~*~*~NCLEX Notes*~*~*~*~*~*~
Prednisone – tx of inflammatory and immunologic conditions. o S.E.- hyperglycemia, gastric and duodenal ulcers, muscle wasting, fluid retention, potassium excretion, and moon face. o Nursing responsibilities include assessing for diabetes and ulcers, monitoring blood pressure and laboratory values, and checking for infections.
Infant dx with PKU- offer Lofenalac o Lack enzyme to convert phenylalanine to tyrosine, accumulates in tissues, leads to mental retardation o Autosomal recessive
Therapeutic Serum Lithium Lvl- Less than 1.5 mEq/L o Signs of lithium toxicity- diarrhea, over-sedation, ataxia, tinnitus, slurred speech, muscle weakness o EARLY SIGN TOXICITY- fine tremors of fingers, wrist, hands, N/V o SEVERE SIGNS- ataxia, confusion, seizures
Raynaud’s phenomenon - cold temperatures or strong emotions cause blood vessel spasms that block blood flow to the fingers, toes, ears, and nose, tingling numbness
Inderal (propanalol) contraindicated in pts with uncompensated Heart Failure and pulmonary edema o Proper meds- Digoxin, Lasix, O2 nasal cannula
Range for IOP (intraocular pressure) 10-21 mmHg
Postmortem care- wash the client, place pad under perineum o Don’t pass buck to chaplain or supervisor
Signs of hypoxia- increased RR, restlessness, cyanosis, anxiety, tachycardia
Pt with Bell’s Palsy- protect face from cold and drafts bc trigeminal hyperesthesia. Heat on affected side 1
Acute Renal Failure (ARF)- inability of kidneys to concentrate urine o Check urine specific gravity
Repair of detached retina- if gas or oil used to reattach, sleep on stomach for several days o Avoid jarring motion of head- increases ICP o Resume work after 3 weeks, avoid strenuous activity for 3 months
Evisceration- happens after surgery, underlying bowel visible, shiny pink area o Cover area with sterile gauze and soak in NS
Glaucoma- IOP is higher during the morning- early morning assessments more accurate in the morning o Lifelong eyedrop treatment needed to prevent blindness o Decreased visual acuity not corrected with glasses
Acute phase of CVA- HOB at 15-30 degrees, facilitates venous drainage from brain
Pleur-Evac Drainage System o Suction control chamber- water bubbles constantly o Water seal chamber- bubbles when pt exhales and when coughing or sneezing
Amount of fluid should fluctuate with respirations, rising with inspiration and falling with expiration
If not fluctuating, either lung is expanded (desired) or obstruction of chest tube- kinked, looped, clots
o First 24 hrs after surgery- 500-1,00mL drainage
Continuous Ambulatory Peritoneal Dialysis (CAPD) o Constipation common problem- stool softeners and high fiber diet o Cloudy dialysate output is first sign of peritonitis o Normal- clear and yellow
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Ketonuria during pregnancy- ketoacidosis which contributes to intrauterine death
JVD is symptom of cardiac tamponade, a complication after CABG from bleeding around the heart
Hypoparathyroidism- diet high in CALCIUM and low in PHOSPEROUS
Clomid (clomiphene citrate) works by inducing ovulation by altering estrogen and stimulating follicular growth to produce a mature ovumused for women having trouble conceiving
Erikson’s stages: o Newborn-2: Trust vs. mistrust
Feeding, attention, care lead to trust
o Age 2-3: Autonomy vs. Shame and Doubt
Toilet training leads to independence, personal control
o Preschool 3-5: Initiative vs. Guilt
Assert power and control over environment to gain initiative
o School-age 6-11: Industry vs. Inferiority
School provides social and academic demands
o Adolescence 12-18: identity vs. Role Confusion
Developing sense of self
o Young Adulthood 19-40: Intimacy vs. Isolation
Forming intimate, loving relationships
o Middle Adulthood 40-65: Generativity vs. Stagnation
Having children or legacy to leave behind, usefulness and accomplishment vs. shallow involvement in the world
o Maturity 65-Death: Ego integrity vs. Despair
Look back and feel sense of fulfillment
Pt with CVA- nursing care can PREVENT corneal abrasion- eye can no longer close voluntarily and produce moisture
Tracheal tube suctioning- insert suction tube until resistance is met, then withdraw tube 1-2cm. Apply suction intermittently while 3
withdrawing in twirling motion. Never suction longer than 10-15 seconds
Naproxen Sodium – NSAID used as analgesic o SE- HA, dizziness, GI distress, pruritus, rash
Thorazine- antipsych med o SE- akathesia (restlessness), dystonia (tongue protrusion), pseudoparkinsonian (tremors, rigid), dyskinesia (difficulity swallowing)
Cogentin may be ordered for antiparkinsonian symptoms
Dosage may be decreased if extrapyramidal symptoms
Post op cataract client- avoiding bending over, sudden movements, vomiting, constipation o Increase IOP- pressure on ocular suture line
Blood transfusion reactions o Circulatory overload- bounding peripheral pulses o Febrile- chills o Allergic- wheezing, hives, facial flushing, itching o Hemolytic- lower back pain
Process of adjustment o 1. Denial, isolation o 2. Anger o 3. Bargaining o 4. Depression o 5. Acceptance
Defense mechanisms used in phobias o Projection- attributing thoughts and impluses to something else o Displacement- shifting emotion concerning something to something else less dangerous o Symbolization- something representing something else
Other defense mechanisms
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o Reaction formation- ex: treating someone you hate excessively nice in order to hide true feelings o Intellectualization- avoiding disturbing feelings with the use of logic or over-thinking o Sublimation- channeling unacceptable impulses into acceptable ones ex: anger to kick boxing o Internalization- using someone else’s opinion as your own
Infant barium swallow study- make NPO 3 hours prior
Colostomy care o Irrigated at the same time every day o Once per day o Catheter inserted no more than 4 inches o Solution at body temperature
Purpose of Digoxin- increase force of myocardial contraction
During 4th stage of labor- uterus palpable at umbilicus
SHARE- organization for parents who lost newborn
Position of fractured hip- shortened, adducted, internally rotated
Milestones for children o Posterior fontanelle closed at 2-3 months o Solid food (rice cereal) 4-5 months o Sitting with assist at 6 months o Pincer grasp at 9 months o Eating using fingers at 10-12 months o Tripling birth weight at 1 year o Anterior fontanelle closed at 1.5 years o Builds tower of blocks at 16-18 months o Discriminates between pictures of objects at 2 years
Musculoskeletal milestones for children o Child stands without support – 15 months o Child runs after ball- age 2 o Child climbs up and down stairs- age 2-4 5
o Child hops and skips- age 6 o Child neatly ties laces- above age 6
LTB- larygnotracheobronchitis – edema and inflammation of upper airways, inspiratory stridor and restlessness
Kussmaul respirations assoc. with DKA
Hemophilia is SEX-LINKED- transmitted by mother to son
IVP – intravenous pyleogram o Looks at urinary tract by X-ray
Cytoscopy o Looks at renal pelvis
Lead Poisoning- increase calcium bc it binds to lead and inhibits absorption
Rinne test- tuning fork held on mastoid until no longer heard then moved in front of the auditory canal. Air conduction should be better than bone conduction
Osmitrol used in increased ICP bc it is osmotic diuretic and decreases ICP- UO will increase
Hypothyroidism o Cannot tolerate cold temps o Sensitive to narcotics, barbiturates and anesthetics o Require high fiber high cellulose diet
Cortisol- converts proteins and fats into glucose
Amniocentesis indicates- spinal cord problems, blood problems, lung function
US determines gestational age
Addison’s disease o Muscle weakness, fatigue, dark pigmentation of skin, GI disturbances, and anorexia o Addisonian crisis- restlessness, rapid and weak pulse
Triad of preeclampsia o HTN 6
o Edema o Proteinuria
Eclampsia- blurred vision, oliguria, epigastric pain and HA are signs of seizure
Prolixin (fluphenazine decanoate) used in psychotic disorders, given IM or SQ every 1-6 weeks o Good for pts with poor med compliance
Dilantin – seizure med o SE- reddish-brown urine, constipation; longterm- acne, hirsutism (hairiness), gingival hyperplasia o Interferes with normal vit D metabolism= need supplement or osteomalacia may occur o Overdose/toxicity- ataxia, slurred speech, nystagmus
Hemophiliac- at risk for crippling knee and joint deformities bc repeated bleeding episodes into joints
Granular casts in UA = renal disease
Hydralazine hydrochloride (Apresoline)-direct vasodilator, lowers BP and decreases peripheral resistence
Atenolol (Tenormin)- beta blocker, slows HR and decreases cardiac contractility and CO, lowers BP o Less effective on blacks (also ACEs)
Chlorothiazide (Diuril)- thiazide diuretic, sodium and water excretion, lowers BP o Especially effective in blacks
Nifedipine (Procardia)- CCB, stops calcium from moving into cells, relaxes smooth muscles, causes vasodilation o Especially effective in elderly and blacks
When angle between nail plate and proximal nail fold is straightened to 180 degrees, spongy on palpation= early clubbing= hypoxia
Spoon nails (koilonychias)- iron deficiency anemia
Small pits in nail plate seen in psoriasis 7
Horizontal depressions in nail plate- infection or severe malnutrition
Signs and symptoms of air embolism- restless, complains of difficulty breathing o Place pt on left side in Trendeleberg position and initiate O2 therapy, contact physician o Increases likelihood air will pass into right atrium and dispersed by pulmonary artery
Fainting episode may be due to cardiac arrhythmia
Sign patient is developing shock (could be from burns)- cool, clammy skin, and tachypnea o Body responds to early hypovolemic shock by adregnic stimulation o Vasoconstriction compensates for loss of fluid
Identifying PMI for fetal heart tone o If baby is BREECH (left/right sacrum anterior) it will be at or above the umbilicus
Rapid labor is risk factor for early postpartum hemorrhage and amniotic fluid embolism- labor pattern that progresses quickly ends in less than 3 hours
Hantavirus Pulmonary Syndrome (HPS) caused by rodent droppings o Symptoms- fever, aching, nausea o Can cause severe cardiopulmonary disease o Can cause thrombocytopenia
Observe for hematuria, hematemesis, bleeding gums and melena
Polyarteritis nodosa- inflammation of the small arteries causing diminished blood o 90% remission rate with cortisone
Immunizations o DtaP- 2 months, 4 months, 6 months o Inactivated polio- 2 mo, 4 mo 8
o MMR- 15 months o TB skin testing- 12 months
Pain in lower extremities not relieved by rest= peripheral artery disease o Numbness, burning, skin is dry, scaly, dusky, pale, mottled, cold o Pulses may be weak or absent
Signs of HF- fatigue, SOB, tachycardia, edema, weight gain
Left sided HF o Dyspnea o Orthopnea o Cough o Crackles o Tachycardia o Fatigue o Anxiety o Restlessness
Right sided HF o JVD o Dependent edema o Hepatomegaly o Right upper quandrant tenderness o Ascities o Anorexia o Nausea o Weight gain o Weakness o GI distress
Tx for Heart Failure o Oxygen therapy o Digoxin o Diuretics 9
o Vasodilators o Potassium supplements o Low sodium diet o High fowler’s position
Thiazide diuretics block reabsorption of sodium and increase excretion of water and potassium from body= can lead to hypokalemia
After aortofemoral bypass keep pt in full supine position, bending of hip and knee contraindicated
Digoxin increases the strength of the heart’s contractions by slowing the HR and conduction through AV node o SE- bradycardia, anorexia, N/V, fatigue, dysrhythmias, diaphoresis o S&S of toxicity- N/V, diarrhea, confusion, visual disturbances o Hold med if HR below 60
Nitroglycerin dilates coronary arteries, decreases preload
Lidocaine prevents premature ventricular contractions
Atropine increases heart rate
Dopamine used for hypotension and increases CO and urine output o SE- nausea, tachycardia, angina, dysrhythmias, increased IOP o Headache- early symptom of drug excess
Propanolol (Inderal)- beta blocker used for HTN, dysrhythmias, angina, and MI o SE- bronchospasm, weakness, fatigue, CHF o Blocks signs of hypoglycemia
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