HESI MILESTONE #2 VERSION A AND B LATEST 2023-2024 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |AGRADE/1000 QUIZZES +

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Schizophrenia care-
Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality.

Grief therapeutic response-
Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping strategies to promote a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about significant life experiences.

Delirium care-
Know usual mental status and if changes noted are long-term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important – if untreated, it can lead to permanent, irreversible brain damage and death.

The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOGICAL AND PSYCHOLOGICAL NEEDS.

Ensure patient safety (fall risk) and manage behavioral problems.

Alert the prescriber of nonessential medications.

Nutritional and fluid intake must be monitored.

A quiet and calm environment.

Encourage visitors to touch and talk to patients.

Assess/manage pain.

Alzheimer’s hallucination-
Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol

Alcohol withdrawal-
Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms.

Nursing Plans and Interventions

A. Maintain safety, nutrition, hygiene, and rest.

B. Obtain a BAL on admission or when a client appears intoxicated after admission.

C. Implement suicide precautions if assessment indicates risk.

D. In general

1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide (Librium) or lorazepam

(Ativan)

6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.

Methadone-
Detoxification and maintenance therapy for opioid use disorder.

Suppression of withdrawal symptoms during detox related to opioids such as heroin.

It can cause respiratory depression.

Do not give it to patients with acute or severe bronchial asthma.

It is contraindicated for patients taking MAOIs.

Methadone Overdose:

A). Physical Assessment

-Constricted pupils

• Respiratory depression leading to respiratory arrest

-Circulatory depression leading to cardiac arrest

-Unconsciousness leading to coma

-Death

B). General Appearance

-General physical and mental deterioration

-Rapid tolerance-overdose likely if not monitored.

-Impaired judgment

Aggression response-
The nurse must protect others from these clients’ manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps:

Inform clients of the rule or limits.

Explain the consequences if clients exceed the limit.

State expected behavior.

Nursing Plans and Interventions: Conduct and Defiant Disorders

A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts.

B. Use a nonauthoritarian approach.

C. Avoid asking “why” questions.

D. Initiate a “show of force” with a child who is out of control.

E. Use a “quiet room” when external control is needed.

F. Clarify expressions or jargon if meanings are unclear.

G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag.

H. Implement behavior modification therapy if indicated.

I. Role-play new coping strategies with client.

Duty to warn-
The obligation of a healthcare provider to warn third parties of potential threats or harm aimed at them by another individual.

Schizophrenia- treatment evaluation-
1.) Clients should have decreased agitation, combativeness, and psychomotor activity.
2.) Decreased psychotic behaviors such as decreased hallucinations and delusions.

Anxiety drugs risk-
Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short-term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine use, such as those with panic or generalized anxiety disorder.

I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It’s mentioned both in Realize It and in the HESI prep

ADHD exam-

• Failure to listen/follow direction
• Difficulty playing quietly/sitting still
• Disruptive, impulsive behavior
• Distractibility to external stimuli
• Excessive talking
• Shifting from one unfinished task to another.
• Underachievement in school performance

Obsessive compulsive disorder-Nursing Diagnosis
Nursing Diagnosis

Ineffective Coping

Inability to form a valid appraisal of the stressor

Inadequate choices of practiced responses and/or

Inability to use available resources.

Nursing Assessment

• Recurring, intrusive thoughts and repetitive behaviors that interfere with normal functioning

. Ambivalence regarding decisions or choices

• Disturbances in normal functioning due to obsessive thoughts or compulsive behaviors (loss of job, loss of/or alienation of family members, etc.)
• Inability to tolerate deviations from standards
• Rumination
• Low self-esteem
• Feelings of worthlessness

. Lack of insight

Nursing interventions

A. Actively listen to the client’s obsessive themes.

B. Acknowledge the effects that ritualistic acts have on the client.

C. Demonstrate empathy.

D. Avoid being judgmental.

E. Provide for client’s physical needs.

F. Allow performance of the compulsive activity with attention given to safety (e.g., skin integrity of a hand washer).

G. Explore meaning and purpose of the behavior with client.

H. Avoid punishing and criticizing.

I. Establish routine to avoid anxiety-producing changes.

J. Assist client with learning alternative methods of dealing with stress.

K. Avoid reinforcing compulsive behavior.

L. Limit the amount of time for performance of ritual and encourage client to gradually decrease the time.

M. Administer antianxiety medications as prescribed

N. Administer SSRIs or tricyclic antidepressants as prescribed

Therapeutic communication abuse victim-
-Listen.

-Believe what the person says.

-Empathize: validate the person’s feelings.

-Make it clear that the abuse was wrong and not the victim’s fault.

Suicide Precautions

A. Obtain history.

-A previous suicide attempt is the most significant risk factor. Other risk groups include those with biologic and organic causes of depression, such as substance abuse, organic brain disorders, or other medical problems.

-Clients with a history of a family member’s suicide are at heightened risk for suicide.

B. Be aware of the major warning signs of an impending suicide attempt.

-A client begins giving away the client’s possessions.

• When a previously depressed client becomes happy, he or she may have decided to commit suicide and is no longer debating the possibility. The client may have regained the energy to act on suicidal feelings and has figured out how to accomplish the suicide.

Evaluation of Intent

A. Directly ask the client about intent to harm self. Example: “Have you thought about harming yourself?”

B. Offer the client hope. Example: “We have medication and treatments that can help you through the bad times.”

C. Identify the method chosen; the more lethal the method, the higher the probability that an attempt is imminent. “What is your plan for harming yourself?” Example: A client mentions a shotgun and plans to use the weapon to injure self.

D. Determine the availability of the method chosen. If the method is readily available, the attempt is more likely. Example: The client has a loaded shotgun in the bedroom, so it is readily available.

Appendicitis pre op prep-
The nurse prepares the patient for surgery, which includes

-An IV infusion to replace fluid loss and promote adequate renal function.

-Antibiotic therapy to prevent infection.

-Administration of analgesic agents for pain.

-An enema is not given because it can lead to perforation.

Anorexia Report Findings-
A. Weight loss of at least 15% of ideal or original body weight
B. Excessive exercise
C. Apathy about physical condition and inordinate pleasure in weight loss
D. Skeletal appearance (usually hidden by baggy clothes)
E. Distorted body image (usually sees self as fat)
F. Low self-esteem
G. Hair loss and dry skin
H. Irregular heartbeat, decreased pulse, and BP resulting from decreased fluid volume
I. Delayed psychosexual development (adolescents) or disinterest in sex (adults)
J. Dehydration and electrolyte imbalance (decreased potassium, sodium, and chloride) resulting from

1. Diet pill abuse
2. Enema and laxative abuse
3. Diuretic abuse
4. Self-induced vomiting

Complication HTN high risk-
A. BP equal to or greater than 140/90 mm Hg on two separate occasions

-Obtain BP while client is lying down, sitting, and standing.

-Compare readings taken lying down, sitting, and standing. A difference of more than 10 mm Hg of either systolic or diastolic indicates postural hypotension. Take pressure on both arms.

B. Genetic risk factors (nonmodifiable)

-Positive family history for HTN

-Gender (Men have a greater risk for being hypertensive at an earlier age than women.)

-Age (Risk increases with increasing age.)

-Ethnicity (African Americans are at greater risk than Whites.)

C. Lifestyle and habits that increase risk for becoming hypertensive (modifiable)

-Use of alcohol, tobacco, and caffeine

-Sedentary lifestyle, obesity

-Nutrition history of high salt and fat intake

-Use of oral contraceptives or estrogens

-Stress

D. Associated physical problems

-Renal failure

-Impaired renal function

-Respiratory problems, especially COPD

-Cardiac problems, especially valvular disorders

-Dyslipidemia

-Diabetes

E. Pharmacologic history

-Steroids (increase BP)

-Estrogens (increase BP)

F. Assess for headache, edema, nocturia, nosebleeds, and vision changes (may be asymptomatic).

G. Assess stress level and source (related to job, economics, family).

H. Assess personality type (i.e., determine whether client exhibits perfectionist behavior).

HESI Hint

Remember the risk factors for HTN: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives.

Hypothyroidism-

1. Action is to increase metabolic rates
2. Levothyroxine (Synthroid) T4
3. Adverse Reactions

a. Anxiety

b. Insomnia

c. Tremors

d. Tachycardia

e. Palpitations

f. Angina

g. Dysrhythmias

4. Nursing Implications

a. Give in the early morning before meals.

b. Check serum hormone levels routinely.

c. Check BP and pulse regularly.

d. Weigh daily.

e. Report side effects to the health care provider.

f. Avoid foods and products containing iodine.

g. Initiate cautiously in clients with cardiovascular disease.

5. Advanced hypothyroidism – Inadequate ventilation and sleep apnea can occur with severe hypothyroidism; pleural effusion, pericardial effusion, and resp muscle weakness may also occur.
6. Myxedema coma – pt initially shows signs of depression, diminished cognitive status, lethargy, somnolence

a. ICU admission with IV levothyroxine

b. Watch CV/Lungs

Diverticulosis signs and symptoms-
Description:

Diverticulosis: bulging pouches in the GI wall (diverticula), which push the mucosa lining through the surrounding muscle.

Nursing Assessment S/S

A. Left lower quadrant pain

B. Increased flatus

C. Rectal bleeding

D. Signs of intestinal obstruction

-Constipation alternating with diarrhea

-Abdominal distention

-Anorexia

-Low-grade fever

E. Barium enema or colonoscopy positive for diverticular disease: obstruction, ileus, or perforation confirmed by abdominal radiograph (barium not used during the acute phase of illness)

DM poor compliance-
-To detect poor DM compliance, the patient may use a urine dipstick (Ketostix or Chemstrip UK) to detect ketonuria.

-If the reagent pad on the strip turns purple, it means ketones are present; it shows unmanaged diabetes or a lack of control over DM.

DKA: a complication of type 1 diabetes:

-serum glucose >250,

-ketonuria in large amounts.

HF symptoms-

1. Left-sided HF: pulmonary edema (left ventricular failure)
   a. Description: Results in pulmonary congestion due to the inability of the left ventricle to pump blood to the periphery
   b. Symptoms
   i. Dyspnea
   ii. Orthopnea
   iii. Crackles
   iv. Cough
   v. Fatigue
   vi. Tachycardia
   vii. Anxiety
   viii. Restlessness
   ix. Confusion
   x. Paroxysmal nocturnal dyspnea
2. Right-sided HF: Peripheral edema (right ventricular failure)
   a. Description: Results in peripheral congestion due to the inability of the right ventricle to pump blood out to the lungs; often results from left-sided failure or pulmonary disease
   b. Symptoms
   i. Peripheral edema
   ii. Weight gain
   iii. Distended neck veins (JVD)
   iv. Anorexia, nausea
   v. Nocturia
   vi. Weakness
   vii. Hepatomegaly
   i. Ascites

Small bowel obstruction actions-
Nursing interventions:

1. Maintain client NPO, with IV fluids and electrolyte therapy.
2. Monitor I&O; a Foley catheter maintains strict output.
3. Implement NG intubation.
   -Attach to low suction (intermittent; 80 mm Hg).
   -Document output every 8 hours.
   -Irrigate with normal saline if policy dictates.
   NG tube (passed through the nose into the stomach; Miller-Abbott tube is used for
   decompression; it is passed through the nose and the stomach into the small intestines then connected to suction) placement is usually performed by the health care provider.
4. NG tube
   a. Measure correct length of tubing to be inserted by measuring from the tip of the client’s nose to the client’s earlobe to the xiphoid process.
   b. Advance decompression tube every 1 to 2 hours.
   c. Do not secure to nose until tube reaches specified position.
   d. Reposition the client every 2 hours to assist with placement of the tube.
   e. Connect tube to suction.
   f. Irrigate NG tube with normal saline; irrigate Miller-Abbott tube with air only.
   g. Note amount, color, consistency, and any unusual odor of drainage.
   h. Assess for signs of dehydration (skin turgor, amount and color of urine).
   i. Monitor electrolyte values.
5. Document pain; medicate as prescribed.
6. Assess abdomen regularly for distention, rigidity, and change in status of bowel sounds.
7. If conservative medical interventions fail, surgery will be required to remove obstruction.

Pneumonia action-
A. Assess sputum for volume, color, consistency, clarity, and distinct odors like Pseudomonas.
B. Assist client to cough productively by

1. Deep breathing every 2 hours (may use incentive spirometer)
2. Using humidity to loosen secretions (may be oxygenated)
3. Suctioning the airway, if necessary
4. Chest physiotherapy
   C. Provide fluids up to 3 L/day unless contraindicated (helps liquefy lung secretions).
   D. Assess lung sounds before and after coughing.
   E. Keep client sitting up

• PCV13: >65, >19 with conditions that weaken immune system
• PPSV23: >65, 19-64 year olds who smoke/have asthma

COPD oxygen flow rate –
Administer O2 at 1 to 2 L per nasal cannula.

Diverticulitis NPO-
-Withhold oral intake,
-Administer IV fluids, and
-If vomiting or distended, institute nasogastric (NG) suctioning.
-These are used to rest the bowel.

Provide a well-balanced, high-fiber diet unless inflammation (diverticulitis) is present, in which case the client is NPO, followed by low-residue bland foods.

HF digoxin-
Digoxin produces a cardiotonic (positive inotropic) effect that improves the contractility and pumping ability of the heart. Can be effective in decreasing the symptoms of systolic HF and may help prevent hospitalization.

WATCH THERAPEUTIC LEVELS (0.8-2).

Signs of Toxicity can include anorexia, nausea, visual disturbances, bradycardia, and acute confusion, potentially life-threatening heart rhythm disturbances, ranging from slow to a rapid ventricular rhythm.

Premature ventricular contractions (PVCs) commonly occur with digoxin toxicity and are usually perceived as “skipped” heartbeats by patients. The nurse assesses the apical pulse at the point of maximal impulse for one full minute. If the rate is less than 60 beats/min in adults, 70 beats/min in older children, or 100 beats/min in younger children, the nurse does not give the drug and notifies the health care provider.

IV fluids hypertonic-
Hypertonic solutions pull water from the interstitial and intracellular compartments into the bloodstream. These solutions draw water out of intracellular compartments, causing cellular dehydration. Hypertonic solutions should be administered into central veins so that they can be diluted by large amounts of rapid blood flow.

Used to treat intravascular dehydration with cellular or interstitial overhydration.

Examples: dehydration resulting from surgery; blood loss causes intravascular dehydration, but the tissue cuts inflame and pull fluid into the area, causing interstitial overhydration; may also be seen with ascites and third-spacing.

Hypertonic solutions

a. 5% dextrose in lactated Ringer’s (D5LR)

b. 5% dextrose in 0.45% saline

c. 5% dextrose in 0.9% saline (D5NS)

d. 3% Na

e. 5% NaCl

f. 10% dextrose in water (D10W)

g. 20% Dextrose in water (20W) acts as osmotic diuretic

h. 50% Dextrose in water (50% DW)

Rheumatoid arthritis diagnosis-
A doctor will use blood tests, X-rays, and ultrasound to determine if you have RA.

The goal of treatment at all phases of the RA disease process is to

-Decrease joint pain and swelling,

-Achieve clinical remission,

-Decrease the likelihood of joint deformity,

-Minimize disability.

Initial treatment delays have been implicated in greater long-term joint deformity. Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic Disease-Modifying Antirheumatic Drug (DMARD). The goal of using DMARD therapy is to prevent inflammation and joint damage.

Implement pain relief measures.

1. Use moist heat.

A. Warm, moist compresses (Realize It says alternate cold and hot)

B. Whirlpool baths

C. Hot shower in the morning

2. Use diversionary activities.

A. Imaging

B. Distraction

C. Self-hypnosis

D. Biofeedback

3. Administer medications and teach the client about medications (NSAIDs)
4. Methotrexate

PUD NGT-
During surgery and postoperatively, the stomach contents are drained using an NG tube. The nurse monitors fluid and electrolyte balance and assesses the patient for localized infection or peritonitis (increased temperature, abdominal pain, paralytic ileus, increased or absent bowel sounds, abdominal distention).

Confirmation that obstruction is the cause of the discomfort is accomplished by assessing the amount of fluid aspirated from the NG tube. A residual of more than 400 mL suggests obstruction.

Prostatic hyperplasia-
Benign prostatic hyperplasia (BPH)—also called prostate gland enlargement—is a common condition as men get older. An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking urine flow out of the bladder. It can also cause bladder, urinary tract, or kidney problems.

Treatments: There are three treatment approaches:

1. Active surveillance (watchful waiting),
2. Drug therapy with 5-alpha-reductase inhibitors such as finasteride (Proscar) and alpha-adrenergic receptor blockers (tamsulosin), or
3. Surgery.

The most common treatment is transurethral resection of the prostate gland (TURP). The prostate is removed by endoscopy (no surgical incision), allowing for a shorter hospital stay.

Symptoms:

A. Increased frequency of voiding, with a decrease in the amount of each void

B. Nocturia

C. Hesitancy

D. Terminal dribbling

E. Decrease in size and force of the stream

F. Acute urinary retention

G. Bladder distention

H. Recurrent UTIs

Risk factors-

Smoking, obesity, heavy alcohol consumption, HTN, diabetes, inactivity, western diet.

Type I DM tight control-
Tight glucose control refers to getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 70 and 130 mg/dL before meals, and less than 180 mg/dL 2 hours after a meal, with a glycated hemoglobin A1C level less than 7 percent.

COPD treatment –
Bronchodilator (1st line); corticosteroids, antibiotics, oxygen, and intensive respiratory interventions.

Inflammatory Bowel Disease (IBD) peritonitis-
Secondary peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a result of inflammation, infection, ischemia, trauma, or tumor perforation.
Symptoms
a. Tenderness
b. Distension
c. Rigidity
d. Anorexia
e. N/V
f. Fever

Asthma triggers –
Airway irritants (air pollutants, occupational exposure); Food (shellfish, nut); hormonal factors; medications; viral respiratory tract infections.
A. Infections like sinusitis, colds, and the flu.
B. Allergens such as pollens, mold, pet dander, and dust mites.
C. Cockroaches
D. Irritants like strong odors from perfumes or cleaning solutions
E. Air pollution
F. Tobacco smoke
G. Exercise
H. Cold air or changes in the weather, such as temperature or humidity.
I. Gastroesophageal reflux disease (GERD)
J. Strong emotions such as anxiety, laughter, sadness, or stress

Ulcerative colitis symptoms-
The predominant symptoms of ulcerative colitis include diarrhea, with the passage of mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus. The bleeding may be mild or severe, and pallor, anemia, and fatigue result. The patient may have anorexia, weight loss, fever, vomiting, dehydration, cramping, and the passage of six or more liquid stools daily.

Nursing Assessment

A. Diarrhea

B. Abdominal pain and cramping

C. Intermittent tenesmus (anal contractions) and rectal bleeding

D. Liquid stools containing blood, mucus, and pus (may pass 10 to 20 liquid stools per day)

E. Weakness and fatigue

F. Anemia

(I don’t see how this question can be anything other than the fact that UC has bloody diarrhea associated with it)

Arterial insufficiency diabetic –
Diabetes affects the lining around cells in the blood vessels. Blood vessels are not as flexible as needed to help blood flow smoothly. PAD happens when buildup on the walls of blood vessels causes narrowing, commonly affecting diabetics prone to hyperlipidemia and heart disease.
Nursing Interventions
A. Monitor extremities at designated intervals.

1. Color
2. Temperature
3. Sensation and pulse quality in extremities
   B. Schedule activities within the client’s tolerance level.
   C. Encourage rest at the first sign of pain.
   D. Encourage the client to keep extremities elevated (if venous) when sitting and to change position often.
   E. Encourage client to avoid crossing legs and to wear nonrestrictive clothing.
   F. Encourage client to keep the extremities warm by wearing extra clothing, such as socks and slippers, and not to use external heat sources such as electric heating pads.
   G. Teach methods of preventing further injury.
4. Change position frequently.
5. Wear nonrestrictive clothing (no knee-high hose).
6. Avoid crossing legs or keeping legs in a dependent position.
7. Wear support hose or antiembolism stockings.
8. Wear shoes when ambulating.
9. Obtain proper foot and nail care.
10. Discourage cigarette smoking

GERD instructions-
Management begins with educating the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. Lifestyle modifications include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet.
Determine an eating pattern that alleviates symptoms.

1. Encourage small, frequent meals.
2. Encourage elimination of foods that are determined to aggravate symptoms (these foods are client specific but can include caffeine, ketchup, strawberries, and chocolate).
3. Encourage the client to sit up and remain upright for at least 1 hour after eating.
4. Encourage the client to stop eating 3 hours before bedtime.
5. Elevate the head of the bed on 6- to 8-inch blocks.
6. Teach about commonly prescribed medications (H2 antagonists, antacids).

Pre op labs -Which is abnormal
The standard thing you are worried about with surgery is infection.

Elevated WBC

5000–10000

UA showing nitrites or leukocytes

PT/PTT(checking for the possibility of forming blood clots)

60-70 seconds

HgB

Women 12-15.5

Men 13.5-17.5

HCT

Women 35-49

Men 39-50

Seizure unconscious client-
A. Maintain airway during seizure: Turn client on side to aid ventilation.

B. Do not restrain client.

C. Protect client from injury during seizure and support head (avoid neck flexion).

D. Document seizure, noting all data in assessment.

E. Maintain seizure precautions.

1. Reduce environmental stimuli as much as possible.
2. Pad side rails or crib rails.
3. Have suction equipment and oxygen quickly accessible; set up at the bedside/crib side. Tape oral airway to the head of the bed.

F. Support during diagnostic tests: electroencephalogram (EEG), computed tomography (CT) scan

G. Support during workup for infections such as meningitis

H. Administer anticonvulsant medications as prescribed

1. For tonic-clonic seizures: phenytoin, carbamazepine, phenobarbital, and fosphenytoin
2. For absence seizures: ethosuximide, valproic acid

I. Monitor therapeutic drug levels.

J. Teach family about drug administration: dosage, action, and side effects.

HESI Hint

Do not use tongue blade, padded or not, during a seizure. It can cause traumatic damage to the oral cavity.

Uroliathiasis lithotripsy-
Lithotripsy treats kidney stones by sending focused ultrasonic energy or shock waves directly to the stone, first located with fluoroscopy (a type of X-ray “movie”) or ultrasound (high-frequency sound waves). The shock waves break a large stone into smaller stones that will pass through the urinary system. Extracorporeal Shock Wave Lithotripsy (ESWL).

Electrohydraulic lithotripsy is a similar method in which an electrical discharge creates a hydraulic shock wave to break up the stone. A probe is passed through the cystoscope, and the tip of the lithotriptor is placed near the stone. The strength of the discharge and pulse frequency can be varied. This procedure is performed under topical anesthesia. After the stone is extracted, the percutaneous nephrostomy tube is left in place for a time to ensure that the ureter is not obstructed by edema or blood clots. The most common complications are hemorrhage, infection, and urinary extravasation. After the tube is removed, the nephrostomy tract usually closes spontaneously.

General anesthesia – post anesthesia care –
A). Frequent assessment
-ABC
-Surgical site integrity
-N/V
-Neurological status
-Spontaneous voiding
B). Monitor for complications.
C). Manage pain
D). Focus on items that will increase patient independence.

Assess pt: frequent, basic assessment (airway, LOC, cardiac, respiratory, wound, pain), check tubes and monitoring lines, IV fluids and meds, VS every 5 or 15 minutes
Maintain Patent Airway: prevent hypoxemia and hypercapnia from hypoventilation. Prolonged anesthesia=unconscious with all muscles relaxed. Hypopharyngeal obstruction=supine with lower jaw and tongue obstructing the airway.
Maintain Cardiovascular Stability: assess LOC, VS, rhythm, skin temp, color and moisture, and urine output. Primary complications: hypotension and shock, hemorrhage, HTN, and arrhythmias.
HYPOTENSION: blood loss, hyperventilation, position change, pooling of blood in extremities, and side effects of anesthetics and meds.
HYPOVOLEMIC most common: hemorrhage from surgical site. Signs: pallor; cool, moist skin; rapid breathing; cyanosis; rapid, weak, thready pulse; narrowing pulse pressure; low BP; concentrated urine.

Thrombocytopenia labs –
A. CBC

-Platelet count (low) (less than 100,000)

B. PT/PTT

-Coagulation tests (60-70 secs)

HgB Women 12-15.5

Men 13.5 – 17.5

HCT Women 35-49

Men 39-50

● Excessive bruising, bleeding, and petechiae are seen with platelets below 20,000.

● Spontaneous and potentially fatal CNS or GI hemorrhage are seen when the platelet count is less than 5000.

● Treat with steroids and platelets (when life-threatening).

● Platelet count less than 15,000 platelets per microliter lower than normal; if your

platelet count falls below normal, you may have thrombocytopenia

● Risk for serious bleeding doesn’t occur until the count becomes very low – less than

10,000 or 20,000 platelets

Asthma-leukotriene inhibitors –
Leukotriene inhibitors are potent bronchoconstrictors that also dilate blood vessels and altar permeability.

Action: Leukotrienes exert their action by interfering with leukotriene synthesis or by blocking receptors.

Alternative treatment to inhaled corticosteroids for mild persistent asthma or added to inhaled corticosteroids for severe asthma.

Singular (Montelukast).

Accolate (Zarfirlukast).

Zyflo (Zileuton).

Asthma Inhaler-
Metered dose inhalers (MDI):

Short-acting beta-2-adrenergic agonists (SABAs) (e.g., albuterol, levalbuterol, pirbuterol) are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They are used to relax smooth muscles.

Anticholinergics (e.g., ipratropium): These may be used in patients who do not tolerate short-acting beta-2-adrenergic agonists.

Long-acting control- Corticosteroids are the most potent and effective anti-inflammatory medications currently available.

Transfusion action –
Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, given at a slow rate.
Assess the patient carefully. Compare the vital signs with baseline, including oxygen saturation. Assess the patient’s respiratory status carefully. Note the presence of adventitious breath sounds; the use of accessory muscles; extent of dyspnea; and changes in mental status, including anxiety and confusion. Note any chills, diaphoresis, jugular vein distention, and reports of back pain or urticaria.
Notify the primary provider of the assessment findings, and implement any treatments prescribed. Continue to monitor the patient’s vital signs and respiratory, cardiovascular, and renal status.
Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture. The patient’s identity and blood component identifying tags and numbers are verified.

Sickle cell signs of crisis-
Vasoocclusive crisis; the classic signs include the following: (FAHS)

1. F-Fever.
2. A-Arthralgia
3. H-Hand-foot syndrome (infants); painful edematous hands and feet.
4. S-Severe abdominal pain.
   Sudden pain, chest pain, shortness of breath, nausea, vomiting, and unusual headaches.

Infant Congenital Heart Defect – assessment –
A). Manifestations of CHD

1. Murmur (present or absent; thrill or rub)
2. Cyanosis, clubbing of digits (usually after age 2)
3. Poor feeding, poor weight gain, failure to thrive
4. Frequent regurgitation
5. Frequent respiratory infections
6. Activity intolerance, fatigue

B). The following are assessed:

1. Heart rate, rhythm, and heart sounds
2. Respiratory status/difficulty
3. Pulses (quality and symmetry)
4. Blood pressure (upper and lower).

-First sign: Feeding difficulties; tires easily.

Lab and Diagnostic tests:

-Echocardiography (use of structure and motion of heart),

-Electrocardiogram (EKG)- indicating R ventricle hypertrophy

-Cardiac catheterization and angiography- reveal the extent of structural defects

-Increased HCT, HGB, and RBC indicate polycythemia

Respiratory Syncytial Virus (RSV) distress-
Fast belly breathing,

grunting,

wheezing,

flaring nostrils,

retraction,

fever,

cyanosis,

lethargy.

Nursing Assessment

A. History of upper respiratory symptoms

B. Irritable, distressed infant

C. Paroxysmal coughing

D. Poor eating

E. Nasal congestion

F. Nasal flaring

G. Prolonged expiratory phase of respiration

H. Wheezing, rales can be auscultated

I. Deteriorating condition that is often indicated by shallow, rapid respirations

Nursing Plans and Interventions

A. Isolate child (isolation of choice for RSV is contact isolation).

B. Assign nurses to clients with RSV who have no responsibility for other children to prevent virus transmission.

C. Monitor respiratory status; observe for hypoxia.

D. Clear airway of secretions using a bulb syringe for suctioning.

E. Provide care in mist tent; administer oxygen as prescribed.

F. Maintain hydration (oral and IV fluids).

G. Evaluate response to respiratory therapy treatments.

H. Administer palivizumab to provide passive immunity against RSV in high-risk children (younger than 2 years of age with a history of prematurity, lung disease, or congenital heart disease [CHD]).

HESI Hint

Severe cases of RSV may have to be treated with ribavirin. Ribavirin is a Pregnancy Category X medication; pregnant mothers of children receiving ribavirin inhalation therapy and nurses who may be pregnant should not be exposed to the ribavirin aerosol.

Pyloric stenosis symptoms –
A. Usually occurs in first-born males.
B. Vomiting (free of bile) usually begins around the third to sixth week of life (rarely seen in children over three years old). Projectile vomiting occurs within minutes after eating.
C. Hungry, fretful infant.
D. Weight loss, failure to gain weight.
E. Dehydration with decreased sodium and potassium.
F. Metabolic alkalosis (decreased serum chloride, increased pH, and bicarbonate or CO2 content).
G. Palpable olive-shaped mass in the upper-right quadrant of the abdomen.
H. Visible peristaltic waves.

Intussusception –
Telescoping of one part of the intestine into another, usually the ileum, into the colon (called ileocolic). It is the most common cause of bowel obstruction in children under three.

A. Partial to complete bowel obstruction occurs.

B. Blood vessels become trapped in the telescoping bowel, causing necrosis.

Nursing Assessment

A. Acute, intermittent abdominal pain

B. Screaming, with legs drawn up to the abdomen

C. Vomiting

D. “Currant jelly” stools (mixed with blood and mucus)

E. Sausage-shaped mass in the upper right quadrant and lower-right quadrant is empty

Nursing Plans and Interventions

A. Monitor carefully for shock and bowel perforation.

B. Administer IV fluids as prescribed.

C. Monitor I&O.

D. Prepare family for emergency intervention.

E. Prepare child for barium enema (which provides hydrostatic reduction). Two of three cases respond to this treatment; if not, surgery is necessary.

F. Provide postoperative care for clients who require abdominal surgery.

Placenta abruption-
Placental abruption is the early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage. Abruption occurs when the maternal vessels tear away from the placenta and bleeding occurs between the uterine lining and the maternal side of the placenta.

Treatment of placental abruption is designed to assess, control, and restore the amount of blood lost.

When the woman arrives at the facility, place her on strict bed rest and in a left lateral position to prevent pressure on the vena cava. This position provides uninterrupted perfusion to the fetus.

Nursing Assessment

A. Bleeding: concealed or overt (if overt, is dark red)

B. Uterine tenderness

C. Persistent abdominal pain

D. Rigid, boardlike abdomen

E. FHR abnormalities

First action: massage the uterus.

Expect to administer oxygen therapy via nasal cannula to ensure adequate tissue perfusion. Monitor oxygen saturation levels via pulse oximetry to evaluate the effectiveness of interventions.

Fetal heart rates tachycardia-
Fetal tachycardia is defined as a heart rate of more than 160–180 bpm. It can be intermittent or sustained. It can indicate infection or hypoxemia.

1. Baseline FHR is above 160 bpm (assessed between contractions) for 10 minutes
2. Causes

a. Early sign of fetal hypoxia

b. Fetal anemia

c. Dehydration

d. Maternal infection, maternal fever

e. Maternal hyperthyroid disease

f. Medication-induced (atropine, terbutaline, hydroxyzine)

Nursing actions

1. Immediately turn client onto left side (change position of mom)
2. Discontinue oxytocin (Pitocin) if infusing.
3. Administer O2 at 10 L by tight facemask.
4. Maintain intravenous (IV) line
5. Notify health care provider.
6. Document pattern and response to each nursing action.

Prolapsed Cord Care-Obstetrical emergencies-
Umbilical cord prolapse is a rare obstetric emergency occurring when the cord precedes the fetus.

Risk factors include multiparity, non-cephalic presentations, long length of cord, preterm labor, low birth weight, multifetal pregnancy, and placement of a cervical ripening balloon.

HESI Hint

If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (i.e., knee-chest position) OR push the presenting part off the cord until immediate cesarean delivery can be accomplished.

Shoulder dystocia-
Shoulder dystocia is defined as the obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered. Shoulder dystocia is a fundamentally mechanical problem. Maneuvers to relieve shoulder dystocia.

A.) McRoberts maneuver. The mother’s thighs are flexed and abducted as much as possible to straighten the pelvic curve.

B.) Suprapubic pressure. Light pressure is applied just above the pubic bone, pushing the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis. The newborn’s head is depressed toward the mother’s anus while light suprapubic pressure is applied.

Nursing management of a woman with dystocia requires patience, regardless of the etiology. The nurse should provide physical and emotional support to the client and her family.

Fetal heart rate patterns – deceleration-
A deceleration is a transient fall in FHR caused by stimulation of the parasympathetic nervous system. Decelerations are described by their shape and association to a uterine contraction. They are classified as early, late, and variable only.
Nursing actions for variable decelerations

1. Change maternal position.
2. Stimulate fetus if indicated.
3. Discontinue oxytocin (Pitocin) if infusing.
4. Administer oxygen (O2) at 10 L by tight facemask.
5. Perform a vaginal examination to check for cord prolapse.
6. Report findings to physician and document.

Post-partum hemorrhage-
This is a potentially life-threatening complication that can occur after both vaginal and cesarean births. It is the leading cause of maternal death in both developed and developing countries. PPH is defined as a cumulative blood loss greater than 1,000 mL with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery.

Excessive bleeding can occur at any time between the separation of the placenta and its expulsion or removal.

The most common cause of PPH is uterine atony, failure of the uterus to contract and retract after birth.

Tone: uterine atony, distended bladder.

Tissue: retained placenta and clots; uterine subinvolution.

Trauma: lacerations, hematoma, inversion, rupture.

Thrombin: coagulopathy (preexisting or acquired)

Traction: too much pulling on umbilical cord.

When excessive bleeding is encountered, initial management steps are aimed at

1). Improving uterine tone with immediate fundal massage,

2). Intravenous fluid resuscitation, and

3). Administration of uterotonic medications.

Vomiting and diarrhea- infant –
Vomiting:

If it occurs several hours after feeding = delayed gastric emptying;

If it occurs at the middle of the night or upon waking = intracranial lesion;

If it is effortless = GERD;

If it is projectile vomiting = Pyloric stenosis

Nurse Management:

Note hydration and mental status changes, auscultate bowel sounds and palpate abdomen. Give 0.5-2 oz of oral rehydration solution every 15 minutes.

Diarrhea:

Causes of intractable diarrhea of infants:

• Milk/soy protein intolerance;
• Infectious enteritis;
• Hirschsprung disease;
• Nutrient malabsorption.

Nurse Management:

Restore fluid/electrolyte balance and provide family education.

IUGR ultrasound-
Intrauterine growth restriction (IUGR) refers to the poor growth of a baby while in the mother’s womb during pregnancy.

The ultrasound helps diagnose IUGR by estimating weight, amount of amniotic fluid, and mothers blood pressure status. Performed at 19 weeks of gestation.

Review question from HESI book:

Q: Is one ultrasound examination useful in determining the presence of IUGR?

A: No. Serial measurements are needed to determine IUGR.

Engorgement-
Engorgement is a postnatal physiologic painful condition in which distention and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours. If milk is not removed as it is formed, the alveolar space can become overdistended, causing tender, swollen, and painful breasts. Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours.

Nursing Intervention:

For breast feeding mothers:

• Encourage frequent breastfeeding every 2-3 hours should decrease the engorgement.
• To prevent engorgement, mother should use breast pump or express milk by hand to remove milk remaining after infant is done eating
• To prevent engorgement, begin breastfeeding as soon as possible

For bottle feeding:

• Encourage the woman to apply warm compress or ice packs,
• To wear a snug supportive bra 24 hours a day,
• To take mild analgesics such as acetaminophen.
• Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts.

Cystic fibrosis complications-
S/S: Chronic respiratory failure, diabetes, coughing up blood, lung infection, bowel problems such as gallstones, intestinal blockage, and rectal prolapse, malnutrition, infertility.

• Teach family percussion and postural-drainage techniques.
• Teach dietary recommendations: high in calories, high in protein, moderate to high in fat (more calories per volume), and moderate to low in carbohydrates (to avoid an increase in carbon dioxide [CO2] drive).

HESI Hint

-A child needs 150% of the usual calorie intake for normal growth and development.

-Patients with cystic fibrosis are highly susceptible to infections as well.

-Steatorrhea – abnormal, foul-smelling, bulky stools with fat in them.

Rhogam-refusal
Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process. The usual protocol for the Rh-negative woman is to receive two doses of RhoGAM, one at 28 weeks’ gestation and the second dose within 72 hours after childbirth.

24-hour jaundice-
Pathological jaundice is the most serious type and occurs within 24 hours after birth. It’s characterized by a rapid rise in a baby’s bilirubin level. The most likely cause is blood incompatibility or liver disease.

Hyperbilirubinemia – pathological if within the first 24 hours

12-15 need phototherapy

1. Evaluate for Rh isoimmunization and for ABO incompatibility.
2. Bilirubin (by product of RBC destruction) binds to protein for excretion or metabolism.
3. Promote stooling by early feedings of milk (protein binds bilirubin for excretion).
4. Assess at birth and daily for presence of jaundice.

a. Yellowish skin color, sclera, and mucous membranes

b. Proceeds cephalocaudally (relationship between the head and the base of the spine)

5. Give adequate fluids.
6. Monitor bilirubin levels.
7. Assist with phototherapy if needed.

HESI Hint

NCLEX-RN questions ask about the normal problem of physiologic jaundice, which occurs 2 to 3 days after birth due to the immature liver’s normal inability to keep up with RBC destruction and to bind bilirubin. Remember that unconjugated bilirubin is the culprit.

Hemophilia safety-
Avoid contact sports. Exercise regularly with activities such as swimming, bike riding, and walking.

Teach child and family home care.

1. Teach to recognize early signs of bleeding into joints.
2. Teach local treatment for minor bleeds (pressure, splinting, ice).
3. Teach administration of factor replacement (clients receiving routine treatments of the clotting factors usually have a Port-a-cath).
4. Discuss dental hygiene: Use soft toothbrushes.
5. Provide protective care: Give child soft toys; use padded bed rails.
6. Have child wear medical alert identification.

Tetralogy of fallot complications –
4 heart defects: (PORV)

1). P-Pulmonary stenosis,

2). O-Overriding aorta

3). R-Right ventricular hypertrophy

4). V-Ventricular septal defect (VSD)

Blood flow from R ventricle is obstructed and slowed causing a decrease blood flow to lungs for oxygenation and decrease in oxygenated blood flow returning to L atrium from lungs. The obstructed blood flow increases pressure to the R ventricle. A mix of oxygenated and poorly oxygenated blood is pumped into systemic circulation causing oxygen saturation in blood to be reduced leading to cyanosis.

Major complications: (HIDAB)

1. H-Heart failure
2. I-Infection in the lining of the heart and heart valves (bacterial endocarditis)
3. D-Death
4. A-Abnormal heart rhythms (arrhythmias)
5. B-Blood clots (which may be in the brain causing stroke)

Nurse Management

The child experiences “tet” spells, or hypoxic episodes; they are relieved by the child’s squatting or being placed in the knee-chest position.

Type I DM- Hyperglycemia-
Type 1, which is caused by a deficiency of insulin secretion due to pancreatic β-cell damage. Type 1 DM is an autoimmune disorder that occurs in genetically susceptible individuals who may also be exposed to one of several environmental or acquired factors, such as chemicals, viruses, or other toxic agents implicated in the development process. The end result is hyperglycemia, glucose accumulation in the blood, and the body’s inability to use its main source of fuel efficiently. The kidneys try to lower blood glucose, resulting in glycosuria and polyuria, and protein and fat are broken down for energy. The metabolism of fat leads to a buildup of ketones and acidosis.

Diabetes- fetal risk-
Infants of diabetic mothers are at risk for malformations most frequently involving the cardiovascular, skeletal, central nervous, gastrointestinal, and genitourinary systems; cardiac anomalies are the most common.

IDMs remain at risk for a multitude of physiologic, metabolic, and congenital complications such as preterm birth, macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, hypertrophic cardiomyopathy, and congenital anomalies, particularly of the central nervous system. Overt type 1 diabetes around conception produces marked risk of neural tube defects, cardiac defects, and caudal regression syndrome; later in gestation, severe and unstable type 1 maternal diabetes carries a higher risk of intrauterine growth restriction, asphyxia, and fetal death.

Postpartum blues-
The woman typically experiences rapid-cycling mood symptoms during the first postpartum week. She will exhibit mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, despondency, feelings of being overwhelmed, difficulty thinking clearly, insomnia, loss of appetite, and fatigue.

Emotional lability is the most prominent symptom of maternity blues. The “blues” typically peak on postpartum days 4 and 5 and usually resolve by postpartum day 10. Baby blues are usually self-limiting and require no formal treatment other than reassurance and validation of the woman’s experience and assistance in caring for herself and the newborn.

Late decelerations-
Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. They have a gradual waveform and can be recurrent, occurring with each contraction over a period of time. The FHR does not return to baseline levels until after the contraction ends.

Delayed timing of the deceleration occurs with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression exists.

Meconium stain- decreased FHR-
If the amniotic fluid is meconium stained (green) the baby may have breathing problems or a slow heart rate (bradycardia).

Pitocin contraindications
Pitocin is contraindicated in nonvaginal births and hypersensitivity, high blood pressure, placenta previa, a pregnancy with more than one fetus (twins), previous c-section, grand multiparty (twins, triplet etc), malposition or malpresentation of fetus, and fetal distress.

Postpartum bleeding- action-
Assess lochia in terms of amount, color, odor, and change with activity and time. To assess how much a woman is bleeding, ask her how many perineal pads she has used in the past 1 to 2 hours and how much drainage was on each pad. For example, did she saturate the pad completely, or was only half of the pad covered with drainage? Ask about the color of the drainage, odor, and the presence of any clots. Lochia has a definite musky scent, with an odor similar to that of menstrual flow without any large clots (fist size). Foul-smelling lochia suggests an infection, and large clots suggest poor uterine involution, necessitating additional intervention.

Postpartum depression- action-
-Nursing management focuses on assisting any postpartum woman in coping with the changes of this period.
-Encourage the client to verbalize what she is going through and emphasize the importance of keeping her expectations realistic.
-Assist the woman in structuring her day to regain a sense of control over the situation.
-Encourage her to seek professional help if necessary, using available support systems.
-Also reinforce the need for good nutrition and adequate exercise and sleep.

Chronic Kidney Disease & metabolic acidosis
CKD creates metabolic acidosis especially when in ESRD or on dialysis. Decreased bicarb level.

ABGs –
Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg and a compensatory increase in the plasma HCO3 occurs. It may be either acute or chronic.

pH- 7.35-7.45
PaCO2- 35-45
HCO3- 22-26

Pulmonary edema-first action
Pulmonary edema is defined as abnormal accumulation of fluid in the lung tissue, the alveolar space, or both. It is a severe, life-threatening condition.

First sit the patient up with legs dangling over the side of the bed.

Apply oxygen via NRB.

Rhythm Strip Analysis-
Ventricular and atrial rate: 60 to 100 bpm in the adult.
Ventricular and atrial rhythm: Regular.
QRS shape and duration: Usually normal, but may be regularly abnormal.
P wave: Normal and consistent shape; always in front of the QRS.
PR interval: Consistent interval between 0.12 and 0.20 seconds.
P:QRS ratio: 1:1.

Diabetes insipidus-
A. Definition: Disorder of the posterior lobe of the pituitary gland.

-Low ADH

B. Symptoms

-Increased thirst

-Increased urine output (oliguria and nocturia) of dilute urine with a specific gravity of 1.001-1.005 and 250 ml of urine per hour.

-Hypernatremia

C. Treatment: Vasopressin/Desmopressin

D. Diagnosis: through history and water deprivation test (withholding fluids for 8–12 hrs or until 3% to 5% of the body weight is lost).

-Monitor fluids and electrolytes during the test.

Pulmonary Embolism-
Medical management of the patient with PE revolves around whether the patient is diagnosed with a hemodynamically unstable PE (also called a massive PE) or a stable PE. The patient with a hemodynamically unstable PE, which is a life-threatening emergency, may exhibit hypotension, tachycardia, confusion, and cardiovascular collapse. The immediate objective is to stabilize the cardiopulmonary system in a patient with a hemodynamically unstable PE. Emergent measures are initiated to improve respiratory and cardiovascular status. After initiating emergency measures, the treatment goal is to lyse (dissolve) the existing embolus and prevent new ones from forming.

Treatment: Thrombolytic therapy with t-PA or other agents such as reteplase is used in treating unstable PE. Before starting thrombolytic therapy, INR, aPTT, hematocrit, and platelet counts are obtained.

NB: This could be a case of a patient with the signs of a PE, and you have to contact the provider.

Symptoms: Dyspnea, Chest Pain, Tachypnea, Anxiety, Fever, Diaphoresis

Glaucoma signs and symptoms-
The patient may not seek health care until he or she experiences blurred vision or “halos” around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

A. Early signs

1. Increase in IOP >22 mm Hg
2. Decreased accommodation or ability to focus

B. Late signs include

1. Loss of peripheral vision
2. Seeing halos around lights
3. Decreased visual acuity that is not correctable with glasses.
4. Headache or eye pain that may be so severe as to cause nausea and vomiting (acute closed-angle glaucoma)

Guillain barre assess-
Ongoing assessment for disease progression is critical. The patient is monitored for

life-threatening complications (respiratory failure, cardiac dysrhythmias, VTE [including DVT or PE]) so that appropriate intervention can be initiated. Because of the threat to the patient in this sudden, potentially life-threatening disease, the nurse must assess the patient’s and family’s ability to cope and their use of coping strategies.

A. Paresthesia (tingling and numbness)

B. Muscle weakness of legs progressing to the upper extremities, trunk, and face

C. Paralysis of the ocular, facial, and oropharyngeal muscles, causing marked difficulty in talking, chewing, and swallowing. Assess for

1. Breathlessness while talking
2. Shallow and irregular breathing
3. Use of accessory muscles while breathing
4. Any change in respiratory pattern
5. Paradoxical inward movement of the upper abdominal wall while in a supine position, indicating weakness and impending paralysis of the diaphragm.

D. Increasing pulse rate and disturbances in the rhythm

E. Transient HTN, orthostatic hypotension

F. Possible pain in the back and in the calves of legs

G. Weakness or paralysis of the intercostal and diaphragm muscles; may develop quickly.

Ischemic stroke – expressive aphasia
The most common type of stroke in older people occurs when blood flow to the brain is blocked by the narrowing or blockage of a carotid artery.

Expressive aphasia usually indicates a left hemisphere CVA.

Cardiomyopathy care plan-

• Impaired cardiac output,

•Risk for impaired cardiac function, ineffective tissue perfusion, and impaired peripheral tissue perfusion,

•Impaired gas exchange,

•Activity intolerance.

The major goals for patients include improvement or maintenance of cardiac output, increased activity tolerance, reduced anxiety, effective management of the self-care program, increased sense of power with decision making, and absence of complications.

Nursing interventions: improving cardiac output and peripheral blood flow, increasing activity tolerance and gas exchange, reducing anxiety, decreasing the sense of powerlessness, and promoting transitional care.

A. Monitor CV status and VS

B. Assess oxygenation, apply O2 as needed

C. Administer antihypertensives

-Beta blockers (decrease workload of the heart)

-ACE inhibitors, ARBs (decrease afterload)

-Diuretics (decrease preload)

D. Encourage rest and minimize stress

E. Monitor signs and symptoms

-poor perfusion such as weakness, pale and clammy skin, diaphoresis

-SOB, pink frothy sputum d/t pulmonary edema

F. Educate pt on low-sodium diet (DASH diet)

Compartment syndrome-
Acute compartment syndrome—the most serious complication of casting and splinting—occurs when increased pressure within a confined space compromises blood flow and tissue perfusion.

Ischemia and potentially irreversible damage to the soft tissues within that space can occur within a few hours if action is not taken. This complication is associated with a tight or rigid cast/splint that constricts a swollen limb. If pressure is not relieved and circulation is not restored, an emergent surgical fasciotomy may be necessary to relieve the pressure within the muscle compartment. The nurse closely monitors the patient’s response to conservative and surgical management of compartment syndrome. The nurse records frequent neurovascular responses and promptly reports changes to the primary provider.

HESI Hint:

Compartment syndrome is a progressive decrease of tissue perfusion occurring as a result of increased pressure from edema, or swelling that presses on the tissues and vessels. Compromised circulation with abnormal neurovascular checks is the result of compartment syndrome. If compartment syndrome occurs and is not treated immediately with a fasciotomy, it can result in permanent nerve and vasculature damage, possibly leading to amputation of the limb.

Pain is your first clue this is occurring.

Stroke Broca’s area-
Broca’s area is the area responsible for forming words and comprehending language. A stroke in this area would present as aphasia (expressive or receptive).

Consider the clot-dissolving medicine tPA (tissue plasminogen activator):

-Ask when the symptoms start

Acute pancreatitis assessment-

1. Severe midepigastric pain radiating to the back; usually related to excess alcohol ingestion or a fatty meal
2. Abdominal guarding; rigid, board-like abdomen, and abdominal pain
3. Nausea and vomiting
4. Elevated temperature, tachycardia, decreased BP
5. Bluish discoloration of flanks (Grey Turner sign) or periumbilical area (Cullen sign)
6. Elevated amylase, lipase, triglycerides, and glucose levels
7. Low serum calcium levels

Alcoholic hepatitis teaching-
Hepatitis brought on by alcohol abuse requires complete cessation of alcohol intake.

Be prepared for psych effects – referral to AA or other support groups may be needed.

This includes rest, lifestyle changes, adequate dietary intake, and the elimination of alcohol. The nurse also educates the patient and family about symptoms of impending encephalopathy, possible bleeding tendencies, and susceptibility to infection. Nurses should consider implementing the teach-back method when educating patients and families to ensure they can describe what they have been taught in their own words or perform a task as instructed.

Because of the risk of bleeding from abnormal clotting, the patient should use an electric razor rather than a safety razor. A soft-bristled toothbrush helps minimize bleeding gums, and pressure applied to all venipuncture sites helps minimize bleeding.

Cirrhosis ascites dyspnea-
Patients will present with dyspnea due to fluid build-up in the abdomen. The patient may be prescribed a diuretic to help get rid of some fluids. Primary uses of spironolactone include treatment of heart failure, ascites (in patients with liver disease).

Cirrhosis complications include:

1. Ascites, edema
2. Portal HTN
3. Esophageal varices
4. Encephalopathy
5. Respiratory distress
6. Coagulation defects

Not sure if related but:

HESI Hint

Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level rises.

The metabolism of drugs is slowed down so they remain in the system longer.

Dialysis HTN edema-
HTN and edema with CKD or ESRD indicate fluid volume overload indicating the need for emergency dialysis.

In a non-emergency, consider Lasix.

Acute or urgent dialysis is indicated when there is a high serum potassium level, fluid overload, impending pulmonary edema, increasing acidosis, pericarditis, or advanced uremia.

It may also be used to remove medications or toxins (poisoning or medication overdose) from the blood, for edema or hypertension that does not respond to other treatments, or for hyperkalemia.

Fractured femur assessment-
Assess for the 5Ps. Pain, pulse, pallor, paresthesia, and paralysis.

If you detect a dim pulse in the limb in traction, you need to compare it to the unaffected limb FIRST, and then, if uneven, alert the provider.

Addison’s crisis -hypoglycemia-
HESI Hint

Addison crisis is a medical emergency. It is brought on by sudden withdrawal of steroids, a stressful event (trauma, severe infection), exposure to cold, overexertion, or a decrease in salt intake.

A. Vascular collapse: Hypotension and tachycardia occur; administer IV fluids at a rapid rate until stabilized.

B. Hypoglycemia: Administer IV glucose.

C. Essential to reversing the crisis: Administer parenteral hydrocortisone.

D. Aldosterone replacement: Administer fludrocortisone acetate (Florinef) PO (available only as an oral preparation) with simultaneous administration of salt (sodium chloride) if the client has a sodium deficit.

Chemo side effects

• Nausea and vomiting
• Bone marrow suppression
• Alopecia
• Weight gain or loss
• Anorexia
• Fatigue
• Decline in functional status
• Mucositis
• “Chemo” Brain

. Leukocytopenia

. Toxic to heart, lungs, kidneys, skin and other vital organs.

Multiple sclerosis urinary retention-
HESI Hint

Symptoms involving motor function usually begin in the upper extremities, with weakness progressing to spastic paralysis.

This causes symptoms of frequency, urgency, leaking urine, or interference with a good night’s sleep.

Bowel and bladder dysfunction occur in 90% of cases. MS is more common in women. Progression is not “orderly.”

Teach the client that, as incontinence worsens, the female may need to learn clean self-catheterization; the male may need a condom catheter.

Meningitis care-
A. Administer antibiotics (usually ampicillin, ceftriaxone, or chloramphenicol) and antipyretics as prescribed.

• Consider culture too, which makes sense, but HESI prep doesn’t mention it. Just FYI

B. Isolate for at least 24 hours.

C. Monitor vital signs and neurologic signs.

D. Keep the environment quiet and darkened to prevent overstimulation.

E. Implement seizure precautions.

F. Position for comfort: head of the bed slightly elevated, with the client on the side if prescribed.

G. Measure head circumference daily in infants.

H. Monitor I&O closely.

Acute renal failure priorities-
The priority is identifying the underlying cause and assessing for signs of hyperkalemia.

Nursing Interventions

A. Monitor intake and output (I&O) accurately: fluid restriction during the oliguric phase (600 mL plus previous 24-hr fluid loss)

B. Weigh daily: in the oliguric phase, the client may gain up to 1 lb/day.

C. Document and report any change in fluid volume status.

D. Nutritional therapy

E. Adequate protein intake (0.6 to 2 g/kg/day) depending on the degree of catabolism

F. Monitor laboratory values of serum and urine to assess electrolyte status, especially hyperkalemia indicated by serum potassium levels over 5 mEq/L and electrocardiogram (ECG) changes.

G. Potassium restriction and measures to lower potassium (if elevated). Sodium polystyrene (Kayexalate) may be prescribed if potassium is too elevated.

H. Restrict sodium.

I. Assess the level of consciousness for subtle changes.

J. Prevent cross-infection.

Acute respiratory distress priority findings-
Signs and symptoms of ARDS

1. Hypoxemia that persists even when 100% O2 is given
2. Decreased pulmonary compliance
3. Dyspnea
4. Non-cardiac-associated bilateral pulmonary edema
5. Dense pulmonary infiltrates on radiography

Nursing assessment of ARDS

1. No abnormal lung sounds are present on auscultation because the edema of ARDS occurs first in the interstitial spaces, not in the airways.
2. Dyspnea, hyperpnea, crackles (or rales), wheezing, or decreased breath sounds
3. Intercostal retractions or substernal retractions
4. Cyanosis, pallor, mottled skin
5. Hypoxemia: partial pressure of O2(PO 2) <50 mm Hg with a fraction of inspired O2 (FiO 2) >60%
6. Increasing diminished breath sounds
7. Diffuse pulmonary infiltrates seen on chest radiograph as “white-out” appearance
8. Client verbalization of anxiety, restlessness, confusion, and agitation.

End of life plan of care-
Priority Cares
A. Pain management
B. Alleviating dyspnea
C. Listening, reassuring, and reinforcing nonpharmacologic interventions to help manage anxiety (a mild to severe subjective feeling of apprehension, tension, insecurity, and uneasiness) may need to be followed by pharmacologic agents.
D. Managing GI symptoms of nausea, vomiting, gastritis, constipation, and diarrhea.
E. Assessing for psychiatric symptoms of depression and delirium
F. Recognizing the spiritual needs of older adults
G. Supporting family caregivers
H. Family bereavement support.

Cushing syndrome-
The most common cause of Cushing’s syndrome (also known as Cushing’s disease) is the use of corticosteroid medications, but the syndrome can also be due to excessive glucocorticoid production secondary to hyperplasia of the adrenal cortex.

Clinical Manifestations:

When adrenocortical hormone overproduction occurs, growth arrest, obesity, musculoskeletal changes, and glucose intolerance occur. The classic picture of Cushing’s syndrome in adults is central-type obesity, with a fatty “buffalo hump” in the neck and supraclavicular areas, a heavy trunk, and relatively thin extremities. The skin is thin, fragile, and easily traumatized; ecchymoses (bruises) and striae develop. The patient complains of weakness and lassitude. Sleep is disturbed because of the altered diurnal secretion of cortisol. The patient develops a “moon-faced” appearance and may experience increased skin oiliness and acne.

Assessment and Diagnostic Findings:

The three tests used to diagnose Cushing’s syndrome are serum cortisol, urinary cortisol, and low-dose dexamethasone suppression tests. Two of these three tests need to be unequivocally abnormal to diagnose Cushing’s syndrome.

Nursing Interventions:

A. Encourage the client to protect self from exposure to infection.

B. Wash hands; use good handwashing technique.

C. Monitor client for signs of infection

D. Teach safety measures.

E. Provide a low-sodium diet; encourage consumption of foods that contain vitamin D and calcium.

F. Provide good skin and perineal care.

G. Discuss the possibility of weaning from steroids after surgery. (If weaning is done too quickly, symptoms of Addison disease will occur.)

H. Encourage selection of clothing that minimizes visible aberrations; encourage maintenance of normal physical appearance.

I. Monitor I&O and weigh daily.

J. Provide ulcer prophylaxis.

Medication: ketoconazole – don’t give with antacids; give with fruit juice

ARDS ABGs
Low PO2
High dyspnea
Mild hypoxemia and respiratory alkalosis.

Valve replacement teaching-
The nurse educates the patient about anticoagulant therapy, explaining the need for frequent follow-up appointments and blood laboratory studies. Patients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials used in valvuloplasty) require education to prevent infective endocarditis.

A. Monitor client for atrial fibrillation with thrombus formation.

B. Teach the necessity for prophylactic antibiotic therapy before any invasive procedure, such as dental procedures, that is likely to produce gingival or mucosal bleeding: bronchoscopy, esophageal dilation, upper endoscopy, colonoscopy, sigmoidoscopy, or cystoscopy.

C. Prepare the client for surgical repair or replacement of heart valves.

D. Instruct clients receiving mechanical valve replacement on the need for lifelong anticoagulant therapy to prevent thrombus formation. Tissue (biologic) valves and autografts do not require lifelong anticoagulant therapy.

Cancer intractable pain plan of care
The most common plan of care is palliative sedation.

NGT suction-metabolic alkalosis-
Severe vomiting and gastric suctioning can cause a loss of stomach acids (HCI-hydrogen and chloride ions), which leads to metabolic alkalosis.

Continuous bladder irrigation
-Peri and Foley care will need to be done twice a day

• Will be on this for 24 hrs and then after 24hrs need to be on a lot of fluids
  -Use only sterile saline with bladder irrigation ( prevents fluid and electrolyte imbalance)
• Increase fluids to 3000mL/day
• Sometimes give anti-spasmatic bc they have lots of bladder spasms
• Make sure pt is on stool softener
  -Pt needs to urinate q2-3hr
  -Will have sensation of full bladder
  -Advise the patient to not attempt to void as it will cause bladder spasms

urethritis

• Urethritis: Inflammation of the urethra (Lower UTI)
• S&S: Burning on urination, urinary frequency (voiding more than every 3 hours), urgency, nocturia, incontinence, suprapubic or pelvic pain
• RISK: Female, diabetes, pregnancy, neurologic disorder, gout, incomplete emptying of bladder
• Prevention: Hand hygiene, careful perineal care, and frequent toileting may decrease UTIs
  TX: Antibiotics when bacteriuria present, monitor kidney function, monitor I&O, increase fluid intake if cardiac status does not contraindicate

Renal calculi risk
Risk factors:

• Family history, dehydration, certain diets (high in protein, sodium, and sugar increase risk), strictures, neoplasms, prostatic hypertrophy, medications/supplements (Vit C, laxatives, calcium-based antacids)
  Risks (emergency):
• Can lead to infection with fever and chills à this is an emergency and can be life-threatening
• Calcium and oxalate
  -Risk for developing kidney stone pt with gout (middle age)
  -Strain all urine
  -Avoid supine position
  -regularly scheduled pain medication rather then PRN to prevent spasm and promote comfort

Calculi pain

• Opioid are given to prevent shock and syncope that may result from the excruciating pain
• NSAIDS
• Once stone is passed the pain the relieved
• Hot baths or moist heat to the flank area may also be helpful
• S&S nausea, vomiting, diarrhea, and abdominal distention
  Severity and location of pain are determine, along with any radiation of pain

Imitrex contraindications
Imitrex (Sumatriptan) is used for migraine headaches with or without an aura
(also used to treat cluster headaches)

• Contraindications

1. Older adults should not take
2. Caution when administering to renal impaired patients because elimination takes place in the renal system
3. Caution with hepatic impaired patients because metabolism takes place in liver
4. History of hypersensitivity reactions to the drug
5. Cerebrovascular or peripheral vascular systems

• Important to ask patient about recent administration ergot alkaloids, should not be given within 24 hours of administration (causes cardiac ischemia)
• Administration of MAO inhibitors lead to increased serum levels of sumatriptan and sumatriptan toxicity
• 2 weeks after MAO inhibitor has been discontinued, it is permissible to give sumatriptan in combination with MAO inhibitor
• Administration of St. John’s wort with triptans results in triptan toxicity.

Seizures
-Patient bed in the lowest position with side rails padded
-Suction
-Oxygen equipment must be available at the patient’s bedside
-Document
-Airway patency turn patient head to side

Hyperthyroidism signs/symptoms

• Exophthalmos (bulging eyes)
• Enlarger thyroid gland
• Weight loss
• T3 elevated and T4 elevated
• Diarrhea
• Tachycardic, palpitation, inc BP
• Bruit over thyroid
• Increased appetite
• Heat intolerance
• Diaphoresis
• Nervous, insomnia
• Monitor EKG, heart rate, and blood pressure

Exophthalmos-POC

• Wear sunglasses or eye patches to protect eyes from light
• Antithyroid drugs (Propylthiouracil (PTU) and methimazole
• Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area
• Use artificial tears
  -Tapping pt eyelids shut during sleep
• Natural tears/ eye lubrication
• Sunglasses for light sensitivity
• Corticosteroids
• Smoking cessation
• Antithyroid drugs (propylthiouracil and methimazole)

peripheral neuropathy
-Regular exercise, such as walking three times a week, can reduce neuropathy pain
-Improve muscle strength
-Help control blood sugar levels
-Quit smoking.
-Protect Skin and Feet

Diabetes foot care

• Inspect feet daily
• Wash feet daily with warm soap and water and pat dry
• Instruct to wear flat comfortable walking shoes
• Never walk barefoot
• Look for blisters, cut, ingrown toenails, and contact PCP immediately
  -If pt supine, put a pillow on the lower legs to elevate to alleviate pressure
• If pt sitting on chair, the feet should be positioned so that pressure is not placed on the heels
  -If pt has ulcer on one foot, the nurse provides preventative care to the unaffected foot as well as to the affected foot

Preop lab
Urinalysis: can determine pregnancy, but also infections so patients can be started on antibiotics
WBC 4,500-11,000: can help detect certain fevers and infections, or if patient is using a medication that could change this
Glucose (70-100): managing glucose before surgery reduces risk of infection and cardiac concerns
Potassium (3.5-5): MUST be within range due to cardiac concerns, especially those undergoing a heart surgery
CBC: M (4.25-5.65) F (3.92-5.13) à measures electrolytes within blood and help regulate heart rhythms also detect for anemia and infection
Coagulation (PTT): blood needs to clot after surgery, so identify this is important beforehand. Identifies those with bleeding disorder who might suffer perioperative bleeding.

Informed consent language
-Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed

• The signed consent form is placed in a prominent place on the patient’s medical record and accompanies the pt to the OR
• If the patient is non-English speaking, it is necessary to provide consent in a language that is understandable to the client (interpreter)
• If consent can not be obtain and emergent treatment is required to save life or limb, the emergency laws can be applied
  -14years of age must agree to treatment along with their parent or guardians

malignant hyperthermia

• Severe muscle rigidity or spasms.
  -Rapid, shallow breathing and problems with low oxygen and high carbon dioxide.
  -Rapid heart rate.
  -Irregular heart rhythm.
  -High body temperature.
  -Excessive sweating.
  -Patchy, irregular skin color (mottled skin)
• Recognize symptoms early and discontinue anesthesia
  Tx:
• Cooling blanket
  -O2
  -IV fluids
  -Dantrolene
  -ICU after

Post op pain
Nurse assesses the patient’s pain level using a verbal or visual analog scale and assesses the characteristics of the pain.

• Pts; appearance, pulse, respirations, b/p, skin color (adequate or cyanotic), skin temperature (cold and clammy, warm and moist, or warm or dry)
• Relieved by prescribed analgesic medication, changing the position frequently, and assessing and alleviating anxiety
• Opioid are commonly prescribed for pain and immediate postoperative restlessness
• Nonpharm: guided imagery, music, healing touch, changing position, distraction, apply cool washcloth, back massage
• Early ambulation if possible

Hydromorphone & B/P
-Diladid given to patients who state they have severe pain, given IV and is quick acting

• May suddenly drop blood pressure
  Should not be given to patients with hypotension, hypovolemia, or CNS depression

COPD and breathing
COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs
Ineffective breathing patterns and SOB due to the modified respiratory mechanics of chest wall and lung resulting from air trapping

• Pursed-lip breathing helps slow expiration, prevent collapse of small airways, and control the rate and depth or respiration
• Inspiratory muscle training
  Diaphragmatic breathing training reduces respiratory rate

TB diagnostic test
-Quantiferon TB Gold test (takes 24 hr)
Skin testing

• Positive skin test, blood test, or sputum culture for acid-fast bacilli
• Tuberculin skin test, chest x-ray
• Tuberculin Skin test- the Mantoux method is used to determine whether a person has been infected with TB
  -Sputum culture can indicate disease but does not confirm diagnosis

Perforated bowel first sign
-Sudden and severe abdominal pain.
-Nausea and vomiting.
-Fever is often a sign of infection or disease.
-Chills.
-Swelling and bloating of the abdomen
-Less gas passed

NGT with decreased peristalsis
-Placement is done to give GI system rest. Lack of use will slow the GI system down.

Cholelithiasis N&V

• Nurse notes nausea and vomiting could indicate infection or disruption of the GI tract should be reported promptly
• Should also report RUQ pain, bile drainage around any drainage tube, clay-colored stools, and change in VS
• Biliary colic is usually associated with nausea and vomiting, and it is noticeable several hours after a heavy meal
  -General peritonitis may result

Diverticulitis WBC
-Elevated white blood cell (WBC) count and left shift, although patients with early and mild diverticulitis may have a normal WBC count.

-This result may be blunted in the elderly or immunocompromised.

-Normal number of WBCs in the blood is 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 109/L)

Anemia labs
-Iron deficiency, Sickle cell disease, low HgB and Hct, high creatinine, low erythropoietin level, low B12, low folate
-RCB Male(4.5-5.5) Female(4-4.9)
-Hgb Male(13.5-16.5) Female(12-15)
HCT Male(41-50) Female(36-44)

Plaquenil teach
Used for Lupus- Hydroxychloroquine

• Effective for managing cutaneous, musculoskeletal, and mild systemic features of SLE
• Patient should undergo a thorough ophthalmologic exam before tx and every 6 months after
• Objects may start to appear blurry or distorted.
  -Should be advised to contact the prescriber if any visual disturbance

Blood administration – overload
S/S overload:

• dyspnea, orthopnea, tachycardia, increase B/P, JVD, crackles, hypoxemia, pulmonary edema, pink, frothy sputum
  -More common in people with heart problems
• If mild blood can continue after slowing the rate of infusion and administering diuretics
  -Taking diuretic medicine after a blood transfusion may prevent this problem.
• If severe pt is placed upright with feet in a dependent position, transfusion discontinued, primary provider notified
• Oxygen and morphine may be needed to treat dyspnea
  Can develop as late as 6 hrs after transfusion

Menopause risk of osteoporosis
-Estrogen, a hormone in women that protects bones, decreases sharply when women reach menopause, which can cause bone loss.
Primary osteoporosis occurs in women after menopause (51)

• Should consume approximately 1200 mg of daily calcium
• Engage in exercise (weight-bearing): walking, dancing, climbing
• Accelerated bone resorption within the first 5 years after cessation of menses
  DEXA testing is recommended

Osteoporosis goal
-Reduce bone loss

-Prevent fracture

-Control pain

-Prevent disability.

-Eating foods that are rich in calcium and vitamin D

-Regular weight-bearing exercise, such as weight training, walking, hiking, jogging, climbing stairs, tennis, and dancing.

Osteoarthritis pain assessment
-Physical assessment. Physical assessment of the musculoskeletal system reveals the tender and swollen joints.

-X-ray. OA is characterized by a progressive loss of joint cartilage, which appears on x-ray as a narrowing of the joint space.

-Acute pain related to inflammation of the synovium and irritation of the nerve endings

Gout teach
Hyperuricemia (increased serum uric acid) most common in the great toe

• Restrict consumption of foods high in purines, organ meats, seafood and limit alcohol intake
• Normal body weight encouraged
• Avoidance of factors that increase pain and inflammation; trauma, stress, and alcohol
  Medication adherence

ABG head injury
-Up to one-third of patients with severe traumatic brain injury develop Acute Respiratory Distress Syndrome

-Tachypnea, tachycardia, and respiratory alkalosis

-Respiratory alkalosis (Some of the causes include the build-up of CO2 in the blood, hypoventilation, and increased dead space.)

Celiac disease – diet
Celiac disease- immunologic disorder in which gluten, a product most commonly found in grains, causes damage to the small intestine

• Only treatment is a strict gluten-free diet
• Allowed foods: potato, soy, rice, cornmeal, vegetables, fruits, milk (except malted milk, yogurt), meats, butter, margarine, coconut, marshmallows

Prolapsed cord delivery
-Place sterile dressing soaked with saline on cord to prevent drying

• Positioning mom to modified Sims, Trendelenburg, or knee-chest position also helps relieve cord pressure.
  -Give O2 through non-rebreather mask at 8-10mL
• Prepare women for emergency C-section to save fetus’s life if cervix is not fully dilated
  -Provide space from compressing cord by placing 2 fingers into vaginal canal

Gestational diabetes lab
The urine is analyzed for albumin, glucose, ketones, and bacteria >140mg/dL

• 1-hour glucose tolerance at 24-28 weeks
• If positive notify provider who will order the pt to take 3 hour glucose tolerance test

GBS positive
-Penicillin G is treatment of choice, administered IV at least 4 hours before birth
-Will need antibiotic treatment or neonate can become ill
-Right after birth: low temperature, pyrexia, bradypnea, tachypnea, bradycardia, tachycardia, appear floppy, have the inability to feed, and appear pale or irritable”
-Develop symptoms of rapidly invasive disease including sepsis, pneumonia, and meningitis within the first week after birth

Placenta abruption actions
-Place the woman in a lateral, not supine position to avoid pressure in the vena cava.
-Monitor fetal heart sounds.
-Monitor maternal vital signs to establish baseline data.
-Avoid performing any vaginal or abdominal examinations to prevent further injury to the placenta.

Hemorrhage postpartum care
-Manual massage of the uterus (to stimulate contractions)
-Removal of placental pieces that remain in the uterus.
-Empty Bladder
-Start Pitocin

Variable deceleration actions
-A clinical manifestation of a prolapsed umbilical cord

• Discontinue oxytocin
• Turn the client on her left
  -Provide mother with O2
  -Bolus IV fluids

Post epidural headache

• Hypotension and associated FHR changes are managed with maternal positioning (semi-fowler position), IV hydration, and supplemental oxygen
• Bed rest, fluids, caffeine, oral pain relievers
  Post spinal headache: lay flat, fluids, blood patch
  -Has to do with change in CSF
  -Can last 7-10 days

Cryptorchidism assessment
-Impaired urinary elimination
-Risk for infection
-Visual assessment first
-Palpation of the testis

Acrocyanosis monitor
-Normal in a newborn, wherein the hands, feet, and lips are bluish in color

-May persist for 24 to 48 hours

Vitamin K rationale
-Babies need the shot as they do not have enough clotting factor after birth.
-If the baby didn’t receive the shot they would hemorrhage
-Newborn bowels are sterile, so vitamin K is not produced in the intestine until after microorganisms have been introduced, such as first feeding
-Takes about a week for the newborn to produce enough vitamin K to prevent vitamin K deficiency bleeding

IEO – pediatrics

Sickle cell dehydration
-Dehydration makes the pain worse
-Lack of fluids causes the blood to clot more furthering the sickle cell crisis

Hypoglycemia – milk
Dairy provides protein, carbohydrates, vitamins and minerals and also helps control blood sugar for reactive hypoglycemia

Meningitis assess
-Lumbar puncture
-High pitched cry
-Nuchal Rigidity
-Bulging fontanels
-Projectile vomiting

Congenital hypothyroid
-Shortage of iodine in the diet of the mother and the affected infant
-Jaundice (yellow skin or eyes)
-Sleeping longer or more often than usual.
-Constipation.
-Large soft spot (fontanel) on the head.
-Large, swollen tongue.
-Weak (“floppy”) muscle tone.
-Swelling around the eyes.
-Poor or slow growth.

RSV synagis (Palivizumab)
If born prematurely (at or before 35 weeks) should receive at 6 months of age or less at the beginning of RSV season
-Its a monthly shot

hyperglycemia
-Usually Type 1 for pediatrics
-Body is unable to produce insulin
-Only able to take
-1st sign is bed wetting

Biliary atresia
-Infants in which the bile ducts outside and inside the liver are scarred and blocked
-Bile can’t flow into the intestine, so bile builds up in the liver and damages it.
-Abnormally pale stools
-Dark urine.
-Infants may also have swollen (distended) stomach and/or abnormal enlargement of the liver (hepatomegaly)

Seizure PEDI
Preventing injury during seizures, administering appropriate medication, providing education

• Padding of side rails
• Side rails raised on bed at all times
• Oxygen and suction at bedside
• Supervision, during bathing, ambulation
• Protective helmet during activity
• Should wear bracelet

Wilm’s tumor preop

• Avoid palpating the abdomen after the initial assessment preop

-Will be able to palpate kidney

Measure B/P and auscultate the lungs

-Assess for bleeding from any site and febrile episodes; Monitor WBC, platelet count, hematocrit, absolute neutrophil count.

-Assess the oral cavity. Assess oral cavity for pain ulcers, lesions, gingivitis, mucositis or stomatitis and effect on the ability to ingest food and fluids.

VSD fluid overload
-Incomplete development of the septum that separates the right and left ventricles
-Causes an increase in blood flow to the lungs.

HF pediatric
S&S

-Visible swelling of the legs, ankles, eyelids, face, and (occasionally) abdomen.

-Abnormally fast breathing.

-Shortness of breath or labored breathing.

-Fatigue.

-Nausea.

-Falling asleep when feeding or becoming too tired to eat.

-Lack of appetite.

PDA

-Creates a left to right shunt of blood from the aorta to the pulmonary artery and results in recirculation of pulmonary blood through the lungs

-Indomethacin injection works by causing the PDA to constrict, and this closes the blood vessel

Intussusception stool
-Currant-jelly stools, gross blood, or hemoccult-positive stools
-Severe pain (draw up knees and scream),

Cystic fibrosis sweat test
-The principal diagnostic test to confirm CF is a sweat chloride test using the pilocarpine iontophoresis method to collect sweat and perform a chemical analysis of its chloride content is currently considered to be the only adequately sensitive and specific type of sweat test.

Hemophilia joint care
-Hemarthrosis, or bleeding into the joint spaces
-Rest and icing
-Exercise to promote joint health

Placental previa results
-Side lying position when bleeding occurs

-Monitor BP closely

-Monitor baby HR

-Ultrasound. Early detection of placenta previa is always possible through ultrasonography.

-Diagnosed during a second-trimester ultrasound exam

Self-harm – adolescent
-Self-harm looking for a release

-Symptom of depression that could be correlated with bullying

-Allows teen to feel in control of feeling that they can not verbally or emotionally express

Alzheimer hallucinations
Reorient them to reality do not go along with the patients hallucinations

Therapeutic milieu
-Structured environment that creates a safe, secure place for people who are in therapy

-A milieu counselor, also referred to as a milieu specialist or milieu therapist, assists individuals with crisis intervention, drug and alcohol rehabilitation, or mental health and behavioral disorder recovery.

Aggression source
-Early assessment, judicious use of medications, and verbal interaction with an angry client can often prevent anger from escalating into physical aggression
-A lack of psychological space—having no privacy, being unable to get sufficient rest—may be more important in triggering aggression than a lack of physical space
-A history of violent or aggressive behavior is one of the best predictors of future aggression.

Addiction & relapse
-Detoxification is the initial priority.
-Priorities for individual clients are based on their physical needs and may include safety, nutrition, fluids, elimination, and sleep.
-The remainder of this section focuses on care of the client being treated for substance abuse after detoxification.
-One of the most common relapse triggers which lead to addiction, stress is something that most everyone who has committed to recovery has to deal with.

Heroin history

Depression goal setting
-Reverse negative views of the future, improve self-image, and help clients gain competence and self-mastery
-Able to function in society (sleep, eat, self care)
-Patient is able to verbalize feelings

priority is to determine whether a client with depression is suicidal

• Safe environment
• If the client has a plan, the nurse asks additional questions to determine the lethality of the intent and plan
• The nurse reports this information to the treatment team
  Health care personnel follow hospital suicide precautions

Duty to warn
Mental health professional’s responsibility to break confidentiality and notify the potential victim whom a client has specifically threatened.

Borderline personality disorder – communication
-This disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect, as well as marked impulsivity; borderline personality disorder is the most common personality disorder found in clinical settings

-Promoting client’s safety
-Promoting therapeutic relationship
-Establishing boundaries in relationships
-Teaching effective communication skills
-Helping clients to cope and to control emotions
-Reshaping thinking patterns

Persecutory delusion
-Establishing rapport and trust is crucial to a successful provider-patient relationship.
-Instead of fighting or supporting their delusions, calmly share a different viewpoint
-When a person’s delusions are disputed, they will further believe them. At the same time, “playing along” with the delusion reinforces it.

IPV action
-Assess for SI and seek help from nurse manager if patient speaks of SI
-Report the incident to nurse manager
-It is essential to ask everyone whether they are safe at home or in their relationship

• Do ensure and maintain client’s confidentiality
  -Provide the victim with resources

Elder abuse nursing care
-Mandated reporters
-Seems depressed, confused, or withdrawn.
-Isolated from friends and family.
-Has unexplained bruises, burns, or scars.
-Appears dirty
-Underfed and dehydrated
-Over-or undermedicated, or not receiving needed care for medical problems.
-Has bed sores or other preventable conditions

Maslow-esteem
-Need encompass confidence
-Strength
-Self-belief/ esteem (dignity, achievement, mastery, independence)
-Personal and social acceptance
-Respect from others (desire for reputation or respect from others (e.g., status, prestige)

ADHD – school age
-Can affect a student’s ability to focus, pay attention, listen, or put effort into schoolwork
-Hyperactivity, and impulsivity, which can affect planning, organizing, and managing behavior, many children with ADHD struggle with change.

ADHD early school age
-Being overly fidgety and squirmy.
-Having an inability to sit still for calm activities like eating and having books read to them.
-Talking and making noise excessively.

Tangential speech
-Phenomenon in which a person constantly digresses to random, irrelevant ideas and topics

• Decrease environment stimuli whenever possible; a private room
• Reorient the patient to person, place, and time
• Set limits on the client’s behavior when needed
  Clarify the meaning of the client’s communication

Bipolar impulsivity

• Set limits on the client’s behavior
• Remind the client to respect distances
• Clarify the meaning of the client’s communication
  -During periods of acute mania
  -Safety is key during this time high risk behavior

Water intoxication
Diabetes Insipidus

-If vasopressin is given, monitor for water intoxication

-drinking too much water but unable to urinate enough out.

PR interval – PR interval
-Represent the time required for the impulse to travel from the atria(sinoatrial node) through the atrioventricular node to the purkinje fibers in ventricle
-Measured from the beginning of the P wave to the beginning of the QRS complex
-Represents AV nodal function

Atrial fib
-Disorganized and uncoordinated twitching of atrial musculature caused by overly rapid production of atrial impulses

-Atrial Rate: 350 to 600 bpm

-Ventricular Rate: 120 to 200 bpm

-No true P wave

-PR interval is not measurable

-Irregular ventricle rhythm

-QRS complex is normal

-Rhythm is irregular and usually rapid unless controlled.

-Palpitations

-Dyspnea

-Pulmonary edema

-If the pt has atrial fibrillation, turning off the irregular heart rate alarm is appropriate

Unstable angina
-Chest pain that occurs while a person is at rest and with no exertion
-Increase in frequency and severity and may not be relieved with rest or nitroglycerin.

MI plan of care
Modifiable changes
-Smoking cessation
-Cardiac diet
-Exercise route
-Decrease stress
-Abstain excessive alcohol

MI Nursing Interventions and Nursing Priorities
-Relieve pain, anxiety.
-Reduce myocardial workload.
-Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications.
-Promote cardiac health, self-care.

-Administer oxygen along with medication therapy to assist with relief of symptoms.
-Encourage bed rest with the back rest elevated to help decrease chest discomfort and dyspnea.
-Encourage changing of positions frequently to help keep fluid from pooling in the bases of the lungs.
-Check skin temperature and peripheral pulses frequently to monitor tissue perfusion.
-Provide information in an honest and supportive manner.
-Monitor the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, changes in skin color, and laboratory values.

Valve surgery – activity
-Do light work such as 15 minutes of brisk walking.
-Wait for 6 weeks before having sex
-Recommended that patient sleep upright position for the first few weeks after the surgery
-Prophylactic antibiotics before any invasive procedure
-Lifelong anticoagulation medication and INR draws also (not for biologic and autographs)

Cardiomyopathy – HA onset
-Heart muscle to become enlarged, thick or rigid

• Can lead to heart failure
• Decrease blood flow of the heart
• Pressure, tightness, pain, or a squeezing or aching sensation
• Nausea, indigestion, heartburn, or abdominal pain,
• SOB
• Cold Sweat
• Fatigue
  -Lightheadedness

ABGs – PE
-respiratory alkalosis
-PaCO2 > 40 with a pH < 7.4 indicates a respiratory acidosis
-Respiratory alkalosis occurs when you breathe too fast or too deep and carbon dioxide levels drop too low

Pulmonary embolism signs and symptoms
-Dyspnea. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization.

-Chest pain. Chest pain occurs suddenly and is pleuritic in origin.

-Tachycardia. Increase in heart rate occurs because the right ventricle catches up with its workload.

-Tachypnea. The most frequent sign is tachypnea.

-Respiratory acidosis

ARDS – PaO2 level
-ARDS closely resembles severe pulmonary edema

-Rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating even

-Arterial hypoxemia that does not respond to supplemental oxygen

-Respiratory or Metabolic Acidosis

-Decreased Po2

-Increase PCO2

-intubate at a pH of 7.2 or below

-Severe hypoxemia is classified as a PaO2 Less than 40 (respiratory alkalosis)

Hepatitis C risk
-Used or shared needles, syringes or lancets
-Sex
-Sharing care items like toothbrushes or razors
-Born to a mom with hepatitis C
-Medical mishaps like needle injuries or unsterile instruments

Acute Pancreatitis lipase
-Serum amylase and lipase levels. These are used in making a diagnosis, although their elevation can be attributed to many causes, and serum lipase remains elevated for a longer period than amylase

-Diagnostic: Serum lipase: usually elevates along with amylase, but stays elevated longer.

-blood lipase levels increase within 3 to 6 hours of symptom onset, peak at 24 hours, and remain elevated for up to 2 weeks

Cirrhosis – hematemesis
-Develop upper gastrointestinal hemorrhage from a variety of lesions
-Increased pressure in the portal vein causes blood to be pushed away from the liver to smaller blood vessels, which are not able to handle the increased amount of blood

CKD/ARF diet
DASH Diet:

fruits, vegetables, low-fat dairy products, whole grains, fish, poultry, beans, seeds, and nuts

-Low Sodium, protein, low potassium, phosphate

-Provide sufficient nutrients to limit the catabolic response, and to hasten renal recovery within the restrictions set by the limited renal capacity.

Hemodialysis – low BP
-Drop in fluid levels during dialysis

-Low blood pressure can cause nausea and dizziness

-Best way to minimize these symptoms of low blood pressure is to keep to your daily fluid intake recommendations

-For most patients who experience a drop in blood pressure, small amounts of intravenous fluids are given

Addison’s disease – glucose
-Patients with adrenal insufficiency are likely to experience hypoglycemia. It may require adjustment of insulin dosage.
-Inadequate caloric intake in meals may precipitate hypoglycemia. Promotion of oral intake maintains adequate blood glucose levels and nutrition.
-Depleted cortisol increases insulin sensitivity

Cushing’s findings
-Weight gain.
-Thin arms and legs.
-Moon face .
-Buffalo hump
-Truncal obesity
-Easy bruising.
-Wide purple stretch marks, mainly on the abdomen, breasts, hips, and under the arms.
-Weak muscles
-HTN

Diabetes insipidus & hypernatremia
-Due to excessive urination of free water Na is left behind causing elevated Na.
-Treat by giving D5 and NS, artificial ADH desmopressin DDAVP

Fracture left hip
-Pain
-Muscle spasm
-Shorten leg
-External rotation
-Pain management

Multiple sclerosis teaching
-Exercise can help retain flexibility and balance, promote cardiovascular
-Get plenty of rest
-Eat a balanced diet.
-Education on continence management techniques and even teaching patients to self-catheterize

Guillain Barre swallow
-Tingling and weakness starting in your feet and legs and spreading to your upper body and arms
-Swallowing therapy (if oral feeding is reasonably safe to attempt)
-Speech and language therapy to learn new swallowing techniques

Fibromyalgia
Chronic condition with widespread aching and pain in the muscles and fibrous soft tissue
-Abnormalities in the neuroendocrine and autonomic nervous systems, genetic factors, psychosocial variables, and environmental stressors.

Pilocarpine ophthalmic evaluate
-The pupil of the eye to shrink and decreasing the amount of fluid within the eye
-Used to treat glaucoma
-Causes pupil constriction.
-Allowing excess fluid to drain from the eye

Chemotherapy teach

• Adequate food and fluid intake
• Self-care
• Preventing infection
• Side effects: decreased immune system (infection), anemia, nausea, hair loss
• Avoid infection, such as avoiding other people who have infections and washing hands frequently
• May cause bleeding, decrease likelihood by shaving with an electric razor, avoid aspirin and other NSAID

Macular degeneration patho

• Wet- abrupt onset and is more damaging to the vision; lines appear crooked and distorted or that letter in words appear broken: tx with laser therapy to stop leakage
• Dry- the outer layers of the retina slowly break down: no known therapy for dry
  -Amsler grids are given to the patients to use at home to monitor sudden onset or distortion of vision

CVA visual perception
A stroke can cause visual disturbances

• Visual loss, diplopia, ptosis can occur if the aneurysm is adjacent to the oculomotor nerve
• Homonymous hemianopsia- blindness in half of the visual field in one or both eyes could be temp. or permanent

Well differentiated cells
-Lower grade cancers are typically less aggressive and have a better prognosis.
-How developed the cancer cells are and how well they are organized in the tissue or organ
-Cancer cells are compared to normal cells in an organ or tissue. Grade and differentiation are basically the same but grading is a standardized way of measuring differentiation.
-Tend to be less aggressive (grow and spread slowly)
-Benign