODWHSHSSHUPLQW
5. Peptic Ulcers: Risk factors: Stress, smoking, ETOH
Gastric Ulcers
Duodenal Ulcers
50 years old and older
\HDUV
:HOOQRXULVKHG
Malnourished
3DLQòKRXUDIWHUPHDOV
3DLQKRXUVDIWHUPHDOV
Eating may increase the pain
Food may decrease the pain
Vomiting common
Vomiting uncommon
Weight Loss
Weight gain
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6. Ulcerative colitis:DႇHFWVWKHOHIWGHVFHQGLQJFRORQ
• Severe diarrhea
• VWRROVSHUGD\EORRG\PXFXV
• Predisposition to colon cancer
• 'LVRUGHULVFRPPRQLQ\HDUROG-HZLVKIHPDOHV
Teach:
• Avoid carbonated beverages
• Diet: low residue, low fat, milk free, high protein
7. Regional enteritis (Crohn’s Disease):DႇHFWVWKHLOHXPDQGULJKWVLGHDVFHQGLQJFRORQ
• VHPLVRIWVWRROVSHUGD\
• 'LVRUGHULVFRPPRQLQ\HDUROGVERWKVH[HV
Teach:
• Diet: high calorie, high protein, high CHO, high vitamin, milk free, low fat
Possible treatment for ulcerative colitis and regional enteritis :
• TPN
• Colostomy (partial or total)
• Ileostomy
• Oral or rectal medications: • $QWLLQÀDPPDWRU\GUXJV: Humira (adalimumab), Asacol, Pentasa
PHVDODPLQH RU5HPLFDLGH LQÀL[LPDE • Steroids: Prednisone
• Immune suppressors: 6 mercaptopurine
• Antibiotics: Ampicillin, cephalosporins and or Flagyl (metronidazole)
• Antidiarrheals: Immodium (loperamide), Codeine
8. Hepatitis:
Hepatitis A:WUDQVPLWWHGE\IHFDORUDOURXWHJRRGKDQGZDVKLQJLVLPSHUDWLYH&RQWDFWSUHFDXWLRQVLIGLDSHUHG
or incontinent.
Hepatitis B:WUDQVPLWWHGYLDEORRGERG\ÀXLGV
• First immunization at birth (check for yeast allergy before administering)
7;DFXWH+HSDWLWLV%QRWUHDWPHQWPDQDJHV\PSWRPVFKURQLFDQWLYLUDOVRUSHJLQWHUIHURQ
Hepatitis C:WUDQVPLWWHGE\,9GUXJXVHEORRGWUDQVIXVLRQVPXOWLSOHVH[SDUWQHUVÀXOLNHV\PSWRPVFDQOHDG
to cirrhosis and liver cancer. Chronic infection leads to need for transplant.
7;,QWHUIHURQ ERRVWVWKHLPPXQHV\VWHP DQG5HHEHWURO ULEDYDULQ DQWLYLUDOPHGLFDWLRQ
Hepatitis D and Hepatitis G: Follows Hepatitis B
Hepatitis E: transmitted by fecally contaminated water in under developed areas
Risk factors: IVDA, hemodialysis, transfusions, health care workers, mutiple sex partners, tatoos and body
piercings
Teach: Use of condoms, do not share needles, do not donate blood, avoid Tylenol (acetaminophen)
• BDFWHULDOLQIHFWLRQWUDQVPLWWHGE\ÀLHV¿QJHUVIRRG IHFHV
• Incubation 8 – 48 hours after ingestion of contaminated food
Signs and Symptoms:
• Fever
• Nausea
• Vomiting
• Bloody diarrhea
• Abdominal cramping
'[ Stool culture
5[,9)DQGHOHFWURO\WHUHSODFHPHQWDQWLELRWLFV&LSURÀR[DFLQ$PSLFLOOLQ%DFWULP WULPHWKRSULP
9. Salmonellosis:
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10. Cirrhosis: (scarring of the liver) Caused by many forms of liver disease.
• /DsQQHF¶V&DXVHGE\DOFRKROLVP
• Can lead to Portal hypertension (high blood pressure in the portal vein)
Signs and Symptoms:
• Changes in mental status (hepatic encephalopathy)
• Ascites
• Splenomegaly
• Spider hemangiomas
• Pancytopenia
• Jaundice
• Itching
• 5LVNIRUHVRSKDJHDOYDULFHV6HQJVWDNHQ%ODNHPRUH7XEHDYRLGKDUGIRRGV
Pertinent Lab Values for Cirrhosis:
Increased:
• Alkaline Phosphatase
• Sodium
• AST
• ALT
• $PPRQLDOHDGVWRKHSDWLFHQFHSKDORSDWK\Ļ protein in diet
Decreased:
• Albumin
• Potassium
• Cholesterol
• Platelets
Nursing Interventions:
• 2EVHUYHIRUDVWHUL[LV ÀDSSLQJKDQGWUHPRUVDVVRFLDWHGZLWKKHSDWLFHQFHSKDORSDWK\ • $GPLQLVWHU/DFWXORVHDVSUHVFULEHGPD\FDXVHK\SHUJO\FHPLDDQGGLDUUKHD
• ,QFUHDVHYLWDPLQ% WKLDPLQH LQWKHGLHWJLYHGDLO\
• Encourage rest
• 5HVWULFWÀXLGV
• Daily weights
• Monitor intake and output
• Diet: High calorie, low sodium, low fat, low protein diet (helps to control ammonia level)
• Monitor for bleeding
• TX for portal HTN = Betablockers & Nitrates
11. Appendicitis:3RVLWLYH0F%XUQH\¶VVLJQ5/4UHERXQGWHQGHUQHVV 5[ Surgery
12. Peritonitis:,QÀDPPDWLRQRIWKHSHULWRQHXP
13. Diverticulosis:
5[ Antibiotic therapy
• Outpouching of the colon may be caused by constipation
66DEGRPLQDOSDLQ WHQGHUQHVVLQ//4
*LYH+LJK¿EHUGLHW$YRLGIRRGVZLWKVHHGV
• DiverticulitisLQÀDPPDWLRQRIWKHSRXFK'LHW132SURJUHVVWRFOHDUOLTXLGV
• $YRLGIRRGVZLWKVHHGVORZ¿EHU
14. Gastric Resection:
• Billroth I ( gastroduodenostomy)
• Billroth II (gastrojejunostomy)
• Total Gastrectomy: • Vitamin B12 replacement necessary for life • Will cause pernicious anemia
• To avoid Dumping syndrome teach client: not to drink with meals; lie down after eating
6LJQV 6\PSWRPV • Weakness • Fainting • Tachycardia • Diaphoresis
• PDOSLWDWLRQVPLQXWHVDIWHUHDWLQJ
Teach:
• Diet: High protein, high fat, low carbohydrate
• Increase foods with pectin (i.e. peaches, plums, apples)
• Avoid foods high in sugar and sodium
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15. Ostomy: surgical opening made through the abdomen with a portion of the ileum or colon brought though
the opening to allow temporary or permanent excretion of wastes
Indications:ERZHOREVWUXFWLRQFDQFHULQÀDPPDWRU\ERZHOGLVHDVHDEGRPLQDOWUDXPD
Post op: assess stoma, it should be red – pink, with edema immediately post op
Enterostomal therapist: nurse with specialized training in ostomy care
Ileostomy
Small bowel, Liquid stool; No control
Brooke: conventional ileostomy
.RFNSRXFKFRQWLQHQWLOHDOUHVHUYRLUĻ¶VSUREOHP
of skin care; risk for peritonitis
Colostomy
Large bowel
6HPLIRUPHGWRIRUPHGVWRRO
Client may gain control by diet and irrigation
Diet considerations with an ostomy:
Bulk forming foods: to decrease diarrhea with an ostomy
• Fish • Eggs •Yogurt • Cooked tomato • Cottage cheese • Banana • Beets • Oranges • Natural cheese
Avoid odor producing foods:
• Garlic • Broccoli • Onions • Asparagus • Cabbage • Eggs • Fish
Gas forming foods:
• Beans • Cabbage • Onions • Beers • Cheese • Sprouts
Foods causing obstruction with an ileostomy:
• Corn • Popcorn • Nuts • Celery • Raisins • Raw vegetables
Irrigation: LUULJDWH KRXU DIWHU PHDOV VDPH WLPH HYHU\GD\ WR HQKDQFH HႇHFWLYHQHVV KDYH FOLHQW FKDQJH
SRVLWLRQDPEXODWHPDVVDJHDEGRPHQOLJKWO\GULQNZDUPÀXLGV
16. Pancreatitis: Causes severe upper abdominal pain that may radiate to the back with N/V & fever.
Precipitating factors include:
• Smoking • Alcohol abuse
• Hypercalcemia
Signs and Symptoms:
• Pain
• Increased amylase lipase & bilirubin
• GI distress
• Increased LFT’s
• History of liver or gallbladder disease
• Decreased calcium levels
• Leukocytosis • Hyperglycemia
Signs: • Cullens: discoloration in the periumbilical area
• Turners:EOXLVKFRORULQWKHÀDQN
Treatment: Pain relief: Demerol (meperidine), NPO in acute phase, NGT for decompression
7HDFK$YRLG(72+'LHWVPDOOPHDOVQRGDLU\RUFRႇHHGHFUHDVHUHGPHDWincrease vitamin B, iron, berries;
JODVVHVRIZDWHUSHUGD\
17. Cholecystitis:,QÀDPPDWLRQRIWKHJDOOEODGGHU5LVN)DFWRUV )¶V )DLU)DW)HPDOH)RUW\)HUWLOH
Caused by obstruction of bilary ducts by gallstones
Signs and Symptoms:
• Pain in the right upper quadrant
• Increased pain with a deep breath in (Murphy’s Sign)
• Nausea • vomiting • abdominal distention • fat intolerance
Treatment:
• Low fat diet
• &KROHF\VWHFWRP\ 7WXEHPD\EHSODFHG 99
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XIII. Urinary Function and Disorders
A. Terminology
$]RWHPLDLQFUHDVHG%81DQG&UHDWLQLQHVXJJHVWVUHQDOLPSDLUPHQWDV\PWRPDWLF
Uremia: full blown signs and symptoms of renal failure, decreased calcium, increased potassium
B. Pathophysiology
C. Causes and prevention of urological problems
Urinary stasis, urinary calculi, indwelling catheters, premature infants, poor toilet hygiene, wet bathing suits,
perfumed toilet paper
D. Diagnostic tests and procedures: purpose, description, nursing interventions
• Urinalysis
• Fractional urine
• Urine culture and sensitivity
• Urine osmolarity
• BUN/Creatinine Levels
• Radiological studies
• Cystogram
• Cystoretrography (CMG)
• IVP (Intravenous Pyelography)
• Renal biopsy
• Renal ultrasonography
• CT (Computed axial tomography scan)
• Cystoscopy
• Radionuclide renal scan
• Electromyography of the perineal muscle
*Urinary output is one of the most valuable monitors during shock treatment. Hourly measurements of the
XULQDU\RXWSXWDUHYDOXDEOHLQGHWHUPLQLQJWKHUDWHRIÀXLGUHSODFHPHQW.
Hourly urine output should be:
• Infant/child: 10 to 20 ml/hour
• Adult:
30 to 50 ml/hour
• Elderly:
20 to 30 ml/hour
E. Disorders
&\VWLWLV,QÀDPPDWLRQRIWKHEODGGHU7[&LSUR FLSURÀR[DFLQ 3\ULGLXP SKHQD]RS\ULGLQH
8UHWKULWLV,QÀDPPDWLRQRIWKHXUHWKUD
1HSKULWLV %ULJKW¶VGLVHDVH 1RQLQIHFWLRXVGHJHQHUDWLRQRIFHOOV
4. Acute glomerulonephritis: Follows Strep infection such as impetigo
Signs and Symptoms:
• Headache
• Weight gain
• Hypertension
• Hematuria
• Oliguria
• Proteinuria
• Increased BUN and creatinine
• Children may have periorbital edema
Complications:
• Hypertension • Encephalopathy • Heart failure • Pulmonary edema
Treatment:
• Diuretics • Antihypertensives • Antibiotics • Bed rest • Low protein diet
5. Chronic glomerulonephritis:
• Increased potassium
• Metabolic acidosis
• Increased creatinine
• Increased phosphorus
• Hypertension
• Nocturia
• Decreased calcium
• Increased BUN
• Increased magnesium
100
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6. Nephrotic syndrome: usually follows another kidney disease;
Signs and Symptoms:
• Proteinuria • Hypoalbuminemia • Severe edema
Treatment:
• Antihypertensives, diuretics, high protein diet
• May need protective isolation when hospitalized
7. Nephrosclerosis: caused by hypertension, atherosclerosis, end stage renal disease treatment –
control hypertension
3\HORQHSKULWLVFKLOOV IHYHUÀDQNSDLQOHXNRF\WRVLVS\XULD
Treatment: IVF, IV antibiotics
5HQDOVWRQHVFDQEHFDXVHGE\K\SHUFDOFHPLD±LQFUHDVHÀXLGV
10. Cancer of the bladder: common in smokers, living in urban areas – exposure to nitrates, dye, and rubber
Treatment: surgery – cystectomy & ileal conduit placement
&DQFHURIWKHNLGQH\LQFKLOGUHQFRPPRQO\:LOP¶V7XPRU\HDUROGV
12. Urinary incontinence: involuntary leakage of urine
Prevention: • Bladder exercises (kegels)
0HGLFDWLRQV
• $YRLGFDႇHLQH (72+• Bladder training
‡'HWURO WROWHUGLQH IRUWUHDWPHQWRIRYHUDFWLYHEODGGHU XUJHLQFRQWLQHQFH
6LGHHႇHFWVGU\PRXWKKHDGDFKHGL]]LQHVVFRQVWLSDWLRQ
‡'LWURSDQ R[\EXW\QLQFKORULGH XVHGIRURYHUDFWLYHEODGGHU
6LGHHႇHFWVFRQVWLSDWLRQGU\PRXWKKHDGDFKHEOXUUHGYLVLRQGL]]LQHVV
• Bethanecol (urecholine) stimulates the bladder to empty
6LGHHႇHFWVVWRPDFKXSVHWYRPLWLQJGL]]LQHVVVZHDWLQJRUÀXVKLQJWDNHRQDQ
empty stomach
$FXWHUHQDOIDLOXUHQRUPDO%81
3KDVHV
‡2OLJXULDEHJLQVZLWKWKHUHQDOLQVXOWDQGFRQWLQXHVIRUZHHNV ZHHNV
‡'LXUHVLVEHJLQVZKHQWKHNLGQH\VEHJLQVWRUHFRYHUDQGFRQWLQXHVIRUZHHNV
‡5HFRYHU\FRQWLQXHVXQWLOUHQDOIXQFWLRQLVIXOO\UHVWRUHG PRQWKV\HDU
Treatment :
• Daily weight
• Monitor intake and output
• Complete bed rest
• Restrict protein, sodium, potassium, high carbohydrate
• Good skin care
• Amphogel (aluminum hydroxide) – increases calcium by binding phosphorous
101
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14. Chronic renal failure: Most common causes are hypertesion and diabetes mellitus
• Stage I:
Normal BUN and creatinine, asymptomatic
• Stage II:
Increasing BUN and creatinine, polyuria, nocturia, polydipsia
• Stage III:
Azotemia, hypertension, oliguria, metabolic acidosis, nausea, headaches
anemia, edema
• Stage IV:
Uremia, uremic frost, electrolyte imbalances (hyperkalemia, hypernatremia,
hyperphosphatemia, hypermagnesemia, hypocalcemia)
Treatment: Diet
‡0RGHUDWHSURWHLQ‡+LJKFDUERK\GUDWH‡5HVWULFWVRGLXP‡,QFUHDVHFDOFLXP
• Low potassium, magnesium, phosphate
‡)OXLGUHVWULFWLRQ,QWDNH RXWSXWPO¶V
Medications: Epoetin (epogen), Kayexalate (sodium polystyrene sulfonate), Amphogel (aluminum
hydroxide), antihypertensives, diuretics, iron supplements, calcium carbonate, vitamin D
F. Therapeutic regimen
1. Dialysis:
Hemo5HVWULFWWKHOLPEKROGDQWLK\SHUWHQVLYHVDQGDQWLFRDJXODQWVEHIRUHGLDO\VLV WLPHVSHU
ZHHNXSWRKRXUVHDFKVHVVLRQ 0RQLWRUIRUFUDPSLQJZKLFKRFFXUVLIÀXLGLVUHPRYHGWRRTXLFNO\
Peritoneal ±'ZHOOWLPHKUVWLPHVGD\5LVNVSHULWRQLWLV FORXG\GLDV\ODWH OHDNDJH
Bloody diasylate = Infection. Protein may be lost in diasylate
Complication: dialysis disequilibrium syndrome occurs shortly after beginning hemodialysis or
peritoneal dialysis. Caused by rapid correction of metabolic abnormailities.
Signs & Symptoms: nausea & vomiting, drowsiness, headache, disorientation, can progress to seizures,
coma and death.
Treatment is prevention with slow reduction of BUN.
3RUWDFDWKXVHGIRUKHPRGLDO\VLVRUKHPDWRORJ\RQFRORJ\SDWLHQWVVPDOODSSOLDQFHLQVWDOOHG
beneath the skin. Catheter connects the port to a vein.
,OHDO&RQGXLWXULQDU\GLYHUVLRQFUHDWHGDIWHUEODGGHUUHPRYDO8UHWHUVDUHDWWDFKHGWRWKHLOHXPVWRPD
brought to the abdomen and collection bag attached.
/LWKRWULSV\±XVHRIVKRFNZDYHVWRGLVLQWHJUDWHVWRQHVVLGHHႇHFWVLQWHUQDOEOHHGLQJSDLQLQIHFWLRQ
.LGQH\7UDQVSODQW6LJQVRIUHMHFWLRQ
• Oliguria
• Anuria
• Elevated temperature
• Flank tenderness
‡,QFUHDVHGVSHFL¿FJUDYLW\
102
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XIV. Reproductive System Function and Disorders
A. Female anatomy and physiology
B. Menstrual dysfunction
&&RQWUDFHSWLRQSDWLHQWWHDFKLQJQRSURWHFWLRQDJDLQVW67'¶V
• (PHUJHQF\FRQWUDFHSWLRQPRVWHႇHFWLYHLIXVHGZLWKLQKRXUVRILQWHUFRXUVH
D. Infertility
('LDJQRVWLFWHVWVDQGSURFHGXUHVSXUSRVHGHVFULSWLRQQXUVLQJLQWHUYHQWLRQV %UHDVWVHOIH[DP
9XOYDVHOIH[DP
3HOYLFH[DP
4. Smears and culture
5. Endometrial biopsy
6. Colposcopy: visualization of the cervix
7. Laparoscopy: visualization of the abdomen
8. Hysteroscopy: visualization of the uterus
9. Dilatation and curettage: opening and scraping of the cervix
10. Mammography: no lotion or deodorant before procedure
8OWUDVRXQGLQFUHDVHÀXLGVSUHSURFHGXUHSODFHLQVXSLQHSRVLWLRQ
12. Therapeutic abortion
F. Nursing management
G. Disorders
3HOYLFLQÀDPPDWRU\GLVHDVH 3,' 0RVWFRPPRQO\FDXVHGE\XQWUHDWHG6H[XDOO\7UDQVPLWWHG,QIHFWLRQV
Syphillis – Treponema Pallidum
No alcohol 24 hours before VDRL – may give a false reading; (RPR can also be done for screening)
)7$$%6ÀXRUHVFHQWWUHSRQHPDDQWLERG\DEVRUSWLRQWHVWFRQ¿UPV535 9'5/
• Stage 1 = FKDQFUH SDLQOHVV ZHHNVIRUV\PSWRPVWRDSSHDU
9'5/ EORRGWHVW QHJDWLYHPRQWKV
• Stage 2 =
neg chancre, + rash on palms of hands & soles of feet
9'5/PRQWKV±\HDU
• Stage 3 = \HDUV±DV\PSWRPDWLFEXWLQIHFWLRQVWLOOSUHVHQW
:LWKRXWWUHDWPHQWVKXႉLQJJDLWQHXURORJLFDOV\PSWRPV
Treatment – PCN – (Doxycycline in PCN allergic) - follow up VDRL at 6 & 12 months
Chlamydia: #1 STD in USA
• PD\EHDV\PSWRPDWLFLQIHPDOHVLQFXEDWLRQSHULRGGD\V
• treat with Zithromax (azithromycin) PO or Vibramycin (doxycycline)
Gonorrhea:
• PD\EHDV\PSWRPDWLFXQWUHDWHG67,¶VPD\OHDGWRLQIHUWLOLW\
• vaginal or penile discharge, genital itching, swollen and painful glands
• treat with single dose of Rocephin (ceftriaxone) IM and Zithromax (azithromycin) PO or
Doxycycline for 7 days
• Erythromycin in neonates eyes to prevent/treat Chlamydia/Gonorrhea
2. Vaginitis: caused by overgrowth or invasion of microorganisms
7UHDWPHQWIRU\HDVWYDJLQLWLV'LÀXFDQ ÀXFRQD]ROH 32
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103
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3. Comparison of female cancers risk factors for cervical, ovarian and uterine cancer
Cervical Cancer
Uterine Cancer
Ovarian Cancer
)UHTXHQWXULQDWLRQ'LႈFXOWRU
painful urinating
• Irregular bleeding
(bleeding between periods)
• Pelvic pain or pressure
Late: Watery discharge after intercourse
• Vaginal discharge
Advanced:
• Leg pain
Early:
• No symptoms
• Irregular bleeding
• Metrorrhagia
• Dysuria
• Rectal bleeding
• Vague Gl disturbance
• Pelvic pressure
• Bloating
• Increased abdominal girth
• Leg pain
• Pelvic pain
Diagnosis
Diagnosis
Diagnosis
• Pap smear
• Biopsy
• Median age 61
• CA 125 blood test
• Biopsy
‡\HDUROGVSHDNDJH
Risks
Risks
Risks
• Multiple sex partners
• Obesity
• Sex under age 20
• Multiparas
• Oral Contraceptives
• Family hx
• Early childbearing
•*Smoking
• Low socioeconomic status
• HPV
• HIV infection
• 1XWULWLRQDOGH¿FLHQFLHV
(folate,beta carotene, Vitamin C)
• Obesity • History of DM
• Nulliparity
(increased estriol level)
• Infertility
• Estrogen without
• Increased fat in the diet
progesterone
• Talc in perineum
• Trunkal obesity
• Breast Cancer
• %UHDVWFDQFHU7DPR[LIHQXVH • Obesity
• Gallbladder disease
• Estrogen without progesterone
• Nulliparity • Infertility
• Family history of breast cancer,
• Late menopause after age 52 ovarian cancer or Colorectal cancer
• Internal radiation: Absolute bed rest head of bed elevated15 degrees
• Deep breathing and coughing exercises: • Flex and extend legs to promote circulation
• Elastic stockings
• Low residue diet (decrease bowel movements)
• Report profuse discharge
• Indwelling catheter (keep urinary bladder empty)
• Avoid pericare
• Report nausea, vomiting, elevated temperature
• Medications: Opoids, muscle relaxants, sedatives may be used
‡7HDFKVPDOODPRXQWRIYDJLQDOEOHHGLQJPD\EHH[SHFWHGIRU±PRQWKVIROORZLQJLQWHUQDOUDGLDWLRQ
4. Endometriosis: dysmenorrhea, dyspareunia, pelvic pain
5;PHGLFDWLRQVIRURYDULDQVXSSUHVVLRQRUDOFRQWUDFHSWLYHV'HSR3URYHUD PHGUR[\SURJHVWHURQH
DFHWDWH 6LGH(ႇHFWVERQHORVVDPHQRUUKHDHGHPD
5. Uterine prolapse (cystocele, rectocele):5[&ROSRUUKDSK\3HVVDU\UHPRYHGDQGFOHDQHGHYHU\
months by M.D.
8WHULQH¿EURLGV OHLRP\RPDV may cause abnormal uterine bleeding. Tx: Myomectomy or
hysterectomy in severe cases.
7. Sterilization: tubal ligation
8. Breast disorders:
D)LEURF\VWLFEUHDVWGLVHDVHFRQWLQXHWRGRPRQWKO\6%(GD\VDIWHU¿UVWGD\RIPHQVWUXDWLRQ
E0DVWHFWRP\H[HUFLVHV1RDEGXFWLRQSRVWRS
c. Paget’s disease of the breast: malignancy of the nipple and areola.
RX: same as breast cancer
9. Lymphedema: complication of mastectomy
10. Vaginal suppository: remain in lying position for at least 20 minutes
104
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H. Male anatomy and physiology
I. Causes and prevention of male reproductive disorders
J. Diagnostic tests and procedures: purpose, description, nursing intervention
1. Digital rectal exam: assesses for irregularity in size shape and texture of the prostate
2. Semen analysis
7HVWLFXODUVHOIH[DPEHVWGRQHDIWHUDZDUPVKRZHU FDQFHUFRPPRQLQPHQ\HDUV 4. Transrectal ultrasound of the prostate
5. Biopsy of the prostate
36$QRUPDOOHVVWKDQQJPOJUHDWHUWKDQQJPOQHHGVLQYHVWLJDWLRQIRUFDQFHU
K. Nursing management
/,QÀDPPDWLRQDQGLQIHFWLRQRIWKHPDOHUHSURGXFWLYHV\VWHP
M. Disorders
1. Testicular cancer (common in young men). Risk factors: cryptorchidism, white men, family history, HIV
2. Tumors
3. Benign prostatic hypertrophy: nocturia, frequency, hesitancy, erectile dysfunction
‡3URVFDU ¿QDVWHULGH VKULQNVSURVWDWH‡$YRGDUW GXWDVWHULGH GRQRWFUXVKRUFKHZ
‡)ORPD[ WDPVXORVLQ+&O ±WDNHPLQXWHVDIWHUDPHDO7DNHZLWKDIXOOJODVVRIZDWHU
• Herbs: Ginseng, Saw Palmetto
Surgical interventions:
‡1XUVLQJLPSOLFDWLRQV7853KHPDWXULDH[SHFWHGIRUGD\V
‡&%, FRQWLQXRXVEODGGHULUULJDWLRQ XVHGSRVWRSH[SHFWRXWSXWJUHDWHUWKDQLQWDNH
‡%ODGGHUVSDVPVDUHQRUPDOGHFUHDVHGXULQDU\RXWSXWLVDQDEQRUPDO¿QGLQJ
‡'LVWHQGHGDEGRPHQ ÀXLGUHWHQWLRQ
4. Prostate cancer: African American males at highest risk. Pain in the back, & lower leg, painful
ejaculation
TX: • Chemotherapy, Radiation, Surgery or Hormone therapy
/XSURQ'HSRWPD\EHSUHVFULEHG6LGHHႇHFWVERQHSDLQKRWÀDVKHVLPSRWHQFHLQMHFWLRQVLWH
pain.
5. Impotence: may be caused by medications, alcohol or drug use
‡7UHDWPHQW9LDJUD VLOGHQD¿O WDNHPLQKRXUVEHIRUHLQWHUFRXUVHRQDQHPSW\VWRPDFK
&LDOLV WDGDOD¿O WDNHXSWRKRXUVEHIRUHLQWHUFRXUVHDIWHUDPHDO
/HYLWUD YDUGHQD¿O WDNHPLQKRXUVEHIRUHLQWHUFRXUVHZLWKIXOOJODVVRIZDWHU
• Avoid with nitrates
• report sudden vision loss
• report erections lasting > 4 hours
Teach correct application of condoms: Place the condom on the tip of the penis so it will unroll correctly (the condom
should unroll outwards). Lightly squeeze the tip of the condom (to remove air) as the condom is applied to the head
of the penis. Unroll the condom all the way down to the base of the penis. There should be at least 1.5 cm reservoir
between the condom and the head of the penis
6. Infertility: 6WHULOL]DWLRQYDVHFWRP\SRVWRS±LFHSDFNVVFURWDOVXSSRUWDQDOJHVLFV
7HDFKWRXVHFRQGRPVIRUPRQWKVRUXQWLOVSHUPIUHHDQDO\VHV
7. Penile implant:VHPLULJLGURG SHUPDQHQWVHPLHUHFWLRQ LQÀDWDEOH QDWXUDOHUHFWLRQ 8. Orchitis:LQÀDPPDWLRQRIWKHWHVWHV6LJQVDQG6\PSWRPVSDLQVZHOOLQJHMDFXODWLRQRIEORRGKHPDWXULD
105
Treatment: Antibiotics (cephalosporins)
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XV. Neurological Function and Disorders
Disorders of the Eye and Ear
A. Terminology
B. Pathophysiology
C. Causative factors/ prevention
'&UDQLDOQHUYHVIXQFWLRQ UHYLHZSDJH
('LDJQRVWLFWHVWVSXUSRVHGHVFULSWLRQQXUVLQJLPSOLFDWLRQV
:KHQXVLQJ,9FRQWUDVWFKHFNDOOHUJ\WRLRGLQHRUVKHOO¿VK
/XPEDUSXQFWXUHOD\ÀDWKRXUVVXSLQHRUSURQHLQFUHDVHÀXLGVFKHFNVLWHIRUEOHHGLQJ &6)
OHDNDJHFRPSOLFDWLRQKHDGDFKH7HDFKDYRLGOLIWLQJ
((*EHIRUHSURFHGXUHZDVKKDLUQRPHWDOVLQKDLUDYRLGFDႇHLQH&OLHQWPD\QHHGWRVOHHSGXULQJWKH
WHVWPD\EHDVNHGWRGHFUHDVHVOHHSWKHQLJKWEHIRUH
(0*(OHFWURP\RJUDSK\±GHWHFWVQHXURPXVFXODUDEQRUPDOLWLHV
4. Myelogram: inject air or dye to check spinal cord and vertebrae
‡$IWHUWKHSURFHGXUHOD\ÀDWKRXUVLQFUHDVHÀXLGV
• If a water soluble dye is used elevate the head of the bed for 8 hours to keep the dye from
irritating the meninges.
5. CT scan and MRI: instruct to lie still, no metals
6. Cerebral angiography
F. Neurological assessment: nursing management
*ODVJRZFRPDVFDOH UHYLHZSDJH
2. Neuro check:
Perform every hour following head injury
Most important check is LOC & mentation
Change suggests deterioration in condition
3RVWXULQJ 'HFRUWLFDWHGDPDJHWRWKHFRUWH[RIWKHEUDLQ
'HFHUHEUDWHGDPDJHWRWKHPLGVWHPRIWKHEUDLQ
TIP: Safety is the minimization of risk factors that can cause injury or harm. When
prioritizing care, patient safety should be considered if the physiological integrity is
intact.
106
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G. Disorders Comparison of Common Neurological Disorders
Multiple Sclerosis
Pathophysiology:
:KRLVDႇHFWHG"
Symptoms:
Diagnosis:
Treatment:
•
Destruction of Myelin
•
•
•
•
•
<RXQJDGXOWV\HDUROGV
:RPHQDႇHFWHGPRUHWKDQPHQ
Primary: fatigue, depression, numbness, loss of balance, diplopia
MRI • Evoked potential studies (determine the extent of disease process)
Avonex
• Copaxone
• Rebif
• Beteseron
•
(Inferon beta1a)
•
Avoid hot baths
,QWHUIHURQEHWDE
•
(Glatiramer Acetate)
•
,QIHURQEHWDD
Parkinson’s Disease
Pathophysiology: •
•
•
Cause unknown
May be linked to environment, head trauma, chronic antipsychotic use
Decreased dopamine
:KRLVDႇHFWHG"
Symptoms:
Diagnosis:
•
•
•
0HQDႇHFWHGPRUHWKDQZRPHQ
• ¶V
*UDGXDORQVHWWUHPRUVDWUHVWULJLGLW\EUDG\NLQHVLDVKXႉLQJJDLWSLOOUROOLQJ
3DWLHQWKLVWRU\RXWRIFRPPRQV\PSWRPV
Treatment:
•
•
•
•
•
Control symptoms; Safety is the priority
Levodopa (sinemet) Use cautiously with glaucoma, avoid B6
Symmetrel (amantidine)
Eldepryl (seligiline)
&RPWDQ HQWDFDSRQH H[WHQGVWKHHႇHFWRIHDFKGRVHRI6LQHPHW OHYRGRSD
Amytrophic Lateral Sclerosis: Lou Gehrig’s Disease
Pathophysiology: • Loss of motor neurons
:KRLVDႇHFWHG"
• \HDUROGV
• 0HQDႇHFWHGPRUHWKDQZRPHQ
Symptoms:
• Fatigue, progressive muscle weakness, cramps, twitching
Diagnosis:
•
Based on signs and symptoms
Treatment:
•
•
•
•
Dopamine Agonists: Requip (ropinirole), Mirapex (pramipexole), Riluzole (rilutek)
Lioresal (baclofen), Dantrium (dantrolene): for muscle spasms
'HDWKLQ\HDUV
Supportive Care
•
EMG
•
MRI
Guillain Barre’ (Respiratory assessment is essential)
Pathophysiology: • Autoimmune attack of peripheral nerve myelin
:KRLVDႇHFWHG"
• Respiratory infection
Predisposing event may be:
• Vaccination
• G.I. Infection
• Pregnancy
• Surgery
Symptoms:
Diagnosis:
Treatment:
•
•
•
•
•
Ascending paralysis
Dyskinesia: inability to move voluntarily
Increased serum protein in CSF
(YRNHGSRWHQWLDOVWXGLHVVKRZORVVRIQHUYHFRQGXFWLRQ
Anticoagulants
• IVIG: intravenous immunoglobulin G
•
3ODVPDSKHUHVLV VLGHHႇHFWK\SRWHQVLRQ 107
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Alzheimer’s Disease
Pathophysiology: •
•
•
:KRLVDႇHFWHG"
•
•
Symptoms:
•
Diagnosis:
•
Cause unknown
Decreased acetylcholine
Microscopic plaque found in brain tissue
\RDႇHFWVPDOHVDQGIHPDOHVHTXDOO\
Prevent injury
*UDGXDOORVVRIFRJQLWLYHIXQFWLRQDSUD[LDFDQQRWSHUIRUPSXUSRVHIXO
movement, forgetfulness
Health history • Family history •
EEG • MRI • CT Scan
Treatment:
•
•
•
•
Tacrine (cognex)
Hepatotoxic
Exelon (rivastigmine)
Razadyne (galantamine)
•
•
•
•
•
$XWRLPPXQHDႇHFWVP\RQHXUDOMXQFWLRQ
Lack of acetylcholine
:RPHQ\HDUROGVPRUHIUHTXHQWO\WKDQPHQ
0HQ\HDUROGV
9ROXQWDU\PXVFOHZHDNQHVVLQFUHDVHVZLWKDFWLYLW\ H\HPXVFOHVDUHDႇHFWHG
¿UVW DYRLGFURZGV FRQVWLSDWLRQ
Initial: diplopia
0\DVWKHQLF&ULVLVOLIHWKUHDWHQLQJLIEUHDWKLQJPXVFOHVDUHLQYROYHG
Positive tensilon testFRQ¿UPVGLDJQRVLV
EMG
$QWLFKROLQHVWHUDVHDJHQWV0HVWLQRQ S\ULGRVWLJPLQH
Prostigmin (neostigmine): improves communication between the nerves and
the muscles S/E: abdominal pain, diarrhea, nausea
Plasmapheresis
IVIG: intravenous immunoglobulin G
6XUJHU\7K\PHFWRP\
Myasthenia Gravis
Pathophysiology:
:KRLVDႇHFWHG"
Symptoms:
Diagnosis:
Treatment:
•
•
•
•
•
•
•
•
•
•
•
•
•
Ĺ$FHW\OFKROLQH
Aricept (donepezil)
Namenda (memantine)
Supportive care
Huntington’s Disease
Pathophysiology:
•
Degeneration of neurons in certain areas of the brain
:KRLVDႇHFWHG"
•
•
•
•
&KLOGRI+XQWLQJWRQ¶V'LVHDVHSDUHQW
Autosomal dominant
Gene 50/50 chance
3HUVRQDOLW\FKDQJHVĻFRJQLWLYHDELOLW\GHSUHVVLRQEDODQFHSUREOHPV involuntary facial movements
/DWHVXGGHQMHUN\PRYHPHQWV&KRUHD
CT
MRI
Blood test for the gene
No cure: control symptoms, Klonopin (clonazepam), Haldol (haloperidol),
&OR]DULO FOR]DSLQH 3UR]DF ÀXR[HWLQH
Speech therapy
Symptoms:
Diagnosis:
Treatment:
•
•
•
•
•
•
•
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1. Increased intracranial pressure (ICP):FDQUHVXOWIURPRUFDXVHEUDLQLQMXU\an early sign is change in
/2&1RUPDO,&3UDQJHPP+J,QWUDYHQWULFXODUFDWKHWHUXVHGWRPRQLWRU,&3RUGUDLQÀXLG
• Monitor for Dilation of the pupil in one eye
• Increase in systolic blood pressure, bradycardia, wide pulse pressure (Cushings Triad)
3XOVH3UHVVXUH GLႇHUHQFHEHWZHHQV\VWROLFDQGGLDVWROLFSUHVVXUH
120 = 40 pulse pressure (normal)
80
Mannitol (osmitrol) is used to decrease cerebral edema - monitor urine output hourly
'HFDGURQ GH[DPHWKDVRQH LVDVWHURLGWKDWPD\DOVREHSUHVFULEHGIRUFHUHEUDOHGHPD
2. Meningitis:LQÀDPPDWLRQRIWKHOD\HUVFRYHULQJWKHEUDLQ
• Signs and Symptoms: lethargy, pale skin, fever, petechiae, nuchal rigidity, seizures, nausea,
vomiting, opisthotonos (spasm of the muscles causing backward arching of the head, neck, and
VSLQH .HUQLJ¶VRU%UXG]LQVNLVLJQ
• Dx: blood culture, spinal tap, CT scan of head
• Rx: IV antibiotics
• Droplet precautions
Encephalitis: infection of the brain
• Rx: Symptom relief
4. TIA : temporary loss of neural function: warns of impending CVA
CVA: sudden death of brain cells due to lack of oxygen, blockage or rupture of an artery.
• 6LJQVDQG6\PSWRPVGHSHQGRQSDUWRIWKHEUDLQDႇHFWHGPRVWFRPPRQV\PSWRPLVZHDNQHVVRU
paralysis of one side of the body.
• Rx: antihypertensives, anticoagulants, anticholesterol agents, thrombolytics, antiplatelet agents,
• supplemental O2
5. Cerebral aneurysm/ arteriovenous malformation: EDOORRQLQJRIDZHDNHQHGEORRGYHVVHOWKDW¿OOVZLWK
blood. RX: B/P control, surgery
6. 6HL]XUHGLVRUGHUV HSLOHSV\safety is the priority
Generalized seizures involves both hemispheres of the brain
Partial seizures involve a single area of the brain
Status epilepticus - VHL]XUHVODVWLQJPRUHWKDQPLQXWHVOLIHWKUHDWHQLQJ7;,99DOLXP GLD]HSDP RU
Ativan (lorazepam)
• 0HGV.HSSUD OHYHWLUDFHWDP PD\FDXVHZHDNQHVVYRPLWLQJ
• Topamax (topriamate) SE – dizziness, vision changes;
• Dilantin (phenytoin) – SE: discolors urine, gingival hyperplasia
• 6DEULO YLJDEDUWLQ WUHDWVFRPSOH[SDUWLDOVHL]XUHVRQO\LQSHRSOHZKRGRQRWUHVSRQGWRRWKHUPHGV
SE: permanent peripheral vision loss; suicidal thoughts
7. Trigeminal neuralgia: 5th cranial nerve disorder
8. Bells Palsy 7th nerve paralysis. 5HYHUVLEOHLQZHHNV(\HGURSVPD\EHSUHVFULEHG
9. Herniated disc (herniated nucleus pulposus): bulging of cushion between vertebrae of spine
• 5[UHVWKHDWLFHSK\VLFDOWKHUDS\DQWLLQÀDPPDWRU\DJHQWVVWHURLGV
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11. Spinal cord injury: Disrupts signal transmission to & from the brain. Log roll to stabilize the spine.
,QFUHDVHGULVNIRU$XWRQRPLF'\VUHÀH[LDUHVXOWVLQLQFUHDVHG%3OHDGLQJWRVWURNHDQGGHDWK,QMXULHVDW
levels of T6 or higher at risk. Avoid stimulating the bladder, the bowels, or the skin.
6LJQV RI DXWRQRPLF G\VUHÀH[LD LQFOXGH pounding headache, nausea, decreased pulse, profuse
diaphoresis, severe hypertension
Treatment: elevate HOB, eliminate the cause, notify MD
Level of injury
Functional ability
Self care capability
C 3 and above:
Inability to control muscles of
breathing
Unable to care for self; ventilator support
essential; usually rapidly fatal
C 4:
No upper extremity muscle
function; able to move neck
Unable to care for self
5HVSLUDWRU\GLႈFXOW\
C 5:
Neck movement, possible partial
strength of shoulder & biceps
Can propel electric W/C. may be able to feed
self with powered devices
C 6:
Muscle function in C5 level,
partial strength in wrist
C 7:
Can propel electric W/C. may be able to feed
self with powered devices; can write and care
for self, can transfer from chair to bed
Muscle function in C6 level,
Can propel W/C independently, can dress
SDUWLDOVWUHQJWKLQKDQG QR¿QJHU lower extremities with minimal assistance; can
muscle power)
drive car with hand controls
C 8: (nerve)
Muscle function in C7 level,
normal arm, hand weakness
Same as C7, activities easier
T 1 – 10:
Good upper extremity muscle
VWUHQJWKEDODQFHGLႈFXOWLHV
W/C ambulation: walk with long leg braces
T 11 and below:
Trunk and pelvis muscle function
intact
W/C not essential; may use crutches or canes
for ambulation
12. Basilar skull fracture:&6)RWRUUKHDUKLQRUUKHD
Battle’s sign (bruising and ecchymosis over mastoids)
Raccoon’s eyes (periorbital ecchymosis)
Fibromyalgia:FKURQLFPXVFOHVWLႇQHVVVSDVPVVHQVRU\FKDQJHVLQVRPQLD7[SDLQPDQDJHPHQW
14. Migraine headaches:LQÀDPPDWLRQDQGSDLQFDXVHGE\YDVRGLODWLRQWKDWFDXVHVWKHUHOHDVHRIFKHPLFDOV
IURPQHUYH¿EHUVDURXQGWKHODUJHDUWHULHVRIWKHEUDLQ
5[,PLWUH[ VXPDWULSWDQ =RPLJ ]ROPLWULSWDQ DFHWDPLQRSKHQRU16$,'¶VPD\DOVREHXVHG
Avoid sumatriptan and zolmitriptan with ischemic heart disease, uncontrolled HTN, stroke, TIA or PVD.
Use may make these conditions worse.
15. Tension headaches: associated with chronic contraction of the muscles of the neck and scalp.
Treatment: aspirin, ibuprofen, naprosyn, indomethacin, ketorolac
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H. Care of patient with eye disorders
Instillation of eye drops:
• Have client lie down or tilt the head back.
• :LWKWKHLQGH[¿QJHUSXOOGRZQWKHORZHUOLGRIWKHH\HWRIRUPDSRFNHW
• Drop the correct number of drops (wait about 1 minute between each drop) into the
• pocket made between the lower lid and eyeball.
• Do not squeeze the bulb too hard.
I. Diagnostic tests:
• Opthalmoscopy: visualization of the structures of the eye
• Visual acuity: Snellen chart
• Tonometer: test intraocular pressure
J. Common disorders
1. Cataracts:
2SDFLW\RIWKHOHQVOHDGVWRORVVRIVLJKW&OLHQWUHSRUWVDJODUH0RVWHႇHFWLYHWUHDWPHQWLVVXUJHU\
•
3UHRSPHGLFDWLRQVLQFOXGHP\GULDWLFV DWURSLQH DQGF\FORSHJLFV
•
3RVWRS
• ,QFUHDVHWKHKHDGRIWKHEHGGHJUHHV
• Teach to wear dark glasses while outdoors.
• 6LJQL¿FDQWVZHOOLQJRUEUXLVLQJLVDEQRUPDO
2. Glaucoma:
,QFUHDVHGLQWUDRFXODUSUHVVXUH QRUPDO REVWUXFWLRQRIWKHÀRZRIWKHDTXHRXVKXPRU VORZDQG
LQVLGLRXV ORVVRISHULSKHUDOYLVLRQ9LVXDO¿HOGWHVWGRQHWRDFFHVVIRUJODXFRPD
• Acute (closed angle): sudden onsetXVXDOO\XQLODWHUDOSDLQLQDQGDURXQGWKHH\HEOXUUHGYLVLRQ
QDXVHDYRPLWLQJDQGKDORV,QFUHDVHGLQWUDRFXODUSUHVVXUHPXVWEHUHOLHYHGDVVRRQDVSRVVLEOH
maintain supine position. Treatment: Diamox (acetazolamide), Timoptic (timolol), Prednisolone
• Chronic (open angle)WLUHGIHHOLQJLQWKHH\H³KDORV´DURXQGWKHOLJKWV
• Treatment includes: myotics (Pilocar), Diamox (acetazolamide), Mannitol, Isordil (isosorbide
dinitrate), Alphagan (brimonidine). Quiet, dark environment.
Retinal detachment: client reports visual gaps may report seeing ÀDVKLQJOLJKWV
• Pre op: place an eye patch.
• Post op: lie on operative side
4. Strabismus: both eyes unable to focus in the same direction; patch the good eye
5. Macular degeneration: loss of central vision - due to damage to the retina
6. Eye trauma: cover both eyes; never remove penetrating object
7. Diabetic retinopathy: can lead to blindness – refer to opthamology
8. Care of the prosthetic eye: review steps
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K. Therapeutic regimen
Related pharmacology
0LRWLFVFRQVWULFWWKHSXSLOSLORFDUSLQH SLORFDU 'LDPR[ DFHWD]RODPLGH
Mydriatics- dilate the pupil; Isopto Atropine (atropine)
Surgical intervention
L. Care of patient with ear disorders
M. Causes and prevention of hearing loss
N. Diagnostic tests: purpose, description, nursing implication
1. Rhomberg test: test to detect poor balance
2. Weber test: place tuning fork on top of the head. Client should be able to hear the sound
bilaterally.
5LQQHWHVWSODFHWXQLQJIRUNRQWKHPDVWRLGERQHDQGQHDUWKHHDU&OLHQWVKRXOGUHSRUW
that the sound is loudest near the ear as air conduction is greater than bone conduction.
O. Nursing management: nursing process
P. Common disorders
1. Hearing impairment
a. Presbycusis: hearing loss associated with aging
Hearing Aid: when not in use store in a clean, dry place, clean with a toothpick or pipe cleaner
0pQLqUH¶VV\QGURPH³0pQLqUH¶VLQWKHHDUV´
Signs and Symptoms:
RX:
• Vertigo
• Tinnitus
• Hearing loss
• Low sodium diet
• 'HFUHDVHÀXLG
• Place patient in quiet environment
• $YRLGFDႇHLQHDQGQLFRWLQH
• Meclizine (antivert)
• Benadryl (diphenhydramine)
• Atropine
• Valium (diazepam)
• Compazine (prochlorperazine)
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VI. Musculoskeletal Function and Disorders
A. Terminology
B. Pathophysiology
C. Causes and prevention of musculoskeletal disorders
D. Diagnostic tests: purpose, description, nursing implications
;UD\RIERQHVDQGMRLQWV
2. Bone scan – radioactive material injected to visualize bone
05,±QRPHWDOV±DVVHVVIRUSUHJQDQF\LPSODQWDEOHFOLSVSDFHPDNHUDELOLW\WRUHPDLQLQRQH
position 45 – 60 minutes. Remove NTG, nicoderm or birth control patches before procedure.
$UWKURVFRS\DSSO\LFHVZHOOLQJRNHOHYDWHWKHSDUWSRVWSURFHGXUH
$UWKURFHQWHVLVUHPRYDORIÀXLGIURPWKHMRLQW
E. Nursing management: nursing process including interventions to prevent
disabiity.
1. 3RVLWLRQLQJ3UHYHQWIRRWGURSDSSO\IRRWERDUG
2. Special equipment: Continuous passive range of motion (CPM)GHYLFH
Used to help achieve and maintain good joint motion after sugery
check the alignment and positioning frequently
LQVSHFWWKHVNLQIRUDQ\DUHDVRIUHGQHVVRULUULWDWLRQ
apply padding to protect the skin
UHVWWKHMRLQWE\WXUQLQJRႇWKHPDFKLQHDVSUHVFULEHG
&UXWFKZDONLQJPDQHXYHUV±NHHSHOERZVH[WHQGHGOLPLWÀH[LRQWRƕRUOHVV
4. Two, three and four point gait
•
Two point gait: move one leg together with one crutch
on & the opposite side.
•
Three point gait: one leg is not in use. Move both
FUXWFKHVWRJHWKHUZLWKWKHDႇHFWHGOHJ
Four point gait: move right crutch then left foot, move
left crutch then right foot (four separate movements)
When ambulatiQJVWDLUV7HDFK³8SZLWKWKHJRRGGRZQZLWKWKHEDG´
•
5. &DVW FDUH KDQGOH ZHW FDVW ZLWK WKH SDOP RI \RXU KDQG
support on a pillow, check peripheral circulation, fracture bed
SDQQHYHUXVHDKRWGU\HUFKHFNIRUKRWVSRWV LQÀDPPDWLRQ
Teach: do not stick foreign objects into cast
$PEXODWLRQZLWKZDONHU±:DONHUZLWKDႇHFWHGOHJ
&DQH:DONLQJFDQHVKRXOGEHSODFHGRQWKHXQDႇHFWHGVLGH
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F. Disorders
1. )UDFWXUHV25,) RSHQUHGXFWLRQLQWHUQDO¿[DWLRQ VXUJHU\GRQHWRVWDELOL]HDIUDFWXUHXVLQJQDLOVRU
screws.
2. Major complications
•
•
•
•
Fat embolism:XVXDOO\RFFXUVZLWKLQKRXUVEXWFDQWDNHXSWRGD\VDIWHUDEUHDNLQDÀDWRU
long bone
6LJQVDQG6\PSWRPVSHWHFKLDHLQFUHDVHGSDLQDQGVZHOOLQJ$VVHVVWKHS¶V
Arixtra (fondaparinux): anticoagulant given s/p hip fracture, hip or knee replacement
Compartment syndrome:GXHWRODFNRIFLUFXODWLRQSUHVVXUHPXVWEHUHOLHYHGLQKRXUVRU
permanent neurological damage may occur
The most common fracture in children are greenstick
A fracture of the femur will result in the leg being shortened, adducted, and externally rotated
&DUSDOWXQQHOV\QGURPHFRPSUHVVLRQRIWKHQHUYHFDXVHGE\UHSHWLWLYHPRYHPHQWRIWKHKDQG V
7UHDWPHQW16$,'¶VVSOLQW UHPRYHVHYHUDOWLPHVSHUGD\WRSHUIRUPGDLO\JHQWOHUDQJHRIPRWLRQ
exercises
4. Osteoporosis: deterioration of bone tissue that causes low bone mass, leads to fractures of
vertebrae and femur.
Risk factors:
•
•
•
+HUHGLW\
Decreased physical activity
Smoking/ alcohol
Findings:
•
•
•
Back pain (increases with activity and decreases with rest)
Pathological fractures
Decreased bone mass
Diagnosis:
•
Bone density studies
Interventions:
•
Estrogen replacement, Fosamax (aldendronate), Actonel (risendronate) or
•
•
•
Low body weight, less than 127 pound
Low calcium diet
3URORQJHGSUHPHQRSDXVDO
amenorrhea
Boniva (ibandronate), take with a full glass of water, on an empty stomach,
SDWLHQWPXVWUHPDLQXSULJKWIRUPLQXWHVDIWHUGRVH
(YLVWD UDOR[LIHQH 6(ZDWHUDQGVRGLXPUHWHQWLRQPRQLWRUZHLJKW %3
IUHTXHQWO\PRQLWRU/)7¶V
‡
+LJKSURWHLQKLJKFDOFLXPYLWDPLQ'GLHWOLPLWFDႇHLQHDQGDOFRKRO
‡
%UDFHIRUVSLQH &RUVHW3KLODGHOSKLD7D\ORU (QFRXUDJHZHLJKWEHDULQJ
exercises like dancing, walking, bicycling or swimming
5.
Paget’s Disease: excessive breakdown and formation of bone tissue; symptoms include constant
DFKLQJGHHSERQHSDLQVZHOOLQJRUMRLQWVWLႇQHVVHQODUJHGERQHVPD\FDXVHQHUYHFRPSUHVVLRQ
Ĺ$ONDOLQHSKRVSKDWDVH
5[16$,'¶V&DOFLWRQLQ FDOFLPDU KHDWRUPDVVDJH
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6. Bone tumors - may replace healthy tissue with abnormal tissue, resulting in fractures. Bone may be
primary site of cancer or as a result of metastasis. TX: Chemotherapy, radiation or surgery
Ollier DiseaseEHQLJQLQWUDRVVHRXVFDUWLODJLQRXVWXPRUVFDOOHGHQFKRQGURPDVSURQHWRIUDFWXUHV VKRUWHQHGOLPERQWKHDႇHFWHGVLGH7UHDWPHQW6XUJHU\WRSUHVHUYHWKHIXQFWLRQRIWKHOLPE
7. Amputation
Care of the patient after amputation
•
•
•
Assess stump, monitor for drainage color and amount
3RVLWLRQSDWLHQWZLWKQRÀH[LRQDWKLSRUNQHHWRDYRLGFRQWUDFWXUHV
Elevate stump for the ¿UVWKRXUVRQO\ place rolled blanket along outer aspect to prevent outward
rotation. Manage pain – Phantom limb pain is real
Stump care
•
•
•
•
Inspect for redness, blister, and abrasions
Wash stump with mild soap, rinse with water, pat dry
Avoid use of alcohol, oils and creams
Change bandages two or more times per day, avoid circular turns (acts as a turniquet)
8. Osteomyelitis: bone infection caused by bacteria or fungi – may be spread from infected skin or
infection from another part of the body. S/S – bone pain, fever, swelling, redness & warmth
Rx: IV antibiotics
9.
•
•
•
•
Gout: (gouty arthritis): elevated uric acid
Low grade fever, swelling of the joints, excruciating pain, renal stones
'HFUHDVHSXULQHLQGLHWIRXQGLQVKHOO¿VKOLYHUNLGQH\VZHHWEUHDGVDUGLQHVDQGDQFKRYLHV
Avoid scallops, haddock, bacon. Client can have chocolate
,QFUHDVHÀXLGVWR/LWHUVSHUGD\DONDOLQHDVKGLHW
Treatment: bedrest, heat or cold therapy; Colchicine, Allopurinol, Probenicid
Alkaline Ash diet: Use with Gout (increased uric acid)
,QFUHDVHVWKHS+UHGXFHVWKHDFLGLW\RIWKHXULQH
Foods to include:
Milk
Fruit except (cranberries, plums, and prunes)
Rhubarb
Most vegetables
Small amounts of beef, halibut, and salmon included
Acid Ash Diet Use with phosphate stones (increased calcium)
Decreases the pH – increases the acidity in the urine
• Whole grains
• Cheese
Foods to include:
•
Eggs
•
Pastries
•
Meat
•
Cranberries
•
Fish
•
Prunes
•
Poultry
•
Plums
•
Bread
•
Corn
•
Cereal
•
Legumes
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8. Arthritis
Rheumatoid Arthritis
Osteoarthritis
• \HDUVRIDJH
• Systemic
• Unknown cause with exacerbations and remissions
• ,QÀDPPDWLRQRIVPDOOMRLQWVRIKDQGVZULVWV IHHW
• 0RUQLQJVWLႇQHVV
• Pain decreases with activity
• Over 40 years of age
• Degenerative joint disease
• Obesity, genetic predisposition
• +HUEHUGHQ¶V1RGHV
Treatment
• ASA
• 16$,'¶V
• Steroids
• Humira (adalimumab)
• Plaquenil (hydroxychloroquine)
• Rheumatex, Trexall (methotrexate)
•(QEUHO HWDQHUFHSW VLGHHႇHFWVLQMHFWLRQVLWHSDLQ
Treatment
• 16$,'¶V
(nodes around distal interpharyngeal joints)
• %RXFKDUG¶VQRGHV QRGHRISUR[LPDOMRLQWV • weight bearing joints
• Pain increases with activity
• muscle relaxants
• immobilization
• cold packs
• weight loss
URI, headache
*Humira (adalimumab) & Enbrel (etanercept) can cause new infections or worsening of existing conditions
G. Therapeutic regimen
1. Traction: used to reduce and immobilize fractures, decrease spasms, and correct deformities.
Nursing interventions:
• maintain counter traction, the weights must hang free
‡3¶VREVHUYHIRUVLJQVRIWKURPERSKOHELWLV
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XVII. Immunology /Dermatology /Integumentary
A. Disorders of the immune system
,PPXQHGH¿FLHQF\
2. Hypersensitivity / allergy
B. Skin disorders
1. Infectious and parasitic skin disease:
a. diseases requiring contact isolation
2. Herpes zoster-Shingles:QHUYHLQIHFWLRQFDXVHGE\WKHFKLFNHQSR[9LUXVWKHUDVKFOHDUVLQDIHZ
ZHHNV5[=RYLUD[ DF\FORYLU DQGDQDOJHVLD'LVVHPLQDWHGGLVHDVHDLUERUQH FRQWDFWSUHFDXWLRQV
XQWLOOHVLRQVFUXVWRYHU/RFDOL]HGLQIHFWLRQLPPXQRFRPSURPLVHGDLUERUQH FRQWDFWRWKHUZLVH
standard
3. Acne:5HWLQ$UHWLQRLFDFLGDYRLGWKHVXQGRQRWXVHGXULQJSUHJQDQF\H[SHFWUHGQHVVDQGÀDNLQJ
when this medication is in use; salycillic acid may be prescribed.
4. Psoriasis: due to over production of skin cells characterized by thickening of skin with silvery plaques.
• Exacerbated by stress or change in climate
• Treatment: Treatment: Plaquenil (hydroxychloroquine), Humira (adalimumab), Enbrel
(etanercept), steroid ointments and sunlight
5. Terry’s nails: ¿QJHUQDLOVRUWRHQDLOVDSSHDUZKLWHZLWKD³JURXQGJODVV´DSSHDUDQFH2FFXUVZLWKOLYHU
failure, cirrhosis, DM, CHF, hyperthyroidism and or malnutrition.
6. Skin cancer: teach client to avoid the sun and tanning salons
7. BotR[± ERWXOLQXPWR[LQ$ – blocks the chemical signals that cause the muscles to contract. Results
LQVNLQWKDWDSSHDUVPRRWKHURUOHVVZULQNOHG6(SDLQ EUXLVLQJDWLQMHFWLRQVLWHUHGQHVVKHDGDFKHÀX
like symptoms, facial weakness or drooping.
• Teach: stop ASA, Warfarin & Heparin before procedure
0\REORF ULPDERWXOLQXPWR[LQ% treats severe cervical muscle dystonia (torticollis)
6LGH(ႇHFWVZHDNQHVVGLႈFXOW\VSHDNLQJVZDOORZLQJRUEUHDWKLQJGRXEOHYLVLRQEOXUUHGYLVLRQ
8. Steven Johnson Syndrome: severe form of erythema multiforme – an immune complex disorder
characterized initially by conjunctival burning and itching, fever, cough, malaise. (Flu like s/s)
• SJS typically involves the skin and the mucous membranes.
• 0LQRU SUHVHQWDWLRQV PD\ RFFXU VLJQL¿FDQW LQYROYHPHQW RI RUDO QDVDO H\H YDJLQDO XUHWKUDO *, DQG
lower respiratory tract mucous membranes may develop in the course of the illness.
• GI and respiratory involvement may progress to necrosis.
• Lesions (painful, red, purple rash; blisters) may occur anywhere, the palms, soles, dorsum of hands, and
H[WHQVRUVXUIDFHVDUHPRVWFRPPRQO\DႇHFWHG
• 7KHUDVKPD\EHFRQ¿QHGWRDQ\RQHDUHDRIWKHERG\PRVWRIWHQWKHWUXQN6-6LVDVHULRXVV\VWHPLF
disorder with the potential for severe morbidity and even death.
• /LQNHGWRWKHXVHRI$OEXWHUROV\UXSLQFKLOGUHQ16$,'¶V'LODQWLQ SKHQ\WRLQ VXOIDDQWLELRWLFVPDFUROLGHV
• Treatment is systemic. Treat rash like burns.
9. Sjorgen’s syndrome: autoimmune disorder which results in loss of lubrication.
Signs and symptoms: dry eyes, dry mouth.
Rx: Priority is to increase moisture±DUWL¿FLDOWHDUVVDOLYD
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XVIII. Care of the Client with HIV / AIDS
A. Cause: HIV is a retrovirus that integrates itself into the genetic material of the cell and changes the DNA.
3ULPDU\KRVWFHOOLVWKH&'O\PSKRF\WH,QFXEDWLRQSHULRGLVZHHNVWRPRQWKV'HFUHDVHGLPPXQH
system is evidenced by a decrease in CD4 count. Viral load tests and CD4 counts are done every three to
four months.
The viral load test measures the amount of HIV virus in the blood.
Low = 40 – 500 copies/ml High = 5,000 – 10,000 copies/ml
Untreated/uncontrolled = 1 million or more copies
0'EHJLQVPHGLFDWLRQVZKHQ&'LVDWRUOHVVGLVHDVHFODVVL¿HGDV$,'6ZKHQ&'JRHVEHORZ
200 and opportunistic infections occur.
‡(OLVDWHVWLVGRQH¿UVW:HVWHUQEORWFRQ¿UPV(OLVD
• PCR (polymerase chain reaction test) can be done to test viral load. Used on
infants.
• Methods to prevent infection – hand washing, avoid crowds,
neutropenic precautions etc.
• Pancytopenia occurs
B. HIV / AIDS medications: HAART±³+LJKO\DFWLYHDQWLUHWURYLUDOWUHDWPHQW´'HFUHDVHVWKHDPRXQW
of active virus in the blood stream
Nonnucleoside reverse transcriptase inhibitors6WRS+,9SURGXFWLRQDQGSUHYHQWVWKH
conversion of RNA to DNA
Viramune (nevirapine),Sustiva or Stocrin (efavirenz), Rescriptor (delavirdine),
Intelence (etravirene)
PRQLWRU&%& FKHPLVWU\UHQDODQGKHSDWRWR[LFGL]]LQHVV±WDNHDWQLJKW Nucleoside Reverse Transcriptase Inhibitors (NRTI’s) – inhibits DNA synthesis
AZT, Retrovir – (zidovudine) – anemia, monitor CBC,
Epivir – (lamivudine, 3TC)DYRLGIDWW\IRRGV
DDC– (zalcitabine) –causes hepatotoxicity
G7(stavudine) Zerit –peripheral neuropathy
Ziagen (abacavir) IHYHUUDVK19PDODLVH
9LGH[(didanosine)PD\FDXVHSDQFUHDWLWLVKHSDWRWR[LFJLYHRQDQHPSW\VWRPDFKOLYHU
damage
Protease inhibitors- prevents infection of new cd4 cells
Invirase 500 (saquinavir)– elevated liver enzymes, hyperglycemiaJLYHZLWKIRRG
Crixivan (indinavir) –take on an empty stomach; causes nephrolithiasis and
K\SHUELOLUXELQHPLDDYRLGZLWKJUDSHIUXLWMXLFH
Viracept QHO¿QDYLU FDXVHVGLDUUKHDLQFUHDVHGEOHHGLQJZLWKKHPRSKLOLD
Norvir – (ritonavir) – liver dysfunction, pancreatitis, arrthymias; refrigerate liquid
Kaletra (lopinavir/ ritonavir) – nausea, vomiting, diarrhea, monitor LFTs
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• Antivirals: Foscavir- (foscarnet) Treatment of CMV retinitis in HIV patients resistant to Acyclovir
SE: seizures, renal impairment, hypocalcemia, hypo/hyperphosphatemia, hypomagnemesia,
K\SRNDOHPLD PRQLWRUFUHDWLQLQHDQGHOHFWURO\WHV
• Multi-Class Combination Drugs
Atripla ± HIDYLUHQ] VXVWLYDPJ WHQRIRYLU YLUHDGPJ HPWULFLWDELQH (PWULYDPJ FRQWDLQVRQHQRQQXFOHRVLGHUHYHUVHWUDQVFULSWDVHLQKLELWRU 1157, DQGWZRQXFOHRVLGHUHYHUVH
transcriptase inhibitors (NRTIs) – Take once daily on an empty stomach
6LGH(ႇHFWVIUHFNOHVOLYHUG\VIXQFWLRQ
*Standard precautions when hospitalized
'LHWIRU+,9 $,'6SDWLHQWhigh protein, high calorie; liquids before meals, decrease residue
Interdisciplinary approach needed; support groups
C. Opportunistic infections
1. Bacterial: Mycobacterium complex
2. Fungal infection: candida albicans; yeast overgrowth – oral thrush, yeast vaginitis
5['LÀXFDQ ÀXFRQD]ROH
3URWR]RDO,QIHFWLRQVSQXHPRF\VWLVFDULQLL 3&3 5[%DFWULP WULPHWKRSULP
WR[RSODVPRVLV– transmitted through infected cat feces, eating raw or under cooked meats
Rx: Pyrimethamine & Sulfadiazine
cryptosporidiosis – oral fecal spread through contaminated water. Incubation 2 days – 2 weeks.
Rx: supportive, may be prescribed Mepron (atovaquone)
0DOLJQDQFLHVNDSRVLVDUFRPD1RQ+RGJNLQ¶VO\PSKRPDFHUYLFDOFDQFHUWHVWLFXODUFDQFHU
5. Management Guidelines for Occupational Exposure & Post Exposure Prophylaxis:
• Two or more PEP drug regimen for 4 weeks based on the level of risk of HIV transmission
• )ROORZXS+,9WHVWLQJDWPRQWKV
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XX. Care of the elderly a systemic approach
• Reproductive:
Females: ovulation and menstruation cease
Vaginal walls become thin and dry due to Llubrication & Lestrogen levels; may lead
WRDWURSKLFYDJLQLWLV LQÀDPPDWLRQ Males: Prostate may enlarge (PSA test, digital rectal exam)
• Endocrine:
Decrease in levels of estrogen
:HLJKWJDLQKRWÀDVKHVGLDEHWHVPHOOLWXVOLNHO\WRGHYHORS
Lower medication dosages may be required due to slower metabolism
• Cardiovascular:
Decreased cardiac output and circulation secondary to narrow blood vessels
• Digestive:
Sense of taste may be decreased
Increased constipation
Digestive system slows down
• Urinary:
8ULQHSURGXFWLRQLVOHVVHႈFLHQW0D\GHYHORSVWUHVVLQFRQWLQHQFH
• Respiratory:
Decreased breathing capacity, decreased PaO2 to 75mm
• Musculoskeletal:
Increased osteoporosis and arthritis common
Kyphosis – R/T loss of bone mass
Slower movements
Decreased muscle strength
• Sensory:
'LႈFXOW\VHHLQJREMHFWVFORVHSUHVE\RSLD
Cataracts common
+HDULQJPD\EHGLPLQLVKHGSUHVE\FXVLV
Foods have less taste
• Nervous:
Pain sensation decreases
Intelligence remains intact
Alteration in balance (priority is safety)
• Integumentary:
Increased sensitivity to cold; Skin discolorations are common
Hair looses color and thins. Skin dries and is less elastic
• Teach denture care: Brush and rinse dentures daily. Clean dentures over a
folded towel or a full sink of water. Use a denture cleanser (hand soap or mild dish
washing liquid can be used). When not in use, dentures should be placed in a
denture cleanser soaking solution or in water.
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XIX. Emergency Nursing
$ 5HYLHZSULQFLSOHVRI¿UVWDLG
B. Prevention of accidents
C. Checklist for evaluating accident and emergency patients OLDCART
Onset of symptoms, Location of problem, Duration of symptoms, Characteristics client used to describe
symptoms, Aggravating factors, Relieving factors, Treatment received before arrival
D. Review CPR:&KHVWFRPSUHVVLRQVRQHUHVFXHUIRUDOOSDWLHQWV
7KHQHZHVWJXLGHOLQHVGLFWDWHWKDWDE\VWDQGHUVKRXOGFRPSUHVVWKHYLFWLP¶VFKHVWWLPHVDPLQXWH
to a depth of about 2 inches. Rescue breathing is still recommended for children and anyone whose
cardiac arrest is likely due to oxygen deprivation. Sequence CAB (circulation, airway, breathing)
• ([WHUQDOGH¿EULOODWLRQ±WKHXVHRIDQXQV\QFKURQL]HGFRXQWHUVKRFNWRWKHKHDUW8VHGIRU
YHQWULFXODUGH¿EULOODWLRQRUSXlseless ventricular tacyhcardia
E. Control bleeding: apply tourniquet above injury
F. Shock:
• Electric: injury from electricty
• Hypovolemic: caused by inadequate blood volume
• Cardiogenic: associated with decreased cardiac output which results in decreased tissue perfusion
• DistributiveFDXVHGE\LQVXႈFLHQWLQWUDYDVFXODUYROXPHFDXVLQJK\SRWHQVLRQ
• Neurogenic: occurs after injury to the spinal cord. Major clinical signs hypotension and bradycardia
Treatment:
• Intropin (dopamine) - treats heart conditions, provides additional pumping strength to stimulate
the heart muscle. May also improve kidney blood supply. SE: N/V, headache, report dizziness
• IV Fluids
• Supplemental oxygen, protect airway
•
Neurogenic shock may need Atropine
G. Poisoning:
Teach to contact poison control
Activated charcoal blocks the absorption of poisons in the stomach
+ $QDSK\OD[LV%HQDGU\O(SLSHQDLUZD\PDQDJHPHQWLVWKHSULRULW\
I.
Animal bites:VQDNHVNHHSDUHDGHSHQGHQWQRWRXUQLTXHWVDYRLGFDႇHLQHRUVWLPXODQWV
Tetanus vaccination may be prescribed
J. Post-mortem care:
• Formal pronouncement of death may vary slightly by state.
• 7KHQXUVHV¶UROHLVWRUHPRYHDOOWXEHVLQWUDYHQRXVOLQHVDQGPRQLWRUVXQOHVVDQDXWRSV\LV
required or due to religious observance.
• Make the client appear clean and remove visible medical equipment from sight.
• Place a clean sheet over the body and do not cover the face.
• Allow family members to visit, assist in calling clergy and or funeral directors, as desired.
• Some family members may not want heath care providers to touch the deceased body immediately
after death.
• The next of kin will be responsible to make decisions regarding autopsy, organ and tissue donation,
and funeral preparations.
• 5LJRUPRUWLVVWLႇQHVVKRXUVDIWHUGHDWK/LYRUPRUWLVEOXLVKGLVFRORUDWLRQKRXUVDIWHUGHDWK
Algor mortis (algor—coldness; mortis—of death) is the change in body temperature following death.
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OVERVIEW OF PHARMACOLOGY
1. Chemical name: description of drug using chemistry composition
2. Generic name (non proprietary)
A. name assigned by government to drug; universal drug name
B. generic drug may have many trade names
Trade name (proprietary)
A. created by drug companies to sell a product
4. Rights of medication administration and safety
•
Right assessment, right drug, right dose, right time, right route, right patient, right education, right
documentation, right evaluation, the patient also has the right to refuse.
•
.Typically the generic name is listed on the exam. The trade name may be present, but less likely.
Pharmacology Essential Concepts:
•
Medications have several actions. When answering these questions always consider what the
GHVLUHGHႇHFWLVIRUWKDWSDUWLFXODUVLWXDWLRQ([DPSOHClonidine is a hypertensive drug that is
HႇHFWLYHLQWKHWUHDWPHQWRI$'+'RUDepakote (valproic acid) is used as a mood stabilizer or to
control seizures.
•
All medications can potentially alter more than one body function.
•
For each medication prescribed there is:
•
'HVLUHGHႇHFW±SUHGLFWDEOHRXWFRPH
•
6LGHHႇHFWV±XQGHVLUDEOHUHVSRQVHEXWXVXDOO\SUHGLFWDEOH
•
$OOHUJLFUHDFWLRQ±PD\RFFXUIROORZLQJWKH¿UVWGRVHEXWFDQRFFXUZLWK
subsequent dosing (hives, rash, wheezing, SOB, anaphylaxis)
•
'RVLQJPD\QHHGWREHDGMXVWHGEDVHGRQWKHSDWLHQW¶VDJHGLVHDVHSURFHVVNLGQH\RUOLYHU
function or route of administration.
•
(ႇHFWVRIPHGLFDWLRQXVHGLQFRPELQDWLRQ
•
$GGLWLYHHႇHFW±WZLFHWKHHႇHFW
•
6\QHUJLVWLFHႇHFW±PRUHWKDQWZLFHWKHHႇHFW
•
$QWDJRQLVWLFHႇHFW±GHFUHDVHGHႇHFWRIRQHRUERWKGUXJV
•
,GLRV\QFUDWLFHႇHFW±LPPXQHPHGLDWHGWR[LFUHVSRQVHWRWKHGUXJ
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Nursing responsibilities in medication administration
•
1HYHUDGPLQLVWHUPHGLFDWLRQZLWKRXWDSURYLGHU¶VSUHVFULSWLRQ
•
Check for accuracy of the prescription – do not administer medications that are not correctly
prescribed
•
Check results of therapeutic drug levels and report results as necessary
•
7KHQXUVHPXVWEHDZDUHRIWKHSXUSRVHGRVDJHUDQJHFRPPRQVLGHHႇHFWVDQGVSHFL¿F
SUHFDXWLRQVRUDVVHVVPHQWQHHGHGEHIRUHJLYLQJWKHPHGLFDWLRQLH9DVRWHF HQDODSULO FKHFN
B/P
•
&RQ¿UPSDWLHQWLGHQWLW\XVLQJWZRLGHQWL¿HUV QDPH ,'QXPEHULVDFFHSWDEOH$QDOHUWSDWLHQW
could also state their name and date of birth)
•
$VVHVVSDWLHQW¶VFRQGLWLRQEHIRUHDGPLQLVWUDWLRQIRUVLJQVWRKROGWKHGRVHDQGDIWHUGRVLQJWR
evaluate their response to therapy
•
Determine compatibility of prescribed medications; monitor for use of home or herbal remedies
•
,QFDVHRIDPHGLFDWLRQHUURUUHSRUWWR0'DVVHVVWKHSDWLHQWIRUWKHHႇHFWVRIWKHPHGLFDWLRQ
error; document in an incident report and on the chart
•
Time release drugs must not be crushed or chewed (swallow whole)
Abbreviations: EC, SR, Dur, CR, LA, XL, XR, Contin
• Three medication checks should be performed prior to administration
•
Promptly document medication administration and reactions if any
•
Teaching: instruct the patient and or family regarding safe use of medications, dietary
restrictions and assessments (i.e. b/p, pulse) for each medication prior to discharge so that they
will be prepared for self administration. Also teach regarding safe disposal of medications.
5. Commonly used Medications
7KHIROORZLQJLVDVPDOOUHSUHVHQWDWLRQRIYDULRXVW\SHVDQGFODVVL¿FDWLRQVRIPHGLFDWLRQV
)RFXVRQFODVVL¿FDWLRQVDQGFRPPRQVLGHHႇHFWV
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Antihypertensives ±ORZHU%3DQGLQFUHDVHEORRGÀRZWRWKHKHDUW
Angiotensin Converting Enzyme Inhibitors
Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus
&RPPRQ6LGH(ႇHFWV
Drug Name
Generic Drug Names
Vasotec
• Enalapril
Zestril
Prinivil
• Lisinopril
Altace
• Ramipril
Capoten
• Captopril
Monopril
• Fosinopril
Accupril
• Quinapril
Lotensin
• Benazepril
Drug Name
Excrete Sodium & Fluid
Generic Drug Names &RPPRQ6LGH(ႇHFWV
Cough
Anaphylaxis
Palpitations
Taste changes
Orthostatic Hypotension
Potassium increase
Renal impairment
Impotence
Leukocytosis
Nausea, vomiting, dry mouth
Headache, Dizziness
$QJLRHGHPD6WHYHQ-RKQVRQ¶V6\QGURPH
Monitor blood pressure, BUN & creatinine, electrolytes and WBC
Nursing Implications:
Contraindicated in pregnancy, avoid NSAID’s
REMEMBER: ACE Inhibitor side effects = CAPTOPRIL
Diuretics
Loop Diuretics: Potassium Depleting
%XPH[
Edecrin
• Bumetanide
• Ethacrynic acid
/DVL[
• Furosemide
'HPDGH[
• Torsemide
Hypotension
Hypokalemia
Tinnitus
Photosensitivity
Hyponatremia
Constipation
Increased BUN
Hyperglycemia
Thiazide Diuretics: Potassium Depleting
Hydrodiuril
• Hydrochlorothiazide
=DUR[RO\Q
Diuril
• Metolazone
• Chlorothiazide
Hypotension
Hypokalemia
Photosensitivity
Hyponatremia
Headache
Hyperglycemia
BUN, K+ & glucose levels. Monitor intake and output
Nursing Implications: Monitor
Teach: increase potassium in diet
Potassium Sparing Diuretics
Aldactone
• Spironolactone
Dyrenium
• Triamterene
Hyperkalemia
Constipation
Menstrual irregularities
Headache
Dizziness
Muscle cramps
Nursing Implications: 0RQLWRUHOHFWURO\WHV'HFUHDVHSRWDVVLXPLQWKHGLHW
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Calcium Channel Blockers
Treatment of Angina & Hypertension
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Calan, Isoptin
• Verapamil
Procardia
• Nifedipine
Cardizem
• Diltiazem
Plendil
• Felodipine
Norvasc
• Amlodipine
• Hypotension
• Headache
• Peripheral edema
• GI upset
• Flushing
• Syncope
Nursing Implications:
Teach –report ankle edema, avoid operating machinery, avoid
grapefruit juice
Beta Adrenergic Blockers- OLOL Drugs
Management of hypertension, angina pectoris, congestive heart failure & MI prevention
Drug Name
Generic Drug Names &RPPRQ6LGH(ႇHFWV
Tenormin
• Atenolol
Hypotension
Inderal
• Propranolol
Bradycardia
Cogard
• Nadolol
Lopressor, Toprol
• Metoprolol
Hyperglycemia KCHF KPVD
Coreg
• Carvedilol
Bronchospasm
Dizziness
Impotence, diarrhea, nausea
Check pulse before administration
Monitor blood glucose in diabetics
Administer with food
Nursing Implications:
Taper dose to discontinue
Contraindications ABCDE- asthma, heart block, cardiac failure, DM
(hypoglycemic shock), extremities (occlusive arteries)
Vasodilators
Relax the smooth muscles in the blood vessel
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Apresoline
• Hydralazine
Palpitations
Headache
• Nitroprusside
Tachycardia
Diaphoresis
• Nitroglycerin
• Isosorbide mononitrate
• Isosorbide dinitrate
Hypotension
Syncope
Dizziness Pallor
Weakness
Nipride
Tx for hypertensive crisis
Nitrostat
Imdur
Isordil
$SUHVROLQH K\GUDOD]LQH WDNHZLWKIRRG
Nipride (nitroprusside): protect from light, continuous EKG & B/P monitoring
Nursing Implications:
1LWURVWDW QLWURJO\FHULQ IRUVXEOLQJXDOXVHGRQRWVZDOORZZKROHWDEOHWV
good for 3-6 months
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Alpha Agonists
'HFUHDVHVWKHH௺HFWRI'RSDPLQHRQEORRGSUHVVXUH
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Catapres
• Clonidine
Aldomet
• Methyldopa
Postural hypotension
Impotence
Drowsiness
Dry mouth
Angiotensin II Receptor Blockers
Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus
Diovan
• Valsartan
Cozaar
• Losartan
Atacand
• Candesartan
Nursing Implications:
Monitor BUN/ Creatinine and electrolytes. Cozaar prescribed P.O.
Hypotension
Hyperkalemia
Angioedema
Cough
Renal Dysfunction
Alpha 1 Receptor Blockers
Used in the treatment of BPH and HTN
Hypotension
Palpitations
Blurred vision
Nausea
Diarrhea
Dizziness
Light headedness
Edema
Dry mouth
Cardura (BPH & HTN)
• Doxazosin
Minipres (HTN)
• Prazosin
Hytrin (BPH & HTN)
• Terazosin
)ORPD[(BPH)
• Tamulosin
Nursing Implications:
Administer dose at bedtime, monitor B/P, assess for edema
Teach avoid operating machinery
Cardiac Glycosides
7UHDWDWULDO¿EULOODWLRQDWULDOÀXWWHUDQG&+)
Drug Name
Generic Drug Names &RPPRQ6LGH(ႇHFWV
Fatigue
Bradycardia
Anorexia
Nausea & vomiting
/DQR[LQ
Headache
Diarrhea
• Digitoxin
Visual changes
Monitor apical pulse for 1 full minute
Do not give if pulse is: less than 60 in an adult
less than 90 in a child
Nursing Implications:
less than 70 in an older child
Monitor electrolytes – hypokalemia, hypomagnesemia & hypercalcemia
increase risk of toxicity
• Digoxin
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Anticoagulants
Prevent blood clotting
Heparin (injectable only) prevents the conversion of prothrombin to thrombin
Drug Name
Generic Drug Names &RPPRQ6LGH(ႇHFWV
Heparin
Bleeding (remember other words & signs that indicate
bleeding)
/RYHQR[
• Enoxaparin
Fragmin
• Dalteparin
7KURPERF\WRSHQLD,QFUHDVHG/)7¶V
Nausea
Diarrhea
Coumadin
• Warfarin PO/IV
Hemorrhage
5RXWLQHPRQLWRULQJRI37,15$YRLG27&PHGV KHUEDOSURGXFWV
Heparin – Monitor PTT/INR
Coumadin (warfarin) – Monitor PT/INR
Nursing Implications: Fragmin (dalteparin)/ Lovenox (enoxaparin) – Monitor CBC - pt at risk for
H.I.T. (heparin induced thrombocytopenia)
Teach patient to monitor for signs of bleeding
&RXPDGLQOLPLWFDEEDJH JUHHQOHDI\YHJHWDEOHVDYRLGFD௺HLQH (72+
Antiplatelets
Prevent clot formation by blocking platelet aggregation
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
3ODYL[
• Clopidogrel
Bleeding
Ticlid
• Ticlopidine
Aggrastat
• 7LUR¿EDQ
Nausea
Upset stomach
Stomach pain
Diarrhea
Persantine
• Dipyridamole
Rash and itching
Headache
$JJUHQR[
• Dipyridamole + ASA Drowsiness
(remember other words & signs that indicate bleeding)
Avoid if allergic to aspirin, ibuprofen or naproxen
Hold 7-10 days before surgery
Use caution during activities requiring alertness (such as driving a car)
Nursing Implications: Teach: Monitor for signs of bleeding
Do not use any other over-the-counter medication
Avoid use of aspirin, salicylates, and NSAID’s while taking these medications
Avoid in pregnancy
Hemostatics
Used to control bleeding when blood clots are broken down too quickly
3UHVFULEHGIRUDFXWHOLIHWKUHDWHQLQJKHPRUUKDJHGXHWRK\SHU¿EULQRO\VLV
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Amicar
• Aminocaporic Acid
Nausea, vomiting, diarrhea, cardiomyopathy
Nursing Implications: Taken once an hour for about 8 hours or until the bleeding is controlled
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Antibiotics
Used to treat infection
Category
Penicillin’s
Cephalosporins
Aminoglycosides
(Mycin’s)
Tetracyclines
Anti-tubercular
Agents
Drug Name
Penicillin
Amoxil (Amoxicillin)
Omnipen (Ampicillin)
.HÀH[ &HSKDOH[LQ
Rocephin (Ceftriaxone)
Zinacef/Ceftin (Cefuroxime)
Vantin (Cefadoxime)
Fortaz (Ceftazidine)
Tobramycin
Amikacin
Neomycin
Gentamicin
Streptomycin
Tetracycline
Vibramycin (Doxycycline)
INH (Isoniazid)
Rifadin (Rifampin)
Ethambutol
&LSUR &LSURÀR[DFLQ
Fluoroquinolones
$YHOR[ 0R[LÀR[DFLQ
/HYDTXLQ /HYRÀR[DFLQ
)OR[LQ 2ÀR[DFLQ
Flagyl (Metronidazole)
Macrobid (nitrofurantoin)
Macrodantin, Furadantin
Tx for: UTI
Antibacterial
Gantrisin
DFHW\OVXO¿VR[D]ROH (pediatric suspension) Tx for:
&RPPRQ6LGH(ႇHFWV
Nausea, vomiting, diarrhea,
super infection (candidiasis)
'LDUUKHDIXUU\WRQJXHDQHPLDĹ/)7¶V
Oto, neuro & nephro toxicity
Photosensitivity, tinnitus
Peripheral neuropathy, hepatotoxicity,
discolors the urine & contact lenses, visual
disturbances, precipitation of gout
Tendonitis & tendon rupture, nausea, vomiting,
GLDUUKHDUDVKĹ/)7¶VKHDGDFKHSKRWRVHQVLWLYLW\
,QFUHDVHH௺HFW avoid with theophylline,
&RXPDGLQJO\EXULGHGLODQWLQFDႇHLQHVWHURLGV
diuretics, cardiac meds (quinidine, amiodarone,
betapace, bretylluim)
'HFUHDVHH௺HFW antacids, multivitamins, iron
'DUNUHGEURZQXULQHPHWDOOLFWDVWH
FDQGLGLDVLVSHULSKHUDOQHXURSDWK\ĹHႇHFWRI
coumadin
CHRONIC PULMONARY REACTIONS,
GI upset, FGLႈFLOH, dizziness, pruritis, fever,
MDXQGLFHDQJLRHGHPD6WHYHQ-RKQVRQ¶V
syndrome
acute, recurrent or chronic UTI
Zyvox (linezolid)
Tx for: VRE, PNA or complicated
skin infections
Macrolides
Zithromax (Azithromycin)
Biaxin (Clarithromycin)
E’mycin (Erythromycin)
Cleocin (Clindamycin)
Pancytopenia, N/V/D, fever, URI,headache
Nausea, vomiting, diarrhea, thrombocytopenia,
abdominal pain, taste changes, super infection,
6WHYHQ-RKQVRQ¶VV\QGURPH
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Nursing Implications for Antibiotics:
• Patients should be instructed to complete the full course of therapy
• $YRLG&HSKDORVSRULQVLQFOLHQWVDOOHUJLFWRSHQLFLOOLQJLYHP\FLQWHWUDF\FOLQHRUPDFUROLGHGUXJV
• &HSKDORVSRULQVLQFUHDVHULVNIRU&'Lႇ*LYHKRXUVEHIRUHPHDOV
• Mycin drugs –monitor BUN/Creatinine; Monitor peak and trough levels at the third or fourth dose
• Do not give Tetracycline to pregnant women and children under the age of 8 – stains the teeth.
7DNHRQDQHPSW\VWRPDFK KRXUVDIWHUPHDOV 'RQRWWDNHZLWKDQWDFLGVPLONRU\RJXUW
• 7DNH'R[\F\FOLQHZLWKDIXOOJODVVRIZDWHU±UHPDLQXSULJKWIRUPLQXWHV
• 7DNH32&,352 FLSURÀR[DFLQ HLWKHUKRXUVEHIRUHRUKRXUVDIWHUWDNLQJDQWDFLGVPXOWLYLWDPLQVRU
iron. Do not take with milk or yogurt, take on an empty stomach with a full glass of water
• 7DNH0DFURELG PDFURGDQWLQ ZLWKIRRGWRLPSURYHDEVRUSWLRQDQGSUHYHQW*,VLGHHႇHFWV
• Give INH (Isoniazid) with vitamin B6 to prevent peripheral neuropathy
• Zyvox (linezolid) – monitor CBC Q week; avoid foods containing tyramine
• TB medications may be given in combination to prevent resistance
• Avoid ETOH with Flagyl (metronidazole)
Iron preparations
Treats anemias
32XVHDVWUDZWRSUHYHQWVWDLQLQJWKHWHHWK
&RPPRQ6LGH(ႇHFWV
,QFUHDVHYLWDPLQ&KHOSVZLWKDEVRUSWLRQ
,0LQMHFWLRQVVKRXOGEHJLYHQXVLQJWKH=WUDFN GI distress, headache, N/V, constipation, peptic ulcers
method.
$YRLGXVHZLWKDQWDFLGVFRႇHHWHDGDLU\SURGXFWV
eggs or whole grain bread within one hour after iron
Nursing Implications:
/D[DWLYHV
Induces bowel evacuation; treatment of constipation
Type
Drug Names
&RPPRQ6LGH(ႇHFWV
Bulk Forming
Agents
Metamucil (psyllium)
Citrucel
Abdominal fullness; minor bloating
Stool softeners
Surfactants
Colace (docusate)
A bitter taste or throat irritation,
skin rash, diarrhea or mild nausea
Lubricants
Emollients
Mineral oil
Stomach pain, nausea & vomiting,
abdominal pain
Hydrating
Agents
Citroma (magnesium citrate)
0LONRI0DJQHVLD PDJQHVLXPK\GUR[LGH
Epsom salt (magnesium sulfate)
Stomach pain
Gas
Hyperosmotic
Agents
Lactulose, Sorbitol
Glycerin Suppositories
Hyperglycemia, diarrhea
Nausea
Diarrhea
'XOFROD[ ELVDFRG\O Dehydration, dizziness, severe
diarrhea, abdominal cramps
([/D[ VHQQD Monitor for electrolyte imbalance
Metamucil (psyllium): take with 8 ounces of water
Nursing Implications:
Lactulose may be used to decrease ammonia levels in clients
with hepatic encephalopathy
Teach: report rectal bleeding
Stimulants
Irritants
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Steroids
8VHGWRVXSSUHVVLQÀDPPDWLRQ±32,9,QKDOHG7RSLFDO
&RPPRQ6LGH(ႇHFWV
Drug Name
Hyperglycemia
Growth retardation
Hypokalemia
Prednisone
Solumedrol (methylprednisolone) Mood changes
Hirsuitism
Hypertension
Beclovent (beclamethasone)
,QFUHDVHG,23&XVKLQJ¶V'LVHDVH6NLQWKLQQLQJ
Pulmicort (budesonide)
Immune suppression
Menstrual irregularities
Acne
Azamacort (triamcinolone inhaled)
Delayed
wound
healing
Kenalog (triamcinolone topical)
Administer with or after meals
Client teaching: taper dose, wear medic alert, avoid stress, report fever &
Nursing Implications: weight gain, monitor frequent weights, increase potassium & protein in diet,
monitor glucose, rinse mouth after use of inhaled steroid to avoid oral thrush
Topical agents - contact dermatitis, hypopigmentation & maceration
Antiparkinson Agents
Increase dopamine in central nervous system
'RSDPLQHUJLFDJHQW±VWLPXODWHVGRSDPLQH
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Sinemet
• Levodopa
• Carbidopa-Levodopa
Nausea, vomiting, anorexia, dry mouth,
headache, urinary retention, anxiety, blurred
vision, dyskinesias
Nursing Implications:
Use with caution in clients with glaucoma, monitor liver function
Teach: Use caution when operating machinery
May discolor saliva, urine or sweat red, brown or black
Chemotherapeutic Agents
Used to destroy tumor cells
Category
Akylating agents
Antimetabolites
Drug Names
Carboplatin
Cisplastin
&RPPRQ6LGH(ႇHFWV
)8ÀXRURXUDFLO
Bone marrow suppression
CNS damage
Antitumor antibiotics Bleomycin
Bone marrow suppression
Chills, confusion
Plant alkaloids
Vinblastine
Vincristine
Selective estrogen
receptor blockers
7DPR[LIHQ
Pancytopenia, immunosuppression, bone marrow
suppression, N/V/D,
alopecia, hepatotoxicity, neuropathy
Increased risk of uterine CA, blood clots
or stroke
&\WR[DQ
Development of secondary Cancer
0RQLWRUSDWLHQWVIRUSRWHQWLDOWR[LFVLGHHႇHFWVGXULQJWKHQDGLUSHULRG
1DGLU±GD\VDIWHUFKHPR
Nursing Implications:
Contraindicated in pregnancy – teach to use birth control
Handle with gloves
130
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Gastro-Intestinal Meds
Category
&RPPRQVLGHHႇHFWV
Drug Name
Prevacid
(lansoprazole)
Nausea
Anorexia
Headache
Prilosec
(omperazole)
1H[LXP HVRPHSUD]ROH Urinary retention
Blurred vision
3URWRQL[ SDQWRSUD]ROH
Proton Pump Inhibitors
Reduce gastric acid production
$FLSKH[ UDEHSUD]ROH H2 Receptor Blockers
Inhibits gastric acid production
Tagamet
(cimetidine)
Zantac
(ranitidine)
Pepcid
(famotidine)
$[LG QL]DWLGLQH Amphogel (aluminum based)
Antacids
$OXPLQXP+\GUR[LGH
Neutralize the acid in the stomach 0\ODQWD0DDOR[
Malaise
Pancytopenia
Headache
Vomiting
Dry mouth
Dyskinesias
Anxiety
Constipation
Dizziness
Diarrhea
Constipation, Bloody stools,
Diarrhea
(aluminum-magnesium based)
Zofran (ondansetron)
Kytril (granisetron)
Antiemetics
Prevention and treatment of
nausea and vomiting
Headache
Heartburn
used to treat N/V associated with
Diarrhea
chemo or radiation therapy
Reglan (metoclopramide)
Phenergan (promethazine)
Nursing Implications:
Weakness
Constipation
Dizziness
Drowsiness
Dry mouth
Extrapyramidal reactions
Neuroleptic Malignant Sydrome
Dizziness
Blurred vision
Constipation
$QWDFLGV33,¶V+UHFHSWRUEORFNHUPD\GHFUHDVHH௺HFWVRI
antibiotics – separate dose by 6 hours after or 2 hours before
antibiotic administration (especially CIPRO).
7HDFKDYRLGKLJKSURWHLQ FD௺HLQHLQWKHGLHWZKLOHWDNLQJ+
blockers (increases acid), avoid smoking
Teach: PPI’s do not crush or chew
Teach to use caution with the following drugs while taking H2
blockers or proton pump inhibitors: Theophylline, Coumadin
(warfarin),Dilantin (phenytoin), prescription medication for fungal
or yeast problems, Valium (diazepam), digoxin, propanolol, and
Calcium Channel Blocker’s
Monitor for extrapyramdial reactions with antiemetics & PPI’s
0DJLFPRXWKZDVK %HQDGU\O 0DDOR[/LGRFDLQHPD\EHDGGHG XVHGIRUVRUHWKURDWDQGPRXWKVRUHV
131
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Cholesterol Lowering Agents
Treatment of atherosclerosis
Type
Statins
HMG- COA reductase
inhibitors
Drug Names
• Zocor (simvastatin)
• Lipitor (atorvastatin)
• Pravachol (pravastatin)
• Mevacor (lovastatin)
• Crestor (rosuvastatin)
• Caduet (amlodipine/atrovastatin)
• Vytorin (simvastatin/ezetimibe)
• Adicor (lovastatin/niacin)
• Questran (cholestyramine)
• Zetia (ezetimibe)
Bile Acid
Sequestrants
Nursing Implications:
• /RSLG JHP¿EUR]LO
•
B3 (niacin)
•
Welchol (colesevelam)
decreases LDL and HgbA1c
&RPPRQ6LGH(ႇHFWV
Headache
Dizziness
Nausea
Diarrhea
Muscle pain
Fever
Liver damage (jaundice, RUQ
3DLQGDUNXULQHHOHYDWHG/)7¶V
FRQVWLSDWLRQGLDUUKHDDQGÀDWX
lence bad taste in the mouth
abdominal pain, back pain, diar
rhea, joint pain, sinusitis, liver
disease
headache, constipation, vertigo,
rash, eczema, nausea and/or
vomiting, fatigue and diarrhea,
dyspepsia
ÀXVKLQJ KRWÀDVKHVQDXVHDLQ
digestion, gas, vomiting & diarrhea
dyspepsia
Statins contraindicated in pregnancy, give at night, avoid grapefruit juice,
monitor LFT’s. Questran (cholestyramine): mix with water or juice
/RSLG JHP¿EUR]LO *LYHPLQXWHVEHIRUHPHDOV%,'
Antipyretics
Reduce fever
Drug Name
&RPPRQ6LGH(ႇHFWV
Tylenol (acetaminophen)
Liver damage; nausea, urticaria, rash, jaundice
Aspirin
Nursing Implications:
GI upset, nausea
6HYHUHDOOHUJLFUHDFWLRQV UDVKKLYHVLWFKLQJGLႈFXOW\EUHDWKLQJWLJKW
ness in the chest; swelling of the mouth, face, lips, or tongue); black or
bloody stools; confusion; diarrhea; dizziness; drowsiness; hearing loss;
ringing in the ears; severe or persistent stomach pain; unusual bruising;
vomiting. Reyes syndrome in children; respiratory alkalosis with toxicity.
Monitor LFT’s
Avoid with alcohol
Antidote for acetaminophen toxicity - Mucomyst (acetylcysteine)
3 GM/ day maximum dose
7HDFKWDNH$6$ZLWKPHDOVUHSRUWVLJQVRIEOHHGLQJ
132
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Antihistamines
Used to block the release of histamine in allergic reactions
Drug Name
Generic Drug Names
&RPPRQ6LGH(ႇHFWV
Benadryl
• Dipenhydramine
Claritin
• Loratidine
Zyrtec
• Cetirizine
$WDUD[
• Hydroxyzine
Dry mouth, nose, and throat
Drowsiness
Fatigue
Headache
Sleepiness
Dizziness
Nausea and vomiting
Constipation
Nursing Implications:
Teach: Avoid activities requiring mental alertness.
1RWLI\0'IRUYLVLRQSUREOHPVGLႈFXOW\XULQDWLQJRUSDLQIXOXULQDWLRQ
Anticholinergics
Inhibit parasympathetic nerve impulses by blocking the action of acetylcholine
Drug Name
Generic Drug Names
Atrovent
Atropine
(QDEOH[
used to treat overactive bladder
Nursing Implications:
&RPPRQ6LGH(ႇHFWV
:RUVHQLQJRIQDUURZDQJOHJODXFRPD
Mydriasis
Acute eye pain
Hypotension
Palpitations
• Ipratropium bromide
Urinary retention
Tachycardia
Constipation
Bronchospasm
Paradoxical bronchospasm
Dry mouth
Blurred vision
Photophobia
Tachycardia
Blurred vision
• Darifenacin
Decreased sweating leads to over
used in overactive bladder
heating
Teach: medications cause the mucous membranes to become dry,
take with a full glass of water
Atropine- avoid with hepatitis, glaucoma, gastrointestinal obstruction,
decreased liver or kidney function
Use caution when driving, operating machinery, or performing other
hazardous activities
Avoid use of ETOH
133
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Anticonvulsants/Benzodiazepines
Used to manage seizure disorders/anxiety disorders
&RPPRQ6LGH(ႇHFWV
Drug Name
Generic Name
Klonopin
• Clonazepam
Valium
• Diazepam
Librium
• Chlordiazepoxide Slurred speech
Ativan
• Lorazepam
Dalmane
• Flurazepam
Dilantin
• Phenytoin
Tegretol
• Carbamazepine
Drowsiness
Lethargy
Hypotension
CNS depression
Gingival hyperplasia
Hypoglycemia (in DM)
Mild skin rash or itching
Dizziness, nervousness
Discolored urine
Over dose symptoms may include:
Twitching eye movements
Slurred speech
Loss of balance
Tremors
Fainting
Nausea & vomiting
)HHOLQJOLJKWKHDGHG
Slow or shallow breathing
0XVFOHVWLႇQHVVRUZHDNQHVV
Dizziness
Drowsiness
Dry mouth
Nausea
Aplastic anemia
Sleepiness
Keppra
• Levetiracetam
Weakness
Dizziness
Infection
Rash
Lamictal
• Lamotrigene
Dizziness
Headache
Nursing Implications:
Avoid with liver disease and DM. Avoid alcohol
Do not chew or crush tablets.
Avoid taking antacids at the same time with Dilantin (phenytoin) - inhibits
absorption
Tegretol (carbamazepine) - take with meals, avoid grapefruit juice
Monitor LFT’s, monitor CBC
7HDFK$QWLFRQYXOVDQWGUXJVVKRXOGQRWEHVWRSSHGDEUXSWO\ZHDUDPHG
DOHUWEUDFHOHWUHSRUWHDV\EUXLVLQJIHYHURUEORRGLQWKHVWRRO
Romazicon (Flumazenil) - antidote to benzodiazipines
134
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Narcotics/analgesics
Used to relieve moderate to severe pain
Drug Name
Generic Name
&RPPRQ6LGH(ႇHFWV
NARCOTICS
Morphine
Duragesic
• Fentanyl
*Risk of dependency
CNS depression
Nausea and vomiting
Dry mouth
Pinpoint pupils
Itching
Rash
Demerol
• Meperidine
Hives
Dilaudid
• Hydromorphone
Diaphoresis
NSAID’s
Motrin
• Ibuprofen
Indocin
• Indomethacin
Naprosyn
• Naproxen sodium
&HOHEUH[
• Celecoxib
Feldene
• Piroxicam
Nausea
Epigastric pain
Heartburn
Diarrhea
Headche
Dizziness
Vertigo
Hypertension
Oliguria
Rash
Gastric or duodenal ulcer with bleeding
OPIODS
Ultram
Respiratory depression
Dizziness
• Tramadol
Nausea
Constipation
TRIPTANS
Prescribed for migraine headaches
,PLWUH[
Zomig
• Sumatriptan
• Zolmitriptan
Hypotension
Syncope
Tinnitus
Dry mouth
Photophobia
SKELETAL MUSCLE RELAXANTS
Drowsiness
Soma
• Carisoprodol
5RED[LQ
• Methocarbamol
)OH[HULO
• Cyclobenzaprine
Nursing Implications:
1DUFRWLFV5HSRUWSUREOHPVXULQDWLQJVXFKDVSDLQGL௻FXOW\XULQDWLQJIUHTXHQW
urge to urinate, or decreased urine output, constipation, headache, diplopia,
nightmares may be sign of overdose - Antidote: Naloxone
Avoid with other meds causing CNS depression (MAOI’s, antihistamines,
PXVFOHUHOD[DQWV )HQWDQ\OGLVFDUGSDWFKE\IROGLQJHGJHV ÀXVKLQJ
NSAID’s – Take with food, Mointor for signs of bleeding, avoid use of ASA and
DQWLFRDJXODQWVDYRLGRSHUDWLQJPDFKLQHU\&RQWUDLQGLFDWHG63&$%*
Opiods – taper dose to discontinue
Triptans: avoid with ischemic heart disease, uncontrolled HTN, stroke, TIA or
PVD
Asthma attacks
Psychological dependence
Nausea
135
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Osteoporosis Medications
Used in the prevention & management of osteoporosis
Drug Name
Generic Name
&RPPRQVLGHHႇHFWV
Bisphosphonates
Slows the rate of bone thinning and increase bone density
)RVDPD[
'DLO\RUZHHNO\32
Boniva
0RQWKO\±324PRQWKV,9
• Alendronate
* irritation and ulcers of the esophagus
abdominal pain, constipation, gas, or nausea
• Ibandronate
Back pain, indigestion, bronchitis, bone, joint
or muscle pain
• Risedronate
Bladder infection
BPH in men
• Zoledronic acid
Joint pain, fever, hypertension, headache
Actonel
'DLO\32IRUGD\VLQDURZ
q month or q week as prescribed
Reclast
Yearly IV
Selective estrogen receptor modulator (SERM)
Slows bone thinning & causes some increase in bone thickness
Evista
8VHGLQZRPHQRQO\'DLO\32
• Raloxifene
+RWÀDVKHVMRLQWSDLQÀXOLNHV\PSWRPV
edema, muscle pain
Hormone Therapy
Calcimar
Miacalcin
• Calcitonin
Given via nasal spray, IM, or SC
5XQQ\RUVWXႇ\QRVHEDFNSDLQQDXVHD
vomiting
Stroke, blood clots, increased breast cancer
risk, gallstones, headaches, nausea, vaginal
Used only in women who are post hysterectomy
GLVFKDUJHÀXLGUHWHQWLRQZHLJKWJDLQ
*LYHQ32HVWURJHQSDWFKYDJLQDOULQJVNLQFUHDPJHO
breast tenderness
Estrogen
Testosterone
Edema of the hands and feet, prostate
*LYHQLQMHFWLRQVJHORUSDWFKHV
hyperplasia, gynecomastia, painful erections
*men only
(rare), liver dysfunction
4WRZHHNV,04QLJKWSDWFKGDLO\JHO
Fosamax (alendronate), Actonel (risedronate) - sit up after
PHGLFDWLRQIRUPLQXWHV%RQLYD LEDQGURQDWH PLQXWHVWDNH
on an empty stomach, with a full glass of water, early in the mornLQJ$YRLGWDNLQJZLWKDQWDFLGVFD௻QHRUDQJHMXLFHRUFDOFLXP
Nursing Implications:
supplements. Avoid in kidney disease
&DOFLWRQLQVWRUHQDVDOVSUD\LQDQXSULJKWSRVLWLRQUHIULJHUDWH
136
Increase calcium and vitamin D in diet or by supplementation
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During the exam, you may encounter medications that you do not recognize. Many prescribed medications
KDYHFRPPRQDOLWLHV.QRZOHGJHRIWKHFRPPRQGUXJVXႈ[HVPD\EHKHOSIXOLQDVVLVWLQJ\RXWRFKRRVH
an answer.
Review the list below:
SUFFIX
DRUG CLASS
DRUG NAME
VIR
antivirals
Combivir
OLOL
beta blockers
Metoprolol
PRIL
ace inhibitors
Accupril
COR
statins (decreases cholesterol)
Zocor
CORT
steroids
Pulmicort
SONE
steroids
Hydrocortisone
AFIL
erectile dysfunction
6LOGHQD¿O
AZOLE
proton pump inhibitors
Omperazole
TIDINE
H2 receptor blockers
Cimetidine
CAINE
local anesthetics
Lidocaine
CILLIN
antibiotics
Penicillin
CEPH or CEF
Cephalosporins
Cephalexin/cefazolin
CYCLINE
Antibiotics
Doxycycline
DONE
opoids
Oxycodone
IDE
oral hypoglycemics
Glyburide
PAM, LAM
antianxiety
Diazepam, alprazolam
MIDE
diuretics
Furosemide
IPINE
Calcium channel blockers
Amlodipine
ZINE
Antipsychotics
Thorazine
SARTAN
Alpha 2 receptor blockers
Valsartan
ZOSIN
Alpha 1 receptor blockers
Doxazosin
137
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Medication Worksheet:
/LVWWKHFODVVL¿FDWLRQRIGUXJEDVHGRQFRPPRQ VXႈ[URRWRUSUH¿[ JLYHDQH[DPSOHIRUXVH
LHSUD]ROHSURWRQSXPSLQKLELWRUODQVRSUD]ROHUHGXFHJDVWULFDFLGSURGXFWLRQ
1. Osin ______________________________________________________
2. Sartan_____________________________________________________
3UD]ROHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
4. GL________________________________________________________
5. Setron_____________________________________________________
6. One_______________________________________________________
7. Statin______________________________________________________
8. Zepam_____________________________________________________
9. Dronate____________________________________________________
10. Done_____________________________________________________
11. Dipine_____________________________________________________
12. Olol_______________________________________________________
1LBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
14. Pril________________________________________________________
15. Mide______________________________________________________
16. Ceph/Cef__________________________________________________
17. Floxacin___________________________________________________
18. Mycin ( TANGS)_____________________________________________
19. Tidine_____________________________________________________
$¿OBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Worksheet Answer Key
2VLQDOSKDUHFHSWRUEORFNHUGR[D]RVLQ%3++713
6DUWDQDOSKDUHFHSWRUEORFNHUYDOVDUWDQGHFUHDVHGRSDPLQH%33
3UD]ROHSURWRQSXPSLQKLELWRUODQVRSUD]ROHUHGXFHJDVWULFDFLG3
*/RUDOK\SRJO\FHPLFJOLSL]LGHURVLJOLWD]RQH7\SH,,'03
6HWURQDQWLHPHWLFJUDQLVHWURQQDXVHDYRPLWLQJ3
2QHVWHURLGEHFODPHWKDVRQHVXSSUHVVHVLQÀDPPDWLRQ3
6WDWLQVWDWLQ+0*&2$UHGXFWDVHLQKLELWRUORYDVWDWLQDWKHURVFOHURVLV3
=HSDPEHQ]RGLD]HSLQHFORQD]HSDPVHL]XUHVDQ[LHW\3
'URQDWHELVSKRVSKRQDWHVDOHQGURQDWHRVWHRSRURVLV3
'RQHRSLRGVR[\FRGRQHSDLQPDQDJHPHQW3
'LSLQHFDOFLXPFKDQQHOEORFNHUIHORGLSLQHDQJLQD+713
2OROEHWDEORFNHUSUSSUDQRORO+71&+)$QJLQD3
1LYDVRGLODWRUQLWURSUXVVLGHUHOD[VPRRWKPXVFOHVLQWKHEORRGYHVVHO3
3ULODFHLQKLELWRUDFFXSULOWUHDW+71SURWHFWNLGQH\VLQFOLHQWVZLWK'03
0LGHORRSGLXUHWLFWRUVHPLGHH[FUHWHVRGLXPDQGÀXLG3
&HSK&HIFHSKDORVSRULQFHIDGR[LPHDQWLELRWLF3
)OR[DFLQÀXRURTXLQRORQHRÀD[DFLQDQWLELRWLF3
0\FLQ 7DQJV DPLQRJO\FRVLGHWREUDP\FLQDQWLELRWLF3
7LGLQHKUHFHSWRUEORFNHUUDQLWLGLQHLQKLELWVJDVWULFDFLGSURGXFWLRQ3
$¿O±W\SHSKRVGLHVWHUDVHLQKLELWRUWDOGDOD¿OHUHFWLOHG\VIXQFWLRQ3
* Remember there are always exceptions. *Some exceptions: amakacin is an aminoglycoside and ends in
acin, macrolides are a class of drug that also end in mycin, loratidine is an antihistamine and ends with tidine.
138
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ESSENTIAL MEDICATION LIST
• ZĞƐƉŝƌĂƚŽƌLJŵĞĚŝĐĂƟŽŶƐ͗ďƌŽŶĐŚŽĚŝůĂƚŽƌƐͲĂůďƵƚĞƌŽů͕
ƚŚĞŽƉŚLJůůŝŶĞ͕ƌĞƚŚŝŶĞ͕/ŶƚĂůŝŶŚĂůĞƌʹƵƐĞĞǀĞŶǁŚĞŶ
ƐLJŵƉƚŽŵƐĂƌĞŶŽƚƉƌĞƐĞŶƚ
• ĐĐŽůĂƚĞ͕^ŝŶŐƵůĂƌ;ŵŽŶƚĞůƵŬĂƐƚͿͲŐŝǀĞŝŶƚŚĞĞǀĞŶŝŶŐ
• ĞdžƚƌŽĂŵƉŚĞƚĂŵŝŶĞ;ĞdžĞĚƌŝŶĞͿ͕ZŝƚĂůŝŶͲŝƌƌŝƚĂďŝůŝƚLJ
• ŶƟĐŚŽůŝŶĞƌŐŝĐƐ͗ĂƚƌŽƉŝŶĞ͕ƌŽďŝŶŽů
• ŚŽůŝŶĞƌŐŝĐƐ͗ŶĞŽƐƟŐŵŝŶĞ;ƉƌŽƐƟŐŵŝŶĞͿʹDLJĂƐƚŚĞŶŝĂ
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• ŶƟƉƐLJĐŚŽƟĐƐ͗dŚŽƌĂnjŝŶĞ;ĂǀŽŝĚƐƵŶͿ͕^ĞƌŽƋƵĞů͕
LJƉƌĞdžĂ͖,ĂůĚŽů͕ůŽnjĂƌŝůʹǁĞĞŬůLJtŵŽŶŝƚŽƌŝŶŐĨŽƌ
ϲŵŽŶƚŚƐ
• ƐƉŝƌŝŶ͗ƟŶŶŝƚƵƐ͕'/ďůĞĞĚŝŶŐ͕ƚĂŬĞǁͬĨŽŽĚ
• E^/^ͲŝďƵƉƌŽĨĞŶ;ŵŽƚƌŝŶͿ͕ŝŶĚŽŵĞƚŚŝĐŝŶ;ŝŶĚŽĐŝŶͿ
ŶĂƉƌŽƐLJŶ͕ĞůĞďƌĞdž͗ŵĂLJĐĂƵƐĞďůĞĞĚŝŶŐ
• ΎůůĚŝƵƌĞƟĐƐ͕ĨƵƌŽƐĞŵŝĚĞ͕ƚŽƌŽƐĞŵŝĚĞ͕ĂƌŽdžŽůLJŶ
• ƉŝŶĞƉŚƌŝŶĞ;ĞƉŝͲƉĞŶͿ
• ƵƐƉĂƌ;ĂŶƟĂŶdžŝĞƚLJͿ͕sĂůŝƵŵ͕yĂŶĂdž
• DĂŐŶĞƐŝƵŵƐƵůĨĂƚĞ
• ΎDĞƚŚĞƌŐŝŶĞ
• 'ŽƵƚʹĂůůŽƉƵƌŝŶŽů͕ĐŽůĐŚŝĐŝŶĞ
• ,ƵŵŝƌĂ
• DLJĐŝŶĚƌƵŐƐ;ŐĞŶƚĂŵLJĐŝŶͿʹŽƚŽ͕ŶĞƵƌŽ͕ŶĞƉŚƌŽƚŽdžŝĐ
• ĂĐƚƌŝŵʹĂǀŽŝĚƐƵŶ͕ǁĞĂƌůŽŶŐƐůĞĞǀĞƐ
• ΎΎƟǀĂŶʹƉƌĞǀĞŶƚƐĞŝnjƵƌĞƐ
• dĞŐƌĞƚŽů͕ŝůĂŶƟŶ
• dĂŵŽdžŝĨĞŶʹĂŶƟŶĞŽƉůĂƐƟĐʹƌĞĂƐƚĂ;нĞƐƚƌŽŐĞŶ
ƌĞĐĞƉƚŽƌƐͿ
• ĂƉŽƚĞŶʹϭŚŽƵƌďĞĨŽƌĞŵĞĂůƐ
• <ͲĚƵƌ
• ΎŵƉŚŽŐĞůʹĂŶƚĂĐŝĚ͕dhD^
• ĂƌĚŝnjĞŵʹĐŚĞĐŬW͖sĞƌĂƉĂŵŝů͖ŽnjĂĂƌʹƚĂŬĞŶWK͕
ĨĞůŽĚŝƉŝŶĞͲƉĞƌŝƉŚĞƌĂůĞĚĞŵĂ
• EŝƚƌŽŐůLJĐĞƌŝŶʹĂǀŽŝĚǁŝƚŚsŝĂŐƌĂ͕ĂǀŽŝĚǁŝƚŚŐůĂƵĐŽŵĂ
• ,ĞƉĂƌŝŶ͕ΎĐŽƵŵĂĚŝŶ͕ĂƌŝdžƚƌĂͲĂŶƟĐŽĂŐƵůĂŶƚŐŝǀĞŶϲͲϴ
ŚƌƐƐͬƉŚŝƉĨƌĂĐƚƵƌĞ͕ŚŝƉŽƌŬŶĞĞƌĞƉůĂĐĞŵĞŶƚ͖>ŽǀĞŶŽdž
;ŶŽdžŽƉĂƌŝŶͿ͕&ƌĂŐŵŝŶ;ĂůƚĞƉĂƌŝŶͿ͗ůŽǁŵŽůĞĐƵůĂƌ
ǁĞŝŐŚƚŚĞƉĂƌŝŶͲŵŽŶŝƚŽƌ
• ƚŚĂŵďƵƚŽůн/E,;ŝƐŽŶŝĂnjŝĚͿʹĨŽƌd͕ŵƵůƟƉůĞĚƌƵŐƐ
ĚĞĐƌĞĂƐĞƌĞƐŝƐƚĂŶĐĞ
• DLJůĂŶƚĂʹ,ϮĂŶƚĂŐŽŶŝƐƚʹǁĂŝƚϭͲϮŚŽƵƌƐďĞĨŽƌĞƚĂŬͲ
ŝŶŐŽƚŚĞƌŵĞĚƐ
• ǀŝƐƚĂ;ZĂůŽdžŝĨĞŶĞͿʹƵƐĞĚĨŽƌŽƐƚĞŽƉŽƌŽƐŝƐŝŶƉŽƐƚ
ŵĞŶŽƉĂƵƐĂůǁŽŵĞŶ
• ΎŝŐŽdžŝŶʹƉĂƟĞŶƚƚĞĂĐŚŝŶŐ
• /ƌŽŶ;ĨĞƌƌŽƵƐƐƵůĨĂƚĞͿ
• ΎdĞƚƌĂĐLJĐůŝŶĞ
• DĞƞŽƌŵŝŶ;ŐůƵĐŽƉŚĂŐĞͿʹƚĂŬĞǁŝƚŚŵĞĂůƐ͖'ůŝƉŝnjŝĚĞ͖
ŵĂƌLJů͕WƌĂŶĚŝŶ͕'ůƵĐŽƚƌŽů
• /ŶƐƵůŝŶZĞŐƵůĂƌͬEW,;WĞĂŬƐͿ͕>ŝƐƉƌŽ
• d;njŝĚŽǀŝĚŝŶĞͿʹƚĂŬĞŽŶĂŶĞŵƉƚLJƐƚŽŵĂĐŚ͕ĐŚĞĐŬ
;ĂŶĞŵŝĂͿ
• ĐĐƵƚĂŶĞ͕ZĞƟŶ;ƌĞƟŶŽŝĐĂĐŝĚͿ
• Ύ^LJŶƚŚƌŽŝĚʹŚŽůĚĨŽƌƉƵůƐĞŐƌĞĂƚĞƌƚŚĂŶϭϭϬ͖ƚĂŬĞŝŶĂ͘ŵ͘
• ŽƚŽdž
• dĞƐƐĂůŽŶWĞƌůĞƐ;ĞŶnjŽŶĂƚĂƚĞͿͲĂŶƟƚƵƐƐŝǀĞ
• EĞƵƉŽŐĞŶʹŝŶĐƌĞĂƐĞƐt͛Ɛ͕ƉŽŐĞŶͲŝŶĐƌĞĂƐĞƐZ͛Ɛ
• ŽƉĂŵŝŶĞʹďƌĂLJĐĂƌĚŝĂĂŶĚŚLJƉŽƚĞŶƐŝŽŶ
• &ůĞdžĞƌŝů͖ĂŶƚƌŽůĞŶĞƐŽĚŝƵŵ͖ĂĐůŽĨĞŶ;ŵƵƐĐůĞƌĞůĂdžĂŶƚƐͿ
• ΎsŝĂŐƌĂͲŚĞĂĚĂĐŚĞͬĂǀŽŝĚŶŝƚƌĂƚĞƐ͕ƚĂŬĞŽŶĞŚŽƵƌďĞĨŽƌĞƐĞdž͖
ŝĂůŝƐ͕>ĞǀŝƚƌĂ
• Ύ&ŽƐĂŵĂdž;ĂůĞŶĚƌŽŶĂƚĞͿͲƐŝƚƵƉŽƌϯϬŵŝŶƵƚĞƐĂŌĞƌƚĂŬŝŶŐ
ŵĞĚ͕ƚĂŬĞŽŶĂŶĞŵƉƚLJƐƚŽŵĂĐŚ͕ǁŝƚŚĂĨƵůůŐůĂƐƐŽĨǁĂƚĞƌ͕
ĞĂƌůLJD͖ĐƚŽŶĞů;ƌŝƐĞĚƌŽŶĂƚĞͿ
• ΎŽĐŽƌ͕YƵĞƐƚƌĂŶʹĚĞĐƌĞĂƐĞƐĐŚŽůĞƐƚĞƌŽů͕ŵŝdžŝŶũƵŝĐĞ͕
>ŽƉŝĚ͕ŶŝĂĐŝŶ
• DĂŶŶŝƚŽů
• >ŝƚŚŝƵŵ͕>ŝƚŚŽŶĂƚĞͲďŝƉŽůĂƌĚŝƐŽƌĚĞƌ
• >ŝƚŚŽƐƚĂƚͲĨŽƌŶĞƉŚƌŽůŝƚŚŝĂƐŝƐ
• 'Ăďŝƚƌŝů;ƟĂŐĂďŝŶĞͿʹE^ĚĞƉƌĞƐƐŝŽŶ
• DŽƌƉŚŝŶĞ͖ĂƌǀŽŶ
• ŝƚƌŝĐĂůʹ;ĐĂůĐŝƵŵͿŵŽŶŝƚŽƌĐĂůĐŝƵŵůĞǀĞůƐ
• ŶƟŚLJƉĞƌƚĞŶƐŝǀĞƐͲŵĂLJĐĂƵƐĞƐĞdžƵĂůĚLJƐĨƵŶĐƟŽŶ
• ǀŽŝĚĐĞƉŚĂůŽƐƉŽƌŝŶƐŝĨĂůůĞƌŐŝĐƚŽWE;ŝĞ͘<ĞŇĞdžͿ͕DLJĐŝŶ
ĚƌƵŐƐŽŬ͕ZŽĐĞƉŚŝŶ
• ƌƚĂŶĞ͕ĐŽŐĞŶƟŶ
• dĂĐƌŝŶĞ
• yĂůĂƚĂŶͲĚĞĐƌĞĂƐĞƐŝŶƚƌĂͲŽĐƵůĂƌƉƌĞƐƐƵƌĞ
• ΎdŽƉƌŽůͲŵĞƚŽƉƌŽůŽů͖WƌŽƉƌĂŶŽůŽů͕/ŶĚĞƌĂůͲĂǀŽŝĚǁŝƚŚ
ĂƐƚŚŵĂ͕ĐŚĞĐŬƉƵůƐĞďĞĨŽƌĞĂĚŵŝŶŝƐƚƌĂƟŽŶ
• ŝƉƌŽ͗ϮŚƌƐďĞĨŽƌĞŽƌϲŚƌƐĂŌĞƌĂŶƚĂĐŝĚƐ͖ƚĂŬĞŽŶĂŶĞŵƉƚLJ
ƐƚŽŵĂĐŚ͕ŶĐĞĨ
• <ĞŇĞdž͖ŝƚŚƌŽŵĂdžʹƐŝĚĞĞīĞĐƚƐ͕ŝ
• 'ĂŶƚƌŝŶƐŝŶ;ĐĞƚLJů^ƵůĮƐŽdžĂnjŽůĞͿʹƉĞĚƐʹZdžĨŽƌĐŚƌŽŶŝĐhd/
• >ŝƉŝƚŽƌͲĐŽŶƚƌĂŝŶĚŝĐĂƚĞĚŝŶƉƌĞŐŶĂŶĐLJ͕ĞƟĂ͘YƵĞƐƚƌĂŶ
• 'ŝŶŐĞƌ͖<ĂǀĂ<ĂǀĂ͖'ŝŶŬŽŝůŽďĂ͕ĐŚŝŶĂĐĞĂ͕&ĞǀĞƌĨĞǁ͕ůĂĐŬ
ŽŚŽƐŚ
• ZŝĨĂŵƉŝŶʹĚŝƐĐŽůŽƌƐƵƌŝŶĞ
• ZŽĐĞƉŚŝŶʹĨƵƌƌLJƚŽŶŐƵĞ
• ůĂǀŝů͕ZĞŵĞƌŽŶ͕ŽůŽŌ͕īĞdžŽƌ͕dŽĨƌĂŶŝů;ŝŵŝƉƌĂŵŝŶĞͿ;ĂŶƟͲ
ĚĞƉƌĞƐƐĂŶƚͿ͕DKŝŶŚŝďŝƚŽƌƐ͕WƌŽnjĂĐʹƐŝĚĞĞīĞĐƚƐ
• ^LJŵŵĞƚƌĞů͕ůĞǀŽĚŽƉĂ
• ĞƐŵŽƉƌĞƐƐŝŶ;sWͿͲŝŶƚƌĂŶĂƐĂůůLJ
• sĞƌƐĞĚʹƵƐĞĚĨŽƌĐŽŶƐĐŝŽƵƐƐĞĚĂƟŽŶ
• ŝƚƌŽƉĂŶ͕ĞƚƌŽů͕sĞƐŝĐĂƌĞʹƚƌĞĂƚƐLJŵƉƚŽŵƐŽĨŽǀĞƌĂĐƟǀĞ
ďůĂĚĚĞƌ
• ŽŵŝŐʹŵŝŐƌĂŝŶĞŚĞĂĚĂĐŚĞ
• KdžLJƚŽĐŝŶ
• ĞƉŽͲWƌŽǀĞƌĂ
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AFTER THE REVIEW
After the review class is completed, you will need to continue to study. Ready to Pass recommends that you take
the NCLEX exam within 1 month after completion of the course. It is important that you organize your time in
order to cover each section of the review book thouroghly. You must have a good understanding of the
information rather than memorizing facts. Be sure to pay attention to bolded areas, charts and areas that
were highlighted during the review. Prepare for the exam by scheduling as soon as possible. Start by reading the
study manual in order of areas of NCLEX priority.
Recommended order of study:
1. 6WXG\7RROV SULRULW\VHWWLQJ 3DJH$OSKDEHWOLVWDQGPQHXPRQLFV
2. Infection Control
Diabetes/Endocrine System
4. &DUGLDF6\VWHPFRQVLGHUUHYLHZLQJ<RX7XEHYLGHR³(.*IRU1&/(; %HJLQQHUV´$QQHOLVVH*DUULVRQ
5. Pharmacology (a) medication calculation (b) herbal remedies
6. Diagnostic tests & Lab values
7. Respiratory System
8. Maternal Child Health, Pediatrics, Mental Health
9. Everything Else
140
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(66(17,$/&/,1,&$/1856,1*6.,//6 7(&+1,48(6725(9,(:
1.
2.
4.
5.
6.
7.
8.
9.
10.
11.
12.
14.
15.
16.
17.
18.
19.
20.
21.
22.
24.
25.
26.
27.
Obtaining a sputum culture
Performing catheter irrigation (steps listed on pg 140)
Inserting a straight or an indewelling urinary catheter (steps listed on pg 140)
Tracheostomy care
Tracheostomy suctioning
Eye Irrigation
Ear Irrigation
3UHSDULQJDVWHULOH¿HOG'RQQLQJVWHULOHJORYHV
Changing a peripheral intravenous dressing
Administering intravenous medications using a secondary line
Changing a central line dressing
Insertion of and removing a nasogastric tube
Administering eye / ear medication
Correct use of an incentive spirometer
Care of the prosthetic eye
$GPLQLVWHULQJPHGLFDWLRQXVLQJ=WUDFNWHFKQLTXH
Performing wound assessment
Performing wound irrigation; wound vac
Gastric Lavage
Condom catheter application (steps listed on pg 140)
Closed intermittent irrigation (steps listed on pg 140)
Obtaining a specimen from a central line and a peripheral line
Colostomy and Ileostomy stoma care
Safe use of devices: CPM machine, slide board, mechanical lift, gait transfer belt
Application of antiembolic stockings
Post mortem care
Cardiopulmonary Resuscitation (CPR)
Resources
www.LearnersTV.com
www.nursingquality.org
www.fpnotebook.com/surgery/pharm/wnddrsng.htm
http://nursingskillsvideo.blogspot.com
www.practicalclinicalskills.com
www.easyauscultation.com
www.blausen.com
www.dosagehelp.com
www.abg.ninja
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CONTINUOUS BLADDER IRRIGATION (CBI)
•
Continuous bladder irrigation (CBI) of normal saline prevents the catheter from becoming obstructed.
Irrigation Return
Rate Adjustment
•
Pink or Lighter
•
Do not adjust CBI rate (desired return)
•
Bright Red with clots
•
Increase CBI rate
Obstructed catheter EODGGHUVSDVPVGHFUHDVHGLUULJDWLRQRXWÀRZ
•
•
7XUQRႇ&%,
Use a large piston syringe irrigate with 50 mL of irrigation solution
•
•
Document the amount of solution instilled and the amount of solution returned.
7KHGLႇHUHQFHEHWZHHQWKHWZRDPRXQWVHTXDOVXULQDU\RXWSXW
Interventions:0RQLWRUYLWDOVLJQVLQFUHDVHÀXLGVPRQLWRUIRUEOHHGLQJ
Teach: First void after removal may appear red in color with clots present. Color should return to normal (amber)
ZLWKLQWRGD\V([SHFWHGXULQDU\RXWSXWLVP/HYHU\KRXUV.
CLOSED INTERMITTENT IRRIGATION
•
Fill a sterile syringe with irrigant
•
Clamp the catheter in the area between the injection port and extension tubing
•
Clean theh injection port with an alcohol wipe
•
Insert the needle of the sterile syringe into the injection port
•
Inject the irrigant slowly into the catheter
•
Remove the syringe and clamp
•
'LUHFWWKHÀRZRIWKHLUULJDQWWRGUDLQLQWRWKHGUDLQDJHEDJ
STRAIGHT OR INDEWELLING CATHETHER INSERTION
•
Explain procedure & then perform hand hygiene
•
Position client supine: Female with knees bent & apart; Male with thighs abducted slightly
•
Don gloves & wash perineal area
•
Remove gloves, perform hand hygiene
•
Open sterile package, don sterile gloves, Apply antiseptic solution to the cotton balls
•
&KHFNEDOORRQE\LQÀDWLQJLWZLWKWKHSDFNDJHGSUH¿OOHGV\ULQJHWKHQGHÀDWHLW
•
Lubricate tip of catheter
•
Use the sterile drape to expose the meatus, then clean the area.
•
With sterile hand, insert catheter into the meatus, advance it until urine returns, then 2.5 to 5 cm further
•
With the nondominant hand, stabilize catheter
•
)RUDQLQGZHOOLQJFDWKHWHULQÀDWHEDOORRQSXOOJHQWO\WRHQVXUHSODFHPHQW
•
7RVHFXUHWKHFDWKHWHUWDSHWRFOLHQW¶VOHJWKHQSODFHGUDLQDJHEDJDWDORZHUOHYHOWKDQEODGGHU
•
)RUVWUDLJKWFDWKHWHUL]DWLRQRQFHÀRZRIXULQHKDVVWRSSHGUHPRYHFDWKHWHU
CONDOM CATHETHER APPLICATION
•
Perform hand hygiene, explain procedure
•
Don gloves, apply skin prep to area
•
Hold penis with nondominant hand, apply condom leaving 2.5 cm of space between tip and catheter
•
Roll the condom downward to cover the shaft area
•
To secure catheter apply elastic tape in a spiral method, attach to leg or collection bag
•
Observe for urine
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Alphabet List Page
Letters
What they Mean
Related To
4 W’s
6 P’s
4 C’s
5 H’s
5 F’s
3 N’s
3 C’s
5 P’s
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+2:0$1<01(8021,&6'2<285(0(0%(5"
RICE
BROW
RACE
AWFERS
5$7[
BEEP
ANT
HOP
PAN
TPAL
RANDI
AVA
FINDS
STOP
MONA
REEDA
PQRST
PASS
ABCD
CAP
IPPA
BRAT
IAPP
CAPTOPRIL
CAB
PISSCAGE
COAL
NOAH
CAUTION
ABCDE
ABCL
KNIVES
VEAL CHOP
CLAMIE - O
BUBBLE HE
RANDI
RAMS
BED
ROME
OLDCART
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RICE: Tx for sprains
REST
ICE
COMPRESS
ELEVATE
PISSCAGE: Psych assessment
PSYCHOMOTOR MOVEMENT
DECREASED INTEREST
SUICIDAL
Ļ25Ĺ6/((3
DECREASED CONCENTRATION
Ļ25Ĺ$33(7,7(
GUILT
DECREASED ENERGY
CAP: Meds for Gout
COLCHICINE
ALLOPURINAL
PROBENECID
PAN:
ALL
RACE: Fire safety
RESCUE
ALARM
CONFINE
EXTINGUISH
NOAH: Tx for Asthma
NEBULIZERS
OXYGEN
ANTIBIOTICS
HYDROCORTISONE
BRAT: Diet for diarrhea
BANANAS
RICE
APPLES
TOAST
RANDI: Bleeding precautions
NO RAZORS
NO ASA
REDUCE NEEDLE STICKS
DECREASE NEEDLE GAUGE
INJURY PREVENTION
5$7[Early signs of hypoxia
RESTLESS
ANXIETY
TACHYCARDIA
RIGHT (Anatomy)
ATRIUM
TRICUSPID
CAPTOPRIL: S/E of ACE Inhibitors
COUGH
ANGIOEDEMA
POTASSIUM INCREASE
TASTE CHANGES
ORTHOSTATIC HYPOTENSION
PALPITATIONS
RENAL IMPAIRMENT
IMPOTENCE
LEUKOCYTOSIS
ANT: Symptoms of Leukemia
ANEMIA
NEUTROPENIA
THROMBOCYTOPENIA
ABCDE: Contraindications for beta blockers
ASTHMA
HEART BLOCK
CARDIAC FAILURE
DIABETES MELLLITUS
EXTREMITIES
(OCCLUSIVE ARTERIES)
HOP: 6LFNOH&HOO'LVHDVH7;
HYDRATION
OXYGENATION
PAIN MANAGEMENT
KNIVES: Complications of DM
KIDNEY DISORDERS
NEUROPATHY
INFECTIONS,
VASCULAR CHANGES
EYE DAMAGE
SKIN LESIONS
MONA: Tx of MI
MORPHINE
OXYGEN
NITRATES
ASA
CLAMIEO: Assessment
CHECK
LOOK
ASK
MONITOR
INSPECT
EVALUATE
OBSERVE
PQRST: Pain assessment
PROVOKES
QUALITY
RADIATION
SEVERITY
TIME
ABCD: Mole assessment
ASSYMETRY
BORDER
COLOR
DIAMETER
BED: Late signs of hypoxia
BRADYCARDIA
EXTREME RESLTESSNESS
DYSPNEA
IPPA: Lung assessment
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
IAPP: Abdominal assessment
INSPECTION
AUSCULTATION
PERCUSSION
PALPATION
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OLDCART: First aid assessment
ONSET OF SYMPTOMS
LOCATION OF PROBLEM
DURATION OF SYMPTOMS CHARACTERISTICS CLIENT
USED TO DESCRIBE SYMPTOMS AGGRAVATING
FACTORS
RELIEVING FACTORS
TREATMENT RECEIVED BEFORE ARRIVAL
CAUTION: Cancer warning signs
CHANGE IN BOWEL OR BLADDER HABITS
A SORE THAT DOES NOT HEAL
UNUSUAL BLEEDING OR DISCHARGE
THICKENING OR LUMP IN BREAST OR ELSEWHERE
INDIGESTION OR DIFFICULTY IN SWALLOWING
OBVIOUS CHANGE IN WART OR MOLE
NAGGING COUGH OR HOARSENESS
BUBBLE HE: Post partum assessment
BLADDER
UTERUS BOWELS
BREASTS
LOCHIA
EPISIOTOMY
+20$1¶66,*1
EMOTIONS
VEAL CHOP: Decelerations assessment
VARIABLE
CORD
EARLY
HEAD
ACCELERATIONS OK
LATE
PLACENTA
CAB: Dyskinseia meds
COGENTIN
ARTANE
BENADRYL
COAL: Cane walking
CANE
OPPOSITE
AFFECTED
LEG
ABCL: Increase sodium
$'',621¶6
BURNS
CYSTIC FIBROSIS
LITHIUM
ROME: Acid-base balance
RESPIRATORY
OPPOSITE
METABOLIC
EQUAL
BROW: Avoid with celiac disease
BARLEY
RYE
OATS
WHEAT
RAMS: Acid-base balance
RESPIRATORY
ALTERNATE
METABOLIC
SAME
TPAL: Pregnancy assessment
TERM
PRETERM
ABORTIONS
LIVE
SCAB: Safety
SIDE RAILS UP
CALL BELL WITHIN REACH
ASK IF CLIENT HAS PAIN/ COMFORT
BED IN LOW POSITION
5 F’S: Possible causes of abdominal distention
FAT
FLUID
FECES
FLATUS
FETUS
GLAD SHOP: Chronic renal failure
GLOMERULONEPHRITIS
LUPUS
ANALGESICS
DIABETES MELLITUS
SYSTEMIC VASCULAR DISEASE
HYPERTENSION
OBSTRUCTION
POLYCYSTIC KIDNEY DISEASE
SAD: Ketoacidosis
STARVATION
ALCOHOL
DIABETES MELLITUS
SAD PERSON: Suicide risk
6(;6,1*/(6,&.1(66
AGE
DEPRESSION
PREVIOUS ATTEMPT
ETOH
REALITY TESTING
SOCIAL SUPPORT
ORGANIZED PLAN
NO SPOUSE / NOTE
CATS: Hypocalcemia
CONVULSIONS
ARRYTHMIAS
TETANY
SPASMS
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MATERNAL / NEWBORN CARE
147
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Maternal/Newborn Care
Presumptive, Probable and Positive Signs of Pregnancy
Presumptive Signs
• Subjective signs
• Cannot be used to diagnose pregnancy
Amenorrhea
• Increasing levels of HCG major cause
Breast changes
• Due to progesterone secretion
• Results in increased size, tenderness, and darkening of the areola
Urinary frequency
• Enlarging uterus puts extra pressure on bladder
Fatigue
Quickening
• )DLQWDEGRPLQDOÀXWWHULQJIHOWE\PRWKHUDWZHHNV
Probable Signs
• Objective signs determined during physical examination
• Result of vascular congestion in the pelvis
• Occurs irregularly at beginning
• Uterus above pubic symphysis by 12th week
• 5HDFKHVXPELOLFXVE\ZHHNV
Uterine enlargement
• Fundal height in cm matches # of weeks pregnant after 12th week
Hegar’s sign
• Softening of lower uterine segment
• 2FFXUVLQQGDQGUGPRQWKVRISUHJQDQF\
Goodell’s sign
• Softening of cervix and vagina
Chadwick’s sign
• Bluish or purplish discoloration of cervix, vagina, and vulva
Ballottement
•5HERXQGLQJRIIHWXVDJDLQVWH[DPLQHU¶V¿QJHUVRQSDOSDWLRQ
%UD[WRQ+LFNVFRQWUDFWLRQV
• Irregular, painless contractions throughout pregnancy
Abdominal enlargement
• More rapid after 12th week when uterus rises into abdominal cavity
Abdominal striae
• Stretch marks
Skin pigmentation changes
• Results from hormonal changes
• Nipples may darken
• Linea nigra: brown or pink line from umbilicus to pubic symphysis
Positive pregnancy test
• Measures HCG
Positive Signs
• Absolute indicators of pregnancy
Fetal heart sounds
• May be heard at 10 to 12 weeks by Doppler
• May be heard through regular fetoscope by 18 to 20 weeks
• Normal rate 120 to 160 beat / minute
Fetal movements
• Felt by second trimester
Ultrasound of fetus
• $WWRZHHNVIHWDOLGHQWL¿FDWLRQSRVLWLYH
• Earliest positive method of diagnosing pregnancy
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II. Prenatal Care
(1) Prenatal history
(2) Prenatal physical assessment
$([DP
• Total weight gain of 25 lbs is average
B. Pertinent diagnostic tests and lab values
First Trimester
• CBC
• Blood type &screen
• Rubella screen
• HIV screen
• Urinalysis
Second Trimester
•
•
*OXFRVH7ROHUDQFHWHVW *77 /HYHOV!PJG/QHHGIROORZXS
$OSKDIHWRSURWHLQ $)3 'HWHFWVQHXUDOWXEHGHIHFWV ZHHNV
•
•
STD/STI screen
*URXS%HWD6WUHS,ISRVLWLYH3HQLFLOOLQ*DGPLQLVWHUXSWRKRXUV
before delivery
Third Trimester
C. Nutritional status:
• Electrolytes (chemistry)
• VDRL
• TB skin test
• Hepatitis B screen
• Urine culture and sensitivity
‡WRFDORULHVSHUGD\
‡PORIÀXLGSHUGD\
• Increase protein intake
• Increase iron to decrease anemia
• Increase folic acid to prevent neural tube defects
D. Risks and hazards
E. Cardiac disease in pregnancy
(3) Nagele’s Rule:
List The EDC:
$GGGD\VWRWKH¿UVWGD\RIWKHODVWQRUPDOPHQVWUXDOSHULRG
6XEWUDFWPRQWKV
$GGRQH\HDU
LMP:
August 9, 2017 EDC___________________________
January 4, 2018 EDC___________________________
October 5, 2017 EDC___________________________
ANSWERS 0D\
2FWREHU 149
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(4) Routine care and follow up:
• 1x per month for 7 months
• 2x per month in 8th month
• 1x per week in 9th month
(5) Parity (Term Preterm Abortions Living children)
Gravida- total number of pregnancies including current pregnancy
(6) Normal pregnancy discomforts in each trimester
First Trimester
• Nausea, vomiting
• Ĺ urination
• Breast tingling
• Ptyalism (excessive spitting)
Second Trimester
• Constipation
• Heartburn
• Pigmentation
Linea nigra becomes prominent
• PICA
• Leg cramps are normal if no
VXJJHVWLRQRI+RPDQ¶VVLJQ
Third Trimester
• Leg cramps
• Hemorrhoids
• Back pain
• Urinary frequency
(7) Reportable danger signs:
Vaginal bleeding
Abdominal pain
Epigastric pain
Visual disturbances
Severe, persistent headache
Change in fetal movements after quickening
Painful or burning urination
Edema of face, feet or hands
$VXGGHQUXVKRIÀXLG UXSWXUHRIPHPEUDQHV
Elevated temperature above 101° and chills
Persistent vomiting after the 1st trimester
Absence of fetal movements after quickening
(8) High risk monitoring:
Chorionic Villus Sampling
• 3HUIRUPHGDWZHHNVJHVWDWLRQWRGHWHFWJHQHWLFGLVRUGHUV
Amniocentesis
• Performed after 14 weeks to rule out congenital abnormalities
Alphafetalprotein (AFP)
• ĻOHYHOV 'RZQ¶V6\QGURPHSHUIRUPHGDWZHHNV
• Ĺlevels = neural tube defects
L/S ratio
• 2:1 indicates lung maturity
Genetic screening
• Screening for genetically transmitted disorders
Sonogram
• Determines fetal and placental position
%LRSK\VLFDOSUR¿OH
Contraction stress test
(Negative)
Nonstress tests
(Reactive)
• 5 assessment tests using ultrasound to determine fetal well being
• (DFKKDVDSRVVLEOHVFRUHRIPD[VFRUH 1RUPDOOHVVWKDQ
4 may need urgent delivery
• Assesses FHR response to contractions
• Fetus should not have any late decelerations in 10 minutes
• FHR should accelerate 10 – 15 bpm in 10 minutes in response to body
movements
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(9) Complications
Pregnancy Induced Hypertension (PIH) (Preeclampsia):
Triad =
• Hypertension
• Weight gain (edema)
• Proteinuria
Symptoms: • headache
‡K\SHUUHÀH[LD
Maternal Hypertension (PIH): ‡0LOGLQFUHDVHPPKJ
‡6HYHUHLQFUHDVHPPKJ
‡(FODPSVLDï๤๦»ïï๦%3RUJUHDWHUZLWKFRQYXOVLRQV
7[PDJQHVLXPVXOIDWHDQWLGRWH&DOFLXP*OXFRQDWH
• visual disturbances
‡GHFUHDVHGXULQDU\RXWSXW
HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Lowered Platelets
Maternal Hypotension:
• S top pitocin
• T urn on left side
• O xygen
• P XVK,9ÀXLGVLIK\SRYROHPLF
Hyperemesis Gravidarum
• Excessive nausea and vomiting in early pregnancy
• 7UHDWPHQW,9K\GUDWLRQDQGDQWLHPHWLFV=RIUDQ RQGDQVHWURQ RU3KHQHUJDQ SURPHWKD]LQH
Monitor for electrolyte imbalance and dehydration
Placenta Previa
•
•
Partial or complete covering of the cervical os by the placenta.
Painless vaginal bleeding (bright red bleeding may or may not be visible) after the 7th month of
pregnancy
•
&RPPRQLQROGHUPRWKHUVPXOWLSDULW\QRYDJLQDOH[DPV0D\QHHG&VHFWLRQQRWHPHUJHQF\
Placenta Abruptio:
•
Premature separation of the placenta from the uterine wall
•
Painful dark red vaginal bleeding
•
•
Risk factors: PIH, multiparity, trauma, cocaine use
&OLHQWZLOOQHHGDQHPHUJHQF\&6HFWLRQ
Gestational Diabetes:
•
•
Extra glucose passes through the placenta and is metabolized by the fetus
This causes excess insulin to be secreted by the fetus which acts as a growth hormone
•
After birth the neonate may become hypoglycemic as there is a sudden drop in glucose (maternal)
and an increased insulin production by the fetus.
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III. Labor and Delivery
A. True VS. False labor
True Labor
• Begins in the back
False Labor
• Abdominal and groin
• Contractions
• Consistent pattern
• Inconsistent
• Frequency/ fast
• Increases progressively
• Inconsistent
• Duration/ last
• Increases progressively
• Inconsistent
• Pain
• Increases progressively
• Inconsistent
• Cervix
• 'LODWHVDQGHႇDFHV
• ,QVLJQL¿FDQWFKDQJHV
)HWDO0RQLWRULQJ1RUPDO)+5EHDWVSHUPLQXWH
Decelerations:
EARLY
LATE
VARIABLE
Ļ)+5before the contraction
Ļ)+5after the contraction
&RPELQDWLRQRIHDUO\ ODWH
Head compression
8WHURSODFHQWDOLQVXႈFLHQF\
Cord compression
RX: observation
• Oxygen
‡,9ÀXLGV
• Lateral position
• D/C pitocin
‡&VHFWLRQ
• Lateral or trendelenburg position
• Oxygen
‡&VHFWLRQ
VEAL CHOP
V ariable
C ord: V or W shaped occurs during or between a contraction
E arly
H ead: U shaped begins and ends with contraction
A ccelerations
O K: increase of FHR above baseline. Return to normal within 10 minutes
L ate
P lacenta: decreased FHR after a contraction: Fetal hypoxia
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%0DQDJHPHQWRIODERUZKHQ0'GRHVYDJLQDOH[DPVH[SHFWVRPHVSRWWLQJ
Cervical dilatation
)LQJHUWLSFP
FPFP
FPFP
FPFP
FPFP7UDQVLWLRQ
Duration (contraction)
VHFRQGV
VHFRQGV
VHFRQGV
VHFRQGV
VHFRQGV
Interval
PLQXWHV
PLQXWHV
PLQXWHV
PLQXWHV
PLQXWHV
* Contractions should not occur faster than every 2 minutes and should not last longer
than 90 seconds (Stop Pitocin)
• Passenger
• Passage
• Power
• Placenta
• Psyche of mother
1. FIVE P’s
• Risk for infection
2. PROM
• Avoid vaginal exams
• Give Ampicillin
• Never put the cord back inside
‡:LWKVWHULOHJORYHOLIWSUHVHQWLQJSDUWRႇRIWKHFRUGRU
3. Prolapsed cord
• Place mom in trendelenburg or knee chest position
4. Spontaneous Abortion
• Loss of a fetus before the 20th week of pregnancy
5. Ectopic pregnancy
• A pregnancy that occurs outside of the uterus
Signs and Symptoms:
• Vaginal bleeding • Dizziness
• Pelvic or abdominal pain radiating to the shoulder
• DX: Sonogram
Rx: Methotrexate or surgery
6. Pharmacology/pain relief • $QDOJHVLFVPD\EHSUHVFULEHGWRWDNHWKHHGJHRႇWKHSDLQ
• The settling of the fetus in the lower uterine segment
7. Lightening
• Increase in vaginal secretions
• Appearance of bloody show
• False labor pains
Pregnancy losses after the 20th week
Risk Factors:
Can be stimulated by:
8. Premature Labor
• Urinary tract infection
• Multiple gestation
• Diarrhea
• Previous premature delivery
• Dehydration
• Infections
• Laxatives
• Smoking
• Poor weight gain
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C. True labor
Stage 1: Dilation
• First true labor FRQWUDFWLRQXQWLOFRPSOHWHHႇDFHPHQWDQGGLODWLRQRIWKHFHUYL[
• Latent: 0cm - 4cm
• Active: 4cm - 8cm
• Transition: 8cm - 10cm
A: Presentation
3DUWRIWKHIHWXVWKDWLVFRPLQJ¿UVW
%(ႇDFHPHQW
Thinning of the cervix
C: Station
/HYHORIWKHIHWXV¶KHDGLQUHODWLRQWRWKHischial spines
6WDJH%LUWKRUH[SXOVLRQ
‡&RPSOHWHGLODWLRQDQGHႇDFHPHQWRIWKHFHUYL[XQWLOWKHELUWKRIWKHEDE\
‡%XOJLQJRIWKHSHULQHXPLVDQH[SHFWHG¿QGLQJ
• Fetal descent: Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation,
Expulsiion
Stage 3: Placental
• Birth of the baby until expulsion of the placenta
‡,QVSHFWWKHSODFHQWDIRUWZRDUWHULHVDQGRQHYHLQAVA
Stage 4: Recovery Stage
• 'HOLYHU\RIWKHSODFHQWDXQWLOWKHPRWKHU¶VFRQGLWLRQKDVVWDELOL]HG3HOYLFUHVWZHHNV
Stages of Labor
First Stage
Second Stage
Primipara
KRXUV
PLQXWHVWRKRXUV
Multipara
KRXUV
20 minutes to 1 1/2 hours
Third Stage
5 to 20 minutes
Usually helped by oxytocics or
manual pressure
5 to 20 minutes
Usually helped by oxytocics
D. Culture and Pain perception during labor
$QDOJHVLD±3UHVFULEHGMXVWHQRXJKWRWDNHWKHHGJHRႇWKHSDLQ0RUSKLQH0HSHULGLQH
2. Anesthesia – epidural – causes loss of sensation but not unconsciousness
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,93RVWSDUWXPWDNLQJLQGD\VWDNLQJKROGUGGD\OHWWLQJJRWKWKZHHN
Assessment : BUBBLE HE
B ladder:
U terus:
B reasts:
• Check for engorgement, mastitis & cracked nipples
B owels:
• Assess for presence of bowel sounds
L ochia:
• More than 8 pads / day needs follow up
• Encourage voiding
• Check for displaced uterus
• )XQGXVVKRXOGEH¿UPDWWKHOHYHORIWKHXPELOLFXVLPPHGLDWHO\SRVWGHOLYHU\
E pisiotomy: • Redness • Edema • Ecchymosis • Discharge/Drainage • Approximation
HRPDQ¶V6LJQ
Emotions:
‡6KRXOGEHDEVHQW
• Assess for DVT
• Assess for bonding
• Lochia Assessment:
RUBRA
SEROSA
ALBA
• Bright red
• Pink
• Creamy yellow
• Bloody
‡3LQNLVKEURZQ
• Serous
• May be brownish
‡GD\VSRVWSDUWXP
‡GD\VSRVWSDUWXP
‡ZHHNVSRVWSDUWXP
‡1RRGRURUVOLJKWO\ÀHVK\
‡SDGVSHUGD\LVQRUPDO
• No odor
• No odor or stale
• Body odor
• Breast Feeding:
•(QFRXUDJHFDORULHVDQGPOÀXLGLIEUHDVWIHHGLQJ
• Mastitis: Treatment: • Moist heat
• Encourage breast feeding or pump the breast
• Engorgement / cracked nipples: Treatment:
• ,FHRURSHQWRDLUPLQXWHVDWDWLPH
• Mother who does not want to breast feed:
• Teach:ZHDUWLJKW¿WWLQJEUDDQGLFH
• Parlodel (bromocriptine) may be prescribed
• Contraindications to breast feeding include but are not limited to:
• Tuberculosis
• Breast cancer
• Chemotherapy
• Radiation
• HIV
• Hepatitis
• Lactose intolerance (infant)
• Methotrexate
• Lithium
• Herpes lesion on nipples
• ([SHFWHG)LQGLQJV
• IHHGLQJVSHUGD\
• ZHWGLDSHUVSHUGD\
• 4 or more yellow bowel movements per day
• If infant develops diaper rash, keep open to air, use cloth diapers
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V. Care of Newborn
A. Nursing care assessment
1. Apgar score: score < 7 requires resuscitation
APGAR NEWBORN
SCORING SYSTEM
Performed at:
• 1 Minute After Birth
• 5 Minutes After Birth
Heart rate
0
Not detectable
1
Below 100
2
Above 100
5HVSLUDWRU\HႇRUW
Absent
Slow, Irregular
Good (crying)
Muscle tone
Flaccid
6RPHÀH[LRQRIH[WUHPLWLHV
Active motion
5HÀH[LUULWDELOLW\
No response
Grimace
Vigorous Cry
Color
Pale
Blue
Pink
• Data Collection: • Respiratory Status
• Apgar score
• Obtain vital signs
• Temperature Assessment
• Implementation: • Suction mouth then nose
• Dry baby with vigorous rubbing
• Maintain temperature
• Wrap baby in a warm blanket
• Place a stocking cap on the head
• Initiate breast feeding PRN
• Place baby in a warmer
‡(QVXUHSURSHU,'IRRWSULQWQHZERUQ
• Thumb print from mother
• Place ID bracelets on to assist in the prevention of infant abduction
• Administer Viamin K injection (phytonadione)
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VI. Normal Newborn
Normal Newborn Assessment
LENGTH
• ´´FP
WEIGHT
‡$YHUDJHZHLJKWSRXQGV
• Small for gestational age (SGA) < 5 lbs or 2500 grams
• Large for gestational age (LGA) > 9 lbs or 4100 grams
VITAL SIGNS
• 5HVSLUDWRU\UDWH
• +HDUWUDWHESP
• $SQHDODVWLQJ!VHFRQGVUHTXLUHVLQWHUYHQWLRQ
FONTANEL ASSESSMENT
• $QWHULRUFORVHVEHWZHHQPRQWKV
• 3RVWHULRUFORVHVEHWZHHQELUWKDQGPRQWKV
HEAD CIRCUMFERENCE
• FPLQFKHV
CHEST CIRCUMFERENCE
• FPLQFKHV
ACRACYANOSIS
• 1RUPDO¿QGLQJ
STRAWBERRY HEMANGIOMA • Raised rough area of skin
ERYTHEMA TOXICUM
• Harmless rash that looks like little pustules on a red base on the
face, trunk, legs, and arms. It disappears by 1 week.
MONGOLIAN SPOTS
• 1RUPDOIDGHVDJH
JAUNDICE
• 3K\VLRORJLFDOK\SHUELOLUXELQHPLDVHOIOLPLWLQJUHVROYHVLQGD\V
PETECHIAE
• Small red or purple spots
MILIA
• Tiny white bumps on the nose
VERNIX CAESEOSA
• White cheesy protective substance
CAPUT SUCCEDANEUM
• Edematous area on the head
CEPHALO HEMATOMA
• Collection of blood under the periosteum
• Risk with forcep delivery or vacuum extraction
• Note: If hematoma crosses the suture line, suspect skull fracture
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Newborn Care
AIRWAY
• Suction mouth before nose
WARMTH
• Swaddle infant
• Keep infant covered at all times
• 3XWFDSRQQHZERUQ¶VKHDGWRSUHYHQWKHDWORVV
• Heat may be lost by:
• Convection – prevent drafts
• Radiation – do not place bed near window
• Conduction – do not place infant on cold surfaces
• Evaporation – keep infant dry
BATHING
• Performed after temperature within normal limits
REFLEXES
• 3ULPLWLYHPRVWDUHSUHVHQWDWELUWK
CORD CARE
• Clean with mild soap and water
• Keep area clean and dry
CIRCUMCISION
• Jewish child done on day 8 (Bris)
SOCIAL SENSES
• Taste
• Touch
• Smell
• Sensitivity to light
‡6HOHFWLYHOLVWHQLQJ±UHVSRQGVWRPRWKHU¶VYRLFH
FEEDING
• Bottle or Breast: teach the care giver proper positioning
MEDICAL CHECK
‡3.8levels greater than 8: Can lead to mental retardation
• Baby will need to drink lofenolac formula Low protein formula for
life)
‡7KLVLVWKH¿UVWWHVWSHUIRUPHGRQWKHQHZERUQGRQHE\KHHOVWLFN
• Monitor the injection site for infection
• If done before 48 hours it will need to be repeated in 14 days
VII. The high risk neonate
A. Premature: ‡%RUQEHIRUHZHHNV • Transparent skin
• Risk for apnea
• At risk for multiple health problems
‡/RZELUWKZHLJKW
• Weak cry
• Poor feeding
B. Postmature: • Born after 42 weeks
• Increased risk for meconium aspiration
• Monitor newborn for respiratory problems
• Signs and Symptoms:
• Dry peeling skin
• Creases on palms & soles
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C. Complications:
)HWDODOFRKROV\QGURPHGUXJDGGLFWLRQ6\PSWRPVPDQLIHVWKRXUVDIWHUGHOLYHU\
(Neonatal abstinence syndrome)
• Shrill cry
• Poor weight gain
• Yawning
• Sneezing • Seizures
• Jittery – swaddle the infant
• Microcephaly and facial abnormality with
alcohol syndrome
TX: Supportive care to avoid continued exposure to additional medications. Opioids or
Phenobarbital used in severe cases.
2. Facial paralysis: risk increased with forcep delivery
&HUHEUDOSDOV\ULVNVLQFOXGHPDWHUQDODJHORZELUWKZHLJKWDQR[LFHSLVRGH
4. Erythroblastosis fetalis (RH incompatability): Rhogam Administered:
• 28 weeks gestation
• Within 72 hours after birth
• After voluntary termination of pregnancy
• After spontaneous termination of pregnancy
Given to RH negative mothers (occurs if father is RH positive)
&RRPEVWHVWGHWHFWVKHPRO\WLFDQHPLDLQWKHQHZERUQVKRXOGEHQHJDWLYHGLUHFWPHDVXUHV
SUHVHQFHRIDQWLERGLHVRQWKH5%&VXUIDFHLQGLUHFWPHDVXUHVDQWLERGLHVLQWKHVHUXP
5. Sepsis in the newborn: may become infected during birth or related to PROM
T Toxoplasmosis
O Other ( gonnorhea, syphillis, varicella, Hepatis B, HIV)
R Rubella
C Cytomegalovirus
H Herpes
D. Congenital anomalies:
1. Heart disease
6SLQDEL¿GD
(VRSKDJHDODWUHVLD Three C’S
• Coughing
• Choking
• Cyanosis
4. Apnea monitor : • Remove leads when not attached
• Unplug cord when not plugged into monitor
‡(OHFWURGHVDWPLGD[LOODU\OLQH¿QJHUEUHDGWKVEHORZWKHQLSSOH
• If apneic, gently stimulate the trunk by patting or rubbing
• Treatment:&DႇHLQH$PLQRSK\OOLQHRU7KHRSK\OOLQH
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COMMON MEDICATIONS USED IN MATERNITY
3LWRFLQ R[\WRFLQ Labor induction
Postpartum hemorrhage
Brethine (terbutaline):
Asthma
Preterm labor
Given until 37 weeks or lung
maturity
Magnesium Sulfate:
Pregnancy induced HTN
Seizures
Premature labor
Antidote: calcium gluconate
6LGH(ႇHFWV
Hyponatremia
Painful contractions
Contraindicated in uterine
hypertonicity
Discontinue with:
Sustained uterine
contractions
Fetal deceleration
Decreased urinary output
6LGH(ႇHFWV
Nervousness
Restlessness
Tremors
Hyperglycemia
Hypertension
Tachycardia: check pulse prior to administration
Hold if pulse is over 120
6LGH(ႇHFWV
&OLHQWPD\IHHOKRWDQGÀXVKHG
6LGH(ႇHFWVIRUQHRQDWH
Headache
N/V
Hypotonia
Dizziness
Nystagmus
Magnesium levels of
Lethargy
Bradycardia
PJGODUHQRUPDO
Diarrhea
Hypotension
&KHFNSDWHOODUUHÀH[LQ
Urinary retention
newborn
Nurse; monitor vital signs, urinary
output, electrolyte imbalance
Erythromycin:
Used to prevent chlamydia and gonorrhea in the neonate
Eye ointment
Methergine (methylergonovine) 6LGH(ႇHFWVHeadache
Dizziness
Nausea and vomiting
Diaphoresis
Post partum hemorrhage
Hypotension or hypertension
Cramps
Contraindicated in PIH
Given to mother at time of discharge
Rubella vaccine
7HDFKWRDYRLGSUHJQDQF\IRUPRQWKV
Treats post partum hemorrhage after other methods have failed
Hemabate (carboporst tromethaine)
6LGHHႇHFWV19'DEGRPLQDOFUDPSLQJ ÀXVKLQJ
Rhogam
Rh negative mother
Celestone (betamethasone)
*LYHQ,0WRWKHPRWKHU4K;WKHQZHHNO\XQWLOZHHNV
Used to improve L/S ratio
gestation
Common Opiods
Demerol (meperidine)
Stadol (butorphanol tartate)
To decrease pain
1XEDLQ QDOEXSKLQH 2SRLGDQWDJRQLVWQDOD[RQH
,QGXFHRYXODWLRQE\FKDQJLQJKRUPRQDOHႇHFWRQRYDU\
Clomid (clomiphene)
May result in multiple gestation
Apresoline
Treatment for hypertension
(hydralazine hydrochloride)
1DOR[RQH+&/
Treatment for respiratory depression
Prostaglandin
Softens and thins the cervix
Supplement to anesthesia, treats pain during labor
Stadol (butorphanol tartrate)
6LGHHႇHFWVSUXULWLVSDUHVWKHVLDVSDOSLWDWLRQVWLQQLWXV
Ginseng
Avoid ginseng with pregnancy and lactation
160
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PEDIATRIC ESSENTIALS
161
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I. Growth and Development
• A 2 year old walks up the steps, placing both feet on steps
• A 3 year old rides a tricycle, climbs steps with alternate feet on steps
‡$\HDUROGIDYRUVDSDUHQWRIWKHRSSRVLWHVH[ 2HGLSXVFRPSOH[ Weight:OEJDLQVRXQFHVSHUZHHNIRUWKH¿UVWPRQWKV
Height:LQFKHVJURZVLQFKSHUPRQWKIRUWKH¿UVWPRQWKV
Head Circumference:LQFKHV FP HTXDOWRRUVOLJKWO\ODUJHUWKDQFKHVWFLUFXPIHUHQFH
*URZVòLQFKSHUPRQWKIRUWKH¿UVWPRQWKV
PEDIATRIC ASSESSMENT MILESTONES ESSENTIALS
1 MONTH
5 MONTHS
5HÀH[DFWLYLWLHV
Cries to communicate
Mobiles
Cuddling
$EVHQWWHDUVWRPRQWKVRIDJHLVQRUPDO
Safety: Place on back to sleep
1RVWXႇHGDQLPDOVRUSLOORZLQWKHFULE
Monitor temperature of formula
Rear facing car seat up to age 2
2 MONTHS
Social smile
Lifts head
Coos
Bright pictures
Hanging objects
Music
Posterior fontanel closes
Safety: Monitor temperature of bath water
3 MONTHS
Sits with support
Turn from back to side
Babbles
Provide rattles
Soft toys
Safety: Keep side rails up
4 MONTHS
Gains head control
Places objects in mouth
Consonant sounds
Squeeze toys
Grasps toys with hand
Turns from back to abdomen
Safety: Avoid small objects
Inspect toys
Plays with toes
Turns from abdomen to back
Teething toys
Noise making toys
6 MONTHS
Holds bottle
Sits with minimal support
Understands name
Doubles birth weight
7 MONTHS
Begins to crawl
Squeeze toys
Safety: Outlet covers
Lock cabinets
8 MONTHS
Sits without support
Pulls to standing position
Fear of strangers
Plays games: hide and seek
9 MONTHS
Attempts to feed self
Walks holding on to furniture
3HHNDERR
Safety:
Supervise near water
10 MONTHS
Can hold own bottle or cup
Blocks
7R\VWKDWFDQEH¿OOHGDQGHPSWLHG
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11 MONTHS
Shows moods
8VHVLQGH[¿QJHUDQGWKXPEWRJUDVS SLQFHU
grasp)
12 MONTHS
Walks with one hand held or alone
Triples birth weight
Safety: Guard rails on stairs
Turn pot handles inward
First dental visit
15 MONTHS
Pull and push toys
Scribbles on paper
Crawls up stairs
18 MONTHS
Jumps on both feet
ZRUGYRFDEXODU\
Anterior fontanel closes
Safety: Place poisons in locked cabinet
2 YEARS*
%RZHODQGEODGGHUFRQWURO\HDUV
ZRUGSKUDVHV
Climbs steps with both feet on each step
Parallel play; puzzles, blocks; rocking horse,
drum
Can turn the doorknob
Safety: Forward facing car seat up to 40 lbs
then booster seat; Supervise near water;
Avoid chunks of meat
2.5 YEARS*
Full set of 20 baby teeth
Manipulative toys for muscle coordination
Crayons and paper
4 YEARS
Hops on one foot
Recognizes colors
Imaginary playmates
$YHUDJHZHLJKWOEV
$YHUDJH+HLJKW´ GRXEOHWKHELUWKOHQJWK Safety: Car booster seat:
8SWR\HDUVROGRU¶´LQKHLJKW
5 YEARS
2100 word vocabulary
Two wheel bicycle
Throws & catches ball
Average weight 40 lbs
$YHUDJH+HLJKW´
SCHOOL AGE
Ties shoes
Games
Rules
Period of industry:
Likes to accomplish things
Safety: Accident prevention
7UDႈFDQG¿UHVDIHW\
ADOLESCENT
Needs social approval of peers
Change in body size & development
Safety: 09$¶V
Sport injury prevention
Firearm accident prevention
Drug
ETOH
Sex education
High risk for suicide
3 YEARS*
Rides a tricycle
Alternates feet on steps
900 word vocabulary
Puzzles, books, drawing
Puppets
$YHUDJHZHLJKWOEV
$YHUDJH+HLJKWIHHW
Safety: Helmets
Knee pads
Stranger safety
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REFLEXES IN THE NEWBORN
Palmar Grasp
•
•
•
$XWRPDWLFUHÀH[RIIXOOWHUPQHZERUQV
(OLFLWHGE\SODFLQJ¿QJHULQLQIDQW¶VSDOP
Present at birth, disappears at 4 months
Asymmetrical
•
,QIDQWDVVXPHVIHQFHU¶VSRVLWLRQZKHQKHDGLVWXUQHGWRRQHVLGHDUPRQWKDW
VLGHLVH[WHQGHGDQGRSSRVLWHDUPLVÀH[HG
Present at birth, disappears at 4 months
7RQLF1HFN5HÀH[ •
•
:KHQLQIDQWLVVXGGHQO\MDUUHGRUKHDUVDORXGQRLVHWKHERG\VWLႇHQVWKH
legs are drawn up, and the arms are brought up, out, and then in front in an
embracing position
Present at birth, disappears at 4 months
Rooting
•
•
When side of the mouth is touched, child turns to that side
Present at birth, disappears at 4 months
Reciprocal
•
Movements of newborns are jerky and usually alternate in the legs
Kicking
•
Evolving at birth, disappears at 9 months
Sucking
•
•
•
Infants make sucking movements when anything touches their lips
Present at birth
Involuntary sucking, disappears at or about 9 months
Neck Righting
•
When the head is turned to one side, the opposite shoulder & trunk will follow
5HÀH[
•
(YROYLQJDWPRQWKVLQYROXQWDU\PRYHPHQWGLVDSSHDUVDWPRQWKV
•
Extension of the great toe on stroking the sole of the foot upwards
•
Present at birth, disappears after 2 years
•
̅Abnormal in an adult; indicates neurological damage
0RUR¶V5HÀH[
6WDUWOH5HÀH[
%DELQVNL5HÀH[
•
Dancing or Stepping
164
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II. Nutrition: Infant
Breast milk
•
Most complete and easily digested
Commercial formula
•
•
,URQIRUWL¿HGFDQEHXVHGXSWRPRQWKV
/LPLWIRUPXODRUPLONWRR]SHUGD\WRDYRLGLURQGH¿FLHQF\DQHPLD
Solids
•
•
•
,QWURGXFHGDWPRQWKVDIWHUSURWUXVLRQUHÀH[GLVDSSHDUV
Cereal, fruit, vegetables then meats
Introduce one new food/week to assess for allergies
Juices
•
•
Given with 1:1 dilution at 6 months
Use a cup
Chopped table foods •
Given at one year
Malnutrition
• Kwashiorkor:FDXVHGE\DODFNRISURWHLQOHDGLQIDQWLOHFLUUKRVLV
• Rickets: caused by a lack of vitamin D
• Scurvy: caused by a lack of vitamin C
• Infant botulism:FDXVHGE\LQJHVWLRQRIKRQH\EHIRUHDJH
¿UVWVLJQLVFRQVWLSDWLRQLUULWDELOLW\DQGZHDNFU\
III. Hospitalization
A. Child’s reaction
,1)$176 72''/(56
Birth to 2 years old
PRESCHOOLERS
3 to 5 years old
SCHOOL AGE
6 to 12 years old
ADOLESCENT
13 to 18 years old
• Fear separation: encourage parent participation
• Provide consistent care giver
• Provide stimulation & age appropriate toys
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Fears bodily injury: give simple explanations
Parental Involvement
Encourage expression through play
Cover wounds
Fears pain and bodily injury
Fears separation from peers
Communicate honestly
Encourage participation in care
Allow child to make choices where possible
Encourage visitation with peers and siblings
Provide diversional activities
Fears loss of independence
Fears body image disturbance
Fears separation from peers
Involve adolescent in care
Encourage visits
Provide telephone
Promote privacy
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B. Death and Dying
•
•
•
•
No concept of death
Fears separation
See death as temporary and reversible
Magical thinking: believe bad thoughts can cause death
School Age
•
They see death as permanent, but do not think it will happen to them
Adolescent
•
Knows death is permanent and inevitable
Infants and Toddlers
Preschoolers
C. Safety measures:
• Infants up to 20 lbs. or 2yrs old use rear facing car seat in the center rear of the
vehicle
• Then forward facing up to 40 lbs
‡%RRVWHUVHDWXSWR\HDUVROGRU¶´LQFKHVLQKHLJKW
• Check temperature of bath water
‡7HSLGZDWHUƒƒ
• Keep side rails up at all times
• Teach injury prevention
D. Medication administration
• Oral medications can be given using a syringe
• Ear drops: • 8QGHU\HDUVRIDJHSXOOHDUGRZQDQGEDFN
• Older child lobe is pulled up and back to straighten canal
• Intramuscular injections avoided in children
Site of choice: • Vastus lateralis, if not available use ventrogluteal
• Deltoid used over age 6
Drug Conversion for Children
&ODUN¶VZHLJKWUXOHIRUSHGLDWULFGRVDJH Child’s weight in pounds[$GXOWGRVH
150
<RXQJ¶5XOH Age in years[$GXOWGRVH
Age in years + 12
,QWUDYHQRXVPLFURGULSXVXDOO\KDVGURSVPO
4. Conversion of administration units:
1 tsp = 5 ml
1kg = 2.2lbs
1 tbsp = 15 ml
1 gm = 1,000 mg = 1ml
1 ml = 16 minims
R] PO
1 grain = 60 mg
1 dram = 4 ml
*Note: BSA (body surface area) is the most accurate means to calculate pediatric doses.
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IIII. Infant
INFANT: NEUROMUSCULAR AND SKELETAL DISORDERS
• External rotation of hip • Limited abduction
• Increased skin folds
• Shortening of leg
• 2UWRODQL¶VFOLFN
Congenital Hip Dysplasia
• 7UHDWPHQWLPPRELOL]DWLRQVSLFDFDVWRUSDYOLNKDUQHVVWRLPPRELOL]H
hips and thighs
Club Foot
• Dennis Brown Splints
Meningitis
• Droplet precautions
Otitis Media
• Amoxicillin drug of choice
Visual Disturbances
• 6WUDELVPXVSDWFKWKHJRRGH\H
• Observe for hearing loss
INFANT: CARDIOVASCULAR DISORDERS
Cyanotic Defects: Poor suck, bradycardia, fainting spells
Acyanotic Defects: Tachycardia, tachypnea, delayed Growth
Congenital Heart Defects Goals: Decrease workload of the heart
Improve respiratory function
Maintain proper nutrition
Sickle Cell Anemia
• Hydration, Oxygenation & Pain management (HOP)
INFANT: LYMPH, INFECTIOUS DISORDERS, IMMUNE SYSTEM
Acquired Immune
• Signs and symptoms seen at approximately 1 to 2 years of age
'H¿FLHQF\V\QGURPH
B. Immunizations
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Health Promotion: Assess client’s for the need for immunizations, required and recommended.
DTaP Vaccine
Diphtheria, tetanus, pertussis
• 7RWDORI¿YHJLYHQ
Should be given at: • 2 months
• 4 months
• Between 6 & 18 months
• Between 4 & 6 years of age
• Total of 4 doses
This vaccine helps protect young children from developing:
IPV Vaccine
Inactivated Poliovirus
PCV Vaccine
Pneumococcal
• Meningitis
• Blood infection (sepsis)
• CHECK FOR EGG ALLERGY FIRST!
• Not given to anyone younger than 6 months of age.
• 7KHLQDFWLYDWHGÀXYDFFLQH ÀXVKRW LVUHFRPPHQGHGIRU
,QÀXHQ]D9DFFLQH
- All children 6- 23 months of age
- Children 24 months and older with certain medical
conditions such as asthma, chronic heart or lung disorders,
or an imapired immune system
Flu
MMR Vaccine
0HDVOHVPXPSV UXEHOOD
• CHECK FOR EGG ALLERGY FIRST!
• May be combined or separate
• Teach: DO NOT GET PREGNANT WITHIN 3 MONTHS!
TD Vaccine
&RPELQHGWHWDQXV GLSKWKHULD
• Recommended for anyone over age 7
Hepatitis B Vaccine
• CHECK YEAST ALLERGY FIRST
Pertussis
• Treatment for pertussis is Erythromycin
Contraindications for Vaccines:
• Severe illness with fever
• Anaphylactic reaction to initial dose
• Pregnancy especially Rubella and Polio
• HIV or immunosuppression (cancer)
• Recent blood transfusion
• Allergy to gelatin, neomycin or steroids with varicella
vaccine
C. Kawasaki Disease:,QÀDPPDWLRQRIEORRGYHVVHOVDQGO\PSKQRGHVDႇHFWVPXFXVPHPEUDQHV
Strawberry tongue – give ASA and IV gamma globulin
66KLJKIHYHUUHGQHVVRISDOPVDQGVROHVVZROOHQO\PSKQRGHV
7UHDWPHQWVWHURLGVDQWLFRDJXODQWVDQWLSODWHOHWGUXJV
&RPSOLFDWLRQ$QHXU\VPVHFRQGDU\WRLQÀDPPDWLRQRIFRURQDU\DUWHULHV
168
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INFANT: RESPIRATORY DISORDERS
Pneumonia
&\VWLF¿EURVLV
Epiglottitis
(Bacterial Croup)
caused by
+LQÀXHQ]DH type B
• Droplet precautions with bacterial infection
• An inherited disease that causes thick, sticky mucus to build up in
the lungs and digestive tract. Mucus, mucus, mucus
• Steatorrhea: • Greasy, fatty stool
• May cause meconium ileus
• '[6ZHDWFKORULGHWHVW
• 5[3DQFUHDWLFHQ]\PHVXSSOHPHQWV 3DQFUHDVH • Given with meals and snacks,
• Diet: high calorie, high fat. Give salty snacks (also for Lithium)
• Supplement vitamins A, D, E & K
• Prevent respiratory distress:
• Chest physical therapy
• Bronchodilators
• Antibiotics
• Avoid cough suppressants
‡0RQLWRUIRU'0PD\GHYHORSZLWKDJLQJ
‡([FHVVGURROLQJGRQRWXVHWRQJXHGHSUHVVRUWRDVVHVVWKURDW
‡2FFXUVDPRQJDJH
• Inspiratory stridor
• Life threatening emergency
• Mist tent with oxygen, antibiotics
• Protect the airway (may need tracheostomy)
• Droplet precautions
Croup (viral)
• Barking cough: Cool mist tent
• Home Care:
‡%UHDWKLQJPRLVWDLUIURPVWHDPHGZDWHUDKRWVKRZHURUDFRROPLVW
KXPLGL¿HULVKHOSIXOLQWKHPDMRULW\RIFDVHV
‡&RXJKLQJDQGVWULGRUVKRXOGLPSURYHZLWKLQPLQXWHV
Bronchiolitis
• Caused by RSV
‡6WULFWKDQGZDVKLQJ'URSOHWSUHFDXWLRQVIRUKRXUVWKHQFRQWDFW
precautions
‡&RPPRQLQ¿UVW\HDUVRIOLIH
• 3 C’s:
Tracheal
Esophageal Fistula
• Coughing
• Choking
• Cyanosis
169
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INFANT: DIGESTIVE AND ENDOCRINE DISORDERS
DIGESTIVE DISORDERS
Thrush
Gastrostomy Button
(G-button)
Treatment:
• Nystatin suspension; apply with cotton swab
•
•
Skin level device
Allows baby to sleep on their stomach
•
•
•
Used for feedings and medications
Flush with water after feedings and meds to avoid clogging
• Monitor skin around site for irritation
- indicates leakage
Teach parent to carry extra button i • Teach parent to carry extra button in
case ballon breaks
•
• Seen soon after birth
• Thickening of the pyloric sphincter causing narrowing and obstruction
‡&RPPRQLQ&DXFDVLDQ¿UVWERUQPDOHV
Pyloric Stenosis
• Assessment: • Olive size bulge under (R) rib cage
• Vomiting- projectile during and after feeding
• Observe rolling waves in abdomen (peristalsis)
• Failure to thrive
• Poor skin turgor
• Decreased urinary output
• Diagnostic test: • Upper GI series
‡/DE¿QGLQJV • Decreased sodium, K+, CL
• Increased HCT, metabolic alkalosis
• Treatment:
• Thicken feedings
‡S\ORURP\RWRP\ )HGHW5DPVWHGW3URFHGXUH • Nursing interventions:‡0RQLWRUÀXLGDQGHOHFWURO\WHV
• Place in high fowlers
• Place on right side after eating
• Strict intake and output
‡&KHFNVSHFL¿FJUDYLW\
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INFANT: Intestinal Disorders
Intussusception
• Bloody currant jelly stools with sausage shaped mass
Treatment: Barium enema or Surgery
*If baby has a bowel movement prior to surgery, cancel the procedure
Congenital Megacolon • Absence of ganglion cells in distal colon
• Results in obstruction with failure to pass meconium or ribbon like stools
Hirschsprung’s
Disease
• Treatment: surgery ; temporary colostomy
Imperforate anus
No rectal temperature
Diarrhea
• Common in young children
• BRAT diet
• May cause dehydration: ‡5HSODFHÀXLGVFOHDUOLTXLGV
• Monitor electrolytes
Celiac disease
PKU
Cleft Palate and Lip
Failure to Thrive
• Malabsorbtion syndrome
• Fat or gluten intolerance
• Signs & Symptoms: diarrhea, large bulky stool, anemia, recurrent infections
• Supplement vitamins A, D, E & K
‡*OXWHQIUHHGLHW$YRLG%52:
• Can eat rice and corn
• Avoid phenylalanine
• NoPHDW¿VKSRXOWU\HJJVOHJXPHV QXWUDVZHHW
• Lofenolac formula
• Child will need speech therapy and orthodontics
• CLEFT LIP repaired @ 2 months
• Child cannot have a respiratory infection
• Steri strips
• Elbow restraints
‡/RJDQEDUXVHGWRNHHSSUHVVXUHRႇWKHVXWXUHOLQH
̅NO PACIFIERS, STRAWS OR ORAL TEMPS 7-10 DAYS
• CLEFT PALATE IS REPAIRED AT 18 MONTHS
• Risk of infection: • Use a large holed nipple • Give water after each feeding
• Burp infant between feedings
2UJDQLFDQG1RQRUJDQLFFDXVHV
• The sudden and unexplained death of an infant under 1 year of age
Risks: • Previous SIDS death
• Twin gestation
• Prematurity
• Alcohol and drug abuse
Sudden Infant Death
• Smoking
• Teach avoid soft mattresses & pillows
Syndrome
‡$YRLGRYHUKHDWLQJ‡3ODFHRQ³EDFNWRVOHHS´
‡$SQHDPRQLWRULQJ7HHQDJHPRWKHUV RYHUDJH
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IV. Toddler
TODDLER: Integumentary Disorders
Impetigo
•
•
•
Highly contagious
• Contact precautions
Group A Strep
• Antibiotic therapy
Child has characteristic honey crusted lesions
Burns
•
Rule of nines up to 12 years old
•
Isolate known infected persons
Antifungal ointment (Lotrimin – clortrimazole)
Oral Griseofulvin:
• Hepatotoxic
• Give with fatty meal
• Avoid prolonged exposure to sunlight
Tinea Capitis (scalp) •
Tinea corporis (body) •
Tinea pedis (feet)
TODDLER: Musculoskeletal Disorders Fractures/Traction
Bryants
%XFNVH[WHQVLRQ
(skin traction)
Russell
(skin traction)
•
•
•
•
•
•
•
Used for children under 2 years of age
What type of restraints should be on hand? A jacket restraint to prevent
turning and twisting out of alignment
Short term immobilization, or for bone deformities
The body acts as a counterweight
Padded sling under the knee
&KHFNSRVLWLRQVRKLSÀH[LRQLVPDLQWDLQHG
Damage to nerve under knee may cause foot drop
TODDLER:Genitourinary Disorders
Nephrosis
Hypospadias
Wilm’s Tumor
•
•
•
•
•
•
•
•
•
Common in boys age 2 to 7 years of age
3HULRUELWDOHGHPD¿UVWVLJQ
Urethral opening on ventral surface of penis
Foreskin may be needed for surgical repair
Baby should not be circumcised
Non tender, malignant mass of kidney
Felt in abdomen near liver
'RQRWSDOSDWHWKHPDVVPD\UXSWXUH
Treatment – nephrectomy and chemotherapy
TODDLER: Cardiovascular System
,URQ'H¿FLHQF\$QHPLD
•
•
•
•
•
•
Limit milk to 24 oz./day
Treat with supplemental iron – ferrous sulfate
Increase vitamin C to aid absorption
Give liquid via straw to prevent teeth discoloration
Give deep IM using Z track
May cause dark colored stools
TODDLER: Gastrointestinal Disorders
Pinworms
•
•
•
•
•
Intense pruritis at night
Strict hand washing
Treat all family members.
Treatment: Vermox (mebendazole) – single dose.
'RVHPD\QHHGWREHUHSHDWHGLQ±ZHHNV
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TODDLER: Neurosensory Disorders
Head injury
•
Concussion – temporary loss of consciousness following trauma
•
•
•
•
•
6SLQD%L¿GDpina
%L¿GD
•
•
•
•
•
•
•
Abnormal muscle tone and lack of coordination
*RDOLVHDUO\LQWHUYHQWLRQWRPD[LPL]HWKHFKLOG¶VFDSDELOLWLHV
%XOJLQJIRQWDQHO¶VUWLQFUHDVHG,&3
Sunset eyes
7UHDWPHQW93VKXQWDYRLGSUHVVXUHWRVKXQWPRQLWRUIRULQIHFWLRQ &6)
leakage
Mother given folic acid early in pregnancy to prevent
Avoid pressure to the sac
Maintain moist sterile dressings
Treatment is surgery
Child has paralysis below the defect with bowel and bladder dysfunction
Teach: straight cath for residual urine using clean technique at home
High risk for rubber allergy (latex)
Down’s syndrome
•
Risk factor – advanced maternal age
•
•
•
•
•
•
•
8VXDOO\DႇHFWVFKLOGUHQSULRUWRDJH
Hours of repetitive behavior
Bizarre motor behaviors
Severely impaired communication
Child is self absorbed and unable to relate to others
May display, rocking, spinning, twirling
Nursing interventions:
• Maintain consistency
• Determine the way child communicates
• Provide for safety if necessary to prevent self injury
• Refer to social programs
• Parental support
Treatment: OT, PT, Speech therapy, special ED,
antipsychotics, antidepressants
Cerebral Palsy
Hydrocephalus
Autism/Autistic
Disorder
•
TODDLER: Respiratory Disorders
2[\JHQ7KHUDS\
Lead Poisoning
(plumbism)
•
•
•
•
•
•
•
•
Tents most common form of O2 administration for children
Flush tent with oxygen before putting client inside
$YRLGRSHQÀDPHVFLJDUHWWHV±SRVWVLJQV
Wipe away condensation to prevent decreased visualization of child
Keep clothes and linen dry; Plastic or rubber toys appropriate
Leads to cognitive impairment and anemia
Routine screening at 12 months
7UHDWPHQW±LURQFKHODWLQJDJHQWVSHQLFLOODPLQHLQFUHDVHÀXLGV
Child Abuse:
• Be alert for contradiction between injury and explanation of cause.
• Mandatory reporting by health care personnel.
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PRESCHOOL: Musculoskeletal Disorders
Duchenne’s Muscular
Dystrophy
•
•
;OLQNHGLQKHULWDQFHRFFXUVE\DJH
*RZHUV¶6LJQXVHRIKDQGV DUPVWRZDONXSWKHERG\IURPD
squatting position. It indicates lack of muscle in the lower limbs.
PRESCHOOL: Neurosensory Disorders
Seizure disorders
Reye’s syndrome
•
•
•
•
•
•
Generalized – entire brain involved
3DUWLDORUIRFDO±RQO\RQHKHPLVSKHUHRIEUDLQDႇHFWHG
• Protect from injury
• Anticonvulsants: Dilantin (phenytoin), Phenobarbital, Keppra
(levetiracetam), Depakote (valproic acid)
Linked to use of ASA and phenothiazine (anti psychotics)
9DULFHOODRULQÀXHQ]DH
No ASA in children < 18 years old
Tx: Mannitol, Diuretics and Barbiturates
PRESCHOOL: Cardiovascular Disorders
•
•
•
•
•
•
Hemophilia
Leukemia
;OLQNHGLQKHULWDQFH
Prevent injury
Monitor for bleeding
ALL (acute lymphoid leukemia)
$0/ DFXWHQRQO\PSKRLG±0\HORJHQRXVOHXNHPLD Prevent infection
PRESCHOOL: Lymph, Infectious Disorders, Immune System
&KLFNHQSR[±9DULFHOOD
•
•
Spread by direct contact or air droplet
Airborne & contact precautions if hospitalized
Rubeola/Measles
•
•
•
•
Spread by aerosolized droplets
.RSOLNVSRWVLQPRXWK±VPDOOEULJKWUHGVSRWVZLWKDEOXHZKLWHFHQWHU
Rash appears on 4th day
Airborne precautions
Rubella/ German
measles
•
•
•
Spread by direct and indirect contact with droplets
Birth defects if acquired during pregnancy
Droplet precautions
•
•
•
Develops after URI with beta hemolytic strep
Heart, joints, CNS, skin and subcutaneous tissue involved
If untreated, scarring & deformity of cardiac structures leads to
Rheumatic heart disease
Monitor the heart routinely
Diagnosis: increased WBC, increased ESR, + C reactive protein
Droplet precautions
Rheumatic fever
•
•
•
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PRESCHOOL: Respiratory Disorders
Tonsillectomy
Choking hazards
•
Frequent swallowing is a sign of bleeding
•
3RVWRS±PRQLWRUIRUVWULGRUHQFRXUDJHÀXLGVDQGIUXLWLFHV
•
•
•
•
NO RED liquids
Children under 4 at high risk
Objects with small removable parts
Several foods (hotdog, popcorn, grapes, hard candy etc.)
PRESCHOOL : Gastrointestinal Disorders
Rota virus
•
•
•
•
•
•
•
Common cause of diarrhea in young children
Incubation period is 2 days
Symptoms include vomiting, diarrhea, fever and abdominal pain
Transmission: oral – fecal route.
Usual age of occurrence is 2 years of age
Can be spread in day care centers
Treatment includes: oral hydration, & hospitalization if IVF are needed
PRESCHOOL : Genitourinary Disorders
•
Primary cause or as a post infection condition related to streptococcal
or pneumococcal organism
Glomerulonephritis
Urinary tract infections
•
Gross hematuria, oliguria & proteinuria
•
0DLQWDLQÀXLGUHVWULFWLRQV
•
Strict intake and output
•
Protective isolation
•
Penicillin
•
Lasix
•
•
Antihypertensives
E.coli most common causative organism
•
Boys with UTI need further work up
Treatment for chronic UTI:
‡*DQWULVLQ VXO¿VR[D]ROH RU
• Macrodantin (Nitrofurantoin)
9HVLFRXUHWHUDO5HÀX[
•
•
%DFNZDUGÀRZRIXULQHIURPWKHEODGGHULQWRWKHNLGQH\VFDXVHV
recurrent UTI
Treatment is surgery only in severe cases
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SCHOOL AGE: Respiratory Disorders
Asthma
Erythema Infectiosum
5th disease
Scarlet Fever group A strep
•
Teach: regarding triggers, use of MDI
•
•
•
•
•
•
•
&KDUDFWHULVWLFUHGUDVKZLWK³VODSSHGIDFH´DSSHDUDQFH
Look for a rash in 4 to 14 days
Caused by human paro virus B19
$ႇHFWVFKLOGUHQWR\HDUVRIDJH
Common in winter & spring
Droplet precautions
Pregnant women should not be in contact or care for the
infected child
•
•
•
•
•
Transmitted via direct or indirect contact or droplet spread
Fever, red rash, strawberry tongue
Droplet precautions until 24 hours after treatment
Bed rest
Antibiotic therapy
SCHOOL AGE: Integumentary Disorders
Head Lice (Pediculosis Capitus) •
Do not share hats/combs
SCHOOL AGE: Musculoskeletal Disorders
Juvenile Rheumatoid arthritis
•
•
•
•
Swimming is the best exercise
ASA is the drug of choice
16$,'¶VDQGSUHGQLVRQHDOVRXVHG
Goal is to limit deformity
•
Disturbance in circulation causes aseptic necrosis of the
femoral head
7UHDWPHQW%HGUHVWZLWKWUDFWLRQ
Legg – Calves Perthes Disease
•
SCHOOL AGE: Neurosensory Disorders
Treatment: • Ritalin • Quillivant • Concerta (methylphenidate)
• Dextroamphetamine (dexedrine)
$WWHQWLRQ'H¿FLW+\SHUDFWLYLW\
• Strattera (atomoxetine)
Disorder - ADHD
6LGH(ႇHFWV‡,QVRPQLD
• Irritability
Conduct Disorder
• Occurs in children and teens
• Displays a pattern of disruptive & violent behavior
• 'LႈFXOW\IROORZLQJUXOHV
Treatment: Psychotherapy and medications to manage
symptoms
176
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ADOLESCENT: Musculoskeletal Disorders
Scoliosis
• S shaped curvature of spine
‡$GDP¶V7HVWIRUZDUGEHQGWHVW
• Less than 25 º curves – no treatment
‡žžFXUYHVUHTXLUHEUDFLQJ
‡*UHDWHUWKDQžVXUJHU\ZLWK+DUULQJWRQURGSODFHPHQW
‡0LOZDXNHH%UDFHKRXUVSHUGD\
• Body image disturbance
• Risk for alteration in skin integrity
ADOLESCENT: Endocrine Disorders
Type 1 Diabetes Mellitus
• Goal is to maintain blood glucose levels and prevent complications
• Nutritional teaching
ADOLESCENT: Lymph, Infectious Disorders, Immune System
Mononucleosis
³.LVVLQJ'LVHDVH´
Hodgkin Disease
‡7UDQVPLWWHGE\GLUHFWFRQWDFWZLWK6DOLYD‡(SVWHLQ%DUUYLUXV
‡&DQFHULQWKHO\PSKV\VWHP‡%LRSV\VKRZV5HHG6WHUQEHUJFHOOV
ADOLESCENT: Reproductive
6H[XDOO\7UDQVPLWWHG
Infections
Adolescent pregnancy
• Chlamydia and gonorrhea most common
• Teach prevention
• Treat all contacts
‡*DUGDVLO+39YDFFLQH7RSUHYHQWFHUYLFDOFDQFHUV JHQLWDOZDUWV
*LYHQDWDJH\HDUVPDOHDQGIHPDOH
• High risk for pregnancy complications
• Prematurity and neonatal problems
‡,QFUHDVHGDLO\FDORULFLQWDNHE\WRFDORULHV
Mental Health
$QRUH[LD1HUYRVD
‡&RPPRQLQ\HDUROGXQGHUZHLJKWFOLHQWVLQWURYHUW
• Constant exercising
• Fear of gaining weight
• Patient has deliberate self starvation with weight loss
Signs and Symptoms:
• Under weight
• Lanugo
• Amenorrhea
• Cold sensitivity
• Dehydration
• Electrolyte imbalance
• Cardiac arrhythmias
• Constipation
• Bradycardia & brittle nails
• Withdrawal from social activities
Treatment: • Medical management • Behavioral therapy
Bulimia
‡&RPPRQLQ\HDUROG‡8VXDOO\RYHUZHLJKWH[WURYHUW
• Binge eating of large amounts of food then purging by vomiting or
taking laxatives
Signs and Symptoms: • Excessive laxative or diuretic use
• Amenorrhea
• Electrolyte imbalance
• Withdrawn
• Excessive dental caries and stained teeth
• Treatment: similar to anorexia, antidepressants used
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PSYCHOSOCIAL INTEGRITY
178
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PSYCHOSOCIAL INTEGRITY
I. Overview of Mental Health Nursing
Mental illness = inability to cope with or manage stress- DQ\GLVRUGHUWKDWDႇHFWVPRRGRU
behavior
1. Cultural and ethical considerations
2. Legal / ethical issues
7KHUDSHXWLFFRPPXQLFDWLRQYHUVXVEORFNVWRFRPPXQLFDWLRQ
Technique (therapuetic)
Listening
Broad Openings
Blocks QRQWKHUDSXHWLFDYRLG
Hears but does not actively listen
Rejects/ ignores client responses
Restating
&ODUL¿FDWLRQ
5HÀHFWLRQ
Exploring
Voicing Doubt
Verbalizing the Implied
Summarization
Informing
Focusing
Sharing Perceptions
7KHPH,GHQWL¿FDWLRQ
Humor
Silence
Suggesting
Evaluation
Reinforces only part of the message & ignores other parts
Probes; assumes understanding
Reinforces unhealthy parts of client communication; stereotypes responses
Encourages tangential & circumstantial communication
Promotes anger; reinforces need for the idea/perception
Interprets to client; misunderstands the implied message
Forces conclusions; arrives at inaccurate conclusions
Gives advice or inaccurate information, gives information before client is ready or able to learn
Forces client to discuss issues that are threatening
Challenges the client
Ignores themes; gives advice
8VHVODXJKLQJDWKXPRUSURPRWHVXSHU¿FLDOFRPPXQLFDWLRQDYRLGVDSUREOHP
Asks questions; fails to break nontherapeutic silence
Gives advice; offers suggestions too early in the problem-solving process
Focuses on or encourages only positive appraisals
4. Psychiatric assessment: PISSCAGE
• Psychomotor movement
• Decreased Interest
• Suicidal
• ĻRUĹSleep
• Decreased Concentration
• ĻRUĹAppetite
• Guilt
• Decreased Energy
5HPHPEHU\RXUVDIHW\$/:$<6FRPHV¿UVW
Watch for nonverbal cues of aggression/ violence
FOHQFKHG¿VWSDFLQJUDLVHGYRLFHYHUEDOWKUHDWV Always position yourself between the patient and
an exit. Prepare for seclusion if necessary.
Priority $VVHVVFOLHQWVIRUULVNIRUVHOILQMXU\DQGYLROHQFH&OLHQWVZLWKPDMRU
mental illness, substance abuse, and psychopathy are at increased risk for
violence.
Clients at risk for self injury:
•
•
•
•
•
Family problems • relationship issues • self esteem issues
)HHOLQJVRIVWUHVVZRUNRUVFKRRO‡IHHOLQJVRIUHMHFWLRQ
Bereavement
• bullying
• feelings of guilt
Reaction to trauma or abuse
• peer pressure
3RRUERG\LPDJH‡GLႈFXOWLHVDVVRFLDWHGZLWKVH[XDOLW\
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7HFKQLTXHVIRUDQVZHULQJSV\FKRVRFLDOTXHVWLRQV
•
•
•
•
•
•
•
•
Determine who is the client in the question
$OZD\VFKRRVHDQDQVZHUWKDWZLOOGHFUHDVHWKHFOLHQW¶VDQ[LHW\
<RXUUHVSRQVHVKRXOGPDLQWDLQFRQ¿GHQWLDOLW\DQGHVWDEOLVKWUXVW
Avoid responses that could be answered with a yes or no
Never ask why
Maintain therapeutic communication – allow client to express their feelings,
give information and feedback
Choose a response that sets limits on behavior and presents reality
Avoid blocks to therapeutic communication like giving advice, giving false
reassurance and being judgmental
6. Defense mechanisms: unconscious; used by client to decrease anxiety
Compensation
Denial
Displacement
Fantasy
Fixation
,GHQWL¿FDWLRQ
Insulation
Covering up a lack or weakness by emphasizing a desirable trait
Refuse to face reality
Discharging pent-up feelings from one object to a less dangerous object
*UDWL¿FDWLRQE\LPDJLQDU\DFKLHYHPHQWVDQGZLVKIXOWKLQNLQJ
Persistence into later life of interests and behavior patterns appropriate to an earlier age
Assumption of desirable personality attributes of one admired.
Passive withdrawal. Inaccessible to avoid further threatening circumstances
Isolation
Projection
Rationalization
5HDFWLRQ)RUPDWLRQ
Regression
Repression
Walling off of certain ideas, attitudes or feelings. Separating feelings from intellect.
Attribution of one’s own undesirable traits to someone else
The attempt to prove or justify behavior
Preventing the expression of dangerous feelings and desires by exaggerating the opposite attitude.
Resorting to an earlier developmental level in order to deal with reality
Unconscious process that keeps undesirable and unacceptable thoughts from entering the
conscious
Primitive or unacceptable tendency is redirected into socially constructive channels.
Keeping unpleasant feelings and experiences from awareness
An idea or object used by the mind to represent an actual event or object
$VSHFL¿FDFWLRQLVSHUIRUPHGWKDW¶VFRQVLGHUHGWREHWKHRSSRVLWHRIDSUHYLRXVO\DFFHSWDEOHDFWLRQ
Sublimation
Suppression
Symbolization
Undoing
(ႇHFWLYHYV,QHႇHFWLYHFRSLQJPHFKDQLVPV
EFFECTIVE
INEFFECTIVE
+XPRUVHHNLQJVXSSRUWSUREOHPVROYLQJ
Relaxation, physical recreation
Denial, self blame, verbalization of inability to cope
Adjusting expectations
Inability to ask for help, problem solve or meet basic
needs, insomnia, withdrawal
Reluctance to participate in treatment plan
Destructive behavior toward self and others
Inappropriate use of defense mechanisms
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II. Psychiatric Nursing: 3 phases of the nurse client relationship
• Orientation: assessment of client; establish trust
• Working –planning and intervention; establish goals, problem solving,
explore thoughts and feelings; formulate nursing diagnosis
‡7HUPLQDWLRQEHJLQVDWDGPLVVLRQHYDOXDWLRQRIJRDOVDOORZFOLHQWWRGLVFXVVIHHOLQJV
DERXWWHUPLQDWLRQDQGORVV0DLQWDLQOLPLWVRI¿QDOWHUPLQDWLRQ
III. Treatment Modalities
A. Milieu therapy:PDQLSXODWH FRQWURORIWKHSDWLHQW¶VHQYLURQPHQWWRSUHYHQWVHOI
destructive behavior and improve coping skills.
• Individual
• Group: individuals interact together to problem solve
• Family: focus is on family, not individual
• Behavioral: reconditioning of learned behavior
B. Managing Behavioral disorders: 'HHVFDODWLRQWHFKQLTXHVIRUWKHDJLWDWHGFOLHQW
• First attempt to reduce the level of arousal.
• The nurse must appear calm, and self assured. Anxiety can make the client feel
anxious and unsafe which can escalate aggression.
‡8VHDFDOPORZPRQRWRQRXVWRQHRIYRLFH QRUPDOWHQGHQF\LVWRKDYHDKLJKSLWFKHG
tight voice when scared).
• Move the situation outside or to another room, if possible. Give the client plenty of
URRPWRPRYHDQGVLJQL¿FDQWVSDFHEHWZHHQ\RXDQGKLP1HYHUWXUQ\RXUEDFNIRU
any reason.
‡([SODLQOLPLWVDQGUXOHVLQDQDXWKRULWDWLYH¿UPEXWDOZD\VUHVSHFWIXOWRQH
Suggest alternative behaviors where appropriate (“Would you like to take a walk and
KDYHDFXSRIWHD"´ • Do not try de-escalation when a person has a gun or other serious weapon.
C. Somatic Therapy
1. Electroconvulsive (ECT):
• Used to treat depression, schizophrenia, & bipolar mania after medications have failed
• NPO
• No metals in hair, hair should be clean
‡1RFDႇHLQH
‡SRVWRSPRQLWRUIRUVHL]XUHV
• Brain damage, temporary or permanent memory loss
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2. Psychopharmacology
A. ANTIPSYCHOTICS- PHENOTHIAZINES
TYPICAL - TREATS POSITIVE SYMPTOMS
• Thorazine (chlorpromazine)
prescribed for hiccups
ATYPICAL - 75($76326,7,9(
• =\SUH[D (olanzapine)
• Clozaril (clozapine)
• Seroquel (quetiapine)
• Haldol (haloperidol)
• Risperdal (risperidone)
• Geodon (ziprasidone)
• Mellaril (thioridazide)
• Abilify (aripiprazole)
‡&DXVHV$JUDQXORF\WRVLV&KHFN:%&4ZHHN;
PRQWKV4ZHHNV;PRQWKV
• Prolixin (fuphenazine)
SIDE EFFECTS:
• Hypotension
• Tachycardia
• Lethargy
• CNS depression
• Liver disease
• Impaired mobility
1(*$7,9(6<037206
ADVERSE REACTIONS:
• Slurred speech
• Impotence
• Extra pyramidal reactions
• Dry mouth
• Urinary retention
• Photosensitivity
(give Cogentin, Artane, Benadryl)
NURSING INTERVENTIONS:
• 'HFUHDVHK\SRWHQVLRQGDQJOHZKHQVWDQGLQJ • ,QFUHDVH¿EHUWRGHFUHDVHFRQVWLSDWLRQ
• /D\ÀDWIRUKRXUDIWHUPHGLFDWLRQV
• Change position slowly
• Give sugarless candy for dry mouth
• Teach to avoid getting overheated in the sun,
use sunblock
•2EVHUYHIRUHႇHFWLYHQHVVZHHNVDIWHU
administration
• Do not give Geodon (ziprasidone) to cardiac
patients with recent MI, or heart failure (prolongs
QT interval)
Neuroleptic Malignant Syndrome – fatal if untreated.
• Occurs with initiation of neuroleptic medications after change from one medication to
another after dose increase and with medication combinations
‡6HYHUHH[WUDS\UDPLGDOVLGHHႇHFWV
• Emergency treatment needed
• Signs and Symptoms: ‡˶7HPS
‡˶3XOVH
• Tremors
‡˶%ORRGSUHVVXUH ‡0XVFOHULJLGLW\
• Incontinence
• Discontinue medications
‡8VHWKHVHGUXJVZLWKSUHFDXWLRQDVWKH\SRWHQWLDWHWKHHႇHFWRI
• Antidepressants
B. Antidepressants:
TRICYCLICS:
• Elavil (amitriptyline)
• Lithium
• Antihypertensives
• Anticholinergics
6LGH(ႇHFWV
• Tofranil (imipramine)
• Drowsiness
• Pamelor (nortriptyline)
• Nocturnal enuresis
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SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI’S):
‡3UR]DF ÀXR[LWLQH
• Cymbalta (duloxetine)
• Zoloft (sertraline)
‡(ႇH[RU YHQODID[LQH
• Paxil (paroxitine)
• Pristiq (devenlafaxine)
• Lexapro (escitalopram)
• Celexa (citalopram)
6LGH(ႇHFWVQDXVHDGU\PRXWKGL]]LQHVVGHFUHDVHGDSSHWLWHFRQWUDLQGLFDWHGLQSUHJQDQF\
665,6\QGURPHFRPSOLFDWLRQRI665,XVHIHYHUDJLWDWLRQWUHPRUVGLODWHGSXSLOVGLDUUKHDWZLWFKLQJ
MAO INHIBITORS:
• Nardil (phenelzine)
Dietary restrictions of foods containing tyramine
Foods to avoid:
• Parnate (tranylcycpromine)
• All cheeses except cream or cottage
Clients are at risk for hypertensive crisis
• Meats (deli)
Can lead to intracranial hemorrhage
• $JHGRUFXUHG¿VK DQFKRYLHVKHUULQJ Signs and Symptoms:
• Avocados
• Figs
•
Beer
• Red wine
• Increased blood pressure
• Yeast extracts
• Liver
• Palpitations
• Diaphoresis
• Yogurt
• Sauerkraut
• Chest pain
• Headache
• Smoked meats
• Soy sauce
NURSING INTERVENTIONS:
Monitor vital signs frequently
DO NOT STOP ABRUPTLY
Hold medications 2 weeks before surgery
and between change in drug class; 6
weeks before starting Prozac
DRUGS TO AVOID:
• Over the counter medications
• Other antidepressants
• Decongestants
• Narcotics
• Stimulants
• Antacids (inhibit absorption)
• Cocaine
• Amphetamines
• ETOH
• Asthma medications
• CNS depressants
• *LQNR .DYD.DYD,QFUHDVHVWKHH௺HFWRI0$2,¶V
Wellbutrin, Zyban (bupropion Hcl): May be used for smoking cessation
6LGH(ႇHFWV• Drowsiness • Dry mouth • Tremors
• Administer with food
Remeron (mirtazapine):6(±ÀXOLNHV\QGURPHUHSRUWIHYHUFKLOOVVRUHWKURDW
C. MOOD STABILIZERS:
Lithium Monitor levels 1 - 2 times per week until blood level is therapeutic then every month, then
HYHU\PRQWKV1RUPDOP(T/
D. ANTIANXIETY AGENTS:
Xanax (alprazolam)
Librium (chlordiazepoxide)
Buspar (buspirone)
Valium (diazepam)
6LGH(ႇHFWV&16GHSUHVVLRQSK\VLFDODQGRU
psychological dependence.
E. SEDATIVES / HYPNOTICS:
+DOFLRQ WULD]RODP DYRLGXVLQJZLWKFLPHWLGLQH
Restoril (temazepam)
6LGH(ႇHFWV&16GHSUHVVLRQQDXVHDYRPLWLQJ
diarrhea, hepatomegaly
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IV. Mood Disorders
1. BIPOLAR DISORDER – manic – depressive disorder
• Moods alternate between depression and excessive elation
‡&OLHQWPD\EHDULVNWRVHOIDQGRWKHUVVXLFLGHRUKRPLFLGHULVN
• Provide safe environment – PRIORITY
‡'XULQJPDQLFSKDVHFOLHQWPD\QHJOHFW$'/¶VDQGQXWULWLRQ3URYLGH¿QJHUIRRGV
• Treatment:
Eskalith (lithium), Lamictal (lamotrigene), Abilify(aripiprazole)
Individual / family / group therapy, ECT (mania)
2. MAJOR DEPRESSION – SAFETY, SAFETY, SAFETY!!!!
• Suicide – safety is the priority
• Provide 1:1 watch
• Ask patient directly if they have a plan
• Signs of suicidal ideation include elevated mood & giving away prized possessions
• Initiate suicide precautions
Treatment: antidepressants, individual or group therapy
a) Bipolar (manic-depression):
‡/LWKLXPLQLWLDOGRVHPJWLGEORRGOHYHORILVGHVLUDEOH
‡&KHFNOHYHOKRXUVDIWHUODVWGRVHWLPHVSHUZHHNWDNHZLWKIRRG
‡0DLQWHQDQFHGRVHPJWRPDLQWDLQDOHYHORIP(T/FKHFNPRQWKO\
‡7R[LFLW\JUHDWHUWKDQP(T//LIHWKUHDWLQJ6(DUUK\WKPLDVUHQDOWR[LFLW\
• Increase sodium
6,GHHႇHFWVEOXUUHGYLVLRQSRO\XULDOHWKDUJ\YRPLWLQJWKLUVW
b) Postpartum Depression
• Occurs up to 6 months after child birth & not resolving in one or two weeks
• Inability to cope with infant care needs
• Treatment: same as depression and referral to PPD support groups
c) Dysthmic Disorder
‡'HSUHVVLRQLQH[FHVVRIPRQWKV
• Treatment: same as depression
G 6HDVRQDO$ႇHFWLYH'LVRUGHU
• Occurs in the fall and winter months
• Related to decreased sun
• Treatment:
• Vitamin B6
‡6W-RKQ¶VZRUW
‡'HFUHDVHFDႇHLQH IDWLQGLHW
• Increase fruits & vegetables
• Phototherapy
‡665,¶V
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3. ANXIETY:
MILD
• Associated with every day life, can be motivating
MODERATE
• Focus is on immediate concerns
‡1DUURZSHUFHSWXDO¿HOG
• Learning and problem solving can take place
SEVERE
‡6LJQL¿FDQWUHGXFWLRQLQSHUFHSWXDO¿HOG
‡)RFXVLVRQVSHFL¿FGHWDLOV
• Learning and problem solving cannot take place
• Need directions to focus
PANIC
‡³6HQVHRILPSHQGLQJGRRP´
‡3HUVRQDOLW\LVGLVRUJDQL]HGFDQQRWFRPPXQLFDWHRUIXQFWLRQHႇHFWLYHO\
• Loss of rational thoughts
• Inability to concentrate
V. Substance Abuse Disorders
Frequently Abused
Substances
• &DႇHLQH
• Nicotine
• Alcohol
• Cocaine
• Heroin
• Marijuana
&RQWUROOHG ,OOLFLW
Substance Abuse
• Vicodin (hydrocodone)
• Percocet (oxycodone)
• Methadone
• Seconal (secobarbital)
• Phenobarbital
Addiction
• Gambling
• Sex
• Eating
• Shopping
• Internet use
$OFRKROZLWKGUDZDORFFXUVKRXUVDIWHUODVWGULQN
Signs & Symptoms:
• Anxiety
• Nervousness
• Irritability • Headache • Nausea & vomiting
• Levels greater than 100 mg/dl induces seizures
Delirium tremens – HTN, tachycardia, delusions,
hallucinations and seizures
Treatment: IV anti-anxiety agents, Librium
FKORUGLD]HSR[LGH ,9)$QWDEXVH GLVXO¿UDP
Cocaine:
• Dilated pupils
• Weight loss
• Increased heart rate, B/P & temperature
• Perspiration & chills
• Hyperactivity
• Overdose: Cardiopulmonary arrest and seizures
• Treatment: Cardiopulmonary support
Heroin:
• Euphoria
• Flushing
• Pinpoint pupils
• Withdrawal symptoms: 19'FROGÀDVKHV
muscle spasms
• Treatment: Naloxone and respiratory support
Barbiturates:
• CNS depression • Dilated pupils
• Withdrawal symptoms: seizure & delirium
• Treatment: Cardiopulmonary support
• Group support
• Behavioral therapy
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VI. Personality Disorders
Borderline
Unpredictable, self destructive behaviors
Suicide risk
Frequent displays of inappropriate anger
Impulsiveness
Recurrent acts of crisis such as wrist cutting, overdosing or self injury
Treatment: group therapy, medications for mood & depression
Antisocial
Poor impulse control
Suicide risk
Paranoid
Delusions of persecution
Narcissistic
Grandiosity, preoccupied with fantasies of power and success
Exploit others to achieve personal goals
Histrionic
Characterized by a pattern of excessive emotionality & attention seeking behaviors
Excessive need for approval
Inappropriate seductive behavior
A need to be the center of attention
9,,$Q[LHW\'LVRGHUV
Obsessive-Compulsive
High need for routine
Limit, but do not interrupt compulsive acts.
7UHDWPHQWWKRXJKWVWRSSLQJWHFKQLTXHVDQWLDQ[LHW\DJHQWV 665,¶V
Agorophobia
Abnormal fear of open spaces or being alone in public places
3DWLHQWPD\UHIXVHWROHDYHKRPHUHVXOWVLQSDQLFDWWDFNV
Post Traumatic Stress
Disorder
Disturbed response to trauma
&KDUDFWHUL]HGE\ÀDVKEDFNVDQGIHHOLQJVRIJXLOW
Also nightmares, depression or panic attacks
Treatment : crisis management, family therapy
Munchausen Syndrome
The person intentionally fakes, simulates, worsens or self induces
injury or illness for the purpose of being treated like a medical patient
0XQFKDXVHQ¶VE\SUR[\
Refers to a caregiver who fakes symptoms by causing injury to
someone else and wants to be with that person in the hospital setting
VII. Somatoform Disorders
‡2QVHWSULRUWRDJH
• Multiple physical complaints that cannot be explained medically
Hypochondrias
Physical symptoms perceived as life threatening
Conversion
Symptoms without any physiological cause, usually neurological
Somatization
Physical symptoms that involve more than one part of the body, but no physical
cause can be found
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VIII. Psychotic Disorders
SCHIZOPHRENIA
Four A‘s
Types
‡$ႇHFW‡$VVRFLDWLYH
• Ambivalence
• Autistic thinking
• Paranoia type
• Residual type
‡8QGLႇHUHQWLDWHGW\SH
• Catatonic type
• Disorganized type
Signs and symptoms characterized by:
•
•
•
•
•
Disordered thinking
'LVUXSWHGD௺HFW
Perceptual disturbances
Behavioral abnormalities
Impaired social interactions
Thought broadcasting: individual believes that others
can hear his thoughts
̅At least two of these symptoms must be present for a large portion of time during a 1- month
period for diagnosis
Symptoms usually include:
Illusions
Delusions
Hallucinations
Disorganized speech & bizarre behavior
Lack of speech, catatonic behavior
Positive symptom
Positive symptom
Positive symptom
Positive symptom
Negative symptom
Poor social functioning, lack of concentration
Negative symptom
Paranoid type:
•
•
•
•
•
Auditory hallucinations
May appear hostile and angry
3URYLGHSUHSDFNDJHGIRRGV
Monitor for suicide
8VXDOO\KDYHSHUVHFXWRU\GHOXVLRQV'RQRWWRXFKFOLHQW
Catatonic type:
•
•
•
•
Stupor or extreme motor agitation
Inappropriate or bizarre body postures ERG\UHPDLQVLQD¿[HGSRVLWLRQDOPRVWZD[OLNH
Echolalia: Involuntary repetition of words spoken by another person
Echopraxia: Imitation of motions made by others
Disorganized type:
•
'LVRUJDQL]HGVSHHFKDQGEHKDYLRULQDSSURSULDWHRUÀDWDႇHFW
8QGLႇHUHQWLDWHGW\SH
•
Disorganized behaviors, psychotic symptoms (delusions, hallucinations)
Residual type:
•
$EVHQFH RI SURPLQHQW SV\FKRWLF V\PSWRPV LQDSSURSULDWH DႇHFW VRFLDO ZLWKGUDZDO HFFHQWULF
behavior
*Positive symptoms = increased mental experiences (thoughts, feelings, behaviors) than a normal mental state
187
*Negative symptoms = a lack of feelings or behaviors that are usually present
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AUDITORY PROCESSING/PERCEPTUAL ALTERATIONS
Delusion $IDOVH¿[HGEHOLHI
Illusion Misperception of a stimulus
Hallucination Sensory perception but there is no stimulus
DEFINITIONS
Akathisia Restlessness – give Cogentin (benztropine), Artane (trihexyphenidyl), or
Benadryl (diphenhydramine) (CAB)
Dystonia Muscle spasm
Akinesia Lethargy – feeling of fatigue and muscle weakness
Neologism Inventing new words which are only meaningful to that person
Clang association Rhyming words in a sentence that make no sense
Word Salad Disconnected /disorganized thoughts, using recognizable words that do
not make sense.
Flight of ideas Rapid change from one topic to another that is unrelated
IX. Cognitve disorders
Delirium
Acute, reversible
CKURQLFLUUHYHUVLEOHV\QGURPHWKDWDႇHFWVODQJXDJHPHPRU\
Dementia
cognition, personality and judgment
Types:
Symptoms:
Early Phase:
• Impaired abstract thinking, judgment &
• Vascular dementia
impulse control
• HIV dementia
• Neglect of personal appearance & hygiene
• Dementia due to general medical conditions Late Phase:
‡$SKDVLDORVVRIVSHHFK
• Substance induced dementia
‡$SUD[LDORVVRIPRWRUIXQFWLRQ
‡,QDELOLW\WRSHUIRUP$'/¶V
‡$O]KHLPHU¶VW\SH
Alzheimer’s Disease
Early Stage
Middle Stage
Middle- Late Stage
Late Stage
• Slow, progressive loss of intellectual ability
• Forgetfulness
‡'LႈFXOW\LQOHDUQLQJQHZWKLQJV
• Increase in memory loss
• Social withdrawal
‡'HFUHDVHGDELOLW\WRSHUIRUP$'/¶V
• Wanders
• Unable to perform simple tasks without repetition
• Unable to recognize familiar objects and family
‡%HGULGGHQ‡'LႈFXOW\VZDOORZLQJ
• Profound memory loss
• Weight loss, unable to speak or ambulate
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Medications to Increase Acetylcholine
&RJQH[
(tacrine)
Aricept
(donepezil)
([HORQ
(rivastigmine)
Namenda
(memantine)
Razadyne
(galantamine)
Terms:
5 A’s
6LGHHႇHFWV ataxia (unsteady gait, lack of coordination) loss of appetite,
hepatotoxicity, nausea, vomiting, diarrhea
6LGHHႇHFWV nausea, diarrhea, decreased heart rate
8VHGWRWUHDWPLOGWRPRGHUDWHGHPHQWLDRI$O]KHLPHU¶VRU3DUNLVRQ¶V
disease — take with food
6LGHHႇHFWV stomach pain, nausea, vomiting; anorexia, black, bloody or
tarry stools
8VHGWRWUHDWPRGHUDWHWRVHYHUH$O]KHLPHU¶V
Take with full glass of water
Contraindicated with liver disease, kidney disease, seizures, cataracts
6LGHHႇHFWV dizziness, confusion, constipation, chest pain, tachycardia
8VHGWRWUHDWPLOGWRPRGHUDWH$O]KHLPHU¶V
6LGHHႇHFWV bradycardia, syncope, anemia, N/V/D, dizziness,
headache, UTI
Apraxia: impaired motor function
Agnosia: inability to recognize familiar objects
Amnesia: memory loss
Anomia: inability to remember names of things
Aphasia: inability to speak
Reminiscence GroupSDUWLFLSDQWVDUHHQFRXUDJHGWRWDONDERXW
SDVWHYHQWVDWOHDVWRQFHSHUZHHN8VHGLQGHPHQWLDKHOSVLPSURYH
cognition and improve mood along with improved functional ability.
Validation Therapy LV IUHTXHQWO\ XVHG LQ GHPHQWLD FDUH WR
redirect behavior without causing anger or frustration. An important
FRPSRQHQW LV WR ³DJUHH´ ZLWK WKHP EXW WR DOVR XVH FRQYHUVDWLRQ
to get them to do something else without them realizing they are
actually being redirected.
189
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Common Medications Used in Mental Health
ANTIPSYCHOTICS
ANTICHOLINERGICS /ANTIHISTAMINES
Clozaril (clozapine)*
Artane (trihexyphenidyl) *
Haldol (haloperidol)*
Atarax, Vistaril (hydroxyzine)*
Mellaril (thioridazine)
Benadryl (dipenhydramine)*
Navane (thiothixene)
Cogentin (benztropine)*
3UROL[LQ ÀXSKHQD]LQH
ANXIOLYTICS / HYPNOTICS
Thorazine (chlorpromazine)*
Ambien (zolpidem)
Trilafon (perphenazine)
Ativan (lorazepam)*
Risperdal (risperidone)*
BuSpar (buspirone)*
Seroquel (quetiapine)*
'DOPDQH ÀXD]HSDP
Zyprexa (olanzapine)*
Halcion (triazolam)
ANTIDEPRESSANTS
Klonopin (clonazepam)
Celexa (citalopram)
Librium (chlordiazepoxide)*
Desyrel (trazadone)
Restoril (temazepam)
(ႇH[RU;5 YHQODID[LQH
Valium (diazepam)*
Extended –release
Xanax (alprazolam)*
Elavil (amitriptyline)
MOOD STABILIZERS
/XYR[ ÀXYR[DPLQH
Depakote (divalproex sodium)
Paxil (paroxetine)*
Depakene (valproic acid)
3UR]DF ÀXR[HWLQH
Lamictal (lamotrigine)*
Remeron (mirtazapine)*
Lithonate, Eskalith (lithium)*
Cymbalta (duloxetine)*
Neurontin (gabapentin)*
Lexapro (escitalopram)
Tegretol (carbamazepine)*
Pristiq (devenlafaxine)*
STIMULANTS
Serzone (nefazodone)
Adderall (dextroamphetamine)
Sinequan (doxepin)
Cylert (pemoline)
Wellbutrin SR (bupropion)
Dexedrine (dextroampheatamine)
6XVWDLQHGUHOHDVH
Ritalin, Concerta (methylphenidate)*
Zoloft (sertraline)*
Strattera (atomoxetine)
190
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PRACTICE QUESTIONS
191
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6DIH(ႇHFWLYH&DUH(QYLURQPHQW
Management of Care
1. A nurse has become aware of the following client
situations. Which of the following if observed shows
that the UAP needs further teaching? The UAP
A. avoids washing the body of a Jewish client until
thirty minutes after death
B. allows the family of a Buddhist client to chant ritual
rites at the bedside of their deceased father
& SURYLGHVFRႇHHDQGFRRNLHVIRUWKHYLVLWLQJIDPLO\
of a Mormon client
D. removes a cup of tea from the breakfast tray of a
Seventh Day Adventist client
2. A nurse is preparing assignments for the day. Which of
WKHIROORZLQJFOLHQWVVKRXOGWKHQXUVHVHH¿UVW"
$ $FOLHQWZLWK'LDEHWHV0HOOLWXVGULQNLQJ/RIÀXLG
per day
% $FOLHQWZKRLVSRVWRSHUDWLYHGD\DIWHUDFRURQDU\
artery bypass graft (CABG)
C. A client diagnosed with COPD with an oxygen
VDWXUDWLRQRI
D. A client with benign prostatic hypertrophy (BPH)
FRPSODLQLQJRIVFDQWXULQHÀRZ
A nurse is preparing assignments for the day. Which
RI WKH IROORZLQJ FOLHQWV VKRXOG WKH QXUVH VHH ¿UVW"$
client with
A. Type II DM complaining of having cold feet
B. Congestive heart failure (CHF) with SOB after
ambulating
C. abdominal surgery with temperature of 101°
D. Chronic Obstructive Pulmonary Disease (COPD)
with a CO2 of 50
4. A nurse is doing an assessment on several clients.
Which one of them would need follow up?
A. A client with chronic renal failure that did not void
for 8 hours
B. A client with Bells Palsy complaining of tingling in
the face
& $FOLHQWZLWK$O]KHLPHU¶VGLVHDVHVLWWLQJDWWKH
nursing station with lap buddy
D. A client diagnosed with COPD with a pulse
R[LPHWU\RI
5. The nurse from the pediatric unit has been temporarily
assigned to the Emergency Department. It would be
most appropriate to assign that nurse to the client
who
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B.
C.
D.
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has back pain and a pulsating abdominal mass
is HIV+ reporting vomiting and diarrhea
presents with lower abdominal pain and is six
weeks pregnant
6. A nurse has become aware of the following situations.
Which should cause the greatest concern for the
nurse? A client with
A. a bipolar disorder who is screaming at the nurses
station
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C. a transurethral resection of the prostate (TURP)
has blood tinged urine in the urinary bag
D. radon seed implants is seen ambulating in hall
7. After receiving report a nurse is planning an
assignment for the day. Which of the following should
WKHQXUVHVHH¿UVW"7KHFOLHQW
A.
B.
C.
D.
requesting a bedpan
complaining of pain 2/10 on a pain scale
with report of excessive tiredness
who did not receive a breakfast tray
8. The nurse is caring for clients who were recently
removed from a falling building. Who would the nurse
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B.
C.
D.
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dilated pupils and a small laceration to the left ear
a fracture of the right tibia and abdominal pain
confusion and soft tissue injuries
9. A nurse is preparing assignments for the day. Which
RIWKHIROORZLQJFOLHQWVVKRXOGWKHQXUVHVHH¿UVW"
A. A 48 y.o ventilator dependent client who needs a
sputum specimen
B. A 54 y.o on Bleomycin (Blenoxane) complaining
of vomiting
C. A 65 y.o with pneumonia who needs to start IV
antibiotics
D. A 72 y.o asthmatic complaining of SOB after using
Albuterol (Ventolin)
192
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10. Following an accident involving two cars and a bus, a
nurse arrived upon the scene. Which of the following
FOLHQWVVKRXOGWKHQXUVHVHH¿UVW"$FOLHQW
A.
B.
C.
D.
who is restless and combative
with an open fracture of the right tibia
with an eye injury complaining of pain in the face
a fractured arm who is ambulatory
11. A nurse is caring for several infants. Which newborn is
WKHSULRULW\WREHVHHQ¿UVW"
A.
%
C.
D.
2 hours old who is acyanotic
KRXUVROGLQIDQWZKRLVMLWWHU\
20 hours old with descending testicles
24 hours old with a heart rate of 140 bpm
12. The charge nurse is making assignments for the day.
:KLFKFOLHQWZRXOG\RXDVVLJQWRDQ51ÀRDWHGIURP
Maternity to a Behavioral Health unit?
A.
%
C.
D.
A client diagnosed with bipolar disorder
$FOLHQWWKDWIUHTXHQWO\WKUHDWHQVWKHVWDႇ
A quiet patient
A very busy patient
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WKHSULRULW\WREHVHHQ¿UVW"
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$KRXUROGZLWKDUHVSLUDWRU\UDWHRI
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$KRXUROGZLWKSHWHFKLDHRQWKHWUXQN
14. A nurse working on a pediatric unit is made aware of
the following situations. Which child is the priority to be
VHHQ¿UVW"
A. 1 year old with Tetralogy of Fallot with bluish
discoloration to the lips while crying
B. 2 year old with renal failure with a potassium level
of 6.4 mEq/L
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an elevated ESR rate
' \HDU ROG GLDJQRVHG ZLWK 5RWD9LUXV KDYLQJ bowel movements per 8 hour shift
15. The nurse is teaching a group of new nurses about
advance directives. Which of the following statements
LQGLFDWHVDQHHGIRUFODUL¿FDWLRQE\WKHQXUVH"
A. A DNR order is sometimes interpreted to mean
that the client requires less nursing care, when
WKH\DFWXDOO\KDYHVLJQL¿FDQWPHGLFDODQGQXUVLQJ
care needs
B. The ethical obligation to care for all patients is
FOHDUO\LGHQWL¿HGLQWKH¿UVWVWDWHPHQWRIWKH&RGH
of Ethics for nurses
C. A dying patient does not have the right to request
WKDWQRPRUHIRRGRUÀXLGEHDGPLQLVWHUHG
D. The durable power of attorney for health care
LGHQWL¿HV DQRWKHU LQGLYLGXDO WR PDNH KHDOWK FDUH
decisions on his or her behalf
16. A nursing instructor asks a nursing student to identify
a situation that represents an example of invasion
RI SULYDF\ :KLFK RI WKH IROORZLQJ LI LGHQWL¿HG E\ WKH
student indicates an understanding of a violation of
this client right?
A. Performing a procedure without consent
B. Telling the client that he or she cannot leave the
hospital
C. Threatening to give the client a medication
D. Observing care provided to the client without the
FOLHQW¶VSHUPLVVLRQ
17. The community health nurse is assigned to see four
clients. Which of the following clients will the nurse see
¿UVW"
$ $ \HDU ROG ZLWK JDVWUR HVRSKDJHDO UHÀX[
disease who does not tolerate milk
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has given away his favorite shirt
& $ \HDU ROG ZLWK &URKQ¶V GLVHDVH ZKR LV
complaining of abdominal cramps
D. A 55 year old with a gastrostomy tube who will
EHJLQVHOIIHHGLQJIRUWKH¿UVWWLPH
193
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18. After receiving report from the night nurse, which of
WKHIROORZLQJSDWLHQWVVKRXOGWKHQXUVHVHH¿UVW"
$ $ \HDU ROG ZRPDQ ZKR LV ZHHNV
pregnant complaining of a small amount of
vaginal bleeding
% $ \HDU ROG PDQ ZLWK OHIW VLGHG ZHDNQHVV
asking for assistance to the commode
& $\HDUROGZRPDQFRPSODLQLQJRIFKLOOVZKRLV
scheduled for a total abdominal hysterectomy
' $\HDUROGPDQZLWKDQDVRJDVWULFWXEHZKR
had a gastrectomy yesterday
19. After receiving report, which of the following clients
VKRXOGWKHQXUVHVHH¿UVW"
$ $\HDUROGZLWK6WHYHQ-RKQVRQ6\QGURPH
that has a rash on the trunk
% $ \HDUROG SDWLHQW VFKHGXOHG IRU D
colonoscopy who is refusing care
& $ \HDUROG FOLHQW ZLWK %XHUJHU¶V GLVHDVH
complaining of tingling in the digits
' $ \HDUROG LQ VLFNOH FHOO FULVLV ZLWK DQ
LQ¿OWUDWHG,9
20. The nurse is caring for postpartum clients who had
vaginal deliveries within the last eight hours. The
QXUVHVKRXOG¿UVWDVVHVVWKHFOLHQWZKR
A.
B.
C.
D.
has a pulse rate of 66 beats per minute
has saturated one perineal pad in two hours
reports swelling in her right calf
asks if her baby can sleep in the nursery
tonight
21. The nurse is caring for four newborns in the nursery.
Which of the following infants is the priority while
planning care? The infant who is
A.
%
C.
D.
one hour old experiencing acracyanosis
WKUHHKRXUVROGZLWKQDVDOÀDULQJ
one hour old whose eyes appear crossed
three hours old with an edematous area on the
head
22. The nurse received change of shift report, which
of the following clients will take the highest priority
when planning care?
A. The client with (end stage renal disease) ESRD
who has not voided in ten hours
% 7KH FOLHQW ZLWK LQÀDPPDWRU\ ERZHO GLVHDVH
who has had a recent increase in restlessness
C. The client who is four hours post operative
bladder biopsy and is experiencing hematuria
D. The client who is diabetic experiencing tingling
of the toes
7KH QXUVH DUULYHV XSRQ WKH VFHQH RI D PXOWLSOH
vehicle accident with several injuries. Which of the
IROORZLQJFOLHQW¶VVKRXOGWKHQXUVHHYDOXDWH¿UVW"
A. A 16 year old female who is unresponsive with
dilated pupils
B. A 22 year old male with deformity of the right
arm who is reporting pain
& $ \HDU ROG PDOH ZLWK D VPDOO WKLJK
laceration
D. A 50 year old female experiencing anxiety, and
generalized weakness
24. The RN needs to make assignments for four
SDWLHQWV7KHWHDPFRQVLVWVRI/31¶VDQG&1$
Which of the following clients would be appropriately
DVVLJQHGWRWKH&1$ &HUWL¿HG1XUVLQJ$VVLVWDQW "
A. the client who needs a simple dressing change
of an abdominal wound
B. client who needs irrigation of the colostomy
C. the client receiving parenteral feedings
D. the client requiring administration of an enema
prior to a surgical procedure
25. Which of the following clients is appropriate to
assign to an LPN for medication administration?
A. A 25 year old in sickle cell crisis who will need
Morphine intravenously
% $\HDUROGSRVWRSHUDWLYHFOLHQWZKRLVXVLQJ
a PCA pump
C. A 50 year old who will need Regular Insulin
coverage for a glucose reading of 240mg/dl
D. A 60 year old who needs Dopamine
intravenously for blood pressure management
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26. The charge nurse is making assignments for the day.
:KLFKSDWLHQWZRXOG\RXDVVLJQWRWKH51ÀRDWHGIURP
the Pediatric unit to the Emergency Department?
A. A 2 year old admitted with suspected ingestion of
chlorine
B. A 5 year old being treated for Asthma that is not
responding to bronchodilators
C. A 7 year old brought to the department following a
motor vehicle accident
D. A 10 year old awaiting admission following cast
placement
27. Which client would you assign to the new grad RN?
$ 7KH FOLHQW DGPLWWHG IRU VXVSHFWHG *XLOOLDQ%DUUH
exacerbation
B. The client scheduled for transfer to the ICU
C. A client experiencing chest pain after coughing
D. A newly admitted client who needs the initial
assessment completed
28. Which action should the nurse delegate to the UAP
when providing care for the client with CHF?
A.
B.
C.
D.
Checking the clients weight daily
Teaching regarding dietary restrictions
Monitoring the amount of pedal edema
Notifying the physician about the presence of a
cough
29. The Charge nurse is making assignments for the day.
7KHWHDPFRQVLVWVRIWKH51/31/91DQG8$3:KLFK
client is appropriate to assign to the UAP?
A. The client who had a stroke 4 days ago with left
sided weakness who needs feeding
B. The client who needs assistance with oral
suctioning
C. A recently admitted client who needs their vital
signs taken
D. A client who requires chest physiotherapy every
shift
7KH QXUVH LV PDNLQJ DVVLJQPHQWV IRU WKH GD\
Which assignment should be assigned to the
LPN?
A.
B.
C.
D.
Application of wrist restraints
Collection of a 24 hour urine specimen
Assisting a client to ambulate after surgery
Initiation of the clients plan of care
7KHQXUVLQJWHDPFRQVLVWVRID51/31DQG8$3
Which action should be appropriately assigned to
the LPN?
A. Bathing a child admitted with chickenpox
B. Taking the vital signs of the recently admitted
client
C. Transporting a client to the chapel for noon
time prayers
D. Insertion of an indwelling catheter for a client
with urinary retention
,QSURYLGLQJFDUHIRUDFOLHQWEHLQJWUHDWHGIRUÀXLG
volume excess, which of the following interventions
would be best delegated to an experienced UAP?
Select all that apply.
A.
%
C.
D.
E.
F.
Monitor EKG readings
2EWDLQYLWDOVLJQVHYHU\PLQXWHV
Check for the presence of pedal edema
Insert IV line
Document hourly urine output
Measure weight
$ PHQWDO KHDOWK QXUVH LV ÀRDWHG WR ZRUN RQ WKH
medical surgical unit. Which client would be most
appropriate to assign to the nurse? A client that:
A. is 4 hours post operative following
cholecystectomy
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C. has mechanical ventilation and needs to be
suctioned
D. is in traction for a broken femur
<RXDUHPDNLQJDVVLJQPHQWVIRUWKHGD\:KLFKFOLHQW
will you assign to the Maternal Health nurse who is
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A. A postpartum client who is ventilator dependent
B. The client with gestational diabetes admitted with
glomerulonephritis
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exploratory laparotomy
D. A client scheduled for spinal surgery who needs
SUHRSPHGLFDWLRQV
195
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Safety and Infection Control
1. A nurse is caring for the following clients. Which client
is the priority for a private room? A client with
A.
B.
C.
D.
HIV infection
Cirrhosis of the liver
Scabies
Pneumonia
2. A nurse is caring for the following clients. Which client
is a priority for a private room? A client with
A.
B.
C.
D.
Rubeola
Rubella
Klebsiella Pneumoniae
Pediculosis
A. The client with fever and diarrhea for 2 days
after taking antibiotics
B. The client who is HIV + with a temperature of
101°
C. The client with low grade fever and night
sweats
D. The client with Leukemia whose temperature is
100°
7. The infection control nurse is making rounds on
a Medical Surgical unit. Which of the following,
if observed by the nurse requires immediate
intervention?
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is a priority for a private room? A client with
A.
B.
C.
D.
6. The nurse is caring for several clients requiring
isolation. There is one private room available on
the unit. The nurse should place the highest priority
on assigning which of the following clients to the
private room?
Hepatitis
Pyelonephritis
Gastroenteritis
Meningitis
4. A client recently diagnosed with AIDS is being
discharged home from the hospital. Which of the
following statements if made by the client would
indicate a need for further teaching?
A. “I cannot go shopping in the mall during the
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B. “I will have to avoid fresh fruit and vegetables
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C. “I will clean my bird cage as soon as I get
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D. “I should not visit my sister since she has the
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A. A CNA is observed wearing gloves while
emptying a foley catheter
B. An RN is observed wearing a surgical face
mask while caring for a client with tuberculosis
(TB) in a negative pressure room
C. An LPN is observed wearing a gown and
gloves while caring for a mentally ill client with
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D. A RN is observed wearing a gown, gloves,
and shoe covers while caring for a client with
Pertussis.
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successfully assisted the clients to safety during a
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nurse perform next?
A.
B.
&
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Close all open doors
Call for additional help
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5. A nursing student observes the following situation on
the unit . Which occurrence would require an incident
report?
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clients. It would require immediate intervention if
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A. a client reports sexual abuse by a family member
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medication to a client who is scheduled for
surgery
C. a client became angry when the nurse removed
their dentures prior to going to the O.R.
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operative teaching provided
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amputation (AKA) 24 hours ago in a prone
position
B. keeping the head of the bed elevated for the
client who had an supratentorial craniotomy 12
hours ago
C. giving orange juice to a client who has a clear
liquid diet prescribed
D. removing all liquids from the tray before giving
the tray to a client who has dumping syndrome
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10. The nurse should initiate protective precautions for the
client who has
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Hemoglobin (Hgb) 9.0 g/dl
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Health Promotion and Maintenance
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abnormal in a newborn?
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Closed posterior fontannel
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2. A nurse is caring for a client experiencing late
decelerations. The appropriate initial action by the
nurse is to:
A.
B.
C.
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change the clients position
notify the health care provider in charge
increase the Pitocin (Oxytocin) drip
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a prolapsed cord? The initial action of the nurse should
be to
A.
B.
C.
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use a sterile glove to put cord back inside
place the client in trendelenburg position
use a dry sterile gauze to cover the cord
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fetal positon
4. A nurse is caring for a client experiencing mastitis.
Which action would be most appropriate?
A. Advise the client to discontinue breast feeding
B. Encourage the client to express milk from the
breasts frequently
C. Apply ice chips every 15 minutes
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5. A nurse in the prenatal clinic is caring for a client.
7KH ODVW QRUPDO PHQVWUXDO SHULRG ZDV IURP 0D\ 2017 to May 8, 2017. Calculate the expected date of
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B.
C.
D.
March 15, 2018
January 10, 2018
February 10, 2018
February 15, 2018
6. A nurse is teaching a class to parents regarding
appropriate toys for their infants. Which of the
following would be the most appropriate toy for a
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A.
B.
C.
D.
soft, colorful squeeze toys
teething toys with small removable parts
soft padded books and blocks
low lying mobile in the crib
7. A nurse is teaching a class to parents regarding
appropriate toys for their toddlers. Which of the
following would be the most appropriate toy for a
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A.
B.
C.
D.
tricycle
rocking horse
puppets
a ball to throw and catch
8. The nurse is working in a pediatric clinic. A 2
month old baby is brought in for a well baby check
up. The nurse should anticipate the following
vaccinations will be required during this visit
A.
B.
C.
D.
Hepatitis B, Varicella, OPV
Hepatitis B, PCV, MMR
Hepatitis B, DTaP, HIb, IPV, PCV
Hepatitis B, HIb, IPV, MMR, PCV
9. A nurse working in a clinic is doing teaching
regarding sexually transmitted Infections. The
client cannot understand how syphillis was
contracted because there has been no sexual
activity for several days. As part of teaching,
the nurse explains that the incubation period for
syphilis is about:
A.
B.
&
'
1 month
1 week
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10. The nurse working in an adolescent clinic is
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with Measles, Mumps, Rubella (MMR) vaccine.
Important data collection prior to administration
should include
A. a history of the last Tetanus & Diphtheria (TD)
injection
B. checking for allergy to yeast
C. date of the last menstrual period
D. having the client sign a consent form
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nurse should expect the infant to
A.
B.
&
D.
turn from abdomen to back
say one syllable words
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sit without support
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gestation. The nurse would be correct to state that
the client is in the second stage of labor when
A.
B.
C.
D.
the placenta is delivered
bulging is seen in the perineum
contractions are irregular
rubra lochia is noted
Psychosocial integrity
1. A nurse is caring for a client taking Thorazine
(Chlorpromazine). Which statement shows an
understanding of instructions regarding this
medication? The client states
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2. A client on an inpatient psychiatric unit believes the
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&
D.
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Allow the client see others eat their food
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Taste the food in front of the client to prove it is
edible
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who has lithium (Lithotabs) prescribed. The nurse
should suggest that the client have which of the
following snacks?
A.
%
C.
D.
A fresh fruit cup
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Peanut butter and celery sticks
Raw vegetables
4. A nurse is caring for a client who is racing around
the unit and wringing his hands. He is breathing
rapidly and complains of “feeling his heart racing
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attack. This anxiety can be interpreted as:
A.
B.
C.
D.
Mild
Moderate
Severe
Panic
5. A nurse is teaching a parent of an adolescent with
severe depression signs of an impending suicide
attempt. Which of the following should alert the
parent of a high risk for suicide?
A.
B.
C.
D.
The adolescent sleeps most of the day
The adolescent has a plan to kill herself
The adolescent has recently lost ten pounds
The adolescent refuses to eat, and frequently
forces herself to vomit
6. An emergency room nurse is caring for a client with
suspected phenobarbitol use. Which of the following
will result if the client has a barbituate addiction?
A. Watery eyes, slow shallow breathing, frequent
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B. Dilated pupils, shallow respirations, weak and
rapid pulse
C. Constricted pupils, respirations depressed,
nausea, vomiting
D. Sluggish pupils, increased respirations,
decreased pulse
7. A nurse is assessing a client with major depression.
Which statement, if made by the nurse is most
appropriate?
A. Tell me more about the voices you have been
hearing
B. You seem to be very angry, when did you last
feel happy?
C. Have you had any thoughts of harming
yourself?
D. When was the last time you had fun?
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8. The nurse is developing a nursing care plan for a client
who is the manic phase of bipolar disorder. Which
intervention should the nurse include in the plan of
care?
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B. Engage the client in competitive games
C. Encourage the client to avoids foods containing
tyramine
D. Place the client on direct suicide observation
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nervosa. The nurse should assess the client for
A.
%
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D.
stained enamel of the teeth
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persistent ringing in the ears
white patches on the tongue
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care. Which of the following statements if made by the
nurse would require follow up?
A. The family of a client of the Buddhist faith may ask
for a priest to be present at the time of death
B. The family of a client of the Jewish faith may
request to have mirrors covered after the death of
the client
C. The family of a client of the Muslim faith may
request that the body of the client be turned to face
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D. The family of a client of the Hindu faith may request
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death
11. A 45 year old client who was recently diagnosed with
terminal cancer says to the nurse “If God could only
let me live long enough to put my daughter through
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nurse caring for this client recognizes this statement as
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A.
B.
C.
D.
Denial
Acceptance
Bargaining
Anger
Physiological Integrity: Basic care and
Comfort
1. The nurse is teaching a class on nutrition. Which
of the following selections would be the highest in
K+?
A.
B.
C.
D.
Corn, oatmeal, tomatoes
Carrot, broccoli, yogurt
Milk, sardines, beef
Potato, spinach, avocado
2. A nurse is caring for a client admitted with
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may be necessary to include?
A.
B.
C.
D.
Vitamin B6
Vitamin A
Vitamin B1
Vitamin C
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Which of the following statements shows that
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C. “I will have popcorn and juice while I am at
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4. The nurse is observing a client with renal failure
select foods from the lunch menu. Which of the
following selections if made by the client would
indicate a need for further teaching?
A.
B.
C.
D.
Haddock and spaghetti
Cereal with buttermilk
Corned beef and rice
Egg salad on wheat toast
5. Mr. Jones is being treated for uric acid stones.
While doing a dietary history, which of the
following food choices demonstrates a need for
further teaching?
A.
B.
C.
D.
chicken and baked potatoes
asparagus and liver
scrambled eggs and cheese
pancakes and bacon
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6. A client is taking dyrenium (trimterene) and is observed
eating the following foods. Which foods should the
nurse instruct the client to avoid?
A.
B.
C.
D.
fried chicken and rice
baked potatoes and fresh spinach
pasta and gravy
macaroni and cheese and legumes
7. The nurse knows that the plan of care for a client with
severe Ulcerative Colitis would include which of the
following?
A.
B.
C.
D.
Low protein, high carbohydrate diet
Low residue, high protein
High protein, high residue
High carbohydrate, high protein
8. While providing nutritional counseling for a client with
a colostomy the client should be instructed to avoid
the following foods. Select all that apply
1. cabbage
2. corn
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4. parsley
5. spinach
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7. popcorn
8. turkey
A.
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1, 2, 5, 7, 8
1, 2 ,5, 6, 7
9. The nutritionist is providing counseling to several
clients on the unit. They are discussing various
vitamins and minerals. Which of the following
statements need to be corrected by the nurse?
A. vitamin B12 may be needed if a client has a
gastrectomy
B. vitamin D is responsible for proper utilization of
calcium and phosphorous
C. vitamin A can be found in squash, pumpkin, and
carrots
D. vitamin B6 (pyridoxine) is used to treat alcohol
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10. The nurse is attempting to collect a stool sample for
occult blood. Which of the following foods should the
client avoid prior to the test? Select all that apply:
A.
B.
C.
D.
E.
Oranges
Watermelon
Bananas
Kiwi
Avocado
11. A client is performing quadriceps sets to strengthen
the muscles used for walking. When performing
these exercises, the client contracts his quadriceps
with no change in muscle length and no joint
movement. What term does the nurse use to
describe this type of exercise?
__________________
12. A nurse is teaching a client to ambulate with
crutches. The crutch gait the nurse should teach a
client after a single leg amputation is the:
A.
B.
C.
D.
two point gait
three point gait
four point gait
swing through gait
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vascular accident (CVA) is learning to ambulate with
a cane. The nurse should teach the client to
A. hold the cane on the left side and
cane with the right leg
B. hold the cane on the right side and
cane with the left leg
C. hold the cane on the left side and
cane with the left leg
D. hold the cane on the right side and
cane with the right leg
move the
move the
move the
move the
14. A nurse is caring for a client that recently had surgery.
To promote healing of a large surgical incision, the
nurse should encourage the client to increase the
following in the diet:
A.
B.
C.
'
honey dew
apples
oranges
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200
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Physiological integrity: Pharmacological and
Parenteral Therapies
1. Haldol is available in 0.5mg tablets. The desired
dose is 1mg. How many tablet(s) will you give?
____________________tablet(s)
2. An infant is to receive Cefuroxime 10mg/kg. What is
the correct dosage if the child weighs 8 lbs?
____________________mg
Vancomycin is available in 225mg. The desired dose
is 0.45gm. How many tablet(s) should be given?
____________________tablet(s)
4. A nurse is preparing to give a dose of Bumex IV to
an infant. The prescription reads give 1mg/kg daily.
If the infant weighed 6lbs how many mg should the
infant receive?
___________________mg
5. $GPLQLVWHU9HUDSDPLOPJ,97KHGRVDJH
strength is 2.5mg/ml. How many ml should be
given?
__________________ml
6. An IV of RL 1,000 ml is to infuse over 8 hours. The
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11. A client is to receive Dopamine (Intropin) 2 mcg/kg/
min. The client weighs 187 pounds. The available
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milliliters should be administered each hour? (Do
not round)
_______________________ml
12. The nurse is providing client teaching for a client
receiving Bumex (Bumetamide). When selecting
foods, it would be appropriate to include which of
the following?
A.
B.
C.
D.
apricots
organ meats
sardines
milk
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The health care provider suspects a urinary tract
infection. Which of the following medications would
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A.
%
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D.
Zyvox (linezolid)
&LSURÀR[DLQ &LSUR Urecholine (bethanecol)
Gentamycin (garamycin)
14. The health care provider prescribed potassium
chloride 20 Meq, daily. The drug available is liquid
potassium chloride10 mEq, per 5ml. How many ml
should the nurse administer?
__________________________ml
7. 12mg:6ml as 10mg:
___________________ml
15. The Nurse Practitioner ordered Tetracycline
hydrochloride 80 mg by mouth Q6h. The bottle
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the nurse administer? (do not round)
__________________________ml
8. Dilantin is prescribed for a child that weighs 44lbs.
The prescription reads give 6mg/kg. How many mg
should the nurse administer?
____________________mg
16. A nurse is monitoring a client initiated on Lasix
(furosemide) 20mg intravenously daily for the past
2 days. Which of the following should be included?
Select all that apply
__________________gtt(s)/min
9. Heparin 7500 units is desired. The available dose
is 10,000 units/ml. How many ml should the nurse
administer?
_____________________ml
10. $FOLHQWLVWRUHFHLYH'RSDPLQH ,QWURSLQ PFJNJ
min. The client weighs 185 pounds. The available
dose is 400 mg per 500 ml D5NS. How many mil
liliters should be administered each hour? (Round to
the nearest tenth)
______________________ml
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B. tell the client to stand slowly while getting out of
bed
C. monitor electrolytes
D. teach the client to avoid foods high in
potassium
E. administer the medication at night
F. monitor weight
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17. A client is to receive 1500ml of ringers lactate (RL) over
a period of 8 hours. The drop factor is 20gtts/ml. The
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18. The nurse is caring for a client with AIDS and is to
administer Retrovir (AZT). Which of the following should
the nurse be aware of?
A.
B.
C.
D.
the drug may cause drowsiness
it is usually taken once a day in the morning
the client should avoid foods high in protein
the drug may cause renal and hepatic impairment
19. A client has been diagnosed with rheumatoid arthritis.
A prescription for Plaquenil (hydroxychloroquine) has
been prescribed. The nurse should inform the client:
A. it will be necessary to have frequent opthalmological
exams
B. that the medication may cause diarrhea and
hypertension
C. it is best absorbed on an empty stomach
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20. A nurse is preparing to administer Cefazolin sodium
.HI]RO ,9 ,W LV DYDLODEOH DV PJ LQ PO RI GH[WURVH LQ ZDWHU ,W LV WR EH DGPLQLVWHUHG RYHU D minute period. The drop factor is 15 drops per milliliter.
How many drops per minute should the nurse regulate
the infusion to run at:
__________________gtt/min
21. A physician prescribes Ceftriaxone (rocephin) 2.5g
IVBP every 8 hours for a client. The vial is labeled 5g
per 10ml. The nurse would be correct to administer
_________ ml.
A.
B.
&
D.
1.25 ml
2.5 ml
PO
5 ml
22. A physician has selected a medication for a client
with glaucoma that is to be administered one time
per week. Which of the following medications is
a direct acting parasympathomimetic agent used
as a miotic in the treatment of glaucoma?
A.
B.
C.
D.
humorsol (demecarium)
cyclogyl (cyclopentolate)
pilocarpine (pilocar)
timolol (timoptic)
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home from the hospital. While reviewing the
medications prescribed which of the following
statements if made by the client requires further
teaching?
A. “The meclizine (antivert) will help with my
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B. “The diazepam (valium) will help to control
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C. “The promethazine (phenergan) will help my
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D. “The hydrochlorothiazide (hydrodiuril) will
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24. The nurse is caring for a client taking the
medication Clozaril (Clozapine). Which of the
following statements if made by the client shows
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C. “I should expect a decrease in my risk of
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D. “I must remember that hypertension is
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25. A student nurse is preparing to administer Cardura
(Doxazosin). Which of the following should be
included in teaching? Select all that apply
A.
B.
C.
D.
E.
F.
avoid driving
expect increased libido
double doses if one dose is missed
continue to take cold remedies
blurred vision may occur
palpitations are expected
202
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26. The nurse is teaching a client about the use of Amaryl
(Glimepiride). Which of the following is a possible
adverse reaction?
A.
B.
C.
D.
hyperglycemia
thrombocytopenia
hypernatremia
leukocytosis
27. The nurse is teaching a client about possible adverse
reactions to the drug Thorazine (Chlorpromazine).
Which of the following should be included in client
teaching? Select all that apply
A.
B.
C.
D.
E.
)
blurred vision may be expected
avoid going to the beach
diarrhea is common
expect an increase in appetite
sugarless candy may be helpful
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psychoses in an adult
28. The parent of a child taking Concerta (Methylphenidate)
calls the clinic and reports the following symptoms.
The nurse knows which of the following is an expected
VLGHHႇHFW"
A.
B.
C.
D.
lethargy
increased appetite
weight gain
metallic taste in the mouth
29. The nurse is teaching a client about the use of
the medication Prilosec (Omeprazole). Which of
the following if verbalized by the client shows an
understanding? Select all that apply
A. “My tablet may be crushed and mixed with
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Cotazym (Pancrelipase). Which of the following
if stated by the client shows a need for further
instruction?
A. “My capsules may be opened and sprinkled on
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B. “I will administer the medication before or with
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is receiving Norvir (Ritonivir). Which of the following
is not related to the use of this medication?
A.
B.
C.
D.
cholesterol level of 250mg/dl
calcium level of 15.0mg/dl
creatinine level of 5.0mg/dl
glucose level of 200mg/dl
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used herbal products. Which of the following is not
true?
A. Black Cohash may be used for dysmenorrhea
B. Don Quai should not be used while taking
aspirin
C. Echinachea may be used to treat Multiple
Sclerosis
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of several herbal remedies. Which of the following
statements if made by the client indicates a need for
further teaching? Select all that apply
A. “I usually take my Fever Few on an empty
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of the following diuretics require additional potassium
consumption?
A.
B.
C.
D.
midamor (amiloride)
aldactone (spironolactone)
demadex (torsemide)
dyrenium (triamterene)
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oz of egg nog. The calculated intake would be:
A.
B.
C.
D.
515 ml
585 ml
625 ml
645 ml
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medical history includes coronary artery disease. A
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168 and total Cholesterol 270. Which of the following
medications might be included in the plan of care?
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C.
D.
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Coumadin (Warfarin Sodium) 2 mg po at bedtime
Questran (Choleystyramine) 4 gms po every day
Reglan (Metoclopramide) 10mg po as needed
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aware of the importance of which the following health
teachings?
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administration
B. take medication after breakfast daily
C. change position slowly while taking this
medication
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used in Labor and Delivery. The nurse would be
correct to state that the drug used to stimulate lung
development in the fetus is
A.
B.
C.
D.
Terbutaline (Brethine)
Oxytocin (Pitocin)
Hydralazine (Apresoline)
Bethamethasone (Celestone)
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(Lanoxin) for a client. It would be a priority for the
nurse to ask the client if they are using which of
the following herbal remedies?
A.
B.
C.
D.
Ginseng
Echinacea
Aloe Vera
Black Cohash
40. The nurse is providing discharge teaching for
the client receiving Prozac (Fluoxetine). Patient
teaching must include avoidance of which herbal
remedy?
A.
B.
C.
D.
St. Johns Wort
Echinacea
Valerian Root
Saw Palmetto
Physiological integrity: Reduction of Risk
Potential
1. The nurse is caring for a client with Chronic Renal
Failure. Which lab is of most concern?
A.
B.
C.
D.
potassium 7.2 mml/L
creatinine 15 mg/dl
blood urea nitrogen 68 mg/dl
calcium 7.8 mg/dl
2. A nurse is caring for a client who is complaining of
muscle spasms and rigidity. It would be a priority
for the nurse to check which lab value?
A.
B.
C.
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Ca+
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following values. Which lab result is of most
concern?
A.
%
C.
'
K+ 5.2 meq/L
1DPHT/
Ca+ 10.9 mg/dL
0JPHT/
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4. A nurse is caring for a client with Multiple Myeloma.
The nurse would expect abnormalities in which of the
following lab values?
A.
B.
C.
D.
ammonia
red blood cells
glucose
potassium
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the physician documented that the client has a renal
disorder. Which of the following would be indicative of
the condition?
A.
B.
C.
D.
hemoglobin level of 16
potassium level of 4.0 mEq/L
blood urea nitrogen (BUN) level of 40mg/dl
white blood count of 5,000
6. The nurse is visiting a client with renal calculi. Which
of the following statements if made by the client
indicates a need for further teaching?
A. “I will eats lots of spinach and take my calcium
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include
A.
B.
C.
D.
weight loss
decrease in blood pressure
decreased inspiratory rate
coughing and wheezing
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employment physical had the following laboratory
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prompt investigation?
A.
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hemoglobin of 16 g/dl
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blood urea nitrogen of 15 mg/dl
9. Which of the following statements regarding cancer
is false?
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testicular cancer
B. the risk for cancer of the prostate increases
with age
C. early cervical cancer rarely produces
symptoms
D. pap smears are essential to detect uterine
cancer
10. While teaching a class about the risks for breast
cancer the nurse should include which of the
following risk factors? Select all that apply:
A.
B.
C.
D.
E.
)
Early onset of menstruation
Low fat diet
Menopause after age 55
First child late in life
Nulliparity
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11. A client who has had a colostomy is one day
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colostomy stoma is moist and pink with no drainage.
Which of these actions should the nurse take?
A.
B.
C.
D.
Irrigate the colostomy with normal saline
Apply petroleum gauze dressing to the stoma
Document the condition of the stoma
Palpate the abdomen around the stoma
12. The nurse is assessing a new graduate nurse
who is caring for a client with a nasogastric tube.
The nurse would intervene immediately if the new
graduate
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she placed her stethoscope over the stomach
to listen for bowel sounds
B. Stated “the length of the tube placement is
determined by measuring from the nostril to the
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D. Asked the patient to sit in high fowlers position
before initiating the feeding
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brought into the emergency room after swallowing a cup
of chlorine bleach. After interviewing the parent, which
of the following would cause the greatest concern?
A. the parent called the poison control center to obtain
information
B. the parent administered a glass of milk
C. the parent administered syrup of ipecac
D. he parent attempted to perform CPR when the
child could not respond
14. A nurse is using the Glasgow coma scale to assess
a client who had a head injury. During assessment,
the following is observed: Eyes open to speech, motor
response appropriate, client obeys commands, and
conversation is confused. The client should receive a
score of:
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A.
B.
C.
D.
macular degeneration
closed angle glaucoma
exacerbation of cataracts
retinal detachment
18. A nurse is caring for a client with a diagnosis of
gout. Which of the following laboratory values
would the nurse expect to note in the client?
A.
B.
&
D.
uric acid level of 9.0mg/dl
calcium level of 9.0mg/dl
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potassium level of 4.0 mEq/L
19. The nurse is caring for an adult client that was
injured in a welding accident. According to the
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to their anterior chest and arm have an injury that
approximates:
15. The nurse is caring for a client status post trauma to the
brain. The nurse should be aware that the normal range
of intracranial pressure is:
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17. A client was recently admitted into the emergency
room reporting rapidly progressing visual
impairment and loss of peripheral vision. The
most likely diagnosis for this client is:
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Disease. Which of the following actions if taken by the
student would be most appropriate?
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water for snack
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water
C. The client is encouraged to ambulate frequently in
the hall
D. The student places the client in a room close to the
nurses station
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20. A nurse is caring for a client that recently had
surgery on the left inner ear and is being discharged
home. Which of the following statements if made
by the client would indicate a need for further
teaching?
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21. The nurse is caring for a client who underwent
surgical repair of a detached retina of the right
eye. Which of the following interventions should
the nurse perform? Select all that apply.
A.
B.
C.
D.
E.
F.
place the client in the prone position
approach the client from the left side
encourage deep breathing and coughing
discourage bending at the waist
orient the client to his environment
administer a stool softener as prescribed
206
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22. The patient with emphysema reports dyspnea at night.
Which of the following positions would be appropriate
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night?
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C.
D.
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Side lying with the head propped up
Supine position with 4 pillows under his head
Place the patient in a recliner to sleep
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that apply
A.
B.
C.
D.
E.
F.
Diarrhea
Dry skin
Anorexia
Tachycardia
Excessive menstruation
Heat intolerance
Constipation
Dry skin
Anorexia
Insomnia
Bradycardia
Palpitations
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C.
D.
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a white blood count of 10,000 cc mm
a HGB (hemoglobin) of 15 mg/dl
a BUN (blood urea nitrogen) of 19 mg/dl
28. The nurse is assessing a client who is 5 hours
status post a transurethral resection of the prostate
7853 :KLFK RI WKH IROORZLQJ ¿QGLQJV UHTXLUHV
immediate intervention?
25. A nurse is teaching a client being discharged after
surgery on the right eye for glaucoma. Which of the
following statements if made by the client requires
further teaching?
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by introducing small needle electrodes into
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(PET) of the head the client can resume normal
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the client to be NPO for 12 hours before the
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27. While doing a routine check up with the gynecologist,
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infections. The nurse knows which of the following
may be noted?
24. The nurse is caring for a client with hypothyroidism.
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that apply
A.
B.
C.
D.
E.
F.
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conference on preparing clients for neurological
diagnostic tests. Which of the following statements,
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A.
B.
C.
D.
bladder spasms
abdominal distention
blood tinged urine
nausea
29. A client who has had a spinal cord injury is scheduled
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nurse should instruct the client to avoid
A.
B.
C.
D.
foods that are spicy
people who have upper respiratory infections
developing urinary retention
emotional stress
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who
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eating
B. had a transurethral resection of the prostate (TURP)
24 hours ago reports blood in the urinary bag
C. had a fractured femur 2 days ago reports a rash on
the chest
D. removed a hearing aid requests a toothpick for
cleaning
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returned to the unit after a liver biopsy. The nursing
student would be correct to position the client
A.
B.
C.
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in the trendelenburg position
on the right side with a small pillow
on the abdomen with the legs abducted
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elevated 45 degrees
Physiological Integrity: Physiological
Adaptation
1. A nurse is providing care for a client with Type I DM
complaining of a headache. What should the nurse do
¿UVW"
A.
B.
C.
D.
Give one cup of orange juice
Call the nurse in charge
Check the clients glucose level
Administer insulin as prescribed
2. A client is experiencing acute renal failure that is post
renal in nature. The nurse should know that this is
probably due to
A.
B.
C.
D.
(
cardiogenic shock
hypovolemia
nephrotoxic substances
urethral obstruction
³,ZLOOVOHHSRQP\OHIWVLGH´
7KHQXUVHLVLQVWUXFWLQJDFODVVRQFRPPRQ
neurological disorders. Which of the following
statements, if made by the nurse is incorrect?
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paralysis and may be caused by a predisposing
event such as respiratory or gastrointestinal
infection
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females equally and may be caused by a
decrease in acetylcholine
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environmental trauma and is commonly
treated with Levodopa
D. Multiple Sclerosis is common in middle aged
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test
4. A nurse is noted to ask a client to protrude the
tongue and move it from side to side. Which
cranial nerve is the nurse assessing?
A.
B.
C.
D.
Glossopharyngeal (IX)
Vagus (X)
Spinal accessory (XI)
Hypoglossal (XII)
5. A community health nurse is teaching a class
about the risks for developing cervical cancer.
The nurse would be correct in saying that risks
include: select all that apply
A.
%
C.
D.
E.
F.
sex after age 20
DKLVWRU\RI¿EURLGV
nulliparity
smoking
multiple sex partners
exposure to the human papilloma virus
(HPV)
6. The nurse is caring for a client who reports
right side facial pain associated with drinking
hot beverages. The nurse suspects a possible
diagnosis of
A.
%
&
D.
Trigeminal neuralgia
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Transient Ischemic Attack
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7. The nurse is caring for a newborn infant who has
been diagnosed with Coarctation of the Aorta. Which
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diagnosis?
A.
B.
&
D.
Weak femoral pulses
Bluish discoloration to the lips while crying
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Respiratory distress
8. A client is admitted to the hospital with a diagnosis
of type 1 Diabetes Mellitus. The nurse is assessing
the client for signs of Diabetic Ketoacidosis. The
following should be expected? Select all that apply
A.
B.
C.
D.
E.
F.
Fruity breath
Anorexia
Kussmaul respirations
Metabolic acidosis
Increased blood pressure
Bradycardia
9. The nurse is caring for a client that is suspected to
have Diabetes Insipidus. Which of the following
symptoms would be suggestive of this condition?
Select all that apply
A.
B.
C.
'
E.
F.
urinary frequency
hyponatremia
dehydration
VSHFL¿FJUDYLW\RI
increased thirst
preference for hot liquids
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$%* UHVXOWV ZKLFK UHYHDO WKH IROORZLQJ S+ 3D2 PP +J 3D&2 PP +J +&2 mEq/L. The nurse should recognize that this result is
suggestive of which acid base imbalance?
A.
B.
C.
D.
compensated metabolic acidosis
compensated respiratory acidosis
compensated metabolic alkalosis
compensated respiratory alkalosis
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RATIONALES FOR PRACTICE
QUESTIONS
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Rationales
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Management of care
9. D. Albuterol is a short acting bronchodilator which
should improve breathing. If there is no change in
UHVSLUDWRU\HႇRUWWKLVFOLHQWLVWKHSULRULW\
1. C. The statement further teaching indicates you
are looking for an incorrect response. Clients of the
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Choices A, B, and D are correct.
10. A. Restlessness and combativeness are signs of
hypoxia. This client would take priority. According
to disaster triage Choices B and D are (priority level
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11. B. Jitteriness is indicative of opioid withdrawal in
the newborn. Choices A, C, and D are normal for a
newborn.
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12. C. A quiet patient is most likely exhibiting signs
of depression. The maternity nurse can manage
this patient. Clients A, B, and D should be cared
for by the behavioral health nurse who has more
experience in this area.
4. C. The term follow up indicates you need to intervene.
The client with a lap tray or (lap buddy) needs
intervention as this is considered an illegal restraint.
&KRLFHV$%DQG'DUHH[SHFWHG¿QGLQJV
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60 per minute. A rate of 70 indicates tachypnea
suggestive of distress. Choices A, C, and D are
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experiencing a cardiac event; clinical manifestations
suggestive of abdominal aortic aneurysm include
abdominal mass and abdominal throbbing; the client
who is 6 weeks pregnant experiencing abdominal
pain must be evaluated to rule out ectopic pregnancy
which could be life threatening.
6. D. A client with radon seed Implants should be on
absolute bed rest in a private room to avoid emission
of radioactive material. Clients should also avoid
infants and pregnant women. Choices A, B, and C
DUHH[SHFWHG¿QGLQJV
7. C. Excessive tiredness may be a sign of hypertension
or increased intracranial pressure. This client should
EHVHHQ¿UVW&KRLFHV$%DQG'DUHQRWDSULRULW\
at this time.
8. '&RQIXVLRQLVWKH¿UVWVLJQRILQFUHDVHGLQWUDFUDQLDO
pressure and or hypoxia. According to disaster
triage choices A and C are considered (priority level
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priorities.
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Hyperkalemia places the client at risk for arrythmias.
This infant is the priority. Choices A, C, and D are
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looking for an incorrect statement. A dying client does
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needed. Choices A, B, and D are FRUUHFW¿QGLQJV
16. D. Clients have the right to privacy while hospitalized.
Permission should be granted prior to observation
of any care provided.
17. B. Clients that give away their favorite possessions
may be an increased suicide risk. This client should
EHVHHQ¿UVW&KRLFHV$&DQG'FDQEHVHHQDWD
later time.
18. C. Chills may indicate a temperature elevation.
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DQLQIHFWLRQKDVDQ³$LU´QHHG7KLVFOLHQWVKRXOGEH
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19. D. Priorities for a client in sickle cell crisis include
oxygenation, hydration, and pain relief. Choices A,
B, and C can wait to be seen at a later time.
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20. C. Reports of swelling in the calf 8 hours postpartum
may be suggestive of the development of a deep vein
thrombosis, a potentially life threatening condition.
Immediate intervention is needed; other symptoms
include pain, warmth, chills, diminished peripheral
pulses, erythema, or shiny white skin on the extremity.
$7KLVWDVNFDQVDIHO\EHGHOHJDWHGWRWKH/31&KRLFH
B & C should be delegated to the UAP. Initiation of the
FOLHQW¶VSODQRIFDUHVKRXOGEHGRQHE\WKH51
'. Choices A and C would be most appropriate to
delegate to a UAP. Choice B requires assessment and
should be seen by the RN.
% 1DVDO ÀDULQJ LQ DQ LQIDQW LQGLFDWHV UHVSLUDWRU\
distress; therefore this infant is the priority. Choices A,
&DQG'DUHH[SHFWHG¿QGLQJVLQDQHRQDWH
% ( ) DUH FRUUHFW &KRLFHV$ & DQG ' VKRXOG EH
done by a nurse.
22. B. Restlessness is suggestive of hypoxia so this client
VKRXOGEHVHHQ¿UVW&KRLFHV$&DQG'DUHH[SHFWHG
¿QGLQJV
%$GPLQLVWUDWLRQRILQWUDYHQRXVÀXLGVKDVDSUHGLFWDEOH
outcome. A, D and C require the more experienced
PHGVXUJQXUVH
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HYDOXDWHG ¿UVW $FFRUGLQJ WR GLVDVWHU QXUVLQJ WULDJH
Choice A would be considered (category 4) and choices
%DQG&ZRXOGEHFRQVLGHUHG FDWHJRU\ 24. D. The CNA can administer an enema prior to surgery.
Choices A, B, and C need a LPN or RN.
25. C. Care of the client requiring insulin administration
is appropriate for the LPN. Choices A, B, and D, may
require assessment and are therefore more appropriate
to delegate to the RN.
26. D. This client is stable and appropriate for management
by the pediatric nurse. Choices A, B, and C are unstable
and should be cared for by the emergency room
nurse.
27. C. A client experiencing chest pain after coughing is
appropriate for the new graduate RN. The coughing
may explain why the pain is being manifested. Clients
A, B, and D need assessment and should be seen by
an experienced RN.
28. A. Checking daily weight is an appropriate task to
delegate to a UAP. Choices B, C, and D should
performed by the nurse.
29. B. This choice is the most appropriate to delegate to
a UAP. Choices A and D are stable clients and can be
seen by an LPN. Initial vital signs should be done by an
RN.
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delivery. An exploratory laparotomy is also abdominal
surgery therefore this client would be appropriate.
Choices A, B, and D would be most appropriate for the
medical surgical nurse to care for.
6DIH(ႇHFWLYH&DUH(QYLURQPHQW6DIHW\
and Infection Control
1. D. Bacterial Pneumonia requires droplet precautions
Viral Pneumonia needs standard. The type of
SQHXPRQLD LV QRW VSHFL¿HG $V D UHVXOW WKLV FOLHQW
should be isolated. A client with HIV and cirrhosis of
the liver do not require automatic isolation. A client with
Scabies requires contact precautions which would
QRW WDNH SULRULW\ RYHU GURSOHW SUHFDXWLRQV LI VXႈFLHQW
isolation rooms were not available.
2. A. Rubeola requires airborne isolation which is
the priority. Rubella requires droplet precautions.
Klebsiella Pneumoniae and Pediculosis require
contact precautions.
D. Meningitis requires droplet precautions. Choices
A, B, and C do not require isolation unless further
information is given ie (infectious diarrhea)
4. C. Clients with AIDS have the potential for
immunosuppression. As a result they are at increased
risk for acquiring an infection. Contact with pets
should be limited or avoided. Choices A, B, and D are
correct.
5. B. According to the department of occupational health
and safety: accidents or incidents involving property
damage, personnel, student, or visitor injury are
reported in accordance with the Hospital Incident
Report Program. If a nurse forgets to administer a
medication the nurse can be liable for negligence.
Sexual abuse by a family member may constitute the
need to report to legal authorities such as the police
or child abuse reporting agency depending on the age
of the client. Choices C and D does not require an
LQFLGHQWUHSRUWWREH¿OHG
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6. C. A client with low grade fever and night sweats is
exhibiting signs of tuberculosis (TB). TB requires airborne
isolation. Choices A and B do not require a private room.
A client with leukemia may require a private room if they
are immunosuppressed. However, they would not take
priority over a client with TB.
7. B. The CDC guidelines mandate the use of a N95
respirator mask prior to entry into a room with a client on
airborne precautions. The surgical mask is appropriate
ZKHQ FRPLQJ ZLWKLQ IHHW RI WKH SHUVRQ RQ GURSOHW
precautions.
%:KHQUHVSRQGLQJWRD¿UHWKHUHDUHIRXUVHTXHQWLDO
priorities that must be followed: Rescue the clients,
which was already done in this situation, Alarm (call for
DGGLWLRQDOKHOS &RQ¿QHWKH¿UH([WLQJXLVKWKH¿UH
9. C. Placing a client in prone position after above the knee
amputation is done to prevent contractures; following
supratentorial surgery the head of the bed is elevated
GHJUHHV WR SURPRWH YHQRXV RXWÀRZ 5HPRYLQJ DOO
liquids is not necessary for clients experiencing Dumping
Syndrome. The client should be taught to avoid drinking
with meals.
10. D. A white blood cell count of 2,500/mmis low therefore
the client is at risk for infection. Protective precautions
should be implemented. The normal White blood cell
count (WBC) is 5,000 – 10,000/mm; The normal red
blood cell count (RBC) is 4 – 5 million/mm D GH¿FLW
of red blood cells is indicative of anemia. The normal
platelet count is 150,000 – 400,000µ/Liter. A low platelet
count predisposes the client to bleeding; the normal
KHPRJORELQYDOXHLV±JGOPDOHDQGJGO
female. Low hemoglobin is suggestive of anemia and
possible active bleeding.
Health Promotion and Maintenance
1. C. The posterior fontannel closes between birth and 2
months of age. The fontannel should not be closed at
birth this is suggestive of a congenital defect. Choices A,
B, and D are normal.
$7KHFOLHQW¶VSRVLWLRQVKRXOGEHFKDQJHGLQLWLDOO\WRVHH
if the FHR tracing improves. Choices B, C, and D are not
indicated at this time.
%7UHQGHOHQEXUJ RUNQHH FKHVWSRVLWLRQV DUH WKH PRVW
appropriate positions for a client with a prolapsed cord.
Choices A, C, and D are incorrect.
4.
B. A client with mastitis should relieve the breasts of
milk frequently. This should be done by encouraging
the baby to suck or by using a breast pump if the
baby is unable to suck. Choices, A, C, and D are
incorrect.
&6XEWUDFWPRQWKVDQGDGGGD\VWRWKH¿UVWGD\
of the last normal menstrual period (LNMP). Add
one year if the pregnancy occurs in April through
December.
6. A is correct. Small removable parts are unsafe.
Blocks are appropriate for a 2 year old a low lying
mobile is a strangulation hazard.
7. B. is correct. A tricycle and puppets are appropriate
IRUDQROGHUWRGGOHU DJH $EDOOWRWKURZDQGFDWFK
LVDSSURSULDWHIRUD\HDUROG
8. C. This indicates the 2008 recommended schedule
for routine administration of childhood vaccines at
this age.
9. C. The time between infection with syphilis and the
VWDUWRIWKH¿UVWV\PSWRPFDQUDQJHIURPWR
days (average 21 days).
10. C. The MMR vaccine should not be administered
ZLWKLQPRQWKVRISUHJQDQF\$\HDVWDOOHUJ\VKRXOG
be assessed prior to administering the Hepatitis B
vaccine. Choices A and D are incorrect.
11. A is correct. The infant should be able to say a one
syllable word at approximately 6 months, sit without
support at 8 months and use the pincer grasp
between 9 and 11 months of age.
12. B. Stage 2 is known as the birth or expulsion stage
and is characterized by complete dilation and
HႇDFHPHQWRIWKHFHUYL[XQWLOWKHELUWKRIWKHEDE\
Choices A, C, and D are incorrect.
Psychosocial Integrity
.
1. C. Clients using the drug Thorazine should stay out
of the sun secondary to the risk of photosensitivity.
&2ႇHULQJWKHFOLHQWIRRGWKDWLVIDFWRU\VHDOHGZLOO
GLPLQLVKWKHFOLHQW¶VDQ[LHW\DQGSDUDQRLDUHJDUGLQJ
WKHVWDႇWU\LQJWRSRLVRQKHU
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&7KH FOLHQW UHFHLYLQJ /LWKLXP (VNDOLWK VKRXOG
be careful to include sodium in the diet to prevent
hyponatremia which predisposes the client to
/LWKLXP WR[LFLW\ &DႇHLQH VKRXOG EH DYRLGHG
EHFDXVH RI WKH GLXUHWLF HႇHFW ZKLFK ZLOO IXUWKHU
increase the risk of hyponatremia; There is no
contraindication for fresh fruit or raw vegetables.
11. C. During the bargaining stage the client attempts to
QHJRWLDWHWRSURORQJWKHLUOLIH.EOHU5RVVLGHQWL¿HG
the stages of death and dying as denial (disbelief),
anger (hostility), bargaining, depression (sadness)
and acceptance (coming to terms with death).4.
4. D. Panic is a form of anxiety that is characterized
by unexpected and repeated episodes of intense
fear accompanied by physical symptoms that may
include chest pain, heart palpitations, shortness
of breath, dizziness, or abdominal distress
1. D. Potato, spinach and avocado are all sources of
potassium. This is the best choice.
5. B. When a client actually has a plan they are at
the highest risk to commit suicide.
6. B. is correct. A, C, and D are incorrect choices.
7. C. When clients have thoughts of harming
themselves they are more likely to carry out the
act. Choices A, B, and D are incorrect.
8. A. A client in the manic phase of bipolar disorder
PD\ KDYH GLႈFXOW\ PHHWLQJ QXWULWLRQDO QHHGV
because of their inability to sit still; competitive
games are avoided because the client is
hyperactive, impulsive and distractible. Structured
activity is more appropriate; foods containing
tyramine are avoided in clients prescribed MAO
inhibitors; placing the client on suicide observation
may be indicated during the depressed phase.
9. B. Lanugo type hair on the body is a characteristic
of anorexia nervosa; stained enamel of the teeth
is associated with bulimia nervosa related to
the frequent vomiting; persistent ringing in the
ears and white patches on the tongue are not
associated with anorexia nervosa.
Physiological Integrity: Basic Care and Comfort
& /DsQQHF¶V FLUUKRVLV FRPPRQ LQ DOFRKROLFV FDQ
OHDGWRWKLDPLQHGH¿FLHQF\'H¿FLHQF\RIWKLVYLWDPLQ
can lead to alcoholic brain disease.
&%DUOH\U\HRDWDQGZKHDW %52: DUHIRRGVWREH
avoided with Celiac Disease. Corn (popcorn) and rice
are allowed.
4. C. Clients with renal failure require decreased sodium
in the diet. Corned beef is high in sodium.
5. B. Clients with an increase in uric acid or Gout should
decrease purine in the diet. Foods such as organ meat,
sweetbread, sardines, beer, mushroom, spinach,
asparagus and anchovies should be avoided.
6. B. Dyrenium is a potassium sparing diuretic and foods
high in potassium should be avoided.
7. B. is correct.
8. B. Cabbage, strawberries and popcorn may cause
DQ REVWUXFWLRQ ¿VK LV RGRU SURGXFLQJ 7KHVH IRRGV
should be avoided.
9. D. Vitamin B1 (thiamine) is used to treat alcohol
LQGXFHGGH¿FLHQF\QRW%
10. D. It is customary in the Hindu faith that only
family members touch the body after death. The
other statements are correct. Follow up is not
necessary.
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10. A, B, D. Foods high in vitamin C should be avoided
GD\V EHIRUH WKH WHVW DV WKH\ PD\ JLYH D IDOVH
positive result; Red foods should be avoided as they
may be mistaken for blood.
11. Isometric is the correct term to describe this type of
exercise.
% :KHQ XVLQJ WKH SRLQW JDLW ¿UVW PRYH ERWK
crutches and the weaker limb forward. Then bear
all your weight down through the crutches, and then
PRYHWKHVWURQJHURUXQDႇHFWHGORZHUOLPEIRUZDUG
7KLV HOLPLQDWHV DOO ZHLJKW EHDULQJ RQ WKH DႇHFWHG
leg.
%7KHSURSHUWHFKQLTXHWREHXVHGZKHQWHDFKLQJD
client to ambulate with a cane is to hold the cane in
WKHKDQGRSSRVLWHWKHDႇHFWHGOHJ
14. C. Vitamin C is necessary to improve wound healing.
Oranges and other citrus fruit are a good source of
vitamin C.
Physiological Integrity: Pharmacological and
Parenteral Therapies
1. 2 Tablets Desire 1.0 mg = 2 mg
Have 0.05 mg
2. 36 mg
Remember 2.2 lbs = 1 kg
OEV· NJ
NJ;PJ PJ
2 Tablets
Desire 0.45 gm (convert gm to mg)
Have 225mg
450mg = 2 tablets
225mg
4. 2.7 mg
Remember 2.2 lbs = 1 kg
6lbs ÷ 2.2 = 2.7 kg
2.7kg X 1MG = 2.7mg
5. 1.5 ml
6. 31 gtts/min
'HVLUHPJ PO
Have 2.5 mg
7. 5 ml
12mg : 6ml :: 10mg : Xml
12 X = 60 = 5
12
12
OR Desire 10mg X 6
Have 12mg
60
12
8. 120mg
Remember 2.2 lbs = 1 kg
44 lbs ÷ 2.2 = 20 kg
20kg X 6mg = 120 mg
9. 0.75 ml
7,500 units X 1 ml = 0.75
10,000 units
10. 18.9ml or if instructed to round 19ml/hr
Formula: Desire X Volume X Weight X Min.
Have
Remember 2.2 lbs = 1 kg 185 lbs ÷ 2.2 = 84.09 kg
PFJ;PO;NJ;PLQXWHV
400 mg
Convert 400 mg to mcg = 400,000 mcg
PFJ;PO;NJ;PLQXWHV
400,000 mcg
Simplify division by dividing 500ml into 400,000mcg
PFJ;PO;NJ;PLQV 4,000 mcg
18.9ml if instructed round to 19ml/hr
11. 8.5ml
Formula Desire X Volume X Weight X Min.
Have
Remember 2.2 lbs = 1 kg 187 lbs ÷ 2.2 = 85 kg
2mcg X 250 ml X 85 kg X 60 minutes
PJ
&RQYHUWPJWRPFJ PFJ
2mcg X 250 ml X 85 kg X 60 ninutes
PFJ
6LPSOLI\GLYLVLRQE\GLYLGLQJPOLQWRPFJ
2mcg X 25 ml X 85 kg X 60 mins = 255,000
PFJ
Ans. 8.5ml
1000 ml X 15 gtt/ml JWWVPLQ
(8hrs X 60 minutes)
215
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12. A. Bumex is a potassium wasting diuretic. As
a result, foods/ fruits with potassium should be
increased in the diet.
%&LSURLVFODVVL¿HGDVDÀXRURTLQRORQHXVHGLQ
the treatment of urinary tract and gynecological
LQIHFWLRQV =\YR[ LV DQ DQWL infective used
IRU WKH WUHDWPHQW RI YDQFRP\FLQ UHVLVWDQW
infections, nosocomial pneumonia and skin
infections. Urecholine is a urinary tract stimulant
used for urinary retention. Gentamycin is an
aminoglycoside used for serious gram negative
infections.
OR Desire 20 mEq X Volume 5ml
Have 10 mEq
PO
80mg : Xml :: 125mg : 5ml
125 X = 400 PO
125
125
Desire 80 mg X Volume 5ml
Have 125 mg
16. B, C, F are correct. A, D, E are incorrect
5gm: 10ml : : 2.5gm : Xml
5X = 25 = 5ml
5X 5
OR Desire 2.5gm X Volume 10ml = 25 =5
Have 5gm
5
' 7KH SKUDVH IXUWKHU WHDFKLQJ LQGLFDWHV WKDW \RX
are looking for an incorrect response. Clients on
hydrochlorothiazide need additional potassium as it
is a potassium wasting diuretic.
%&RQVWLSDWLRQLVDFRPPRQVLGHHႇHFWRI&OR]DULO
Choices A, C, and D are incorrect. Hyperglycemia,
an elevated white blood count and hypotension are
common.
25. A, E, and F are correct. Cardura may decrease libido.
Choices C and D are incorrect.
26. B. is correct. Hypoglycemia, hyponatremia, and
leukopenia are possible adverse reactions.
JWWVSHUPLQXWH Volume 1500ml X drop factor 20 gtts/ml =
Minutes (60X8) = 480
18. D. AZT causes insomnia not drowsiness. It
should be taken around the clock. There is no
direct relationship with protein.
19. A. Plaquenil may cause retinopathy and/or vi
sual disturbances. Dark glasses may be worn
in sunlight to decrease this risk. Hypotension
is common. It should be taken with food or
milk to minimize GI distress not on an empty
VWRPDFK,WLVQRWQHFHVVDU\WRGHFUHDVHÀXLGV
while taking Plaquenil.
JWWPLQ
21. D. 5 ml
22. C is correct. Humorsol is a cholinergic that is
XVHG ZKHQ PLRWLFV DUH QRW HႇHFWLYH &\FORJ\O LV D
mydriatic. Timolol is a beta blocker used for ocular
hypertension.
14. 10ml
20 mEq : Xml :: 10 mEq : 5ml
10 X = 100 X = 10 ml
10
10
OR
volume 50 ml X 15 gtts/ml = 750 minutes 20
20
27. A, B, E, and F are correct. Constipation and anorexia
are common.
28. D is correct. Hyperactivity, anorexia, and weight loss
are common adverse reactions.
29. B, C, D, and F are correct. Prilosec should not be
crushed. Dizziness is a common adverse reaction.
'&RWD]\PVKRXOGQRWEHFKHZHGWKHUHIRUHIXUWKHU
teaching is required.
%$QHOHYDWHGFDOFLXPOHYHOLVQRWH[SHFWHGZLWKWKH
XVH RI 5LWRQLYLU +\SHUOLSLGHPLD UHQDO LQVX¿FLHQF\
and hyperglycemia are common.
& (FKLQDFHD LV FRQWUDLQGLFDWHG LQ FOLHQWV ZLWK
Multiple Sclerosis. Choices A, B, and D are correct.
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$ & DQG ( 7KH SKUDVH QHHG IRU IXUWKHU WHDFKLQJ
indicate you are looking for an incorrect response. A,
C, and E are incorrect. Fever Few should be taken
with food. Hawthorne causes hypotension and Valerian
root is used to treat insomnia. Choices B, D, and F are
correct.
6. A. a client with renal stones should avoid foods
with high oxylate content. These include but
are not limited to; spinach, eggplant, chocolate,
beer, peanuts, oatmeal, strawberries, kiwi, and
drinking beer. Also, a diet high in calcium causes a
predisposition to renal calculi.
& 'HPHGH[ LV QRW SRWDVVLXP VSDULQJ WKHUHIRUH
additional potassium is indicated when using this
medication.
7. D. Coughing and wheezing may indicate left sided
KHDUWIDLOXUHDVDUHVXOWRIÀXLGYROXPHH[FHVV
8. C. PSA levels of 4ng/ml warrant further diagnostic
testing. Levels of 10 or greater may suggest prostate
LQIHFWLRQLQÀDPPDWLRQRUFDQFHU
'PO 5HPHPEHUPOHTXDOVRXQFH
; 9. D. Pap smears can only detect cervical not uterine
cancer. Choices A, B, and C are true.
&4XHVWUDQLVDOLSLGORZHULQJDJHQW
$$FWRQHOVKRXOGEHWDNHQPLQXWHVSULRUWREUHDNIDVW
The client should be encouraged to participate in
exercise. The pulse rate does not need to be monitored
prior to administration.
'*OXFRFRUWLFRLGVDUHJLYHQWRVWLPXODWHJURZWKLQWKH
lungs of the fetus. Brethine is given to control premature
contractions. Apresoline is given for hypertension and
Pitocin may be given to induce labor.
&$ORH9HUDPD\LQFUHDVHWKHULVNIRU'LJR[LQWR[LFLW\
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3UR]DFDVWKH\ERWKKDYHDQDQWLGHSUHVVDQWHႇHFW
Physiological integrity: Reduction of Risk Potential
1.
A. Hyperkalemia increases the risk for cardiac changes
including weak pulse and cardiac arrest. This lab result
is the priority at this time.
2. C.
These symptoms
hypocalcemia.
are
representative
of
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WKHPDJQHVLXP1RUPDOPDJQHVLXPOHYHOLVPJ
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VRGLXP LV PPRO/ DQG QRUPDO SRWDVVLXP LV
P(T/
4. B. Multiple Myeloma causes an interference with red
blood cell, white blood cell and platelet production.
5. C. An increase in BUN indicates an impairment in renal
function. Choices A, B, and D are normal.
10. A, C, D, E are true. Choices B and F are not risk
factors for the development of breast cancer.
11. C. A stoma that is moist and pink is normal. No
further interventions are needed at this time.
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normal saline or any liquid can result in aspiration.
& 7KH SRLVRQ FRQWURO FHQWHU VKRXOG EH FDOOHG
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in damage to internal organs and structures as
the substance is regurgitated. The national poison
FRQWUROWHOHSKRQHQXPEHULV
14. C. The glascow coma scale is the most widely used
scale to quantify level of consciousness following
traumatic brain injury. The maximum score is 15 the
PLQLPDO VFRUH LV /HYHOV OHVV WKDQ LQGLFDWH D
coma. The following scores should be given. Eye
RSHQLQJWRVSHHFK FOLHQWREH\VFRPPDQGV FRQIXVHGFRQYHUVDWLRQ WRWDO
15. B. is correct.
16. B. is correct. Sodium should be restricted. The
client is encouraged to remain still and rest in a
quiet environment.
17. B. Glaucoma is characterized by loss of peripheral
vision. Macular degeneration is characterized by
loss of central vision. Cataracts cause opacity of
the lens. Retinal detachment will cause the client to
KDYHDQLQFUHDVHLQWKHQXPEHURIÀRDWHUVRUVHH
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217
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18. A. Gout is indicated by a uric acid level greater
than 7.8 mg/dl.
& $FFRUGLQJ WR WKH ³5XOH RI 1LQHV´ WKH DQWHULRU
FKHVW DFFRXQWV IRU SOXV IRU WKH DUP
WRWDOLQJ
20. C. Flying in an airplane will cause an increase
in pressure which is contraindicated after ear
surgery. Choices A, B, and D are correct therefore
no further teaching is required.
21. B, D, E, F. The client should be placed on the
DႇHFWHG VLGH &RXJKLQJ LV FRQWUDLQGLFDWHG DIWHU
eye surgery.
22. C. High fowlers or orthopneic position is most
DSSURSULDWHIRUDFOLHQWKDYLQJGLႈFXOW\EUHDWKLQJ
$ ' ) 'U\ VNLQ DQG DQRUH[LD DUH FRPPRQ LQ D
client with hypothyroidism. Menstruation will be
scanty.
24. A, B, C, E. Insomnia and palpitations are common
in a client with hyperthyroidism.
25. C. Exercise is contraindicated after eye surgery.
26. C. NPO is not required prior to an EEG. The client
LVDOORZHGWRKDYHEUHDNIDVWLISUHVFULEHG&DႇHLQH
and other stimulants should be avoided for 24
hours prior to the procedure; the other statements
are true of those diagnostic tests, therefore follow
up is not required.
27. A. A female with frequent yeast infections should
be evaluated for Diabetes Mellitus and HIV.
28. B. Abdominal distention may indicate a distended
bladder which indicates a complication after a
(TURP).
29. C. Clients with a spinal cord injury should avoid
stimulating the bowels, bladder and skin which
PD\OHDGWRDXWRQRPLFG\VUHÀH[LD
&$IDWHPEROLVPLVDSRVVLEOHFRPSOLFDWLRQDIWHUD
fracture of a long bone. Petechiae, increased pain,
and swelling are some signs of a fat embolism.
Physiological integrity: Physiological Adaptation
&7KHQXUVHVKRXOGDVVHVVWKHFOLHQW¶VJOXFRVHOHYHO
before proceeding to the subsequent steps.
2. D. Post renal failure is caused by an acute obstruction
WKDWDႇHFWVWKHQRUPDOÀRZRIXULQHRXWRIERWKNLGQH\V
The blockage causes pressure build in all of the renal
nephrons. The excess pressure causes the kidneys
to shut down. Cardiogenic shock and hypovolemia
cause pre renal ARF. Nephrotoxins result in intrarenal
ARF.
'0\DVWKHQLD*UDYLVLVGLDJQRVHGXVLQJWKHWHQVLORQ
test. Choices A, B, and C are correct.
4. D. The hypoglossal nerve controls tongue movements.
The glossopharyngeal and vagus nerves are assessed
E\HOLFLWLQJWKHJDJUHÀH[7KHVSLQDODFFHVVRU\QHUYH
is tested by assessing muscle strength of the head
and shoulders.
5. D, E, F. Risk factors for developing cervical cancer
includes smoking, multiple sex partners, Human
Papilloma Virus (HPV) sex before the age of 20 is a
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risk factors.
6. A. Trigeminal Neuralgia is a disorder that causes
intense pain along the areas innervated by the
5th cranial nerve. Extremes in temperature can
exacerbate the pain symptoms.
7. A. Coarctation of the Aorta is an acyanotic defect
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in the upper extremities than the lower. There may also
be a heart murmur and diminished or absent pulses
below the femur. The other choices are symptoms of
cyanotic defects.
8. A, B, C, D are correct. The other choices are incorrect.
The patient experiences low blood pressure and
increased heart rate.
9. A, C, E are correct. The other symptoms include
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dilution and a preference for cold liquids.
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a liver biopsy to minimize the risk of bleeding.
218
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acidosis there is an increase of carbon dioxide. Generally the renal and pulmonary systems compensate for each
other to return the pH to normal. In this situation, the kidney increased the retention of HCO to normalize the pH.
Study Tool
Arterial Blood Gas
Normal range
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
pH 7.35-7.45
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pCO2 35-45mm Hg
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HCO3(bicarbonate)
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22-26 mm Hg
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Infection Control- list the type of isolation required:
HIB_______________________________
Bacterial Pneumonia_____________________
MRSA_____________________________ Klebsiella Pneumonia____________________
TB_______________________________
Group A Strep__________________________
Epiglottitis_________________________
Small pox______________________________
Fifths Disease______________________
Rubeola______________________________
Infection Control- list the type of isolation required: Page 45
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219
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READY TO PASS INC.
Detailed Answer Key for Page 28
1. 600ml_ X 15 gtt/mL = 9000
(60 X 8 hours) = 480 minutes (60 min = 1hr)
Answer: 18.75 = 19 gtt/min
8. 75ml/hr x 24hrs = 1800ml
50mlx 4 (Q6hrs) = 200ml
200ml x 1
= 200ml
2200ml in IV Fluids
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Answer: 800ml PO
Answer: 400 ml/hr
PO[R] PO
180ml
PO[R] 180ml
1080ml
Formula: Volume X 60
minutes ordered
Answer: 1080ml
*Do not add pureed chicken, it is a solid
PJ;NJ
10. 1500 mg/day = 500mg per dose
GRVHV
2. 100ml x 60 (minutes in 1 hour) = 4 x 100mL
15 minutes
(22lbs/2.2 remember 2.2 lbs =1kg)
Answer: 1 tablet/500mg per dose
500 mg X 1mL = 5ml
100 mg
Answer: 5ml
JP PJ = 2
15mg
11. 160mg[PO 80mg
Answer: 2 tabs
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5: 500mg = 2
250mg
12. PO x 10gtt/ml = 5
600 minutes (60min x 10 hours)
Answer: 2 tabs
Answer: 5gtts/min
6. JP[PO = 7.2 ml
1gm
100ml x 10gtt/ml = 16.6
60 minutes (60 minutes = 1 hour)
Answer: 7.2 ml
Answer: 17gtts/min
7. 5000mcg = 5mg x 1ml = 0.5ml
10 mg
14. 10 units/hr x 100ml = 1000 = 40ml/hr
25units
25
(remember 1mg = 1000 mcg)
Answer: 40 ml/hr
Answer: 0.5ml
220
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