NCLEX EXAM REGISTERED NURSE KING PASCAL | EVERYDAY | MAY
Informed Consent: 3 Principles
The surgeon explains the diagnosis, procedure, risks, outcomes, expectations, alternative options, prognosis if procedure is not performed to performed to the client The client indicates understanding understanding of of the information The client gives voluntary gives voluntary legal consent for consent for the procedure The nurse must be there to witness the client’s consent and understanding of the information IF there’s a need for additional procedure during surgery, the family can give consent after speaking with the surgeon.
8 Times you can call the DOCTOR? 1. 2. 3. 4. 5. 6. 7. 8.
When a client deteriorates deteriorates significantly When a client dies When a client leaves against medical advice (AMA) When a client runs runs away When a client falls falls When a client refuses refuses key treatment treatment in the relevant time period When a prescription needs clarification clarification When there is abnormal lab results
SPLEENSPLEEN- A part of the immune system that functions as a filter that purifies the blood of micro-organism that cause infections (eg. Pneumonia, P neumonia, meningitis). Spleen Rupture is a serious complication of INFECTIOUS MONONUCLEOUS which is MONONUCLEOUS which caused by Epstein-Barr virus & it presents sudden onset of left upper quadrant abdominal pain. Kawasaki Diseases
S/S: Skin peeling
Overwhelming Post-Splenectomy Infection (OPSI) or abrupt onset of sepsis/ bacterial infection on someone without a spleen is a major concern. A client who has splenectomy and complains of headache or minor fever needs urgent attention. Polycythemia Vera is a chronic myeloproliferative disease which causes overproduction ov erproduction of RBC, WBC & Platelets by the bone marrow. marrow. This leads to increased Hematocrit over 53%. A client with marked anemia can develop exertional dyspnea due to the body’s inability to meet the metabolic demands (oxygen) associated with physical activity. Myasthenia Gravis- is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness of skeletal muscle especially in the bulbar region that involves the eye movement, swallowing, speaking & breathing. This client gets tired as the day progresses. The client shows symptom of ptosis ptosis (drooping (drooping of the upper eyelids) Thrombocytopenia- is low level of platelet level due to heparin therapy.
PAGE 1
Addison’s disease or Chronic Adrenal Insufficient occurs Insufficient occurs when the adrenal gland does not produce enough steroid hormones (mineralocorticoids, (mineralocorticoids, glucocorticoids, androgens). Symptoms: 1. Weight 1. Weight loss 2. Muscle weakness. weakness. 3. Hypoglycemia. Hypoglycemia. 4. Low BP. 5. Hyperpigmentation
Cushing’s disease
Clogged Tube when Tube when a feeding tube is clogged, clogged, the nurse should should first attempt to unclog the tube with a large-barrel syringe to flush and aspirate with warm with warm water in a back and forth motion. If that does not work, a digestive enzyme solution should be used. Instilling a carbonated beverage is not appropriate. The Brain Hypothalamus exerts control over the actions of the autonomic nervous system and regulates appetite and temperature. 2. Thalamus integrates all sensory input (except smell) on its way to the cortex and is involved with emotions and mood. play a major role in 3. Amygdala is in the temporal lobe of the brain and may play memory processing and “learned fear.” 4. Medulla of the brain contains vital centers that regulate heart rate; blood pressure; respiration; and reflex centers for swallowing, sneezing, coughing, and vomiting.
1.
Allen TestTest- Tests the patency of the ulna artery.
If the Allen test is positive (when blood returns to palm, ABG can be drawn. If the test is negati ve, ve, move on to to another site…brachial, site…brachial, femoral. The Radial ARTERY is the preferred site for collecting arterial blood gas because it’s on the surface, easy to palpate and stabilize and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be verified by the t he positive Allen test
Repositioning Guideline
to reduce risk of injury to staff & client…
Use a full body sling LIFT to move non-participating clients Use a gait/transfer belt to transfer a partially weight-bearing client to a chair. Use 2 or more staff to transfer a client who is uncooperative or comatose (sedated) Use 2-3 caregivers to move cooperative clients weighing less than 200lbs Use 3 or more caregivers to mover cooperative clients weighing over 200lbs Unstable clients or clients with neck or spinal cord injury need the presence of the nurse before transfer.
Medical Battery/battery : Intentionally touching a person without person without the person’s consent. Assault: Assault: A deliberate threat with power to carry out the threat
PAGE 2
Acanthosis Nigricans Nigricans a skin condition that occurs with obesity or diabetes that appear like dark lines or grooves on the neck or underarms.
Fern Test- Check the presence of amniotic fluid.
Uses nitrazine paper Turns blue when positive
During circumcision During circumcision,, sterile technique must be followed, and
the infant should NOT be fed. They should be swaddled with a wrapped blanket or placed on a special board. A non-nutritive concentrated sucrose sucrose sucking is offered for pain management. management.
Abdominal paracentesis is paracentesis is used to remove ascetic fluid from peritoneal cavity in an End-Stage Liver Disease (Cirrhosis). Client should void before procedure to reduce risk of bladder puncture Client should sit upright or high fowler to facilitate the fluid to the bottom of the peritoneal cavity where the needle will be inserted
Hospice Care- is given to a client who is terminally ill with a life expectancy of 6 months or less. The purpose of hospice is to allow the client to die naturally and as pain free as possible. Hospice can be done at home, hospital or nursing home. While in hospice, a client will not receive curative treatment, but if client’s health improves, the client can come out of hospice. Medicare covers hospice care Diabetes
A diabetes client experiencing experiencing nausea, nausea, vomiting and and abdominal pain is a priority due to the possibility of DKA, diabetes ketoacidosis. DKA is a serious condition that can cause death. It presents abdominal pain and polyuria. Treatment : IV Fluid replacement Medication (insulin) compliance is common among teenagers. The body breaks down fat which turns to ketones and can cause abdominal pain. Client experiencing rapid respiration, Kussmaul’s breathing should blow off Kussmaul’s breathing carbon dioxide in a bag to compensate metabolic acidosis
Emancipated Minor: Someone under 18 who has been legally freed from parental control through a court order due to military enlistment, marriage, pregnancy Air Embolism, Embolism, the client should be placed in Trendelenburg Trendelenburg (head (head down, feet up), and positioned on LEFT SIDE, this SIDE, this would allow the air to rise to the right atrium and the physician should be notified immediately and nurse stays with the patient. Tube Insertion – arm should be raised above the head of the affected side and client placed 30-60 degrees to reduce risk of injuring the diaphragm.
PAGE 3
After Liver Biopsy- client should be placed on the affected side (right side) for a minimum of 2 hours to apply pressure and splint the puncture site. Then 12-14 hours on the back side (supine). During Lumber Puncture- Client Puncture- Client should be place in fetal position After Lumber Puncture – client should be place supine (on back) at 30 degrees. Ankylosing Spondylitis An Spondylitis An inflammatory arthritis affecting the the spine and large joints.
Client takes NSAID to control back pain and are at risk of gastric ulcer The meds can cause melena (black stool)
Heimlich Maneuver (abdominal (abdominal thrust) is the primary rescue intervention for chokings on adults and children over 1 year of age. Back Blows and Chest Thrust are Thrust are used for infants and children under the age of 1 Pulsus Paradoxus is defined as a fall of systolic blood pressure of >10 mmHg during the inspiratory phase.
Pulsus paradoxus can be observed in cardiac tamponade and in conditions where intrathoracic pressure swings are exaggerated or the right ventricle is distended, such as severe acute asthma or exacerbations of chronic obstructive pulmonary disease.
Aphasia involves the inability to express feelings and thoughts due to a brain dysfunction and includes both verbal and writing skills. A Sentinel Event is Event is an unanticipated event in event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness Abdominal Aneurysm is a life threatening abdominal problem which can present back pain, pulsating mass around the periumbilical area, left to the midline. Rigid abdomen and diffuse pain indicates peritonitis. UTI- Fever, suprapubic pain & dysuria. Patient’s Rights
R ight ight to adequate evaluation and treatment of pain Right to know the identity/names of care provider and position Right to personal information and how to share it
Ethical Nursing Practice:
Autonomy: Is freedom for a competent person to make medical decision by himself even if the nurse or family does not agree (e.g informed consent, A.D) Accountability: accepting responsibility for one’s actions and actions and admitting error. Confidentiality: means that information shared with the nurse is kept secret unless permission is given to share it or it’s required by law to share it such as STD suicidal ideation to help protect the client.
PAGE 4
Justice: is treating everyone equally regardless of gender, sexual orientation, race/ethnicity, religion or social standing. Nonmaleficence: means doing no harm and protecting others Beneficence: To do good- to implement intervention to promote health. Veracity means to tell the truth to build a trusting relationship
Acute Pyelonephritis Pyelonephritis is a severe, life-threatening bacterial infection of the kidney that causes it to swell. It can lead to a permanent scaring of the kidney and can be.
Treatments: Treatments: IV parenteral fluid and IV antibiotics.
Extravasation is the infiltration of a drug into the tissue surrounding the vein. Ground Coffee emesis indicates emesis indicates upper gastrointestinal bleeding. Ear drop
Kids 3 and adults – UP and back Kids 3 and down – Down and back
Enema
During instillation, client complains of pain and cramp, stop, wait 30 secs and continue slowly
Nurse as a client ADVOCATE #S In the role of client advocate, the nurse protects the client's human and legal rights and provides assistance in asserting those rights if the need arises:
The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse also defends clients' rights in a general way by speaking out against policies or actions that might endanger the client's well-being well-b eing or conflict with his or her rights. Informed consent is part of the health care provider– provider –client relationship; in most situations, obtaining the client's informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client's client's signature signature on the consent consent form, the nurse nurse does not legally legally assume the duty of obtaining informed consent. The nurse needs to consider the client's religion and culture when functioning as an advocate and when providing care. The nurse would not ignore the client's religious or cultural beliefs in discussions about treatment plans, so that an informed decision can be made.
PICC-- Peripherally Inserted Central Catheter- is inserted through the cephalic or PICC
PAGE 5
basilic veins into the superior vena cava.
The nurse should measure and document the length of the external PICC during dressing changes. A change in the length of the external PICC indicates migration of the tip of the catheter from the original position. The nurse should hold IV hold IV fluids, medications and secure the tube to avoid further shifting & notify DR to obtain x-ray to verify placement of the tip.
A client with MALABSORPTION MALABSORPTION syndrome syndrome should not be able to digest nor absorb nutrients from the gastrointestinal tract. Peripheral parenteral nutrition of 10% dextrose is the proper treatment. PCA- Patient-Controlled Analgesia- delivers a set of IV analgesia each time the pt. presses a button
Needs normal saline to keep the veins open If HCP stops the order, call to clarify
BLOOD TRANSFUSIONBLOOD TRANSFUSION
Verify 2 identifiers 2 identifiers with another RN Prime with normal saline Transfuse btw 2-4hrs (not over 4hrs) RN stays in room for first 15 minutes/50 ml Check vital signs Fourth vital sign can be delegated to CN 1hrs after infusion
Phlebotomy-Procedure
Clean the site with alcohol Insert needle bevel at 15 degrees’ angle, degrees’ angle, not more than 30 degrees If pulsating red blood is noticed, pull out and press the site for at least 5 minutes ulsating red blood indicates artery was assessed . P ulsating After 2 unsuccessful unsuccessful attempts to withdraw blood, another nurse or phlebotomist phlebotomist should try. Avoid hands with mastectomy Never draw blood above an IV infusion Tube should be inverted 5-10 times to mix with anticoagulant.
PAGE 6
Juglar Vein Distention (JVD):
Position client on 30-45 degree to reveal prominent neck vein or pulsation If fluid overload is observed, reposition patient to 60-90 degree.
Central Venous Access Device (CVAD)
Catheter occlusion is a common complication Kinked tube, catheter malposition, medication precipitate or thrombosis can cause occlusion Flushing CVAD maintains patency.
Medical Interpreter- when working with medical interpreters, nurse should use best practice to maximize communication and understanding with the client.
Use a professional interpreter if possible Address the client/patient client/patient directly in first person Speak directly to the client not the interp Have pre-conference with the interpreter to review goals of on the interview Ask one question at a time/Speak time/Speak in short sentences sentences and allow the interpreter to speak
Type of Lochia Lochia Rubra
Time Frame 1 to 3 days
Lochia Serosa
4 to 10 days
Lochia Alba
11 days to 6 weeks
Normal Dark Red flow consisting of blood, small clot, fleshy odor. Serous, pink / brownish, watery, decreased flow Creamy white, light yellow, decreased flow
Abnormal Foul odor, large clots, saturated perineal pad Continuous/recurrent, red color, excessive flow, foul odor Recurrent rubra, continuous serosa, foul odor
implantation of the placenta. placenta. The types of placenta placenta Placenta Previa is the low implantation previa are the following: 1. Low-lying placenta previa – the implantation took place in the lower portion rather than the upper portion of the uterus. 2. Marginal placenta previa – the placental edges are approaching the cervical 3. Partial placenta previa – a portion of carvel os is occluded by the placental portion. 4. Total placenta previa – implantation that totally obstructs the cervical os. that cause PP:>> Increased parity. Advanced maternal age. Past cesarean births. Past uterine curettage. Multiple gestation PAGE 7
Bleeding – bright red blood. blood . The lower uterine segment begins to differentiate with the upper upper segment later in pregnancy. Placenta has the inability to stretch to accommodate the differing shape of the lower uterine segment or the cervix, thus, abrupt and bright red bleeding occurs.
Therapeutic Management 1. Place the woman immediately on bed rest in a side-lying position position.. 2. Weigh perineal pads. 3. NEVER attempt a pelvic or rectal examination because it may initiate massive blood loss. loss. 4. Blood typing 5. Initiate 2 large IV catheter for Fluid restoration and blood transfusion
Abruptio Placenta Placenta this is when when correctly implanted placenta separates prematurely. Risk factors >>High parity. Advanced maternal age. A short umbilical cord. Chronic hypertensive disease. Pregnancy-induced hypertension. Direct trauma
Vasoconstriction from cigarette use.
Signs and symptoms
Sharp, stabbing pain high in the uterine fundus (during initial separation)
Tenderness felt on uterine palpation
Heavy bleeding (not clear). Blood can either pool under the placenta and be hidden from view. External bleeding is only present if i f the placenta separates separates first at the edges edges and blood blood escapes freely freely from the cervix.
Hard, boardlike uterus with no apparent or minimally apparent bleeding
Dark red blood (in bleeding episodes)
Management
Fluid replacement. Oxygen by mask. Monitor FHR. Keep the woman in a lateral position. DO NOT perform any vaginal or pelvic examinations or give enema
Pregnancy must be terminated because the fetus cannot obtain adequate oxygen and nutrients. If birth does not seem imminent, cesarean birth is method of choice for delivery.
situation, background, assessment & recommendation
PAGE 8
& Prioritization can be achieved with two frameworks: 1. ABC +V = Airway, Breathing, Circulation + Vital signs 2. Mental status change, acute pain, unresolved medical issues, acute elimination issues, abnormal lab values and risks 3. Longer-term issues such as health education, edu cation, rest and coping Marslow’s Hierarchy of NeedsNeeds -
ABO Incompatibility Incompatibility reaction reaction is most dangerous in the first 15 minutes or 50 ml of transfusion.
PAGE 9
Constipation is normal after abdominal surgery due to opioid usage and peristalsis manipulation during surgery. Phantom limb pain is a sensation pain or tingling on an amputated body part. Wrapping the body part or apply heat until HCP examines examines it. N/V, bowel obstruction and abdominal distension can signal bowel obstruction which leads to electrolyte imbalance, dehydration and infection = Lif e threatening. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). CAUSES: Electrolyte imbalance and ischemia. Mature Minor are adolescents who are ages 14-18 and are deemed able to understand treatable risks. They are legally allowed to give consent or refuse treatment to limited conditions such as testing for STI, family planning, blood donation, alcohol/drug abuse and mental health issue. Emancipated Minor is a self-supporting minor under the age of 18 who is legally Emancipated married, pregnant or enlisted in the military or granted by court or not living at home.
W hen hen you see a question, check for ABSOLUTE WORDS like: only, every, all & get rid of them before going back to crosscheck your elimination. EXCEPT in a SAFETY ISSUE question.
Check for REPEATING WORDS in the answers as were in the question. Answers with with more repeated repeated words are likely the answer. SBAR
W hen hen solving PRIORITY problems, consider this: ABC’s
PAIN
Education, well being, feeling & coping
PAGE 10
Using the NURSING PROCESS The nurse must assess FIRST.
If they ask you what to do first, you ASSES something If there is assessment data within the question & you’re you’re asked what to do first or next, you INTERVENE.
hift in thinking…
Triage: from the French verb, meaning “to sort” In health care, triage is a screening process used to determine priority for treatment. Most of us understand that if there is a room full of people in a hospital emergency department, the most seriously ill or injured person is the one who is treated first.
PAGE 11
But in a disaster situation, there is a shift from doing what is best for the individual to doing the greatest good for the largest largest number of people. The key is to maximize patient survival with an efficient use of available resources. Who to help first??? To help determine how to “sort” victims, a widely accepted and systematic colorcolor coding system has been developed: RED = “immediate” – people – people whose lives are in immediate danger and require immediate treatment. YELLOW = “delayed” – these people’s lives are not in immediate danger; they will require urgent, not immediate, medical care (usually most victims). GREEN = “minimal” – the “walking wounded”, who will eventually require treatment. BLACK = “expectant” (or no priority) – people whe n initially assessed – people who are dead when or those with such extensive injuries that they cannot be saved with the limited available resources. When checking victims and determining which group they should be assigned to, the primary assessments to use can be remembered remembere d using the acronym: R-P-M R = respiration P = perfusion (check for radial pulses – not carotid) M = mental status
PAGE 12
Children under 10 should automatically be UPGRADED to 1 level higher than the triaged urgency of their medical issues. UAP/CNA- Unlicensed Assistive Personnel
Can empty, measure and record output from a surgical drainage BUT only the RN can assess the drainage i.e. determine the type. Amount, odor and color.
Can courier blood products to and from the lab.
Can carry put comfort measures such as escorting family members to waiting room. Can perform ROM range of motion exercises Reapply restraints after exercise Report changes in skin integrity Turn and reposition client in bed
A child with ASHMATICUS with ASHMATICUS is at is at risk of rapid deterioration of respiratory failure. Oxygen level for asthmatics is above 95 degree. Hyperthyroidism is the excessive secretion thyroid hormone. Thyroid Storm is Storm is a life-threatening form of hyperthyroid.
S/S: Fever, tacchy, a-fib, n/v, altered mental status. Care: Reduction of fever, hydration and prevention of cardiac compromise
RN REPORTABLE CASES- STI CASES, ABUSE
PAGE 13
RNs are RNs are required by law to report suspected abuse to vulnerable clients: minors, elderlies, demented even IF other practitioners don’t agree or the client denies it.
Client diagnosed of gonorrhea: partners need to know and get treated & PH Child with STI - sexual - sexual abuse must be reported Adult with injuries injuries
ADVANCED DIRECTIVES- 2 common types
LIVINNG WILL- Represent the client’s medical decisions (e.g. (e.g. DNR) & Durable POWER OF ATTORNEY-Designates ATTORNEY-Designates a REPRESENTATIVE to act on a person’s behalf if the individual becomes incapacitated. There are types of POA- including medical including medical and financial A POA takes effect when there is NO living-will indicating what actions to be taken on behalf of a client.
is an early sign of internal hemorrhage
It can be caused by an onset of an infection
Pancreatitis is Pancreatitis is a very painful condition and sinus tachycardia is expected and can develop 3rd spacing which spacing which can be cured with large quantities of Inguinal Hernia- is a protrusion of intraperitoneal contents (e.g. Bowel tissue) through a weakened area in the the abdominal wall (groin, (groin, scrotum). Client Client will feel pain exacerbated with exercise or straining straining and a palpable palpable bulge on assessment.
PAGE 14
Manifestations of a mechanical bowel obstruction (pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Intestinal obstruction and strangulated bowel are bowel are life threatening complications associated with incarcerated hernia and require immediate evaluation and urgent surgical intervention. Bronchiolitis Bronchiolitis is a lower respiratory tract infection that is mostly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract.
UAP (Unlicensed Assistive Personal)- can do the following
COMPATMENT SYNDROME is a medical emergency from from swelling and increased pressure of a confined place (compartment). It’s popular on lower extremities but can occur on arms. Pressure from injury/edema can be greater than tissue capillary perfusion pressure and cause tissue ischemia below the site of increased pressure.
S/S: Pain unrelieved by opioids or elevation, pain with passive motion. TX: R elieve elieve pressure within 4-6hrs of onset.
PAGE 15
S3 SOUND is SOUND is made when blood from atrium is pumped into noncompliant ventricle.
It can be a normal finding in young people BUT in OLDER ALDUTS it’s significant as it shows heart failure or fluid overload.
COPD- Chronic Obstructive Pulmonary Disease- is a group of lung disease (asthma, bronchitis & emphysema) known for blocked airflow and difficult breathing; primarily caused by bacteria. Oxygen goal = 90 – 93% They rely on their hypoxemic drive to breath consistency or volume Be worried only when sputum changes color, consistency Cheyne-Stokes respiration is respiration is an abnormal, repetitive, irregular breathing pattern that is characterized by alternative deep and slow respiration followed by period of apnea (20-30 seconds). It’s associated with neurological conditions such as stroke Post procedure for client who have undergone heart catheterization should focus on hemodynamics: BP, HR, distal pulse strength , color and temperature of extremities.
Client should be assessed several times per hour Back or plank pain should be assessed for retroperitoneal or internal bleeding Inter bleeding after cardiac catheterization is dangerous
Munchausen Syndrome is a disorder in which a person repeatedly claims he or she is physically or mentally ill when it is not true. Munchausen Syndrome by Proxy is a disorder in which a caregiver deliberately causes an injury to a person in his or her care Obstructive Sleep Apnea (OSA) is (OSA) is characterized by partial or full obstruction of the airway due to the relaxation of the pharyngeal muscle, airway closure or lack of airflow. Opioid analgesics can exacerbate OSA by decreasing pharyngeal muscle tone and increases chances of airway closure. Patients with OSA need to be on continuous positive airway pressure (CPAP).
PAGE 16
NORMAL LAB VALUES Albumin = 3.5 – 5.0 g/dL Albumin = Made by the liver Maintains intravascular pressure and prevent fluids from leaking out of the vessels. Hypoalbuminemia causes pitting edema, periorbital edema, and ascites.
Calcium = 8.5 – 11 Hypocalcemia = causes muscle reflexes, spasm, tingling, confusion, petechiae. Hypercalcemia = causes constipation and polyuria
Hemoglobin level- Male 13.2 – 17.3 Female 11.7 – 15.5 Low level may cause blood loss 15.5 Low (during or due to surgery), cardiac and respiratory complications during surgery. Creatinine = Male: 0.6 – 1.2 Female 0.5-1.1 -Increased Creatinine level signifies impaired kidney functions Glucose – Normal blood fasting = 70 – 110 mg/dL INR = 0.75 – 1.25 Assesses and monitors coagulation status status on clients clients on anticoagulation anticoagulation therapy. Therapeutic INR = 2-3: For a patient on anticoagulant: warfarin (coumadin) Lower than normal INR means blood clots faster than usual which can lead to stroke.. stroke Higher than normal INR means blood is too thin, at risk of heavy bleeding b leeding Potassium = 3.5 – 5.5 Hypokalemia = causes cardiac arrhythmia, muscle weakness/paralysis, soft, flabby muscle, Hyperkalemia = occurs when there is cellular damage like during skin burn
causes ECG changes Partial thromboplastin time ( time (PTT PTT)) -30-40 seconds-is a blood test that measures the time it time it takes your blood to clot. PAGE 17
aPTT- (a aPTT(activated Partial Thromboplastic Time) Therapeutic range for clients on anticoagulant = 40- 70 seconds (times 1.5-2 of normal range of 30- 40 seconds) Magnesium = 1.5 – 2.5 Hypomagnesemia is a low level of magnesium associated with alcohol abuse due to poor absorption, inadequate nutritional intake and increased losses via gastrointestinal and renal systems.
Urine Specific Gravity = 1.010 -1.030 BUN = 10 – 30 mg/dL Sodium (Na) = 135 – 145 Hyponatremia = Can lead to seizures and altered mental status. Hypernatremia = ALT & AST are AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are 2-3 times higher than normal values
RESPIRATION COPD- Chronic Obstructive Pulmonary Disease –Permanent airflow limitation causes trapped air
Client is very susceptible to pulmonary infections Client with COPD has cough and mucus production at baseline Report increased sputum and purulence – indicates infection/bacterial Advice client to get pneumococcal vaccine & influenza vaccine vaccine Anxiety is common for clients with COPD teach them breathing exercises & relaxation.
Steroid Therapy & nebulizer treatment are common pharmaceutical intervention of COPD exacerbation. BIPAP Therapy ( bilevel positive airway pressure) is an effective way treatment of decrease CO2 in client with hypercapnic respiratory failure. BIPAP machine provides positive pressure oxygen and expels CO2 from the lungs. lu ngs. Asthma – is a disease characterized by airway hyper activities, use of accessory muscles, high-pitched sibilant wheezing on expiration, chest tightness, diminished breath sounds, tachypnea, cough and chronic inflammation resulting in
PAGE 18
Acute Pancreatitis Pancreatitis can cause respiratory complications including pleural effusion, atelectasis (1 or more lung collapse), & ARDS (acute respiratory distress syndrome). These complications are due to activated enzymes released into the circulation and they cause systemic inflammation. ARDS can cause respiratory failure in minutes. Refractory Hypoxemia is life threatening & the inability to improve oxygenation hallmark of ARDS.
Pneumonia is an inflammatory process in the alveoli and interstitium. Advanced age is the major factor for risk of pneumonia.
Cough & mucus production are normal in client with pneumonia. Increased temperature is common on pneumonia pts on antibiotic therapy SOB, fatigue, activity intolerance
Pneumonia Discharge Teaching:
Avoid OTC cough med med Schedule follow up with HPC & chest X-ray Use a cool mist humidifier in your bedroom at nights Continue use of incentive spirometer at home Limit caffeine and alcohol Increase exercise slowly over 2 weeks and take rest periods Increase fluid intake to 2500-3000ml/day. (Normal=3000ml/day) (Normal=3000ml/day)
f rom a Deed Vein Pulmonary Embolism (PE)- is a blood clot which originated from of the leg, travels to the pulmonary circulation and blocks pulmonary artery resulting in decreased perfusion and hypoxemia caused by prolonged hospitalization, immobility and more.
S/S: D yspnea, Pleural chest pain, Tachycardia, Tachypnea, H ypoxemia (ineffective gas exchange), Anxiety and Apprehension. Dislodged Trachea Tube when a tracheostomy is dislodged, the first thing the nurse do should be to: Separate the suture if there is one, lift the trachea and hold the STOMA open until the emergency team arrive. 2nd, apply sterile cover over the stoma.
Cystic Fibrosis- is a genetic disorder involving the cells that line the respiratory tract, the gastrointestinal tract and the reproductive system. Pleural Effusion - Is the accumulation of fluid into the pleural space that prevents the LUNGS from expanding, decreases lung volume, atelectasis, and ineffective ineffe ctive gas exchange. PAGE 19
Signs & Symptoms: Dyspnea on exertion, nonproductive cough, diminished breath sounds, dullness to percussion, percussion, decreased tactile fremitus. Fremitus- palpable vibration on the chest wall. Chronic Bronchitis is characterized by edema of the abdomen and on the leg, productive cough and they are called BLUE BLOATERS. Emphesima is characterized by HYPERventilation, barrel chest, hypercapnia (high CO2) use of accessory accessory muscles during breathing and are known as pink puffers. PNEUMOVAX is is give every 5 years, not annually. When Spirivia & Pulmicort are prescribed together as inlahers, take Spirivia first and Pulmicort later in 5 minutes.
Integumentary 1st degree burn or superficial = 2nd degree burn or partial thickness = 3rd degree burn or full thickness= Brown, white, charred leathery. No pain because nerves are damaged. Burn injuries cause increased vascular permeability and fluid shift (2 nd and 3rd spacing). 24 – 72 hours after a burn, fluids leak out of the vascular v ascular tissue causing hypovolemia. Potassium, the predominant cellular cation gets released whenever there is a cellular damage causing hyperkalemia which hyperkalemia which causes tall, peaked T waves. Burn clients are mostly given their medications via intravascular (IV) (IV) Urine output of 30ml/hr. is a good indication fluid resuscitation has taken place in someone with a burnt injury. First fluid given to a severe burnt client is lactated Ringer’s solution made of Na, Ca, Cl, K and H2O. PARKLAND FORMULA The amount of fluid required for the first 24 hours is calculated using Parkland formula: 4ml X kg (of ( of BODY WEIGHT) X % of TBSA burned. 1/2 is infused in the first 8 hrs. 1/4 of 2 nd ½ is infused in the 2 nd 8hrs and the 2 nd 1/4 of 2nd ½ is infused in the last 8hrs = 24hrs. 24hrs.
PAGE 20
BLEEDING Sanguineous (bright Sanguineous (bright red)- active bleeding Serosanguineous (pink)Serosanguineous (pink)- expected 2 hours after surgery. s urgery.
Cardiac Ventricular arrhythmia (torsades de pointes) Hypocal
Pharmacology Sulfasalazine (Azulfidine) = Treats ulcerative colitis & rheumatoid arthritis Side Effects: Turn eyes, skin/eyes, urine into permanent yellow.
Potassium Chloride- Corrects or prevents hyperkalemia. Oral KCL is available in extended releases capsule, tablets, dissolvable packages. IF client can’t swallow, contact pharmacy to require a different form of the medication The use of loop diuretic like furosemide is the common cause of potassium depletion Antihistamines: Antihistamines: Diphenhydramine and loratadine & NSAID interfere with skin allergy test. They need to be stopped for a week before skin test. Albuterol (Proventil, Albuterol (Proventil, Ventolin) Nebulizer is a rescue drug. Fast acting! A bronchodilator. agonist. A beta-adrenergic agonist. Faster than Ipratropium (Atrovent) inhaler
PAGE 21
S/E= Tremor, S/E= Tremor, tacchy, palpitations
Glyburide is used to treat diabetes mellitus It causes low blood sugar if ingested by a client who does NOT have a DIABETES Enoxaparin (Lovenox) – Treat DVT Is given subcutaneous 2 inches from left left of right side side of the navel/umbilicus navel/umbilicus Injects at 90 degrees angle Discourage the client from rubbing on the injection site to prevent excessive bruising
Roflumilast is a phosphodiestrace-4 inhibitor that is used in the treatment of patients Roflumilast is with severe COPD due to chronic bronchitis. This medication can cause increased suicidal thoughts, thoughts, and the patient should be monitored for this while taking Roflumilast. Prednisone is Prednisone is a corticosteroid and can cause hyperglycemia and bruising.
Heparin Insulin Venlaphazine = antidepressant Dobutamine – Treats heart failure/ helps the heart pump blood ACE Inhibitors: Inhibitors: (-prils-cause hyperkalemia): captopril, enalapril, Lisinopril, Ramipril = treat high blood pressure. Angiotensin Receptor Blockers: (-sartans): (-sartans): valsartan, losartan, telmisartan (cause hyperkalemia) Ethambutol (Myambutol) – Treats tuberculosis but can cause vision loss. Monitor vision. Levofloxacin (Levaquin)- quinolone (Levaquin)- quinolone antibiotic.
Wait 2hrs before giving any other drugs
Sucralfate (Carafate, Sulcrate)- Treats gastric ulcer.
Give 2hrs before meals and 2hrs after 2hrs after other medications
Rifampin (Rifadin)- Treats TB.
Causes red-orange discoloration of body fluids.
Leflunomide (Arava)- Treats rheumatoid arthritis
Assess for ROM, check check for onset of rash rash or cough
Lamivudine (Epivir)Lorazepam (Ativan) – Prescribes for epilepsy, sedative and also given to cocaine addicts every 15 minutes to reduce withdrawal symptoms. Lansoprazole (Prevacid)-
PAGE 22
Norepinephrine (Levophed) is vasoconstrictor and a vesicant than can cause tissue necrosis IF absorbed into the tissue.
If extravasation of norepinephrine occurs Stop the infusion right away and disconnect the tubing o Use syringe to aspirate the drug from IV catheter and remove catheter o Elevate the affected side above the heart to reduce edema o Notify the health care provide and prepare o Prepare phentolamine (Regitine/antidote) a (Regitine/antidote) a vasodilator that is used to o counter the effects of adrenergic drugs like epi, dopamine. Flush the site and reuse again o
Platelet- Normal count- 150,000 – 400,000 (Thrombocytopenia- a complication of heparin therapy- is low level of platelet) Nifedipine (Procardia) – is a potent calcium channel blocker antihypertensive. Should not be given when client’s BP i s low.
PEDIATRICS REVIEW Normal Infant respiration= 30- 60 Glucose= 40 - 60
Sepsis in Neonates may NOT show visible symptoms but rectal temperature greater than 100.4 F (38.0 C) or less than 96.8 F, FEVER, INSCREASED SLEEPING, POOR FEEDING is RED FLAG.
PAGE 23
SAUDERS REVIEW The situational leadership style uses style uses a style depending on the situation and events. This type of leadership style st yle is used in emergency situations when the nurse manager needs to quickly delegate activities to achieve a successful outcome for the situation. A laissez-faire leader abdicates leader abdicates leadership and responsibilities, allowing staff to work without assistance, assistance, direction, or supervision. supervision. Participative leadership demonstrates leadership demonstrates an "in-between" style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is leadership is task oriented and directive. directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals or solutions. A client with acute glomerulonephritis commonly glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction restriction, as well as monitoring weight and intake and output. The client may be placed on bedrest or at least encouraged to rest because a direct correlation exists among proteinuria, hematuria, edema, and increased
PAGE 24
activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
PAGE 25
