1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?
A. Checking the client’s blood pressure
B. Checking the client’s peripheral pulses
C. Checking the most recent potassium level
D. Checking the client’s intake-and-output record for the last 24 hours
A. Checking the client’s blood pressure
Checking the client’s blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client’s blood pressure immediately before administering each dose. Checking the client’s peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?
A. “The test will take about 30 minutes.”
B. “I need to fast for 8 hours before the test.”
C. “I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test.”
D. “I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for the test can be constipating.”
C. “I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test.”
An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.
3-A nurse on the evening shift checks a physician’s prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician’s answering service and is told that the physician is off for the night and will be available in the morning. The nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
B. Ask the answering service to contact the on-call physician
4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client’s carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client’s cardiac status
D. Informing the client that PVCs are expected after an MI
B. Asking the ED physician to check the client
5.NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client’s record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
A. Administer the antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft surgery comes to the physician’s office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?
A. “Tell me more about what you’re feeling.”
B. “That’s a normal response after this type of surgery.”
C. “It will take time, but, I promise you, you will get over this depression.”
D. “Every client who has this surgery feels the same way for about a month.”
A. “Tell me more about what you’re feeling.”
7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority?
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
A. Contacting the physician Correct
8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client’s blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed rate
D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency
A. Call the radiography department to obtain a chest x-ray
9 A rape victim being treated in the emergency department says to the nurse, “I’m really worried that I’ve got HIV now.” What is the appropriate response by the nurse?
A. “HIV is rarely an issue in rape victims.”
B. “Every rape victim is concerned about HIV.”
C. “You’re more likely to get pregnant than to contract HIV.”
D. “Let’s talk about the information that you need to determine your risk of contracting HIV.”
D. “Let’s talk about the information that you need to determine your risk of contracting HIV.”
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
C. Take the medication with food
11 A client’s oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client’s Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client’s total intake during the 24-hour period? Type your answer in the space provided.
Answer: ________mL
Correct Responses: “1670”
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:
A. 3 minutes
B. 10 seconds
C. 15 seconds
D. 30 minutes
A. 3 minutes Correct
13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of:
A. Depression
B. Diabetes mellitus
C. Hyperthyroidism
D. Coronary artery disease
A. Depression
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness
D. Neck stiffness or soreness Correct
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication?
A. The client has a history of cataracts.
B. The client has a history of hypothyroidism.
C. The client takes a prescribed antihypertensive.
D. The client is allergic to acetylsalicylic acid (aspirin).
C. The client takes a prescribed antihypertensive.
16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?
A. Fever
B. Diarrhea
C. Hypertension
D. Tongue protrusion
D. Tongue protrusion
17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client’s record, would indicate a need to contact the physician who is scheduled to perform the ECT?
A. Recent stroke
B. Hypothyroidism
C. History of glaucoma
D. Peripheral vascular disease
A. Recent stroke
18 A client scheduled for suprapubic prostatectomy has listened to the surgeon’s explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:
A. A lower abdominal incision
B. An upper abdominal incision
C. An incision made in the perineal area
D. The urethra, with the use of a cutting wire
A. A lower abdominal incision
19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply.
A. Seek medical advice if you find a skin lesion.
B. Use sunscreen with a low sun protection factor (SPF).
C. Avoid sun exposure before 10 a.m. and after 4 p.m.
D. Wear a hat, opaque clothing, and sunglasses when out in the sun.
E. Examine the body every 6 months for possibly cancerous or precancerous lesions.
A. Seek medical advice if you find a skin lesion.
D. Wear a hat, opaque clothing, and sunglasses when out in the sun.
20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d’orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client’s breast?
SEE PICS
A.
B.
C.
D.
B. Correct
21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child’s participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:
A. To always administer less insulin on the days of soccer games
B. That it is best not to encourage the child to participate in sports activities
C. That the child should eat a carbohydrate snack about a half-hour before each soccer game
D. To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present
C. That the child should eat a carbohydrate snack about a half-hour before each soccer game
22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, “Why should I even bother to watch what I eat and drink? It doesn’t really matter what I do if I’m never going to get better!” On the basis of the client’s statement, the nurse determines that the client is experiencing which problem?
A. Anxiety
B. Powerlessness
C. Ineffective coping
D. Disturbed body image
B. Powerlessness
23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?
A. “What are your feelings right now?”
B. “Why don’t you feel like washing up?”
C. “You aren’t talking today. Cat got your tongue?”
D. “You need to get yourself cleaned up. You have company coming today.”
A. “What are your feelings right now?”
24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note?
A. Clear and yellow
B. Thick and opaque
C. White and odorless
D. Clear, with a foul odor
B. Thick and opaque
25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?
A. Administering 100% oxygen
B. Having a crisis counselor available
C. Instituting suicide precautions for the client
D. Obtaining blood for determination of the client’s carboxyhemoglobin level
A. Administering 100% oxygen
26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client’s concern, which problem does the nurse identify?
A. Anxiety
B. Powerlessness
C. Disruption of thought processes
D. Inability to maintain health
A. Anxiety
27 A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?
A. “Do you chew tobacco?”
B. “Do you smoke cigarettes?”
C. “Have you ever worked in a mine?”
D. “Are you frequently exposed to paint products?”
C. “Have you ever worked in a mine?”
28 A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads “4 mg/mL.” How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided.
Answer: _____mL
Incorrect
Correct Responses: “1, .625, 0.625”
29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:
A. To call his physician
B. That he needs to drink more fluids
C. That this is an occasional side effect of the medication
D. That this may be a sign of developing toxicity of the medication
C. That this is an occasional side effect of the medication Correct
30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
D. Improved swallowing function
D. Improved swallowing function
31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson’s disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?
A. Insomnia
B. Rigidity and akinesia
C. Bilateral lung wheezes
D. Orthostatic hypotension
C. Bilateral lung wheezes
32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply.
A. Smoking Correct
B. A high-calcium diet
C. High alcohol intake Correct
D. White or Asian ethnicity Correct
E. Participation in physical activities that promote flexibility and muscle strength
A. Smoking Correct
C. High alcohol intake Correct
D. White or Asian ethnicity Correct
33 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:
A. Corn
B. Cocoa
C. Peaches
D. Sardines
D. Sardines
34 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply.
A. Drinking 2 to 3 L of fluid each day
B. Applying heat packs to the affected joint
C. Resting and immobilizing the affected area
D. Consuming foods high in purines
E. Performing range-of-motion exercise to the affected joint three times a day
A. Drinking 2 to 3 L of fluid each day Correct
C. Resting and immobilizing the affected area Correct
35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.
A. Fatigue
B. Anemia
C. Weight loss
D. Low-grade fever
E. Joint deformities
A. Fatigue Correct
D. Low-grade fever Correct
36 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply.
A. Fever
B. Vasculitis
C. Weight gain
D. Increased energy
E. Abdominal pain
A. Fever Correct
B. Vasculitis Correct
E. Abdominal pain Correct
37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.
A. Beer
B. Apples
C. Yogurt
D. Baked haddock
E. Pickled herring
F. Roasted fresh potatoes
A. Beer Correct
C. Yogurt Correct
E. Pickled herring Correct
38 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:
A. Contact the physician
B. Hold the next dose of imipramine
C. Document the laboratory result in the client’s record
D. Have another blood sample drawn and ask the laboratory to recheck the imipramine level
C. Document the laboratory result in the client’s record Correct
39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.
A. “I need to avoid salt in my diet.”
B. “It’s fine to take any over-the-counter medication with the lithium.”
C. “I need to come back the clinic to have my lithium blood level checked.”
D. ” I should drink 2 to 3 quarts of liquid every day.”
E. “Diarrhea and muscle weakness are to be expected, and if these occur I don’t need to be concerned.”
A. “I need to avoid salt in my diet.” Correct
B. “It’s fine to take any over-the-counter medication with the lithium.” Correct
E. “Diarrhea and muscle weakness are to be expected, and if these occur I don’t need to be concerned.” Correct
40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:
A. Contact the physician
B. Document the findings
C. Institute seizure precautions
D. Have a blood specimen drawn immediately for serum lithium testing
B. Document the findings Correct
41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:
A. Having the client perform a healthy coping behavior
B. Having the client perform a ritualistic or compulsive behavior
C. Providing a high degree of exposure of the client to the stimulus that the client finds undesirable
D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening
D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening
42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, “I’m really thirsty — may I have something to drink?” Before giving the client a drink, the nurse should:
A. Check the client’s vital signs
B. Check for the presence of a gag reflex
C. Assess the client for the presence of bowel sounds
D. Ask the client to gargle with a warm saline solution
B. Check for the presence of a gag reflex
43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?
A. Inability to cope
B. Decreased nutrition
C. Decreased fluid volume
D. Inability to tolerate activity
C. Decreased fluid volume
44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:
A. The sex of the fetus
B. Genetic characteristics
C. An accurate age for the fetus
D. The degree of fetal lung maturity
D. The degree of fetal lung maturity
45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.
A. Bananas
B. Potatoes
C. Spinach
D. Legumes
E. Whole grains
F. Milk products
C. Spinach Correct
D. Legumes Correct
E. Whole grains Correct
46 A nurse caring for a client with pre-eclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client’s bedside?
A. Vitamin K
B. Protamine sulfate
C. Potassium chloride
D. Calcium gluconate
D. Calcium gluconate
47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client’s heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:
A. Contacting the physician
B. Documenting the findings
C. Continuing to monitor the client
D. Increasing the rate of the infusion
A. Contacting the physician
48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:
A. Sodium intake is restricted
B. Fluid intake must be limited to 1 quart each day
C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period
D. Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein
C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period
49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.
Answer: _ Correct Responses: “1”___
Nursing Progress Notes
- Hyperreflexia is present.
- Urinary protein is not detectable.
- Urine output is 45 mL/hr.
- Blood pressure is 128/78 mm Hg.
50 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?
A. Spontaneous bruising
B. Decrease in uterine size
C. Urine output of 30 mL/hr
D. Brownish vaginal discharge
A. Spontaneous bruising
51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:
A. Stops the oxytocin infusion Correct
B. Checks the vagina for crowning
C. Encourages the client to take short, deep breaths
D. Increases the rate of the oxytocin infusion and calls the physician
A. Stops the oxytocin infusion
52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation?
A. Repositioning the mother
B. Documenting the finding Correct
C. Notifying the nurse-midwife
D. Taking the mother’s vital signs
B. Documenting the finding
53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client?
A. Nausea
B. Bloody urine
C. Hearing loss
D. Electrocardiographic changes
C. Hearing loss
54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client?
A. Painful vaginal bleeding
B. Sustained tetanic contractions
C. Complaints of abdominal pain
D. Soft, relaxed, nontender uterus
D. Soft, relaxed, nontender uterus
55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?
A. A discoid uterus
B. Sudden sharp vaginal pain
C. Shortening of the umbilical cord
D. A sudden gush of dark blood from the introitus
D. A sudden gush of dark blood from the introitus
56 A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?
A. The client reports a history of sexual abuse by her father.
B. The client reports that her relationship with her spouse is stable.
C. The client reports a satisfying intimate relationship with her spouse.
D. The client reports that her and her spouse have never been able to conceive children
A. The client reports a history of sexual abuse by her father.
57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?
A. “I can resume sexual activity in 4 to 6 weeks.”
B. “I need to avoid straining when I have a bowel movement.”
C. “I should wear support hose for 6 months and elevate my legs frequently.”
D. “I need to contact my surgeon immediately if I feel any numbness in my genital area.”
D. “I need to contact my surgeon immediately if I feel any numbness in my genital area.”
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.
A. Skin tenting
B. Flat neck veins
C. Weak peripheral pulses
D. Moist oral mucous membranes
E. A heart rate of 88 beats/min
F. A respiratory rate of 18 breaths/min
A. Skin tenting Correct
B. Flat neck veins Correct
C. Weak peripheral pulses Correct
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided.
Answer ____mL
Correct Responses: “350”
60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:
A. Salt substitutes
B. Herbs and spices
C. Salt with cooking only
D. Processed foods as desired
B. Herbs and spices
61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?
A. Coffee
B. Broccoli
C. Cheeseburger
D. Chocolate milk
C. Cheeseburger
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington’s disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?
A. Headache
B. Drowsiness
C. Photophobia
D. Urinary frequency
B. Drowsiness
63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?
A. Diarrhea
B. Vomiting
C. Epistaxis
D. Epigastric pain
C. Epistaxis
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?
A. Count the number of times that the infant swallows during a feeding
B. Weigh the infant every day and check for a daily weight gain of 2 oz
C. Count wet diapers to be sure that the infant is having at least six to 10 each day
D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant
C. Count wet diapers to be sure that the infant is having at least six to 10 each day
65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?
A. “My child will need to do exercises.”
B. “My child needs to wear the brace 18 to 23 hours per day.”
C. “Wearing the brace is really important in curing the scoliosis.”
D. “I need to check my child’s skin under the brace to be sure it doesn’t break down.”
C. “Wearing the brace is really important in curing the scoliosis.”
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:
A. Milk
B. Water
C. Any meal
D. Tomato juice
D. Tomato juice
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:
A. Increase
B. Decrease
C. Remain unchanged
D. Double from what they normally are
B. Decrease
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client’s foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:
A. No edema is present
B. The client is dehydrated
C. Pitting edema is present
D. Blood is not pooling in the extremities
C. Pitting edema is present
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
A. Contact the physician
B. Document the findings
C. Ask the client to walk for 5 minutes, then recheck the reflexes
D. Perform active and passive range-of-motion exercises of the client’s lower extremities, then recheck the reflexes
B. Document the findings
70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?
A. Hysterectomy
B. Insertion of an indwelling catheter
C. Administration of oxytocin (Pitocin)
D. Replacement of the uterus through the vagina into a normal position
D. Replacement of the uterus through the vagina into a normal position
71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client’s temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:
A. Notify the physician
B. Recheck the temperature in 4 hours
C. Encourage the client to breastfeed the newborn
D. Institute strict bedrest for the client and notify the physician
B. Recheck the temperature in 4 hours
72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be:
A. Documenting the findings
B. Encouraging the woman to walk
C. Helping the woman empty her bladder Correct
D. Massaging the fundus gently until it becomes firm
C. Helping the woman empty her bladder
73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks’ gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client’s vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client’s plan of care, which client concern does the nurse identify as the priority at this time?
A. Anxiety Correct
B. Premature grief
C. Fluid volume loss
D. Fluid volume overload
A. Anxiety
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?
A. Increased platelet count
B. Shortened prothrombin time
C. Positive result on d-dimer study
D. Decreased fibrin-degradation products
C. Positive result on d-dimer study
75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.
A. Tachycardia Correct
B. Cool, clammy skin
C. Decreased respiratory rate
D. Diminished peripheral pulses Correct
E. Urine output of less than 30 mL/hr
A. Tachycardia Correct
D. Diminished peripheral pulses Correct
76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?
A. Checking the client’s urine output
B. Inserting an intravenous (IV) line
C. Obtaining informed consent for a cesarean delivery
D. Placing the client in a lateral position with the bed flat
D. Placing the client in a lateral position with the bed flat
77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?
A. Pink lochia on postpartum day 4
B. White lochia on postpartum day 11
C. Bloody lochia on postpartum day 2
D. Reddish lochia on postpartum day 8
D. Reddish lochia on postpartum day 8
78 A nurse in a physician’s office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:
A. Document the findings
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then recheck the abdome
A. Document the findings
79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?
A. “Many of my antibodies are passed through the placenta.”
B. “The placenta maintains the body temperature of my baby.”
C. “Glucose, vitamins, and electrolytes pass through the placenta.”
D. “It provides an exchange of oxygen and carbon dioxide between me and my baby.”
B. “The placenta maintains the body temperature of my baby.”
80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is:
A. June 2, 2013
B. July 2, 2013
C. October 2, 2013
D. September 18, 2013
B. July 2, 2013
81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?
A. Steak
B. Spinach
C. Chicken
D. Oranges
A. Steak
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?
A. Sodium 140 mEq/L
B. Hemoglobin 12.5 g/dL
C. Blood urea nitrogen (BUN) 20 mg/dL
D. White blood cell count of 2500 cells/mm3
D. White blood cell count of 2500 cells/mm3
83 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse?
A. Nulliparity
B. Early menarche
C. Multiple sexual partners Correct
D. Hormone-replacement therapy
C. Multiple sexual partners
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?
A. Umbilical cord compression
B. Pressure on the fetal head during a contraction
C. Uteroplacental insufficiency during a contraction Correct
D. Inadequate pacemaker activity of the fetal heart
C. Uteroplacental insufficiency during a contraction
85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
C. When pelvic sensation and response to stimuli return
D. In about 6 weeks, when the vaginal vault is satisfactorily healed
D. In about 6 weeks, when the vaginal vault is satisfactorily healed
86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:
A. Monitoring the client for signs of returning peristalsis
B. Instructing the client in dietary changes to prevent constipation
C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct
D. Encouraging the client to talk about the effects of the surgery on her femininity and sexual
C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer
87- A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?
A. Fever
B. Dizziness
C. Flatulence
D. Drowsiness
A. Fever
88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician?
A. Nausea
B. Dark urine
C. Urinary frequency
D. Decreased appetite
B. Dark urine
89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?
A. Frequent suctioning
B. Maintaining cuff pressure
C. Maintaining mechanical ventilation settings
D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis
B. Maintaining cuff pressure
90 – A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?
SEE PIC
A.
B.
C.
D.
D.
91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply
A. Keeping the room slightly darkened
B. Placing the client in a room with a quiet roommate
C. Encouraging isometric exercises if bed rest is prescribed
D. Monitoring the client for changes in alertness or mental status
E. Restricting visits to close family members and significant others and keeping visits short
A. Keeping the room slightly darkened Correct
D. Monitoring the client for changes in alertness or mental status Correct
E. Restricting visits to close family members and significant others and keeping visits short Correct
92 -A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.
A. Hunger
B. Weakness
C. Blurred vision
D. Increased thirst
E. Increased urine output
A. Hunger Correct
B. Weakness Correct
C. Blurred vision Correct
93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician’s instructions, understanding that the gait was selected after assessment of the client’s:
A. Physical and functional abilities
B. Feelings about restricted mobility
C. Uneasiness about using the crutches
D. Understanding of the need for increased mobility
A. Physical and functional abilities
94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, “I don’t think I’ll be able to do these feedings by myself.” Which response by the nurse is appropriate?
A. “Have you told your doctor how you feel?”
B. “Tell me more about your concerns regarding the tube feedings.”
C. “Don’t worry. We’ll keep you in the hospital until you’re ready to do them by yourself.”
D. “We’ll ask the doctor about having a visiting nurse come to your home to give you your feedings.”
B. “Tell me more about your concerns regarding the tube feedings.”
95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to:
A. Continue monitoring the client
B. Increase the amount of humidified oxygen
C. Continue administering humidified oxygen
D. Assist in intubating the client and beginning mechanical ventilation
D. Assist in intubating the client and beginning mechanical ventilation
96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client’s alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next?
A. Providing pin care
B. Medicating the client
C. Notifying the physician Correct
D. Removing some weight from the traction
C. Notifying the physician
97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse
A. Bivalve the cast
B. Ask the physician to reapply the cast
C. Use a nail file to smooth the rough edges
D. Place small pieces of tape over the rough edges of the cast
D. Place small pieces of tape over the rough edges of the cast
98 -A client says to the nurse, “My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it’s probably cancer. Does this mean I’m going to die?” The nurse interprets the client’s initial reaction as:
A. Fear
B. Denial
C. Acceptance
D. Preoccupation with self
A. Fear
99 -A nurse notes documentation in the client’s medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?
A.
B.
C.
D.
B. Correct
100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:
A. Always perform the exercises while lying down
B. Expect an improvement in the control of urine in about 1 week
C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day
D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10
D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10
101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication?
A. Cough
B. Fatigue and lethargy
C. Dizziness and fatigue
D. Numbness and tingling of the fingers or toes
D. Numbness and tingling of the fingers or toes
102 -A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn’t like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?
A. “That’s all right. I’d stop, too, if it made me feel funny.”
B. “Tell me more about how the medication was making you feel.”
C. “Did you let your doctor know that you stopped taking the medication?”
D. “It doesn’t make sense to stop the medication. I don’t know why you took it upon yourself to do that.”
B. “Tell me more about how the medication was making you feel.”
103- A nurse provides information to a client with peripheral vascular disease about ways to limit the disease’s progression. Which of the following measures does the nurse tell the client to take? Select all that apply.
A. Crossing the legs at the ankles only
B. Engaging in exercise such as walking on a daily basis
C. Washing the feet daily with a mild soap and drying them well
D. Inspecting the feet at least once a week for injuries, especially abrasions
E. Using a heating pad on the legs to help keep the blood vessels dilated
B. Engaging in exercise such as walking on a daily basis Correct
C. Washing the feet daily with a mild soap and drying them well Correct
104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?
A. Providing food and fluid as the client requests
B. Offering high-calorie and high-protein foods and fluids frequently throughout the day
C. Completing the dietary menu for the client to ensure that adequate nutrition is provided
D. Weighing the client daily so that the client may determine whether the nutritional plan is working
B. Offering high-calorie and high-protein foods and fluids frequently throughout the day
105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:
A. That driving is prohibited while the client is taking the medication
B. To take the medication immediately if the desire to drink alcohol occurs
C. That the effect of the medication ends as soon as the client stops taking the medication
D. That the medication cannot be started until at least 12 hours has elapsed since the client’s last ingestion of alcohol
D. That the medication cannot be started until at least 12 hours has elapsed since the client’s last ingestion of alcohol
106 A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, “I can’t draw or paint.” Which of the following responses by the nurse is therapeutic?
A. “Why don’t you really want to attend?”
B. “This is what your physician has prescribed for you as part of the treatment plan.”
C. “OK, let’s have you attend music therapy. You can sing there. How does that sound?”
D. “Perhaps you could attend and talk to the other clients and see what they’re drawing and painting.”
D. “Perhaps you could attend and talk to the other clients and see what they’re drawing and painting.”
107 A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, “Boys in blue are fun to do! Boys in blue are fun to do!” What is the appropriate response by the nurse?
A. “Why are you saying that?”
B. “Stop saying that. It’s not true!”
C. “You wouldn’t like someone saying that to you. Would you?”
D. “Don’t say that. If you can’t control yourself, we’ll help you.”
D. “Don’t say that. If you can’t control yourself, we’ll help you.”
108- A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
A. Stay with the client and observe her behavior
B. Take the client to the bathroom and provide her with a warm bath
C. Tell the client that it is time for sleep and that she needs to go to her room
D. Tell the client that other clients are trying to sleep and that she is being disruptive
B. Take the client to the bathroom and provide her with a warm bath
109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?
A. “I need to limit my intake of fluids while I’m taking this medication.”
B. “I need to stop the medication and call my doctor if I have severe diarrhea.” Correct
C. “I can expect skin redness and a rash when I take this medication.”
D. “I may get a burning feeling in my throat, but it’s normal and will go away.”
B. “I need to stop the medication and call my doctor if I have severe diarrhea.”
110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder?
A. Neediness
B. Perfectionism
C. Preoccupation with details
D. Hypersensitivity to negative evaluation
D. Hypersensitivity to negative evaluation
111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client’s symptoms?
A. Agoraphobia
B. Avoidant personality disorder
C. Obsessive-compulsive disorder
D. Dependent personality disorder
C. Obsessive-compulsive disorder
112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?
A. Inflexible and rigid
B. Self-sacrificing and submissive
C. Highly critical of self and others
D. Projecting blame, possibly becoming hostile
D. Projecting blame, possibly becoming hostile
113 -A client on the mental health unit says to the nurse, “Everything is contaminated.” The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:
A. Temporarily eases anxiety in the client
B. Is an attempt on the client’s part to punish herself
C. Is an attempt on the client’s part to seek the attention of others
D. Is a response by the client to voices telling her that everything is contaminated and that she must engage in this behavior
A. Temporarily eases anxiety in the client
114 -A male client arrives at the emergency department and reports to the nurse, “I woke up this morning and couldn’t move my arms.” He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee’s hands were severed by a machine. What is the priority response by the nurse?
A. Assessing the client for organic causes of loss of arm movement
B. Calling the crisis intervention team and asking them to assess the client
C. Performing active and passive range-of-motion (ROM) exercises of the client’s arms
D. Asking the client to move his arms and documenting the loss of movement he has experienced
A. Assessing the client for organic causes of loss of arm movement
115 -A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?
A. Perform the physical assessment
B. Tell the client about the nursing unit rules
C. Establish a trusting nurse-client relationship
D. Tell the client that he or she will have to participate in self-care
C. Establish a trusting nurse-client relationship
116 -A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:
A. Severe anxiety
B. Conversion disorder
C. Posttraumatic stress disorder (PTSD)
D. Obsessive-compulsive disorder
B. Conversion disorder
117 -A client experiencing delusions says to the nurse, “I am the only one who can save the world from all of the terrorists.” What is the appropriate response by the nurse?
A. “Tell me your plan for saving the world.”
B. “Why do you think that you can accomplish this by yourself?”
C. “I don’t think anyone can save the world from the terrorists by himself.”
D. “You must be powerful. Do you really believe that you can do this by yourself?”
C. “I don’t think anyone can save the world from the terrorists by himself.”
118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.
A. Eat foods that are low in fat and protein
B. Obtain pneumococcal and influenza vaccines
C. Drink copious amounts of fluid and void frequently
D. Avoid contact with any individual who has signs or symptoms of a cold
E. Avoid contact with all individuals other than immediate family members
C. Drink copious amounts of fluid and void frequently Correct
D. Avoid contact with any individual who has signs or symptoms of a cold Correct
119- A client who is scheduled to undergo chemotherapy asks the nurse, “Is my hair going to fall out?” The nurse responds by telling the client that:
A. Her hair will definitely fall out
B. She should not be worrying about her hair at this point
C. Her hair may fall out but will regrow after the chemotherapy is discontinued
D. Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss
C. Her hair may fall out but will regrow after the chemotherapy is discontinued
120 -A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching?
A. “I can’t drink alcohol.”
B. “I have to avoid having sex until the test for antibodies comes back negative.”
C. “I need to rest a lot during the day and get enough sleep at night.”
D. “I need to eat three meals a day with foods high in protein, fat, and carbs.”
D. “I need to eat three meals a day with foods high in protein, fat, and carbs.”
121- A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:
A. Drink fluids to eliminate the dye
B. Contact the physician if the skin appears yellow
C. Expect that the urine will be bright green until the dye has been excreted
D. Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal
B. Contact the physician if the skin appears yellow
122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply.
A. Nausea
B. Eye pain
C. Vomiting
D. Headache
E. Diminished central vision
F. Increased light perception
A. Nausea Correct
B. Eye pain Correct
C. Vomiting Correct
D. Headache Correct
123 – A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?
A. 8 mm Hg
B. 14 mm Hg
C. 20 mm Hg
D. 28 mm Hg
D. 28 mm Hg
124- An emergency department nurse assessing a client with Bell’s palsy collects subjective and objective data. Which of the following findings does the nurse expect to note?
A. A symmetrical smile
B. Tightening of all facial muscles
C. Ability to wrinkle the forehead on request
D. Complaints of inability to close the eye on the affected side
D. Complaints of inability to close the eye on the affected side
125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate?
A. Asking the child to describe the intensity of the pain
B. Asking the child to use a numeric rating scale of 0 to 100
C. Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain
D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain
D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain
126 A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?
A. Contacting the child’s physician to report the findings
B. Administering acetaminophen (Tylenol) to the child to relieve the pain
C. Asking that the child not attend the physical education class until the neck pain has subsided
D. Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control
A. Contacting the child’s physician to report the findings
127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?
A. “When was your last menstrual period?”
B. “When was your last bowel movement?”
C. “Are you having any difficulty hearing?”
D. “Are you having any difficulty breathing?”
C. “Are you having any difficulty hearing?”
128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction?
A. “It’s important to rotate injection sites.”
B. “I need to store the insulin in a cool, dry place.”
C. “I need to keep any unopened bottles of insulin in the freezer.”
D. “I need to check the expiration date on the insulin before I use it.”
C. “I need to keep any unopened bottles of insulin in the freezer.”
129 -A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test:
A. Is a measure of the client’s hematocrit level
B. Is a measure of the client’s hemoglobin level
C. Helps predict the risk for the development of chronic complications of diabetes mellitus
D. Provides a determination of short-term glycemic control in the client with diabetes mellitus
C. Helps predict the risk for the development of chronic complications of diabetes mellitus
130- A client living in a long-term care facility shouts at the nurse, “Get out of my room! I don’t need your help!” What is the appropriate way for the nurse to document this occurrence in the client’s record?
A. Writing that the client is very agitated
B. Writing that the client yelled at the nurse
C. Writing that the client is able to perform her own care
D. Writing down the client’s words and placing them in quotation marks
D. Writing down the client’s words and placing them in quotation marks
131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client’s bedside?
A. Bedside commode
B. Suctioning equipment
C. Electrocardiography machine
D. Oxygen cannula and flowmeter
D. Oxygen cannula and flowmeter
132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to:
A. Increase fluid intake
B. Consume low-fiber foods
C. Consume foods that are low in potassium
D. Contact the physician if the urine turns yellow-brown
A. Increase fluid intake
Acute Respiratory Distress Syndrome (ARDS)
The exchange of oxygen for carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production within the body’s cells
Characteristics of ARDS
Hypoxemia that persists even when 100% oxygen is given; decreased pulmonary compliance; dyspnea; non-cardiac associated bilateral pulmonary edema; dense pulmonary infiltrates on X-ray
ARDS
No abnormal breath sounds are present in this disorder on auscultation because the edema occurs first in the interstitial spaces and not the airways.
ARDS
Unexpected, catastrophic pulmonary complication occurring in a person with no pervious pulmonary problems.
ARDS
Common laboratory finding is a lowered pO2; not responsive to high concentrations of oxygen and often need intubation and mechanical ventilation with PEEP
PEEP Positive end-expiratory pressure
The instillation and maintenance of small amounts of air into the alveolar sacs to prevent then from collapsing each time the client exhales; amount of pressure can be set and is usually around 5-10cm of water
Nursing Assessment of ARDS
Dyspnea, hyperpnea; intercostals retractions; cyanosis, pallor; hypoxemia; diffuse pulmonary infiltrates seen on chest radiograph as “white-out” appearance; verbalized anxiety, restlessness
Hypoxemia
PO2 < 50mmHg with FiO2 >60%
Common causes of respiratory failure
COPD; pneumonia; tuberculosis; contusion; aspiration; inhaled toxins’ emboli; drug OD; fluid overload; DIC; shock
Suction
When providing care to a patient with ARDS, only do this when secretions are present
7.35-7.45
PH normal value
35-45 mmH
PCO2 normal value
22-26 mEq
HCO3 normal value
80-100mm
PO2 normal value
95-100%
O2 normal value
Allen Test
Perform this test before drawing an ABG from the radial artery
Common cause of respiratory failure in children
Congenital heart disease; respiratory distress syndrome; infection, sepsis; neuromuscular diseases; trauma and burns; aspiration; fluid overload and dehydration; anesthesia and narcotic OD
Nursing assessment of child in respiratory failure
Kid just “looks bad;” very slow or very rapid RR, dyspnea, apnea, gasping; tachycardia; cyanosis, pallor, or mottled color; irritability and lethargy; retractions, nasal flaring, poor air movement; hypoxemia, hypercapnia, respiratory acidosis
Respiratory Failure
PCO2 > 45 or PO2 < 60 on 50% O2; a child in severe distress should be on 100% O2
Shock
Widespread, serious reduction of tissue perfusion which, if prolonged, leads to generalized impairment of cellular functioning
System Hypotension
Marked reduction in either cardiac output or peripheral vasomotor tone, without a compensatory elevation in the other results in this
Early signs of shock
Agitation and restlessness that results from cerebral hypoxia
Hypovolemic Shock
Related to external or internal blood or fluid loss
Cardiogenic Shock
Related to ischemia or impairment in tissue perfusion resulting from MI, serious arrhythmia, or HF; all cause decrease CO
Vasogenic Shock
Related to allergens, spinal cord injury, or peripheral neuropathies, all resulting in venous pooling and decreased blood return to the heart, which decreases cardiac output over time
Septic Shock
Related to endotoxins released by bacteria, which cause vascular pooling, diminished venous return, and reduced CO
High fowler position with legs down
Position to reduce venous return in order to decrease further venous return to the left ventricle
Medical treatment for shock
Rapid infusion of volume-expanding fluids such as whole blood, plasma, plasma substitutes; isotonic, electrolyte IV solutions; CVP artery catheters; CVP measurements, urine output, HR, clinical and mental state; immediate attendtion to improvement of perfusion; administration of drugs is withheld until circulating volume has been restores; O2 administration
Pulmonary edema
If shock is cardiogenic in nature, the infusion of volume-expanding fluids may result in this
Cardiac Function
When treating a patient with shock, the restoration of what should take priority
Increase Cardiac Contractility
Administration of cardiotonic drugs such as digitalis does what?
Dopamine and digitalis
Increases the contractility
Dopamine (Dopram) and norepinephrine (Levophed)
Vaso-constricting agents that may be used in cardiogenic shock
Nursing Assessment of patient in shock
Tachycardia, tachypnea, decrease in BP (systolic <80mmHg) ; mental status changes; cool, clammy skin; diaphoresis, paleness; urine output decreases; CVP <4cm of H2O; urine SG >1.020
Hypovolemia
Urine SG >1.020 indicates?
Early shock mental status changes
Restless, hyper-alert
Late shock mental status changes
Decreased alertness, lethargy, coma
Patient in shock
Maintain a urine output of at least 30ml/hr and notify health care provider if it drops below this
CVP
Administer prescribed fluids until designated ?? is reached in patients with shock
CVP
When a patient is in shock, this number is usually elevated to 16-19 cm of H2O as compensation for decreased cardiac output
Patient in shock
Place this patient in Trendelenburg position (feet up 45 degrees, head flat
IM or Subcutaneous route
Do not administer medications via these routes to a patient in shock until perfusion improves to the muscles and subcutaneous tissues
Vasopressors or adrenergic stimulants
When administering these medications to a patient in shock, they must be administered via a volume-controlled pump; monitor BP q 5-15 min; watch IV site carefully for extravasation and tissue damage; ask about the target mean systolic BP
Vasopressors or adrenergic stimulants used in shock patients
Epinephrine (Bronkaid). Dopamine (Dopram), Dobutamine (Dobutrex), norepinephrine (Levophed), isoproterenol (Isuprel)
Vasodilators used in shock patients
Hydralazine (Apresoline), nitroprusside (Nipride), labetalol hydrochloride (Normodyne, Trandate)
Vasopressor and vasodilator drugs
Potent drugs used in shock patients; dangerous and require that the client be weaned onto and off them. Don’t change both infusions rates simultaneously.
Vasodilator; Vasopressor
If drop in BP occurs, decrease ?? infusion rate first, then increase ?? rate
Vasopressor; Vasodilator
If BP increases, decrease ?? rate first, then increase the rate of the ??
Stage 1 of hypovolemic shock
Initial stage; blood loss of less than 10%; compensatory mechanisms triggered; apprehension and restlessness; increased HR; cool, pale skin; fatigue; arteriolar constriction; increased production of ADH; arterial pressure maintained; CO normal; reduction in blood flow to the skin and muscle beds
Stage 2 of Hypovolemic Shock
Compensatory stage; blood volume reduced by 15%-25%; decompensation begins; flattened neck veins and delayed venous filling time; increased HR&RR; pallor, diaphoresis and cool skin; decreased UP; sunken soft eyeballs; confusion; marked reduced in CO; arterial pressure decline; massive adrenergic compensatory response; decrease cerebral perfusion
massive adrenergic compensatory response
Tachycardia, tachypnea, cutaneous vasoconstriction and oliguria
Stage 3 of Hypovolemic shock
Progressive stage; edema; increased blood viscosity; excessively low BP; dysrhythmia, ischemia, and MI; weak, thread, or absent peripheral pulses; rapid circulatory deterioration; decreased CO; decreased tissue perfusion; reduced blood volume
Stage 4 of Hypovolemic shock
Irreversible stage; profound hypotension that is unresponsive to vasopressor drugs; severe hypoxemia that is unresponsive to O2; anuria, renal shut down; HR slows, BP falls with consequent cardiac and respiratory arrest; cell destruction so severe that death is inevitable; multiple organ system failure
Severe shock
Leads to widespread cellular injury and impairs the integrity of the capillary membranes
Fluid and osmotic proteins
Seep into the extravascular spaces, further reducing CO
Mean arterial pressure
Normal value in adults 100mmHg
Mean arterial pressure
Level of pressure in the central arterial bed measured indirectly by BP; measured directly through arterial catheter insertion
MAP calculation
CO x total peripheral resistance = systolic BP + 2/3
Cardiac Output
Volume of blood ejected by the left ventricle per unit of time
Cardiac output
Normal value is 4-6L/min
CO calculation
Stroke volume (amount of blood ejected per beat) x HR
Peripheral resistance
Resistance to blood flow offered by the vessels in the peripheral vascular bed.
Central venous pressure
Pressure within the right atrium
Central venous pressure
Normal values are between 4-10cm H2O
Packed RBC
Less danger of fluid overload; used for acute blood loss
Frozen RBCs
Prepared from RBCs using glycerol for protection and then frozen
Frozen RBCs
Must be used within 24 hours of being thawed; used as an auto transfusion; infrequently used because filters remove most of the WBCS
Platelets
pooled 300mL; one unit contains single donor (200mL)
Platelets
Bag should be agitated periodically; used for bleeding caused by thrombocytopenia
Fresh frozen plasma
Liquid portion of whole blood is separated from cells and frozen
Fresh frozen plasma
The use of this is being replaced by albumin plasma expanders; used for bleeding caused by deficiency in clotting factors
Albumin
Prepared from plasma and is available in 5% and 20% solutions
Albumin
25g/100mL is osmotically equal to 500mL of plasma; used for hypovolemic shock and hypoalbuminemia
Cryoprepcipitates and commercial concentrates
Prepared from fresh frozen plasma with 10-20mL/bag
Cryoprepcipitates and commercial concentrates
Used in treated hemophilia; replacement of clotting factors, especially factor VII and fibrinogen
Acute hemolytic
Chills, fever, low back pain, flushing, tachycardia, hypotension pressing to acute renal failure, shock and cardiac arrest
Nursing interventions for acute hemolytic Reaction
STOP TRANSFUSION; change tubing, then continue saline IV; treat for shock; draw blood samples for serologic testing; monitor UOP hourly; give diuretics
Febrile nonhemolytic reaction
Most common blood transfusion reaction; sudden chills and fever, headaches, flushing, anxiety, and muscle pain
Febrile nonhemolytic reaction nursing interventions
Give antipyretics
Mild allergic reaction
Flushing, itching, hives (urticaria)
Mild allergic reaction nursing interventions
Give antihistamine
Anaphylactic and severe allergic reaction
Anxiety, uricaria, wheezing progressive cyanosis leading to shock and possible cardiac arrest
Anaphylactic and severe allergic reaction nursing interventions
Initiate CPR
Magnesium sulfate
CNS depressant administered to a preeclamptic client to prevent seizures, may be used as a tocolytic to stop preterm labor contractions; adverse reactions: CNS depression: depressed RR, depressed DTRs, decreased urine output, pulmonary edema; hold if RR <12 or urine output <100ml/4hr; DTRs absent; monitor levels; therapeutic range 5-8mg/dl; remind client of warm, flushed feeling with IV administration; keep calcium gluconate antidote
Magnesium toxicity
RR<12, urine output <100ml/4hr, absent DTRs, levels >8mg/dl
Tachycardia
Major side effect of terbulatine (brethine) and ritodrine (yutopar); used to stop preterm labor; withhold if pulse >120-140
Fentanyl citrate (Sublimaze)
Used as an adjunct to anesthesia; adverse reactions: respiratory depression, apnea, bradycardia, hypotension; have resuscitation equipment readily available; don’t mix with IB barbiturates
Morphine sulfate
Often first choice for severe pain; adverse reactions: NV, constipation, respiratory depression, depression of cough reflexes, hypotension; chest RR and BP before administration; have narcan available just incase
Ampicillin (ampicin, ampilean)
Broad-spectrum antibiotic used to treat postpartum endometritis, mastitis; adverse reactions: rash, dermatitis, NV, GI irritation; don’t administer to clients with penicillin; does appear in breast milk but may not cause neonate discomfort
Gentamicin sulfate (garamycin)
Indication: aminoglycoside antibiotic used for serious puerperal infections; adverse reactions: GI irritation, nephrotoxicty, ototoxicity, neurotoxicity, possible hypersensitivity; don’t mix with any other drug; observe fro ototoxicity, ataxia, tinnitus, headache, nephrotoxicitym elevated BUN and creatinine, neurotoxicity, parenthesia, muscle weakness, I&O closely
Sodium bicarbonate
Indicated for correction of severe metabolic acidosis in asphyxiated infants after adequate ventilation begun; adverse reaction: fluid overload, hypernatremia, intracranial hemorrhage; don’t mix with calcium solutions; pediatric concentration; infuse slowly and monitor I&O; newborn resiscitation
Epinephrine
Indicated for asystole or severe bradycardia; adverse reactions: tachyarrhythmias; make sure ventilation of newborn is adequate, do not inject directly into artery; monitor apical pulse or connect to ECG before use
Circulatory overload
Cough, dyspnea, pulmonary congestion, headache, hypertension
Circulatory overload nursing interventions
Place client in upright position with feet in dependent position and administer diuretics, O2 and morphine
Sepsis
Rapid onset of chills, high fever, vomiting, marked hypotension, or shock
Sepsis nursing interventions
Ensure patent airway, obtain blood for culture, administer prescribed antibiotics, take VS q 5 min
Nursing skills for blood transfusion
Use central venous catheter or 19 gauge needle; only use blood administration tubing; run blood products with saline only; check and double check product before infusing – correct product, correct blood type and RH factor
What to do if patient in shock arrives at the hospital
Maintain patent airway; keep client warm and free of constricting clothing; keep clients legs elevated
Epinephrine
1:1000, 0.2-0.5mL SUBCU for mild shock cases
Epinephrine
1:10,000; 5mL IV for severe cases of shock
Volume expanding drugs
Usually given to patients in shock
Drugs of choice for shock
Digitalis and vasoconstrictors preparations
Digitalis preparations
Increase contractility of the heart muscle
Levophed, Dompamine (vasoconstrictors)
Provides more blood to the heart to help maintain cardiac output
Disseminated intravascular clotting (DIC)
A coagulation disorder with paradoxic thrombosis and hemorrhage
DIC
Acute complication of conditions such as hypotention and septicemia; suspected when there is bloody oozing from two or more unexpected sites.
DIC
First phase involves abnormal clotting in the microcirculation, which uses up clotting factions and results in the inability to form clots, so hemorrhage occurs
DIC diagnosis
Prothrombin time (PT): prolonged; partial thromboplastim time (PTT): prolonged; fibrinogen: decreased; platelet count: decreased; fibrin degradation products: increased
DIC nursing assessment
Petechiae, purpura, hematomas; oozing from IV sites, drains, gums and wounds; GI and GU bleeding; hemoptysis; mental status changes; hypotension, tachycardia; pain
DIC nursing intervention
Administer heparin IV during first phase to inhibit coagulation
Heparin
Blocks the formation of thrombin
Care of a patient with DIC – hemorrhage stage
Administration of clotting factors, palliative treatment of the symptoms
Cardiopulmonary arrest
Necrosis of the heart muscle aused by inadequate blood supply to the heart; usually caused by MI; MI’s usually occur at rest or with moderate activity
Symptoms immediately preceding MI
Chest pain or discomfort at rest or with ordinary activity; change in previous angina pain; increase in frequency in CP or severity or rest angina; chest pain in a client with known coronary heart disease that is unrelieved by rest of nitroglycerin
Cardiopulmonary arrest
O2 is necessary for survival
Chest pain
Described as crushing, pressing, constricting, oppressive or heavy; increase in intensity for a few minutes; substernal or more diffused; may radiate to one or both shoulders and arms or to neck, jaw or back
When to seek emergency medical services
The symptoms of anterior myocardial infarction characteristically last more than 15 minutes and are more intense than angina; if chest discomfort worsens or is unimproved 5 minutes after taking one tablet of spray of nitro.
Management of cardiac arrest unwitnessed; out of hospital
Position person supine, tap and call out are you okay?; no response = call for help, ask someone to call 911, obtain AED; extend neck with head-tilt, chin-lift; assess breathing sounds by look-listen-feel method; no breathing is noted = ventilate with 2 mouth-mouth breaths, assess circulation by palpating carotid pulse; no pulse = compressions at 100/min
CPR
Performed at a 30:2 ratio of compression to ventilations; after 5 phases, reassess for breathing and pulse
20 weeks pregnant and beyond CPR
Shift the gravid uterus to the left by placing the woman in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left
In hospital cardiac arrest
No response, call a code; position on cardiac board; ventilate with O2 mask; initiate chest compressions; apply cardiac monitor “quick look” paddles to determine whether defibrillation is necessary; resume CPR after defibrillation
Defibrillation
Indicated in ventricular fibrillation or pulseless ventricular tachycardia
Bicarbonate
Not to be used unless hyperkalemia, tricyclic antidepressant overdose, or preexisting metabolic acidosis is documented
Neonatal resuscitation
Ventilations are done over the mouth and nose; palpate brachial pulse in infant <1 years; HR under 60 = compressions are done with thumbs side by side over the lower third of the sternum; compression to ventilation ratio of 3:1 (90 compressions; 30 breaths)
Child 1-8 resuscitation
Ventilations are mouth to mouth; chest compressure 1 inch with one palm at a rate of 100/min; 2 ventilations to 30 compressions; most common rhythm is asystole and bradycardia; give epinephrine at 0.01mg/kg body weight using a 1:10,000 solution
Pulseless arrest algorithm (PALS)
Search for treatment of possible contributing factors checking for Hypovolemia, hypoxia, hydrogen ion acidosis, hypo/hyper kalemia, tamponade, tension pneumothorax, thrombosis, trauma
Homeostasis
The process of maintaining a relative state of equilibrium; occurs in relation to maintenance of the composition of fluids
Osmolarity
Changes in this cause shifts in fluids
Extracellular fluid
The osmolarity of this is almost entirely due to sodium
Intracellular fluid
The osmolarity of this is almost entirely due to potassium
ECF & ICF
Pressures of these are almost identical
Lower; higher
Shift from the area of _ concentration to _ concentration
Dextrose 10%
A hypertonic solution and should be administered IV
Normal saline
An isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medications
Kidneys
Selectively maintain and excrete body fluids; retain needed substances and excrete unneeded substances; regulate pH by excreting or maintaining hydrogen ions and bicarbonate; excrete metabolic wastes and toxic substances
Lungs
Rid the body of 300mL of fluid/day; play a role in acid-base balance; regulate CO2 concentrations
Adrenal glands
Secrete aldosterone
Aldosterone
Causes sodium retention and potassium excretion
Parathyroid glands
Regulate calcium and phosphorus balance
Pituitary gland
Secretes ADH
ADH
Causes the body to retain water
Potassium
Imbalances that are potentially life-threatening
Low Magnesium
Often accompanies a low K+
Fluid volume deficit
Occurs when the body loses water and electrolytes isotonically; serum electrolyte levels remain normal; dehydration
Dehydration
State in which the body loses water and serum sodium levels increase
Fluid volume deficit signs and symptoms
Weight loss, decreased skin turgor, oliguria, dry/sticky mucous membranes, postural hypotension or weak, rapid pulse
Fluid volume deficit causes
Vomiting, diarrhea, GI suctioning, inadequate fluid intake, massive edema, ascites, forgetting to drink
Fluid volume deficit lab findings
Elevated BUN and creatinine; increased serum osmolarity; elevated HBG and HCT; urine osmolality and SG increases
Fluid volume deficit treatment
Strict I&O; replacement of fluids isotonically; water is hypotonic
Elevated BUN
Measures the amount of urea nitrogen in the blood; urea is formed in the liver as the end product of protein metabolism; directly related to the metabolic function of the liver and excretory function of the kidneys
Creatinine
Directly proportional to renal excretory function; affected very little by dehydration, malnutrition, or hepatic function
Serum osmolality
Measures the concentration of particles in a solution
Fluid volume excess
Occurs when the body retains water and electrolytes isotonically
Fluid volume excess causes
HR, renal failure, cirrhosis, liver failure, excessive ingestion of table salt, over hydration with sodium containing fluid, poorly controlled IV therapy
Fluid volume excess symptoms
Peripheral edema, increased bounding pulse, elevated BP, distended neck and hand veins, dyspnea; moist crackles head when lungs are auscultated, attention loss, confusion, aphasia, altered LOC
Fluid volume excess lab findings
Decreased BUN, decreased HBG&HCT, decreased serum osmolality, decreased urine osmolality and SG
Fluid volume excess treatment
Diuretics, fluid restriction, strict I&O, sodium restricted diet, weighed daily, K+ serum monitored
Normal sodium levels
135-145
Hyponatremia
Caused by diuretic, GI fluid loss, hypotonic tube feedings, D5W or hypotonic IV fluids, diaphoresis; S&S: anorexia, NV, weakness, lethargy, confusion, muscle cramps, twitching, seizures; level below 135Meq/L; restrict fluids, administer IV solutions SLOW
Hypernatremia
Caused by water deprivation, hypertonic tube feedings, diabetes insipidus, heat stroke, hyperventilation, watery diarrhea, renal failure, cushing syndrome; S&S: thirst, hyperpyrexia, stick mucous membranes, dry mouth, hallucinations, lethargy, irritability, seizures; level above 145meq/L; restrict sodium in diet, increase water intake
Normal potassium levels
3.5-5.0
Hypokalemia
Caused by diuretics, diarrhea, vomiting, gastric suction, steroid administration, hyperaldosteronism, amphotericin B, bulimia, cushing syndrome; S&S: fatigue, anorexia, NV, muscle weakness, decreased GI motility, dysrhythmias, paresthesia, flat T waves on ECG; levels less than 3.5; administer this supplement (never give IV bolus), assess renal status, encourage foods high in this
Hyperkalemia
Caused by hemolyzed serum sample produces pseudohyperkalemia, oliguria, acidosis, renal failure, Addison disease, multiple blood transfusions; S&S: muscle weakness, bradycardia, dysrhythmias, flaccid paralysis, intestinal colic, tall T waves, levels above 5.0meq/L; eliminate this from IC infusions and meds; administer 50% glucose with regular insulin; administer kayexalate; monitor ECG; administer calcium gluconate to protect the heart, IV loop diuretics, renal dialysis
Normal calcium levels
8.5-10.5
Hypocalcemia
Caused by renal failure, hypoparathyroidism, malabsorption, pancreatitis, alkalosis; S&S: diarrhea, numbness, tingling of extremeties, convulsions, positive trousseau sign; levels below 8.5meq/L; at risk for tetanty; administer these supplements 30 min before meals; increase intake; administer IV slowly
Hypercalcemia
Caused by: hyperparathyroidism, malignant bone disease, prolonged immobilization, excess supplementation; S&S: muscle weakness, constipation, anorexia, NV, polyuria, polydipsia, neurosis, dysrhythmias; level above 10.5meq/L; administer calcitonin; renal dialysis, avoid calcium based antacids.
Magnesium normal levels
1.5-2.5
Hypomagnesemia
Caused by: alcoholism, malabsorption, DKA, prolonged gastric suction, diuretics; S&S: anorexia, distention, neuromuscular irritability, depression, disorientation; levels below 1.5meq/L; administer MgSO4 IV; encourage foods high in this
Hypermagnesemia
Caused by: renal failure, adrenal insufficiency, excess replacement; S&S: flushing, hypotension, drowsiness, lethargy, hypoactive reflexes, depressed respirations, bradycardia; levels above 2.5meq/l; avoid magnesium based antacids and laxatives; restrict dietary intake of foods high in this
Normal levels of phosphate
2.0-4.5
Hyperphosphatemia
Caused by renal failure or excess intake; S&S: tetany symptoms, phosphorus precipitation in nonosseus sites; level above 4.5; administer aluminum hydroxide with meals to bind; dialysis
Hypophosphatemia
Caused by refeeding after starvation, alcohol withdrawal, DKA, respiratory alkalosis; S&S: paresthesias, muscle weakness, muscle pain, mental changes, cardiomyopathy, respiratory failure; level below 2.0meq/L; correct underlying cause and administer oral replacements with vitamin D
Isotonic IV solutions
Have an osmolality close to the ECF; don’t cause RBCs to swell or shrink; normal saline (0.9%), lactated ringer (LR), 5% dextrose in water; used to treat intravascular dehydration; dehydration caused by running, labor, fever, etc.
Hypotonic IV solutions
Have an osmolality lower than ECF; cause fluid to move from ECF to ICF; indicated for cellular dehydration; 0.5% normal saline (HNS or 0.45%NS), 2.5% dextrose in 0.45% saline; not a common occurrence; dehydration caused by prolonged dehydration (TPN for prolonged periods of time)
Hypertonic IV solutions
Have osmolality higher than ECF; indicated for intravascular dehydration with interstitial or cellular overhydration; used with extreme caution; high concentrations of dextrose are given; used only when serum osmolality is dangerously low; 5% dextrose in LR, 5% dextrose in 0.45% NS, 5% dextrose in 0.9% NS; dehydration resulting from surgery because blood loss causes intravascular dehydration but the tissue cuts inflame and pull fluid into the area, causes interstitial overhydration; may also see in ascites and third spacing
Infection/phlebitis
Assess:: site for redness, drainage, edema, or tenderness; vital signs; lab findings
Infection/phlebitis interventions
Aseptic technique when starting IV lines; inspect all fluids and containers before use to be sure they have not been opened or contaminated; change administration sets according to policy; use a catheter that is smaller than the vein
Dislodgement/migration/incorrect placement
Assess:: Length of catheter; edema, drainage, and coiling of catheter, neck distension or distended neck veins, change in patency of catheter, chest radiograph, cardiac dysrhythmias, hypotension
Dislodgement/migration/incorrect placement interventions
Provide enough tubing length for client movement; anchor the catheter well; measure and record length of catheter
Skin erosion/hematomas/scar tissue formation over port/infiltration/extravasation
Assess:: loss of tissue or separation at exit site; drainage at exit site; erythema and edema at exit site; spongy feeling at exit site; labored breathing; complaints of pain
Skin erosion/hematomas/scar tissue formation over port/infiltration/extravasation interventions
Dilute medications; administer vesicant drugs; change IV within the timeframe outlined; provide gentle skin care; avoid selecting site over joint; anchor the catheter well
Pneumothorax/hemothorax/air emboli/ hydrothorax
Assess:: SUBCU emphysema, chest pain,dyspnea and hypoxia, tachycardia, hypotension, nausea, confusion
Pneumothorax/hemothorax/air emboli/ hydrothorax interventions
Use clot filters when infusing blood and blood products; avoid using veins in the lower extremities; prevent fluid containers from becoming empty
Acid-base balance
Must be maintained in the body because alterations can result in alkalosis or acidosis
Maintaining acid-base balance
Involves three systems: a chemical buffer system, kidneys, lungs
Acid-base balance
Determined by hydrogen ion concentration in body fluids
Normal pH range
7.35-7.45
Normal PCO2 range
35-45
Normal HCO3 range
22-26
Lungs
Control CO2 through respirations; release excess CO2 by increasing RR; retain CO2 by decreasing RR
Chemical buffers
Act quickly to prevent major changes in body fluid pH by removing or releasing hydrogen ions
Bicarbonate-carbonic acid
Main chemical buffer; 20:1 ratio; when the ratio is altered, the pH changes
Kidneys
Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed; very slow compensatory mechanisms; cannot help with compensation when metabolic acidosis is created by renal failure
pH
Measures H+ concentrations
PCO2
Partial pressure of CO2 in arteries; respiratory component of acid-base regulation
Hypercapnia
Respiratory acidosis
Hyperventilation
Respiratory alkalosis
HCO3
Measures serum bicarbonate; reflect primary metabolism disorder or compensatory mechanism to respiratory acidosis
Respiratory acidosis
Hypoventilation; caused by COPD, primary disease, drugs, obesity, mechanical asphyxia, sleep apnea
Respiratory alkalosis
Hyperventilation; caused by overventilation on a ventilator, response to acidosis, bacteremia, thyrotoxicosis, fever, hepatic failure, response to hypoxia, hysteria
Metabolic acidosis
Addition of large amounts of fixed acids to body fluids; caused by lactic acidosis (circulatory failure), ketoacidosis (diabetes, starvation), phosphates and sulfates (renal disease), acid ingestions, secondary to respiratory alkalosis, adrenal insufficiency
Metabolic alkalosis
Retention of base or removal of acid from body fluids; caused by excessive gastric drainage, vomiting, potassium depletion, burns, excessive NaHCO3 administration
Holter monitor
Portable continuous monitor that can be placed o the client to provide a magnetic tape recording of the heart; keep a diary concerning activity, medications, chest pains
30 large squares
How many large squares on an ECG strip equals 6-seconds
Count the number of R-R intervals in the 30 lg. squares and multiply by 10
How to Determine the heart rate for one minute
P wave
Atrial systole; represents depolarization of the artial muscle
QRS complex
Ventricular systole; represents depolarization of the ventricular muscle; normally follows a P wave; normal length is <0.11 seconds
T wave
Ventricular diastole; represents repolarization of the ventricular muscle; critical time in heartbeat; resting and regrouping stage so that the next beat can occur
T wave
If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia
ST segment
Represents early ventricular repolarization; measured by the end of the S wave to the beginning of the T wave
PR interval
Represents the time required for the impulse to travel from the atria (SA node), through the A-V node, to the purkinje fibers in the ventricles; represents A-V nodal function; normal is 0.12-0.20 seconds
U wave
Not always present; most prominent in the presence of hypokalemia
QT interval
Represents the time required to completely depolarize and repolarize the ventricles
R-R interval
Reflects the regularity of the heart rhythm
Preparation phase
Education about postoperative care, including NPO, assistance with meeting family needs
Operative phase
Assessment, management of the operative suite; PACU phase: pain management
Postoperative phase
Prevention of complications, assessment for pain management teaching about dietary restrictions and activity levels
S&S of shock and hemorrhage
Hypotension, narrow pulse pressure, rapid weak pulse, cold moist skin, increased CAP-REFILL time
Common postoperative complications
Urinary retention; pulmonary problems: atelectasis, pneumonia, embolus; wound healing problems; URI; thrombophebitis; decreased GI peristalsis: constipation or paralytic ileus
Urinary retention
Occurs 8-12 hours post-op; monitor hydration status and encourage oral intake; offer bedpan or assist with commode
Pulmonary problems: atelectasis, pneumonia, embolus
Occurs 1-2 days post-op; assist client to TCDB q2h; keep hydrated; enable early ambulation; early IS
Wound dehiscense
Separation of the wound edges; more likely to occur with vertical incisions
Evisceration
Protrusion of intestinal contents and is more likely to occur in clients who are older, diabetic, obese or malnourished and have prolonged paralytic ileus
UTI
Occurs 5-8 days post-op; oral fluid intake, emptying of bladder q4h-q6h, monitor I&O, avoid catheterization if possible
Thrombophlebitis
Occurs 6-14 days post-op; leg exercises q8h while in bed, early ambulation, TED or SCDs, low dose heparin prophylactically
Decreased GI peristalsis: constipation, paralytic ileus
Occurs 2-4 days post-op; NG tubing to decompress GI tract, limit use of narcotic analgesics, early ambulation
HIV infection
Infection with human immunodeficiency virus; caused by a retrovirus, which is attracted to CD4 T cells, lymphocytes, macrophages, and cells of the CNS; destruction of the CD4 T cells causes depletion in the number of CD4 T cells and a loss of the body’s ability to fight infection
Initial S&S of HIV infection
Acute infection that is quite similar to mononucleosis; occur within 3 weeks of first exposure to HIV then the person becomes asymptomatic
AIDS
Persons with specific, serious, opportunistic infections such as PCP, disseminated cytomegalovirus, or Kaposi sarcoma
Laboratory testing for HIV
Positive enzyme-linked immunosorbent assay; confirmation by the western blot test
Polymerase chain reaction test (PCR)
Used to differentiate between HIV infection in the neonate and antibodies the neonate receives from the mother
Seroconversion
Positive on these tests occurs usually within 6 weeks to 3 months but may take as long as 12 months
P24 antigen
Prior to antibody-positive status this antigen assay will be positive (detects antigen of the virus)
S&S of HIV
Extreme fatigue, loss of appetite, unexplained weight loss of more than 10 pounds in 2 months, swollen glands, leg weakness or pain, unexplained fever for more than a week, night sweats, unexplained diarrhea, dry cough, white sports in mouth and throat, painful blisters, painless purple-blue lesions on the skin, confusion, disorientation, recurrent vaginal infections that are resistant to treatment
HIV clients with TB
Require respiratory isolation. Only real risk to non-pregnant caregivers that is not related to a break in standard precautions
Primary infection
Acute HIV infection or acute HIV syndrome; CD4 T cell counts at least 800 cells/mm3; flu-like symptoms, fever, malaise; mononucleosis-like illness, lymphadenopathy, fever, malaise, rash
HIV asymptomatic (CDC category A)
CD4 T cell counts more than 500 cells/mm3; no clinical problems, characterized by continuous viral replication; can last for many years (10+ years)
HIV symptomatic (CDC category B)
CD4 T cell counts between 200-499 cells/mm3; persistent generalized lymphadenopathy, persistent fever, weight loss, diarrhea, peripheral neuropathy, herpes zoster, candidiasis, cervical dysplasia, hairy leukoplakia, oral
AIDS (CDC category C)
CD4 T-cell counts less than 200 cells/mm3; occurs when a variety of bacteria, parasites, or viruses overwhelm the body’s immune system; once classified as category, the patient remains classified as that category
Pneumocystis Carinii Pneumonia
Fever, dry cough, dyspnea at rest, chills; opportunistic infection of HIV
Kaposi’s Sarcoma
Purple-blue lesions on skin, often arms and legs; invasion of GI tract, lymphatic system, lungs and brain; opportunistic infection of HIV
Cryptosporidiosis
Severe watery diarrhea (30-40 stools/day), abdominal cramps, nausea, electrolyte imbalance, malaise; opportunistic infection of HIV
Candidiasis of Cavity and Esophagus
Thick white exudates in the mouth, unusual taste of food, retrosternal burning, oral ulcers; opportunistic infection of HIV
Cryptococcal meningitis
Headache, changes in LOC, NV, stiff neck, blurred vision; opportunistic infection of HIV
Cytomegalovirus (CMV) Retinitis
Most common CMV infection in persons with AIDS, impaired vision in one or both eyes, can lead to blindness; opportunistic infection of HIV
CMV colitis
Diarrhea, malabsorption of nutrients, weight loss; opportunistic infection of HIV
Disseminated CMV
Malaise, fever, pancytopenia, weight loss, positive cultures from blood, urine or throat; opportunistic infection of HIV
Perirectal mucocutaneous herpes simplex virus
Severe pain, bleeding, rectal discharge, ulceration in the rectal area; opportunistic infection of HIV
Lymphomas of CNS
Change in mental status, apathy, psychomotor slowing, seizures; opportunistic infection of HIV
Tuberculosis
Pulmonary and extrapulmonary, lymphatic and hematogenous TB are common, negative skin test doesn’t rule this out; opportunistic infection of HIV
HIV encephalopathy
Memory loss, impaired concentration, apathy, depression, psychomotor slowing, incontinence, CT findings show diffuse atrophy and ventricular enlargement; opportunistic infection of HIV
NRT inhibitors
Didanosine (Videx), Lamivudine (Epivir), Abacavir (Ziagen), Zalcitabine (Hivid), Zidovudine (Retrovier); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: peripheral neuropathies, pancreatitis, increase in triglycerides, fever, rash, NV, cramps; monitor for neuropathies; monitor amylase, lipase, triglycerides; give on empty stomach
Protease inhibitors
Indinavir (Crixivan), Amprenavir (Agenerase), Saquinavir (Invirase), Ritonavir (Norvir, Kaletra), Nelfinavir (Viracept); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: depression, ketoacidosis, seizures, angioedema, steven-johnson syndrome; high-fat, high-protein foods reduce absorption; give with food; reduces contraceptive effects
Non-NRT inhibitors
Efavirenz (sustiva), Delavirdine (Rescriptor), Nevirapine (Viramune), Amprenavir (Agenerse); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions: CNS changes, nausea, rash, increase in triglycerides, hepatotoxicity; monitor liver function tests; reduce contraceptive effects
Combination products
Lamivudine + Zidovudine (Combivir), Zidovudine + lamivudine + abacavir (Trizivir); Indications are HIV infection; classification used in various combinations to reduce viral load and slow development of resistance; adverse reactions & monitoring : monitor for side effects/what to monitor that occur with the individual drugs
Antiinfectives
Atovaquone (Mepron), Trimethoprim/sulfamethoxazole (Bactrim)
Atovaquone (Mepron)
Used for PCP in those unable to tolerate Trimethoprim/sulfamethoxazole (Bactrim)
Antivirals
Acyclovir sodium (Zovirax), Ganciclovir; used for herpes simplex CMV retinitis; adverse reactions: granulocytopenia, thrombocytopenia; monitor liver function tests
Antifungals
Ampherotericin B (Fungizone); IV: crytococcal meningitis; PO: Oral candidiasis; adverse reactions: nephrotoxicity, hypotension, hypokalemia, febrile reaction, muscle cramps, circulatory problems; vesicant:: monitor IV site closely; premedicate with antipyretic, give slowly; swish as long as possible before swallowing PO form
Antoprotozoals
Pentamidine isethionate (Pentam 300); prophylaxis & treatment for PCP; adverse reactions: leucopenia, ECG abnormalities; Give IV or aerosol, not orally
CMV (Cytomegalovirus)
Caregivers who are pregnant may refuse to care for a client with this
Pediatric HIV infection
Infection with HIV in infants and children; perinatal transmission of children born to HIV-positive mothers will be infected unless the mother is treated with Zidovudine during pregnancy and the neonate is treated after birth ; HIB infected blood products, breast milk, sexual abuse
Pediatric HIV infection S&S
Failure to thrive, lymphadenopathy, organomegaly, neuropathy, cardiomyopathy, chronic recurrent infections, unexplained fevers
Pediatric HIV infection interventions
Administer NO live virus vaccines, IGG administration, avoid exposure to persons with infections
Pediatric HIV Client
Evidenced by lymphoid interstitial pneumonitis, pulmonary lymphoid hyperplasia, and opportunistic infections
Gate control theory
Pain impulses travel from the periphery to the gray matter in the dorsal horn of the spinal cord along small nerve fibers; substantia gelatinosa either opens or closes off the transmission of pain impulses to the brain; stimulation of large, fast conducting sensory fibers opposes the input from mall pain fibers, this blocking pain transmission
Endorphin theory
Naturally occurring compounds that have morphine-like qualities; they modulate pain by preventing the conduction of pain impulses in the CNS
Enkephalins theory
Specific neurotransmitters that bind with opiate receptors in the dorsal horn of the spinal cord; they modulate pain by closing the gate and stopping the pain impulse
Oral route for analgesic
Preferred method of administration; drug level peak: 1-2 hours
Intramuscular route for analgesic
Acceptable method of managing acute, short-term pain; onset 30 min; peak effect 1-3 hours; duration of action: 4 hours
Rectal route for analgesic
Useful for clients with nausea and inability to take anything by mouth; reduced effectiveness with constipation
IV bolus (IV push)
Provides the most rapid onset (5 minutes) but has shortest duration (1 hour); useful for acute pain
PCA
Ideal method to control pain; able to prevent pain by administering to self smaller doses of the narcotic as soon as the first sign of discomfort appears; usually IV; predetermined dose and a set lockout interval are prescribed by MD; lock out mechanisms prevent overdose; pump can record number of times the client uses the pump and the cumulative dose delivered
Continuous subcutaneous narcotic infusion
Useful for clients who are NPO but require prolonged administration of parenteral narcotics; constant level of analgesia by continuous infusion
Continuous epidural analgesia
Catheter threaded into epidural space with continuous infusion of fentanyl citrate, morphine or other narcotic analgesics; risk for respiratory depression
Transdermal patches
Applied to the skin; deliver hormonal therapy, nitroglycerin and nicotine; document removal of old patch , site and application date and time of new patch
NSAIDS
Inhibit prostaglandin and other chemical mediator syntheses and other chemical mediator synthesis involved in pain; antipyretic activity through action on the hypothalamic heat-regulating center to reduce fever
Narcotic agonists and antagonists
Counteract narcotic effects; withdrawal symptoms if administered after client has been receiving narcotics; produce side effects including drowsiness, nausea, psychomimetic effect, hallucinations, euphoria
Narcotics
Act as opioids, binding with specific opiate receptors throughout the CNS to reduce pain perception; cause such side effects as nausea and vomiting, constipation, respiratory depression, and CNS depression
Narcan
For narcotic-induced respiratory depression; 0.1mg to 0/4mg IV every 2-3 minutes as needed until 1mg is achieved
Codeine
PO – 30-45min onset; IM or SC – 10-30 min onset; do not administer discolored injection solutions; prescribed also as an antitussive or antidiarrheal
Propoxyphene HCL (Darvon, Eration)
PO – 15-60 min onset; cause false decreased in urinary steroid secretion tests
Hydromorphone (Dilaudid)
PO – 30 min onset; IM – 15 min onset; IV – 10-15 min onset; fast acting potent narcotic; cause appetite loss than other narcotics
Meperidine HCL (Demerol)
PO – 15 min onset; IM -10-15 min onset; IV – 1 min onset; use by persons allergic to morphine; extreme caution in clients with impaired renal function because its active metabolite accumulates in renal failure; Signs of toxicity such as hyperirritability; less likely to cause smooth muscle spasm than other narcotics
Morphine Sulfate
PO – 60-90 min onset; IM – 10-30 min onset; IV – 10 min onset; drug of choice in relieving pain associated with MI; transient decrease in BP; drug of choice in chronic cancer pain
Fentanyl Citrate (Duragesic)
IM – 7-15 min onset; IV – onset within 5 min; intradermal – within 12 hour onset; intrabuccal – 5 to 15 min onset; intrathecal has an immediate onset; synthetic narcotic, MSO4-like; acts quicker with a less duration
Narcotic analgesics
Preferred for pain relief because they bind to the various opiate receptor sites in the CNS
Death
Death is the last developmental task for an individual; completes the life cycle
Grief
Process an individual goes through to deal with loss
Denial
Coping style used to protect self/ego; noncompliance, refusal to seek treatment, ignoring symptoms; changing the subject when speaking about the illness; “not me, this must be a mistake”
Anger
Often directing it at family or health care team members; “why me? Its not fair”
Bargaining
Making a deal with God to prolong life; usually not sharing this with anyone
Depression
Results from the losses experienced because of health status and hospitalization; anticipating the loss of life
Acceptance
Accepting the inevitable; beginning to separate emotionally
Shock, disbelief, rejection, or denial
Anger, crying, conflicting emotions, anger toward the deceased, guilt, preoccupation with loss
Resolution
Process taking up to 1+ years, renewed interest in activities
Complicated grief
Unresolved grief, physical symptoms similar to those of the deceased, clinical depression, social isolation, failure to acknowledge loss
Pneumonia
Inflammation of the lower respiratory tract; caused by infectious agents that reach the lungs through aspiration, inhalation, hematogenous spread
High risk groups for pneumonia
Debilitated by accumulated lung secretions; cigarette smokers; immobile; immunosuppressed; experiencing a depressed gag reflex; sedated; experiencing neuromuscular disorders
Nursing assessment for pneumonia
Tachypnea; abrupt onset of fever with shaking and chills; productive cough with pleuritic pain; rapid, bounding pulse; pain and dullness to percussion over the affected lung area; bronchial breath sounds, crackles; infiltrates with consolidation or pleural effusion; elevated WBC; ABG indication of hypoxemia.
Pneumonia in the elderly
Confusion, lethargy, anorexia, rapid RR
Fever
Can cause dehydration because of excessive fluid loss due to diaphoresis. Also increases metabolism and the demand for oxygen
High risk for pneumonia
Altered LOC, depressed or absent gag and cough reflexes, or is susceptible to aspirating oropharyngeal secretions; when feeding, raise the HOB and position the client on his or her side, not on the back
Pneumonia nursing interventions
Assess sputum for volume, color, consistency, and clarity; TCDB q2h, humidity to loosen secretions, suction airway; 3L/day unless contraindicated to liquefy lung secretions; monitor ABGs (Po2 > 80; PCO2 <44 mmHg); O2 sat > 95%
Bronchial breath sounds
Heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue
Hydration
Enables liquefaction of mucous trapped in the bronchioles and alveoli; essential for client experiencing fever; 300-400mL of fluid are lost daily by the lungs through evaporation
Irritability and restlessness
Early signs of cerebral hypoxia; the client’s brain is not receiving enough oxygen
Penicillin’s
Procraine penicillin G (Wycillin), Benzathine penicillin (Bicillin L-A), Penicillin V (Pen-Vee K); antiinfectives, used primarily for gram-positive infections; adverse reactions: allergic reactions, anaphylaxis, phlebitis at IV site, diarrhea, GI distress, superinfection; use in caution with clients allergic to cephalosporins, monitor for allergic reactions, observe all clients for at least 30 minutes, oral penicillin G should be taken on an empty stomach; alters contraceptive effectiveness
Semisynthetic drugs
Oxacillin sodium, nafcillin sodium, cloxacillin sodium, dicloxacillin sodium; used for antiinfectives, used primarily for gram-positive infections; adverse reactions: allergic reactions, anaphylaxis, superinfections, all penicillin reactions; cannot be used in patients allergic to allergic to penicillin; caution in clients allergic to cephalosporins; monitor for superinfection
Super infection
Sore mouth, vaginal discharge, diarrhea, cough
Antipseudomonal penicillin’s and combinations
Ampicillin; ticarcillin + clavulanate (timentin); piperacillin + tazobactam (Zosyn); Ampicillin + Sulbactam (Urasyn); used as broad spectrum antibiotics and antiinfectives; adverse reactions are similar to penicillin as well as ampicillin rash; contraindicated in clients allergic to penicillin
Tetracyclines
Tetracycline HCL, Doxycycline hyclate (Vibramycin); used as antiinfectives; adverse reactions include photosensitivity and hypersensitivity reactions; decreased effectiveness of oral contraceptives; avoid concurrent use of antacids, milk products; inspect IV site, monitor for superinfections; avoid exposure to sunlight; avoid use in pregnant clients and children under 8 years; can cause yellow-brown discoloration of teeth and growth retardation
Aminoglycocides
Gentamicin sulfate, tobramycin sulfate (Nebcin), Amikacin sulfate, vancomycin hydrochloride, metronidazole (flagyl); used with gram negative bacteria, antiinfectives; adverse reactions include neuromuscular blockade, nephrotoxicity, ototoxicity; monitor renal function, BUN, creatinine, I&O; monitor for ototoxicity; monitor for super infection; monitor serum drug concentrations
Ototoxicity
Headache, dizziness, hearing loss, tinnitus
Cephalosporines
First generation: cegazolin (kefzol), cephalexin (kelflex); Second generation: cefaclor (Ceclor), cefamandole (mandole), cefuroxime (ceftin-po, Zinacef-IV); Third Generation: cefotaxime (Claforan), ceftriaxone (Rocephin), ceftazidime (fortaz), cefepime (Maxipime); used as an antiinfective; adverse reactions: allergic reactions, thrombophlebitis, GI distress, Superinfection; use with caution in patients allergic to penicillin and cephalosporines
Monobactam
Azactam; indicated for pseudomonas aeruginosa and many resistant organisms, most effective against gram-negative organisms; adverse reactions include phlebitis, pseudo-membranous colitis, CNS changes, EEG changes, headache, diplopia, hypotension; monitor for renal and hepatic function, monitor for diarrhea, assess motor sensory function and cardiac rhythm
Macrolides
Clarithromycyn (Biaxin), Azithromycin (Zithromax), Erythromycin; Indications: Biaxin (PO): URI, including strep, as adjunt treatment for H. pylori Zithromax (IV): gram-negative and gram-positive organisms; Adverse reactions: pseudo-membrane colitis, phlebitis, superinfection, dizziness, dyspnea; give biaxin XL with food, space MAO inhibitors 14 days before start and after end of Biaxin; report diarrhea, abdominal cramping; monitor liver/renal labs; PO Zithromax give on empty stomach
Fluroquinolones
Ciprofloxacin (Cipro), levofloxacin (levaquin), gatifloxacin (tequin); used to treat the most difficult to treat respiratory infections, UTIs, skin, bone and joint infections; has been used as conjunctive treatment for TB and AIDS; adverse reactions include superinfections, CNS disturbances, arroyos and cataracts, Cipro is a vesicant; prompt onset, crosses placenta and in breast milk, can lower seizure threshold, monitor liver/renal and blood counts
Lincosamides
Clindamyzin (Cleocin); used for PCP in AIDS, severe infections resistant to penicillin and cephalosporins, used in penicillin and erythromycin sensitive clients; adverse reactions include agranulocytosis, pseudo-membrane colitis, superinfections; highly toxic drug; periodic liver/renal/blood counts; report diarrhea immediately
Streptogramin
Quinupristin/dalfopristin (Synercid); used for life-threatening VRE; adverse reactions: arthralgia, myalgia, severe vesicant, pseudo-membrane colitis, NVD, rash, pruritus; incompatiable with any saline solutions or heparin; monitor total bilirubin
Oxazolidinone
Zyvox; life-threatening VRE and MRSA; adverse reactions include GI disturbances, headache, pancytopenia, pseudo-membrane colitis, superinfection; monitor renal/liver labs and blood counts; may exacerbate hypertension; report diarrhea immediately
Chronic airflow limitation
Chronic lung disease includes chronic bronchitis, pulmonary emphysema, and asthmas
Emphysema and chronic bronchitis
Terms chronic obstructive pulmonary disease; characterized by bronchospasm and dyspnea; damage is not reversible and increases in severity
Primary cause of COPD
Exposure to tobacco smoke
Asthma
Intermittent disease that is reversible airflow obstruction and wheezing
Nursing assessment for chronic airflow limitation
Changes in breathing pattern, use of accessory breathing muscles, cyanosis of lips, mucous membranes, face, nail beds; cough; higher CO2 than average; Low O2; decreased breath sounds; coarse crackles in lung fields that disappear after coughing; dyspnea, orthopnea; poor nutrition; activity intolerance
Semi-fowler or high fowler position
Productive cough and comfort can be facilitated by these positions because they lessen pressure on the diaphragm by abdominal organs.
Gastric distension
This is a priority in people with COPD because it elevates the diaphragm and inhibits full lung expansion
Pink puffer
Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breath; person works harder to breath, but the amount of O2 taken in is adequate to oxygenate the tissues
Blue bloated
Insufficiency oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale)
Cyanosis and slow Cap.refill
Inadequate arterial oxygenation in the body is manifested by…
Nursing interventions for chronic airflow limitation
Sit upright and bend slightly forward to promote breathing; teach diaphragmatic and pursed lip breathing; O2 at 1-2L NC; pace activities; adequate dietary intake, adequate fluid intake; prevention of secondary infections
Oxygen
The stimulus to breathe is hypoxia, not the usual for hypercapnia, in COPD patients – dangerous to give ?? to these patients because they may stop breathing
Water solution
O2 must go through ?? so it can be humified if given at >4L/min or delivered directly to the trachea. When given at 1-4L/min or by mask/nasal prongs, the oropharynx and nasal pharynx provides adequate humidification
Cancer of the Larynx
Neoplasm occurring in the larynx, most commonly squamous cell in origin
Contributing factors to larynx cancer
Vocal straining, chronic laryngitis, family predisposition, prolonged use of alcohol/tobacco, industrial exposure to carcinogens, nutritional deficiencies
Hoarseness or a change in vocal quality
The first and earliest signs of larynx cancer
Nursing assessment for cancer of the larynx
MRI, direct laryngoscopy, hoarseness >2weeks, color changes in the mouth or tongue, radiographs of head neck and chest, CT scan of neck and biopsy; assess for dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to the eat, enlarged cervical nodes, halitosis
Chronic Bronchitis Pathophysiology
Chronic sputum with cough production on a daily basis for a minimum of 3 months per year; chronic hypoxemia, cor pulmonale; increase in mucus, cilia production; increase in bronchial wall thickness which obstructs the airflow; reduced responsiveness of respiratory center to hypoxemic stimuli
Chronic bronchitis precipitating factors
Higher incidence in smokers
Chronic bronchitis assessment
Generalized cyanosis, blue bloaters, right-sided heart failure, distended neck veins, crackles, expiratory wheezes
Chronic bronchitis nursing interventions
Lowest FIo2 possible and prevent CO2 retention; monitor for S&S of fluid overload; maintain Po2 between 55-60; baseline ABGs; pursed lip breathing and diaphragmatic breathing, teach tripod position
Tripod position
When the client is in bed, teach the client to sit with arms resting on overbed table for breathing promotion; when client is in chair, teach to lean forward with elbows resting on knees
Emphysema pathophysiology
Reduced gas exchange surface area; increased air trapping (increased AP diameter); decreased capillary network; increased work, increased O2 consumption
Emphysema precipitating factors
Cigarette smoking, environment/occupational exposure, genetics
Emphysema assessment
Pink puffers, barrel chest, pursed lip breathers, distant quiet breath sounds, wheezes, pulmonary blebs on radiograph
Emphysema nursing interventions
Lowest FIo2 possible to prevent CO2 retention, monitor for S&S of fluid overload, maintain Po2 between 55-60; pursed lip breathing and diaphragmatic breathing, teach tripod position
Asthma pathophysiology
Narrowing or closure of the airway due to a variety of stimulants
Asthma precipitating factors
Mucosal edema, VQ abnormalities, increased work of breathing, beta blockers, respiratory infection, allergic reaction, emotional stress, exercise, environmental/occupational exposure, reflux esophagitis
Asthma assessment
Dyspnea, wheezing, chest tightness, assess precipitating factors, medication history
Asthma nursing interventions
Administer bronchodilators, administer fluids and humidification, education, ABGs, ventilator patterns
Tracheostomy care
Involves cleaning the inner cannula, suctioning, and applying clean dressings
laryngectomy
Natural humidifying pathway is gone for a client who has this
Glottal stop
Take a deep breathe, momentarily occlude the tracheostomy tube, cough, and simultaneously remove finger from the tube; done because the glottis is removed in laryngectomy clients
Tuberculosis
Communicable lung disease caused by an infection by mycobacterium tuberculosis bacteria; airborne transmission bacteria remain dormant until a later time
Ghon Lesion
Bacteria encapsulate after initial exposure of TB
Nursing assessment for tuberculosis
Often asymptomatic; symptoms include: fever with night sweats, anorexia, weight loss, malaise, fatigue, cough, hemoptysis, dyspnea, pleurtic chest pain with inspiration, cavitation or calcification, positive sputum culture
Positive TB skin test
Exhibited by an induration 10mm or greater in diameter 48 hour after;
BCG vaccine
Anyone who has had this will have a positive skin test and must be evaluated by a chest radiograph
When three sputum cultures have come back negative
TB patient can return to work when?
Isoniazid (INH)
Interfers with DNA metabolism of tubercle bacillus; side effects include NH, abdominal pain; rare but possible side effects include neurotoxicity, optic neuritis, and hepatoxicity; metabolism is in liver and excretion by kidneys; pyridoxine as prophylaxis; cross BBB
Rifampin (Rifadin)
Has broad spectrum effects, inhibits RNA polymerase of tubercule bacillus; side effects: hepatitis, febrile reaction, GI disturbance, peripheral neuropathy, hypersensitivity; used in conjunction with at least one other antitubercular agent; los incidence of side effects; suppression of effect of birth control; possible orange urine.
Ethambutol (Myambutol)
Inhibits RNA synthesis and its bacteriostatic for the tubercle bacillus; side effects: skin rash, GI disturbance, malaise, peripheral neuritis, optic neuritis; side effects uncommon and reversible with discontinuation of drug; most common use as substitute drug when toxicity occurs with isoniazid or rifampin
Streptomycin
Inhibits protein synthesis and is bactericidal; side effects: ototoxicity, nephrotoxicity, hypersensitivity; cautious use in older adults, those with renal disease and pregnant women; given parenterally
Pyrazinamide
Bactericidal effect; side effects: fever, skin rash, hyperuricemia, jaundice; high rate of effectiveness when used with streptomycin or capreomycin
Ethionamide (Trecator-SC)
Inhibits protein synthesis; side effects: GI disturbance, hepatotoxicity, hypersensitivity; treatment of resistant organisms; contraindicated in pregnant women.
Capreomycin (Capastat)
Inhibits protein synthesis and is bactericidal; side effects: ototoxicity, nephrotoxicity; cautious use in older adults
Kanamycin (Kantex) & Amikacin
Interferes with protein synthesis; side effects: ototoxicity, nephrotoxicity; use in selected treatment of resistant strains
Paraaubisalicylic acid (PAS)
Interferes with metabolism of tubercle bacillus; side effects: GI disturbance (common), hypersensitivity, hepatotoxicity; interferes with absorption of rifampin; uncommonly used
Cycloserine (Seromycin)
Inhibits cell wall synthesis; side effects: personality changes, psychosis, rash’ contraindicated in individuals with histories of psychosis; used in treatment of resistant strains
Rifampin
Reduces effectiveness of oral contraceptives; gives body fluids orange tinge; stains soft contact lenses
Isoniazid (INH)
Increased dilantin levels
Ethambutol
Vision check before starting therapy and monthly thereafter; may have to take for 1-2 years
Lung cancer
Neoplasm occurring in the lung; cigarette smoking is responsible for 80-90%; poor prognosis
Lung cancer nursing assessment
Dry, hacking cough early, with cough turning productive as disease progresses; hoarseness; dyspnea; hemoptysis, rust colored or purulent sputum; pain in chest area; diminished breath sounds, wheezing; abnormal chest radiograph; positive sputum for cytology
Pursed lip breathing
Improves gas exchange
Thoracotomy
Used in clients who have a resectable tumor – usually detection occurs too late to perform this
Pneumonectomy
Removal of the entire lung; position client on operative side or back
Intussusceptions
Telescoping of the gut within itself
Neurogenic causes of intestinal obstruction
Paralytic ileus and spinal cord lesion
Vascular causes of intestinal obstruction
Mesenteric artery occlusions which can lead to gut infarct
Mechanical bowel obstruction
Due to disorders outside the bowel caused by disorders within the bowel or by blockage of the lumen in the intestine
Nonmechanical bowel obstruction
Due to paralytic ileus, which doesn’t involve any actual physical obstruction but results from inability of the bowel itself to function
Nursing assessment of bowel obstruction
Sudden onset of abdominal pain, tenderness or guarding; history of abdominal surgeries; history of obstruction; distention; increased peristalsis when obstruction first occurs, then peristalsis becoming absent when paralytic ileus occurs; bowel sounds that are high-pitched with early mechanical obstruction and diminished to absent with neurogenic or late mechanical obstruction
Blood gas analysis: alkalotic state
Will show ?? if the bowel obstruction is high in the small intestine where gastric acid is secreted
Blood gas analysis: acidic state
Will show ?? if the bowel obstruction is in the lower bowel where base solutions are secreted
Bowel obstruction nursing plans and interventions
NPO with IV fluid and electrolyte therapy; I&O; implement NG tube; document pain; assess abdomen regulary for distention, rigidity, change in status of bowel sounds
Nasogastric intubation
Attach to low suction (intermittent 80mmHg); document output every 8 hours; irrigate with normal saline
Cantor, miller-Abbott or harris tubes
Passed through the nose and into the stomach; advance tube every 1-2 hours; do not secure to nose until tube reaches specified position; repositioning client q2h to assist with placement of tube; connect to suction; irrigate with air only; note amount, color, consistency and any unusual odor or drainage
Colorectal cancer
Tumors occurring in the colon
Recommended diet to prevent bowel cancer
Eat more cruciferous vegetables, increase fiber intake, maintain average body weight, eat less animal fat
Nursing assessment for colorectal cancer
Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain, nausea, vomiting, weight loss, cachexia, family history of cancer, history of polyps
Nursing plans and interventions for colorectal cancer
Prepare client for surgery; prepare client for bowel preparation; provide high calorie, high protein diet; prevention of constipation with high fiber diet; early detection by screening with hemoccult tests
Rectal bleeding
Early sign of colon cancer
Stoma
The more distal this is, the greater the chance for continence; the lower this is located, the more solid, or formed is the effluence
Stoma in the sigmoid colon on the left side of the abdomen
The greatest chance for continence with a stoma
Ileostomy
Drains liquid material
Peristomal skin
Skin that is often prone to break down
Pouch care
Adhesive backed opening, designed to cover the stoma, should provide about 1/8 inch clearance from the stoma; rubber band or clip is used to secure the bottom of the pouch and prevent leakage; use a squirt bottle to remove effulent from the sides of the bag; pouch system is changed every 3-7 days; pouch should be emptied when 1/3 to ½ full
Irrigation of a colostomy
Those with descending-colon colostomies can do this to provide control over effluence; should do this at the same time each day with warm water; the area around the stoma should be cleaned with lukewarm water and a mild soap
Ileostomy diet
Clients should chew food thoroughly; high fiber foods can cause severe diarrhea and may have to be eliminated
Colostomy diet
Resume regular diet gradually
Cirrhosis
Degeneration of liver tissue, causing enlargement, fibrosis and scarring; caused by chronic alcohol ingestion, vital hepatitis, exposure to the hepatotoxins, infections, congenital abnormalities, biliary tree obstruction, chronic severe HF, idiopathy
Initial sign of cirrhosis
Hepatomegaly
Later sign of cirrhosis
Liver becomes large and nodular and hard
Nursing assessment of cirrhosis
Hx of alcohol and street drugs, work history of exposure to toxic chemicals, medication history of long term use of hepatotoxic drugs; family history
Nursing assessment of cirrhosis
Weakness, malaise, anorexia, weight loss, palpable liver, abdominal girth increases as liver enlarges, jaundice, fector hepaticus, asterixis, mental and behavioral changes, bruising, erythema, dry skin, spider angiomas, gynecomastia, testicular atrophy, ascites, peripheral neuropathy, hematemesis, palmar erythemia
Asterixis
Hand flapping tremor that often accompanies metabolic disorders
Fector hepaticus
Fruity or must breath; a distinctive breath odor of chornic liver disease; results from the damaged liver’s inability to metabolize and detoxify mercaptan
Mercaptan
Produced by the bacterial degradation of methionine
Cirrhosis
Clotting defects noted in lab findings: elevated bilirubin, AST, ALT, alkaline phosphatase, PT, and ammonia; decreased Hgb, Hct, electrolytes, and albumin
Ammonia
Not broken down as usual in the damaged liver; therefore this serum level rises
Complications of cirrhosis
Ascites, edema; portal hypertension; esophageal varices; encephalopathy; respiratory distress; ccoagulation defects
Esophageal varices
May rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade (Blakemore-sengstaken or Minnesota tube) along with vasopressors, vitamin K, coagulation factors, and blood transfusions
Nursing plans and interventions with cirrhosis
Eliminate causative agent; administer vitamin supplements; observe mental status frequently; avoid initiating bleeding and observe for bleeding tendencies; provide special skin care; monitor fluid and electrolyte status; monitor dietary intake carefully, especially protein; dietary restrictions: low sodium, low potassium, low fat, high carbohydrate diet
Esophageal varices management
Esophagogastric balloon tamponade (Blakemore tube), sclerotherapy, portal systemic shunts
Hepatitis
A widespread inflammation of liver cells, usually caused by a virus
Nursing assessment of a patient with hepatitis
Known exposure to hepatitis; recent transfusions or hemodialysis; fatigue, malaise, weakness; anorexia, NV; jaundice, dark urine, clay-colored stools; myalgia, joint pain; dull headaches, irritability, depression; abdominal tenderness in the right upper quadrant; fever; elevations in liver enzymes and bilirubin
Hepatitis nursing plans and interventions
Assess client’s response to activity; assist client with care as needed; provide high calorie, high carbohydrate diet with moderate fats and proteins; small, frequent feedings; provide vitamin supplements; teach importance of personal hygiene; teach to avoid alcohol, aspirin, acetaminophen and sedatives
Environment conductive to eating for a patient who has NV
Remove strong odors immediately; they can be offensive and increase nausea; encourage client to sit up for meals, this decreases the propensity to vomit; serve small, frequent meals
Rest and adequate nutrition
Liver tissue is destroyed by hepatitis; these aspects of care are necessary for regeneration of the liver tissue being destroyed by the disease; drug therapy must be scrutinized carefully; recovery can take months, and previously taken medications should not be resumed without the health care providers directions
Pancreatitis
Nonbacterial inflammation of the pancreas
Acute pancreatitis
Occurs when there is digestion of the pancreas by its own enzymes, primarily trypsin; alcohol ingestion and biliary tract disease are common causes of this
Chronic pancreatitis
Progressive, destructive disease that causes permanent dysfunction; long term alcohol usage is the main cause of this
Nursing assessment for acute pancreatitis
Severe mid-epigastric pain radiating to the back, usually related to excess alcohol ingestion or a fatty meal; adominal guarding: rigid and boardlike abdomen; NV; elevated temp, tachycardia, decreased BP; bluish discoloration of the flanks or periumbilican area; elevated amylase, lipase, and glucose levels
Acute pancreatitis nursing plans and interventions
Maintain NPO status; maintain BG tube to suction; administer meperidine or morphine; administer antacids, histamine-2, receptor blocking drugs, anticholinergics, proton pump inhibitors; assume position of comfort on side with legs drawn up to chest; avoid alcohol, caffeine, fatty and spicy foods; monitoring and regular insulin coverage may be needed temporarily
Acute pancreatic pain
Pain that is located retroperitoneally; any enlargement of the pancreas causes the peritoneum to stretch tightly; sitting up or learning forward reduces pain
Chronic pancreatitis nursing plans and interventions
Administer analgesics such as meperidine or porphine; administer pancreatic enzymes such as pancreatin or pancrelipase with meals or snacks. Mix powdered formed with fruit juice or applesauce; monitor stools for number and consistency to determine effectiveness of enzyme replacement; bland, low fat diet and avoid rich foods, alcohol and caffeine; S&S DM
Cholecystitis
An acute inflammation of the gallbladder
Cholelithiasis
The formation or presence of stones in the gall bladder
Cholecystitis treatment
IV hydration, administration of antibiotics, and pain control with meperidine or morphine
Cholelithiasis treatment
Nonsurgical removal of the stones; dissolution therapy; endoscopic retrograde cholangiopancreatography, lithotripsy
Cholescystectomy
Performed if stones are not removed nonsurgically and inflammation is absent
endoscopic retrograde cholangiopancreatography (ERCP)
Following this the patient may feel sick; the scope is placed in the gallbladder and the stones are crushed and left to pass on their own; prone to pancreatitis
Nursing assessment for cholecystitis and cholelithiasis
Pain, anorexia, vomiting, flatulence precipitated by ingestion of fried, spicy or fatty foods; fever, elevated WBC and other sigs of infection; abdominal tenderness; jaundice and clay colored stools; elevated liver enzymes, bilirubin and WBC
Nursing plans and interventions for cholecystitis and cholelithiasis
Administer analegesic for pain; maintain NPO; maintain NG tube; IB antibiotics; Monitor I&O; electrolyte status ; avoid spic, fried, fatty foods and to reduce intake of caloiries if indicated
Nonsurgical management of a client with cholecystitis
Low-fat diet, medications for pain and clotting, decompression of stomach via NG tube
Hyperthyroidism
Excessive activity of thyroid gland, resulting in an elevated level of circulating thyroid hormones (Graves disease, goiter)
Hyperthyroidism
Can result from a primary disease state, replacement hormone therapy, excess TSH
Grave’s Disease
Thought to be an autoimmune process; diagnosis is made on the basis of serum hormone levels
Common treatment for hyperthyroidism
Thyroid ablation by medication, radiation, thyroidectomy, adenectomy of portion of the anterior pituitary where TSH- producing tumor is located
Nursing assessment for hyperthyroidism
Enlarged thyroid gland, weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, wet or moist skin, nervousness, insomnia, exophthalmost, T3>220, T4>12, low level of TSH, radioactive iodine uptake and thyroid scan indicate the presence of a goiter.
Nursing plans and interventions for hyperthyroidism
Calm, restful atmosphere; signs of thyroid storm; high calorie, high protein, low caffeine diet; eye care for expohthalmost; treat hyperthyroidism
Thyroid storm
Life threatening event that occurs with uncontrolled hyperthyroidism due to graves disease; fever, tachycardia, agitation, anxiety and hypertension; maintain patent airway and adequate aeration
Thyroid ablation
Propylthiouracil and methimazole act by blocking synthesis of T3 and T4; doses is based on body weight and is given over several months; take medications exactly as prescribed
Radiation
Iodine 131 is given to destroy thyroid cells and is very irritating to the GI tract; place client on radiation precautions
Postoperative thyroidectomy
Be prepared for the possibility of laryngeal edema. Put oxygen and a suction machine; Ca++ gluconate should be easily accessible
Thyroidectomy
Check frequently for bleeding; support the neck when moving the client; laryngeal edema damage by watching for hoarseness or inability to speak clearly; keep any drainage devices compressed and empty
Adenectomy
TSH-secreting pituitary tumors are resected using a transnasal approach
Normal serum calcium levels
9.0 to 10.5 mEq/L; the best indicator of parathyroid problems is a decrease in the client’s calcium compared to the preoperative value
Chance of tetany
The chance for this increases when two or more of the parathyroid glands have been removed. Monitor serum calcium levels; check for tingling of toes and fingers and around the mouth; check for chvostek’s sign; check for trousseau’s sign
Chvostek’s sign
Twitching of lip after a tap over the parotid gland
Trousseau’s sign
Carpopedal spasm after BP cuff is inflated above systolic pressure
Hypothyroidism
Hypofunction of the thyroid gland, with resulting insufficiency of thyroid hormone; Hasimoto Disease, Myxedema
Myxedema Coma
Can be precipitated by an acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and carbon dioxide narcosis). The airway must be kept patent and ventilator support is used as indicated; hypotension, hyponatremia, hypoglycemia, respiratory failure
Nursing assessment for hypothyroidism
Fatigue; thin, dry hair, dry skin; thick, brittle nails; constipation; bradycardia, hypotension; goiter; periorbital edema, facial puffiness; cold intolerance; weight gain; dull emotions and mental processes
Diagnosis for hypothyroidism
Low T3 levels <70; low T4 levels <5; presence of T4 antibody
Nursing plans and interventions for hypothyroidism
Daily dose of prescribe hormone; ongoing follow up to determine serum hormone levels; develop a bowel-elimination plan to prevent constipation
Addison disease (primary adrenocortical deficiency)
An autoimmune process commonly found in conjunction with other endocrine diseases of an autoimmune nature; a primary disorder; sudden withdrawal of corticosteroids may precipitate symptoms of Addison’s disease
Addison disease
Characterized by lack of cortisol, aldosterone and androgens
Nursing assessment of Addison disease
Fatigue, weakness; weight loss, anorexia, nausea, vomiting; postural hypotension; hypoglycemia; hyponatremia; hyperkalemia; hyperpigmentation; sighs of sock; loss of body hair; Hypovolemia
Signs of Hypovolemia
Hypotension, tachycardia, fever
Addison disease nursing plans and interventions
VS frequently; monitor I&O and weight; rise slowly; monitor serum electrolyte; need for lifelong hormone replacement; need for close medical supervision; need for medical alert jewelry; signs and symptoms of over and under dosage; high sodium, low potassium, high carbohydrate diet; 3L of fluid/day
Addison crisis
A medical emergency that is rough on by sudden withdrawal of steroids or a stressful event; causes vascular collapse, hypoglycemia, parenteral hydrocortisone is essential to reversing the crisis; aldosterone replacement with fludrocortisones
Cushing syndrome
Excess adrenocorticoid activity; chronic administration of steroids; also caused by adrenal pituitary or hypothalamus
Nursing assessment for cushing syndrome
Moon face; truncal obesity; buffalo hump; abdominal striae; muscle atrophy; thinning of the skin; hirsutism in females; hyperpigmentation; amenorrhea; edema, poor wound healing, easy bruising; hypertension; susceptibility to multiple infections, osteoporosis, peptic ulcer formation, hyperglycemia, hypernatremia, hypokalemia, decreased eosinophils and lymphocytes, increased plasma cortisol, increased urinary 17 hydroxycorticoids
Nursing plan and interventions for cushing syndrome
Protect from infection exposure; wash hands; monitor for signs of infection; teach safety measures; low sodium diet; foods that contain vitamin D and calcium; good skin care; possibility of weaning from steroids; I&O, weigh daily, ulcer prophylaxis
Diabetes mellitus
Metabolic disorder in which there is an absence of or an insufficient production of insulin; characterized by hyperglycemia; affect metabolism of protein, carbohydrate and fat, fasting glucose level of greater than 126mg/dl
Type 1
Insulin dependent diabetes
Type 2
Non-insulin dependent diabetes; obesity is a major factor
Type 1 (IDDM)
Usually diagnosed under the age of 30 years; insuling production is absent; onset is rapid; S&S polydipsia, polyphagia, polyuria, weight loss, weakness; weight is usually thin; ketosis is common; no overwhelming predisposition in regard to genetics; pathogenesis is viral, autoimmune; control is difficult with glycemia swings; meal planning and exercise is imperative; insulin is required by all; long term complications are common
Type 2 (NIDDM)
Usually diagnosed during school age to older adult; insulin production is present but in adequate; onset is insidious; S&S polydipsia, polyphagia, polyuria, weight loss, weakness, blurred vision – symptoms are often unnoticed; weight is usually obese; ketosis is rare; strong predisposition in regard to genetics; pathogenesis is obesity and nutrition; control is often with diet and exercise; meal planning and exercise is imperative; insulin may be required along with oral hypoglycemics; long term complications are common
Type 1 (IDDM)
Hyperglycemic relatively easily; brittle diabetics; can go into ketoacidosis; serum glucose of >350; ketonuria in large amounts; venous pH of 6.8 to 7.2; serum bicarbonate below <15mEq/dl
Type I (IDDM) treatment
Usually with isotonic IV fluids; slow IV infusion by IV pump regular insulin; careful replacement of potassium
Type 2 (NIDDM)
Rare development of ketoacidosis; development of nonketotic hyperosmolar hyperglycemia with extreme hyperglycemia; hyperglycemia, plasma hyperosmoality; dehydration; changes mental status
Type 2 (NIDDM) treatment
Usually with isotonic IV fluid replacement and careful monitoring potassium and glucose levels; IV insulin
Integument system changes in diabetes mellitus
Breaks in skin, infections on skin, diabetic dermopathy, unhealed injection sites
High blood glucose levels
Contributes to damage of the smallest vessels, the capillaries. Damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. Causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, cardiovascular abnormalities
Oral cavity changes in diabetes mellitus
Caries, periodontal disease, candidiasis
Eye changes in diabetes mellitus
Cataracts and retinal problems
Cardiopulmonary system changes in diabetes mellitus
Angina and dyspnea
Periphery changes in diabetes mellitus
Hair loss on extremities, indicating poor perfusion; coolness, skin shininess and thinness, weak or absent peripheral pulses, ulcerations on extremities, pallor, thick nails with ridges
Kidney changes in diabetes mellitus
Edema of the face, hands and feet; UTI; urinary retention
Neuromusculature changes in diabetes mellitus
Atrophy of hands and feet; neuropathies with symptoms of numbness, tingling, pain, burning
Gastrointestinal changes in diabetes mellitus
Nighttime diarrhea, emesis falling into pattern; gastroparesis
Reproductive changes in diabetes mellitus
Male impotence, vaginal dryness, frequent vaginal infections, menstrual irregularities
Glycosylated Hgb
Indicates glucose control over previous 120 days; is a valuable measurement of diabetes control
Nursing plans and interventions of diabetes mellitus
Determine baseline lab data for serum glucose, electrolytes, creatinine, BUN, ABGs; teach injection technique; meals should be timed sccording to medication peak times; teach diet regime: 55% – 60% carbohydrates, 12% – 15% protein, 30% less fat; teach about managing sick days; teach exercise regimen; teach S&S of hyperglycemia and hypoglycemia; teach about foot care
Regular insulin
When mixing insulins, which is drawn up first
Bedtime snack
Can prevent insulin reactions due to long acting insulin peak
Sick day rules
Keep taking insulin, monitor glucose more frequently, water for signs of hyperglycemia
Produce glucose; resulting in hyperglycemia
The body’s response to illness and stress is what? And what does it result in
Treat for hypoglycemia
If in doubt whether a client is hyperglycemic or hypoglycemic, treat for this??
Hyperglycemia S&S
Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope
Hypoglycemia S&S
Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmare
Hyperglycemia nursing actions
Encourage water intake, check blood glucose frequently; assess for ketoacidosis
Ketoacidosis assessment
Urine ketones; urine glucose; administer insulin as directed
Hypoglycemia nursing actions
Usually occurs rapidly and is potentially life-threatening; treat immediately with complex CHO; check blood glucose – may seize if <40
Rheumatoid arthritis
Chronic, systematic, progressive deterioration of the connective tissue of the joint; characterized by inflammation; exact cause is unknown; joint involvement is bilateral and symmetrical
Rheumatoid arthritis nursing assessment
Fatigue, generalized weakness, weight loss, anorexia, morning stiffness, bilateral inflammation of joints, decreased ROM, joint pain, warmth, edema, erythema, joint deformity
Rheumatoid arthritis
The normal cartilage becomes soft, fissures and pitting occurs, and the cartilage thins. Spurs form and inflammation sets in. the result is deformity marked by immobility, pain and muscle spasm. Treatment is corticosteroids, splinting, immobilization
Diagnosis of rheumatoid arthritis
Elevated erythrocyte sedimentation rate, positive rheumatoid factor, presence of antinuclear antibody, joint space narrowing indicated by arthroscopic exam, abnormal synovial fluid indicated by arthrocentesis; C-reactive protein indicated by active inflammation
Synovial tissues
Line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of RA can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction deduces the amount of disability
RA nursing plans ad interventions
Pain relief measures: moist heat; warm, moist compresses, whirlpool baths, hot showers; diversionary activities: imaging, distraction, hypnosis, biofeedback; rest after activity; avoid overexertion and to maintain proper posture and joint position; encourage use of assistive devices: elevated toilet seat, shower chair, can, walker, wheelchair, reachers, adaptive clothing with Velcro closures, straight-backed chair with elevated seat
Lupus erythematosus
Systemic, inflammatory, connective tissue disorder; autoimmune disorder; kidney involvement is the leading cause of death
Discoid Lupus erythematosus
Affects skin only
Systemic Lupus erythematosus
Can cause major body organ and system failure; more prevalent that DLE
Factors that trigger lupus
Sunlight, stress, pregnancy, drugs
Activity recommendations for RA
Do not exercise painful, swollen joints; do not exercise any joint to the point of pain; perform exercises slowly and smoothly; avoid jerky movements
Key management of Lupus erythematosus
Avoiding sunlight
Nursing assessment for DLE
Dry, scaly rash on face or upper body (butterfly rash)
Nursing assessment for SLE
Joint pain and decreased mobility, fever, nephritis, pleural effusion, pericarditis, abdominal pain, photosensitivity
Nursing plans and interventions for Lupus erythematosus
Avoid prolonged exposure to the sun; clean skin with milk soap; administration of steroids
Degenerative joint disease
Noninflammatory arthritis; degeneration of cartilage, wear and tear process; affects one or two joints; occurs symmetrically; obesity and overuse are predisposing factors
Nursing assessment for Degenerative joint disease
Joint pain that increases with activity and improves with rest; morning stiffness; asymmetry of affected joints; crepitus; limited movement; visible joint abnormalities; joint enlargement and bony nodules
Nursing plans and interventions for Degenerative joint disease
Weight reduction diet; excessive use of the involved joint aggravates pain and may accelerate degeneration; correct posture and body mechanics; sleep with rolled terry cloth towel under cervical spine if neck pain is a problem’ wear stretch gloves at night; keep joints in functional position
Osteoporosis
Metabolic disease in which bone demineralization results in decreased density and subsequent fracture; occur prior to the client’s falling; cause is unknown; postmenopausal women are at the highest risk
Nursing assessment for osteoporosis
Classic dowager’s hump, or kyphosis of the dorsal spine; loss of height, often 2-3 inches; back pain, often radiating around the trunk
Nursing plans and interventions for osteoporosis
Hazard-free environment; keep bed in low position; provide a safe environment; ROM exercise several times/day; proper body mechanics; diet high in protein, calcium and vitamin D; discourage use of alcohol and caffeine; hormone replacement therapy; diet high in calcium and vitamin D intake beginning in early adulthood; calcium supplementation after menopause; weight bearing exercise; bone density study as baseline
Fracture
A break in the continuity of the bone; caused by a firect blow, crushing force, a sudden twisting motion or a disease such as cancer or osteoporosis
Complete fracture
A break across the entire cross section of the bone
Incomplete fracture
A break across only part of the bone
Closed fracture
No break in the skin
Open fracture
Broken bone protrudes through skin or mucous membranes
Greenstick
One side of the bone is broken and the other side is bent
Transverse
Break occurs across the bone
Oblique
Break occurs at an angle across the bone
Spiral
Break twists around the bone
Comminuted
Break has more than free fragments
Extracapsular fracture
Below the neck of the femur
Intracapsular fracture
In the neck of the femur
Intracapsular fracture
Fracture that is harder to heal because the blood supply enters the femur below the neck of the femur; greater likelihood that necrosis will occur because the fracture is cute off from the blood supply
Nursing assessment of a fracture
Pain, swelling, tenderness; deformity, loss of functional ability; discoloration, bleeding at the site through an open wound; crepitus; fracture is evident on radiograph; observe the clients use of assistive devices
Crepitus
Crackling sound between two broken bones
Fat embolism
A syndrome in which fat migrates into the blood stream and combines with pletlets to form emboli; the greatest risk is 36 hours after a fracture; more common in clients with multiple fractures, fractures of the long bones, fractures of the pelvis. Initial symptom is confusion due to hypoxemia; assess for respiratory distress, restlessness, irritability, fever and petechiae; notify physician stat, draw ABGs, administer oxygen, assist with intubation
Thromboembolism
In patient’s with hip fractures, this is the most common complication; prevention includes ROM, elastic stocking, elevation of the foot, low dose heparin
Assessment of client with fracture/in a cast
Skin color, temperature, sensation, capillary refill, mobility, pain and pulses
Pain, paresthesia, pulse, pallor and paralysis
The 5 Ps of neurovascular functioning
Joint replacement
A surgical procedure in which a mechanical device, designed to act as a joint, is used to replace a diseased joint; most common joints: hip, knee, shoulder, finger; accurate fitting is essential; excellent pain relief; infection is a post-op concern
Nursing assessment for joint replacement
Joint pathology: arthritis, fracture, pain not relieved by medication, poor ROM
Nursing plans and interventions for joint replacement
Monitor incision site, assess for bleeding ad drainage, assess suture line for erythema and edema, assess suction drainage apparatus, assess for signs of infection; monitor functioning of extremity – check circulation, sensation and movement of extremity distal to placement; I&O; 3Lfluid/day; work closely with health care team to increase client’s mobility gradually
Infection
Big problem after joint replacement
Fracture
Predispose the client to anemia, especially if long bones are involved; check HCTq3-4 days to monitor erythropoiesis
Amputation
Surgical removal of a diseased part or organ; causes are perpherial vascular disease, trauma, congenital deformities, malignant tumors, infection
Nursing assessment for amputation
Assess for symptoms of peripheral vascular disease: cool extremity, absent peripheral pulses, hair loss on affected extremity, necrotic tissue or wounds, leathery skin on affected side, decrease of pain sensation; assess for inadequate circulation: arteriogram, Doppler flow studies
Nursing plans and interventions for amputation
Provide wound care, change dressing as needed, maintain proper body alignment in and out of bed; position the client to relieve edema and spasms at residual limb site: passive ROM
Dressing change for amputation
Maintain aseptic technique, assess wound color and warmth, assess for wound healing, monitor for signs of infection
Care of amputated stump
Elevate for the first 24 hours but do not elevate 48 hours post op; keep stump extended position and turn client to prone position three times a day to prevent hip flexion contracture
Residual limb
Should be elevated on one pillow; if elevated too high, can cause a contracture
Glaucoma
Chronic open-angle also known as adult primary and as primary open angle
Nursing assessment for glaucoma
Early signs: increase in intraocular pressure, >22mmHg; decreased accommodation or ability to focus; late signs: loss of peripheral vision, seeing halos around lights, decreased visual acuity not correctable with glasses, headache or eye pain
Glaucoma
Often painless and symptom free; pick up as part of a regular exam
Diagnostic tests for glaucoma
Tonometer, electronic tonometer, gonioscopy
Tonometer
Used to measure intraocular pressure
Electronic tonometer
Used to detect drainage of aqueous humor
Gonoiscopy
Used to obtain a direct visualization of the lens
Nursing plans and interventions for glaucoma
Administer eye drops for rest of life and must follow regime; vision lost cannot be restored; provide safety measures; avoid activities that may increase intraocular pressure such as emotional upsets, exertion, coughing, wearing constrictive clothing, straining at stool and constipation
Eye drops
Used for cause pupil constriction because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye
Pilocarpine
Commonly used eye drop for glaucoma; vision may be blurred for 1-2 hours after administration and adaptation to dark environments is difficult because of the papillary constriction it causes
Elderly patients with glaucoma
Prone to glaucoma and constipation – nurse should continually assess for constipation and should implement a plan of care directed at prevention of and treatment of constipation
Cataract
Condition characterized by opacity of the lens; aging accounts for 95%; other 5% is from trauma, toxic stundtances, systemic disease or are congenital; surgical removal is done under local anesthesia
Eye physiology
The lens of the eye is responsible for projecting light onto the retina so that images can be discerned; without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred
Nursing assessment for cataract
Early signs: blurred vision, decreased in color perception; late signs: diplopia, reduced visual acuity, progressing to blindness; coulded pupil, progressing to a milky-white appearance
Diagnosis for cataract
Ophthalmoscope, slit lamp biomicroscope
Post operative care for cataract
Warn not to rub or put pressure on the eye, glasses or shaded lens should be worn during waking hours; avoid lifting objects over 15 pounds, bending, straining, coughing or any other activity that can cause an increase in intraocular pressure; avoid lying on operative side; need to keep water from getting into eye; observe and report signs of increased intraocular pressure and infection
Cataract removal
When this is removed, the lens of the eye is gone and replaced with an implant; vision is improved but not perfect; prevention of falls is important
Eye trauma
Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat; permanent visual impairment can occur; every eye injury should be considered an emergency
Nursing assessment for eye trauma
Determine type of injury and symptoms; slit lamp examination; instillation of flurosecein to detect corneal injury; testing of visual acuity for medical documentation and protection
Nursing plans and interventions for eye trauma
Sitting position decreased intraocular pressure; remove conjunctival foreign bodies unless embedded; never attempt to remove a penetrating or embedded object; apply cold compressures to eye contusion; irrigate eye with copious amounts of water; eye medications; eye patch may be applied to rest the eye; reading and watching TV may be restricted for 3-5 days; sudden increase in eye pain should be reported
Detached retina
A hole or tear in, or separation of the sensory retina from, the pigmented epithelium; can be caused from blunt trauma treatment is resealing of the retina through cryotherapy (freezing), photocoagulation (Laser), diathermy (heat), sclera buckling (most often used
Nursing plans and interventions for a detached retina
Bed rest, eye patch on affected eye, administer medication to inhibit accommodation and constriction; cyclopegics (mydriatic and homatropine) are given to dilate pupil before surgery; administer medication for post-op pain;
Conductive Hearing loss
Hearing loss in which sound does not travel well to the sound organs of the inner ear. Volume of sound is less, but the sound remains clear. If volume is raise, hearing is normal; results from cerumen impaction of middle ear disorders
Sensorineural hearing loss
A form of hearing loss in which sound passes properly through the outer and middle eat but is distorted by a defect in the inner ear; involves perceptual loss, usually progressive and bilateral; damage to the 8th cranial nerve; detected using a tuning fork; common causes are infections, ototoxic drugs, trauma, neuromas, noise, aging
Hearing loss nursing assessment
Inability to hear a whisper from 1-2 feet away; inability to respond if nurse covers mouth when talking; inability to hear a watch tick 5 inches from ear; shouting in conversation; straining to hear; turning head to favor one ear; answering questions; raising volume on radio or TV
Nursing plans and interventions for hearing loss
Reduce distractions; turn TV/radio off; devote full attention; look and listen’ being with casual topics; progress to more critical issues slowly; face patient; speak slowly; use helpful aids
Hearing loss nursing interventions
Speak in a low-pitched voice, slowly and distinctly; stand in front of the person with the light source behind the client; use visual aids
Altered state of consciousness assessment
Neuro-vital sign assessment tool; Glasgow coma scar; pupil size, limb movement, vital signs; assess skin integrity and corneal integrity; check bladder for fullness, auscultate lungs and monitor cardiac status
Glasgow coma scale
Assesses eye opening, motor response, and verbal response; maximum scope is 15 – minimum is 3; score of <7 indicates coma; clients with low scores have high mortality rate and poor prognosis
Residual feeding
The amount of previous feeding still in the stomach; presence of 100 ml in adult usually indicates poor gastric emptying and feeding should be withheld
Paralytic ileus
Common in comatose clients; gastric tube aids in gastric decompression
Nursing plans and interventions for a patient with altered LOC
Maintain adequate respirations, airway, oxygenation; provide nutritional, fluid and electrolyte support; prevent complications of immobility; there is a huge potential for thrombus formation, prevent this; vital signs; contractures and joint immobility, urinary calculi; prevent injury and promote safety; maintain hygiene, cleanliness, observe for bladder elimination problems; document and record bowel movements; prevent corneal injury
Maintaining adequate respirations, airway, oxygenation
Position client in three quarters prone position or semiprone position to prevent tongue from obstructing airway and slightly to one side with arms away from chest wall; insert airway keep airway free of secretions; monitor arterial Po2 and PCO2; chest physiotherapy; hyperventilate before and after suctioning
Provide nutritional and fluid and electrolyte support
Keep NPO until responsive; mouth care every 4 hours; maintain calorie count; administer feedings; monitor I&O; record client’s weight
Prevent complications of immobility
Turn clientq2h, assess bony prominences; eggcrate or alternating pressure mattress or waterbed; minimal amount of linens and underpads
Prevent thrombus formation
Passive ROM q4h; elastic hose; avoid positions that decrease venous return; avoid pillows under knees and gatched bed;
Urinary calculi
Increase fluid PO via gastric tube; increase urine for high SG and balance between I&O; reposition every 2 hours; apply splints or other assistive devices to prevent foot drops, wrist drop or other improper alignment
Indications of changing condition
HR <60 or >100 indicates ICP, infection, thrombus formation or dehydration; BP rising or widening pulse pressure indicates ICP; elevation can indicate worsening condition, damage to temperature regulating area of the brain, or infection; LOC changes; papillary changes range from prompt to sluggish or may increase in size
Restlessness
May indicate a return to consciousness but can also indicate anoxia, distended bladder, convert bleeding or increasing cerebral anoxia
Prevention of corneal injury and drying
Remove contact lenses; irrigate eyes with sterile prescribed solution and instill ophthalmic ointment in each eye every 8 hours to prevent corneal ulceration
Head injury
Any traumatic damage to the head
Open head injury
Occurs when there is a fracture of the skill or penetration of the skill by an object
Closed head injury
The result of blunt trauma – more serious because of chance of increased ICP in closed vault
Increased ICP
The main concern in the head injury; it is related to edema, hemorrhage, impaired cerebral autoregulation, and hydrocephalus
Acceleration
Which is caused by the heads being in motion and deceleration injury which occurs when the head stops suddenly
Nursing assessment for head injury
Unconsciousness or disturbances in consciousness; vertigo; confusion, delirium, or disorientation; symptoms of increased ICP; changes in vital signs; headache; vomiting; papillary changes; seizures; ataxia; abnormal posturing; cerebral spinal fluid leakage; CAT & MRI; EEG
Increased ICP signs
Widening pulse pressure, tachycardia, slowing of respirations, possible decrease in pulse; temperature rise
CSF leakage
Can occur from the nose (rhinorrhea) or through the ear (otorrhea); carries the risk for meningitis and indicates a deteriorating condition.
Nursing plans and interventions for head injury
Adequate ventilation and airway; keep HOB elevated 30-45 degrees to aid venous return from neck and decrease cerebral volume; neurologic vital signs q2h; avoid activities that increase ICP; take immediate measures to reduce temperature; ICP monitoring (>20mmHg report STAT); administer hyperosmotic agents and diuretics to dehydrate brain and cerebral edema; foley catheter; passive hyperventilation of ventilator; seizure precautions; prevent complications of immobility
Passive hyperventilation of ventilator
Causes respiratory alkalosis which causes cerebral vasoconstriction and decreased cerebral blood flow, and therefore decreased ICP
Spinal cord injury
Disruption in nervous system function which may result in complete or incomplete loss of motor and sensory function. Changes occur in the function of all physiologic systems
Nursing assessment of spinal cord injury
Assess breathing pattern, auscultate lungs; chest neuro-vital signs and cardiac status frequently; assess abdomen for girth, bowel sounds, assess lower abdomen for bladder distention; assess temperature; assess psychosocial status; hypotention and bradycardia are associated with injuries above T6
Physical assessment of spinal cord injury
Should concentrate on respiratory status, especially in clients with injury at C3 to C5 because of the cervical plexus innervates the diaphragm
Nursing plans and interventions of spinal cord injury: acute phase
Maintain client in extended position with cervical collar; stabilize client when transferring between accident scene and the emergency room; maintain a patent airway; cervical injuries, skeletal traction is maintained by use of skull tongs or halo ring; high dose corticosteroids; kinetic therapy treatment table; stryker frame or very firm mattress; assess for respiratory failure; evaluate for present of spinal shock and autonomic dysreflexia; acute paralytic ileus, lack of gastric activity; suction with caution to prevent vagus nerve stimulation
Spinal shock
Medical emergency; complete loss of all reflex, motor, sensory and autonomic activity below the lesion; hypotentsion, bradycardia; complete paralysis and lack of sensation before lesion; bladder and bowel distension
Autonomic dysreflexia
Exaggerated autonomic responses to stimuli; medical emergency; occurs in clients with lesions at or above T6; occurs after spinal shock; trigged by noxious stimulus and vaginal examination; elevated BP, pounding headache, sweating, nasal congestion, goose bumps, bradycardia, bladder and bowel distention
Nursing plans and interventions of spinal cord injury: rehabilitation phase
Encourage deep breathing; chest physiotherapy; kinetic bed to promote blood flow to extremities; antiembolic stockings; ROM; mobilize ASAP; TCDB frequently; observe for impending skin breakdown; importance of impeccable skin care; perform intermittent catheterization q4h;I&O; acidify vitamin C; teach bladder emptying techniques; begin bowel training program; talk with client and family about permanent disability
Urinary tract infection
Common cause of death after spinal cord injury; bacteria grow best in alkaline media; keep dilute and acidic; keep emptied to assist in avoiding bacterial growth
Brain tumor
Neoplasm occurring in the brain; primary can arise in any tissue of the brain; secondary are a result of metastasis from other areas such as the lungs and breast
Benign brain tumor
Continue to grow and take up space in the confined area of cranium, causing neural and vascular compromise in the rain, increased ICP and necrosis of the brain tissue; must be treated because they can have malignant effects
Nursing assessment for brain tumors
Headache that is more severe upon awakening; vomiting not associated with nausea; papilledema with visual changes; behavioral and personality changes; serizures; aphasia, hemiplegia, ataxia; cranial nerve dysfunction; abnormal CAT scan
Nursing plans and interventions for brain tumors
Similar to those with a patient who has increased ICP and head injury; elevate HOB 30-40 degrees; radiation therapy’ administer chemotherapy; craniotomy
Craniotomy preoperative medications
Corticosteroids to reduce swelling; agents and osmotic diuretics to reduce secretions; agents to reduce seizures; prophylactic antibiotics
Multiple sclerosis
Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses; onset is insidious, increased white matter density seen on CAT scan; presence of plaques on MRI; CSF electrophoresis shows presence of oligoclonal (IGG) bands; auto immune
Multiple sclerosis
Symptoms usually begin in the upper extremities with weakness progressing to spastic paralysis
Nursing assessment for MS
History of symptoms, pregression of illness, types of treatment received and the responses, additional health problems; current medications; client and family’s perception of illness; community resources used by client; optic neuritis; visual or swallowing difficulties; gait disturbances, intention tremors; unusual fatigue, weakness and clumsiness; numbness on one side of the face; impaired bladder and bowel control; speech disturbances; scotomas
Optic neuritis
Loss of vision or blind spots
Scotomas
White spots in the visual field, diplopia
Nursing plans and interventions for MS
Encourage self care and frequent rest periods; work until the point of fatigue; for muscle spascitiy and that stretch – hold- relax exercises are helpful as are riding a stationary bicycle and swimming; adequate fluid intake, high fiber foods, bowel regime for constipation; steroid therapy and chemotherapeutic drugs; interferon beta products
Drug therapy for MS
ACTH, cortisone, cytoxan, and other immunosuppressive drugs; teach prevention of infection
Myasthenia gravis
Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body; autoimmune disease characterized by the presence of acetylcholine receptor antibodies, which interfere with neuronal transmission
Nursing assessment for Myasthenia gravis
Diplopia, ptosis; mask-like affect: sleepy appearance due to facial muscle involvement; weakness o laryngral and pharyngeal muscles: dysphagia, choking, food aspiration, difficulty speaking; muscle weakness improved by rest, worsened by activity; advanced cases: respiratory failure, bladder and bowel incontinence; myasthenic crisis and cholinergic crisis
Cholinergic crisis
Attributed to anticholinesterase over dosage; diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms resulting from overmedication; associated with negative tensilon test
Nursing plans and interventions for Myasthenia gravis
Tracheostomy kit available at bedside for possible Myasthenia crisis; administer anticholinergic drugs; schedule nursing activities to conserve energy; avoid situations that produce fatigue or physical or emotional stress; TCDB q4-6h
Myasthenia crisis
Associated with positive edrophonium (tensilon) test
Bed rest
Relieves Myasthenia gravis symptoms; bladder and respiratory infections are recurrent problems
Parkinson disease
Disorder affecting movement involving the basal ganglia and substantia nigra
Nursing assessment of Parkinson disease
Rigidity of extremities; mask like facial expressions associated with difficulty swalling, chewing and speaking; drooling; stooped posture and slow, shuffling gait; tremors at rest, pill rolling movement; emotional lability
Tremors
Disappear during sleep and purposeful activity
Nursing plans and interventions for Parkinson disease
Activities later in the day to allow sufficient time for client to perform self care activities; encourage activities and exercise; eliminate activities environmental noise; soft diet
Guillain-barre syndrome
Clinical syndrome of unknown origin involving peripheral and cranial nerves; preceded by a respiratory or GI infection 1-4 weeks prior to the onset of neurologic deficits; potential complication of respiratory failure; full recovery can occur within several months to a year after symptoms onset
Nursing assessment for Guillain-barre syndrome
Paresthesia, muscle weakness of legs progressing to the upper extremities, trunk and face; paralysis of the ocular, facial and oropharynheal muscles, causing marked difficulty in talking; breathlessness while talking, shallow and irregular breathing; accessory muscle usage; change in respiratory pattern; paradoxic inward movement of the upper abdominal wall ; increasing pulse rate and disturbances in rhythm; hypertension, orthostatic hypotension; pain in the back and in calves of the legs; weakness or paralysis of the intercostals and disaphragm muscles
Nursing plans and interventions of Guillain-barre syndrome
Monitor for respiratory distress and initiate mechanical ventilation
Stroke: Cerebral Vascular Accident
Sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain; classified as thrombotic or hemorrhagic
Hemorrhagic stroke
Caused by a slow or fast hemorrhage into the brain tissue; often related to hypertension
Embolytic stroke
Caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. Related to atherosclerosis
Risk factors for Stroke: Cerebral Vascular Accident
HTN; previous TIAs; cardiac disease; advanced age; diabetes; oral contraceptives; smoking
Atrial flutter and fibrillation
Produce a high incidence of thrombus formation following arrhythmia caused by turbulence of blood flow through all valves and heart chambers
Diagnosis of CVA
CT scan, MRI, Doppler flow studies, ultrasound imaging
CVA
Motor loss, hemiparesis or hemoplegia; communication loss, dysathria, dysphasia, aphasia, or apraxis; perceptual disturbance that can be visual, spatial and sensory; change in LOC
Nursing assessment for CVA
Change in LOC; paresthesia, paralysis, aphasia, agraphia, memory loss, vision impairment, bladder and bowel dysfunction; behavioral changes; assessment of client’s functional abilities; ability to swallow, eat, and drink without aspiration
Apraxia
Inability to perform purposeful movements in the absence of motor problems
Dysarthris
Difficulty articulating
Dysphasia
Impairment of speech and verbal comprehension
Aphasia
Loss of the ability to speak
Agraphia
Loss of the ability to write
Alexia
Loss of the ability to read
Dysphagia
Dysfunctional swallowing
Nursing plans and interventions for CVA
Control hypertension to help prevent future stuff; proper body alignment; minimize edema, prevent contractures, and maintain skin integrity; full ROM exercises 4xd; personal care; set realistic goals; teach appropriate self-care activities for hemiparetic person; assist with dressing activities and modify them; analyze bladder elimination pattern; follow up speech program initiated by the speech and language therapist; do not place client in sensory overload; one instruction set at a time;
Steroids
Administered after a stroke to decrease cerebral edema and retard permanent disability
H2 inhibitors
Administered after a stroke to prevent peptic ulcers
Anemia
Deficiency of RBCs reflected as decreased HCT, HBG, RBCs
Nursing assessment for anemia
Pallor; palmar crease; conjunctiva; fatigue, exercise intolerance, lethargy, orthostatic hypotension; tachycardia, heart murmurs, heart failure signs of bleeding; dyspnea; irritability, difficulty concentrating; cool skin and cold intolerance
Risk factors for anemia
Diet lacking in iron, folate, and/or vitamin B12; family history of genetic diseases; medication history of anemia-producing drugs, salicylates, thiazides, diuretics; exposure to toxic agents, lead or insecticides
Diagnostic tests for anemia
HBG < 10; HCT<36%; RBCs<4×10^2; bone marrow positive for anemia
Physical symptoms
Occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system; CO increased when HGB drops below 7
Nursing plans and interventions for anemia
Blood products; periods of rest and activity; increase iron by meating red meats, organ meats, whole wheat products, spinach, carrots; eat folic acid foods such as green vegetables, liver, citrus fruits; consume vitamin B12 foods such as glandular meats, yeasts, green leafy vegetables, milk, cheese; vitamin supplementations;
Administration of iron parenterally
Use Z track method to prevent staining of skin; do not use deltoid muscle and do not massage the site
Sickle cell crisis
Precipitated by hypoxia; provide pain relief, provide adequate hydration; avoid activities that cause hypoxia
Normal saline
Use only this product to flush IV tubing or to run with blood. Never add medications to blood products; two RNs should check physicians prescription, client’s identity and the blood bag label
Leukemia
Malignant neoplasm of the blood-forming organs; characterized by an abnormal over production of immature forms of any of the leukocytes; interference with normal blood production that results in decreased number of RBCs and platelets
Results of leukemia
Anemia results from decreased RBC production and blood loss; immunosuppression occurs because of the large number of immature WBCs or profound neutropenia; hemorrhage occurs because of thrombocytopenia
Chemotherapeutic agents
Toxic to cancer cells and normal cells in the client and caregiver; pregnant nurses should not work with these; wear gloves; check the drug with another nurse against the health care provider’s prescription and the client’s record to ensure it is the right medication/right patient; verify life placement and patency with another nurse; aspirated a blood return;peripheral site is used for infusion, stay with patient for the entire infusion and use a new site daily; dispose of all IV equipment in the prescribed receptacle so that personnel handing trash don’t come in contact with the vesicant
Chemotherapy
Nurse must be credentialed in order to administer this; should recognize complications of this product related to administration, safety, side effects, and nursing assessment parameters and should report these to the RN and health provider
Risk factors for leukemia
Genetic abnormalities; ionizing radiation; viral infections; exposure to benzene; alkylating chemotherapeutic agents; immunosuppreants; chloramphenicol; phenylbitazone
Acute myelogenous leukemia
Involves the inability of leukocytes to mature; those that do mature are abnormal; any time during the life cycle; onset is insidious; prognosis is poor; cause of death = overwhelming infection
Chronic myelogenous leukemia
Results from abnormal production of granulocytic cells; biphasic disease; chronic stage lasts 3 years; acute phase last 2-3 months; young to middle-aged adults; know causes include ionizing agents, chemical exposure; prognosis is poor; treatment is conservative and involves oral antineoplastic agents: hydroxyura, interferon, and imatinib mesylate
Acute lymphocytic leukemia
Abnormal leukocytes are found in blood forming tissue; occurs in children; prognosis is favorable
Chronic lymphocytic leukemia
Increased production of leukocytes and lymphocytes and proliferation of cells within the bone marrow, spleen and liver; after the age of 35; most clients are asymptomatic and are not treated
Nursing assessment for leukemia
Tendency to bleed; anemia; infection; GI distress
Tendency to bleed
Petechiae; nose bleeds bleeding gums; eccymosis
Anemia
Fatigue, headache, bone and joint pain, hepatosplenomegally
Infection
Fever, tachycardia, lymphadenopathy, night sweats, skin infection, poor healing
GI distress
Anorexia; weight loss, sore throat, abdominal pain, diarrhea, oral lesions,
Infection
May not be manifested with an elevated temperature in the immunocompromised patient; imperative that the nurse perform a total and thorough assessment of the client OFTEN
Nursing plans and interventions in the client who is immunocompromised and clients with BM suppression
Monitor WBC dailyl assess oral cavity and genital area often; monitor VS frequently; administer antibiotics; monitor blood levels of antibiotics; importance of infection control for patient, staff and family; oral hygiene regime; encourage TCDB; avoid rectal temperature and suppositories; monitor I&O, fluid status and electrolyte balance; encourage mobility; provide care for invasive catheters and lines using aseptic techniques;
What patients on chemotherapy should not do
Eat raw fruits or vegetables; be present in crowded areas or around people with infection; eat raw foods
Hodgkin disease
Malignancy of the lymphoid system; characterized by a generalized painless lymphadenopathy; higher in males and young adults; prognosis is good; diagnosis is made by excision of a node for biopsy with the characteristic cell being reed-sternberg
Stage 1 Hodgkin disease
Involvement of single lymph node region or a single extralymphatic organ or site
Stage 2 Hodgkin disease
Involvement of two or more lymph nodes on the same side of the diaphragm or localized involvement of an extralymphatic organ site
Stage 3 Hodgkin disease
Involvement of lymph node areas on both sides of the diaphragm to localized involvement of one extralymphatic organ, the spleen or both
Stage 4 Hodgkin disease
Diffuse involvement of one or more extralymphatic organs, with or without lymph node involvement
Treatment for Hodgkin disease
Radiotherapy; chemotherapy: nitrogen mustard, adriamycinm vincristine, prednisone
Nursing assessment for Hodgkin disease
Enlarged lymph nodes; anemia, thrombocytopenia, elevated leukocytes, decreased platelets; fever, increased susceptibility to infections; anorexia, weigh loss; malaise, bone pain; night sweats
Nursing plans and interventions for Hodgkin disease
Protect client from infection; monitor temperature; observe for signs of anemia; adequate rest; preoperative and postoperative care; high nutrient foods
Hodgkin disease
One of the most curable of all adult malignancies; emotional support is vital; chemotherapy leaves men sterile; may bank sperm to treatment if desired
Cancer
A disease characertized by uncontrolled growth of abnormal cells
Neoplasm
A new formation
Carcinoma
A malignant tumor arising from epithelial tissue
Sarcoma
A malignant tumor arising from nonepithelial tissue
Differentiation
Degree to which neoplastic tissue is different from parent tissue
Metastasis
Spread of cancer from the original sire to other parts of the body
Adjuvant therapy
Therapy supplemental to the primary therapy
Palliative procedure
Relieves symptoms without curing the cause
Adeno
Glanduar tissue
Angio
Blood vessels
Basal cell
Epithelium (sun exposed areas)
Embryonal
Gonads
Fibro
Fibrous tissue
Lympho
Lymphoid tissue
Melano
Pigmented cells of epithelium
Myo
Muscle tissue
Osteo
Bone
Squamous cell
Epithelium
Warning signs of cancer
Change in usual bowel and bladder function; sore that doesn’t heal; unusual bleeding or discharge; thickening or a lump in the breast or elsewhere; indigestion or dysphagia; obvious changes in a wart or mole; nagging cough or hoarsenes
Benign tumors of the uterus
Benign tumors arising from the muscle tissue of the uterus; most common symptom is abnormal uterine bleeding; tend to disappear after menopause; rarely become malignant; intervention for severe symptoms is hysterectomy
Nursing assessment of benign tumors of the uterus
Menorrhagia; dysmenorrheal; uterine enlargement; low back pain and pelvic pain
Menorrhagia
Profuse or prolonged menstrual bleeding; the most important factor related to benign uterine tumors; assess for signs of anemia
Uterine prolapsed
The downward displacement of the uterus
Cystocele
The relaxation of the anterior vaginal wall with prolapse of the bladder
Rectocele
The relaxation of the posterior vaginal wall with prolapse of the rectum
Measures to prevent uterine prolapse, cystocele, and rectocele
Postpartum perineal exercises; spaced pregnancies; weight control
Uterus
When this is displaced, it impinged on other structures in the lower abdomen; the bladder, rectum and small intestine can protrude through the vaginal wall
Nursing assessment for prolapse, cystocele, and rectocele
Predisposing conditions: multiparity, pelvic tearing during childbirth, vaginal muscle weakness, obesity; symptoms associated with uterine prolapse: dysmenorrheal, dragging sensation in pelvic and back, dyspareuria; symptoms associated with cystocele: incontinence or stress incontinence, urinary retention, bladder infections; symptoms associated with rectocele: cosstipation; hemorrhoids; sense of pressure; need to defecate
Nursing plans and interventions for hysterectomy
Edema and douche as prescribed pre-op; not amount and character of vaginal discharge; avoid rectal thermometers or tubes; check extremities for warmth and tenderness as indicators of thrombophlebitis; pain management; encourage ambulation; monitor urinary output; assess voiding patterns; observe for incision bleeding; note abdominal distention; increase diet from liquids to general; stool softeners prior to first bowel movement; limit tampon use; avoid douching; refrain from intercourse; avoid heavy lifting; maintain adequate fluid intake; notify MD at first sign of infection
Cancer of the cervix
Of cancers occurring in the cervix; 95% are squamous cell in origin; linked to HPV; easily detected early by the papanicolaou test; precursor to cancer of the cervix is dysplasia
Early dysplasia treatment
Cryosurgery, electrocautery, laser, conization, hysterectomy
Early carcinoma treatment
Hysterectomy; intracavity radiation
Late carcinoma treatment
External beam radiation along with hysterectomy; antineoplastic chemotherapy; pelvic exenteration
Laser therapy or cryosurgery
Used to treat cervical cancer when the lesion is small and localized
Invasive cancer
treated with radiation, conization, hysterectomy or pelvic exenteration; chemotherapy is not useful for this type of cancer
Care of the client with radiation implants
Used to treat disease by delivering high dose radiation directly to the affected tissue; not radioactive, isolation time is limited; private room and place warning on door; do not permit pregnant caretakers to care for client; discourage visits by small children; keep lead lined container in the room for disposal of the implant; remain in bed with as little movement as possivle; all client secretions have the potential of being radioactive; wear radiation badge when providing care to clients with radiation implants; plan care to limit overall time in the room
Ovarian cancer
Cancer of the ovaries can occur at all ages, including infancy and childhood. Early diagnosis is difficult because no useful screening test exists at present
Nursing assessment of ovarian cancer
Asymptomatic in early stages; laparotomy is the primary tool for diagnosis and staging of the disease; pelvic discomfort; low back pain; weight change; abdominal pain; NV; constipation; urinary frequency
Ovarian cancer
The leading cause of death from gynecologic cancers in the US; growth is insidious so it is not recognized until it is at an advanced stage
Nursing plans and interventions for ovarian cancer
Provide that care required after any major abdominal surgery following laparotomy
Breast cancer
Cancer originating in the breast; 90% are discovered through BSE; generally adenocarcinoma, originating in epthial cells and occurs in the ducts or lobes; tend to be located in the upper outer quadrant of the breast and more often in the left breast than the right; early detection is important; tumors <4cm
Risk factors for breast cancer
Positive family history, menarche before 12 years of age and menopause after age 50; nulliparous and those breathing first child after age of 30; history of uterine cancer; daily alcohol intake
Common sites of metastasis from breast cancer
Axillary, supraclavicular, and medistinal lymph nodes, followed by spread to the lungs, liver, brain, and spine
Diagnosis of breast cancer
Made by biopsy
Nursing assessment of breast cancer
Hard lump that is not freely movable and not painful; dimpling of the skin; retraction of nipple; alterations in contour of the breast; change in skin color; change in skin texture; discharge from the nipple; pain and ulcerations; mammogram; biopsy and frozen section
Nursing plans and interventions for breast cancer
Assess lesion by location, size, shape, consistency, fixation to surrounding tissues, lymph node involvement
Post-operative care of breast cancer
Monitor bleeding, check under dressing, hemovac, and under client’s back; position arm on operative side on a pillow, slightly elevated; avoid BP measurements, injections and venipuncture in affected arm; avoid injury to affected arms; perform activities that will use arm; post mastectomy exercises
Testicular cancer
Cancer of the testes is the leading cause of death from cancer in males 15-35 years of age; death usually occurs within 2-3 years;
Nursing assessment of testicular cancer
Early signs: subtle and usually go unnoticed; feeling of heaviness of dragging in lower abdomen and groin; lump or swelling on the testicle; late change: low back pain, weight loss, fatigue
Most common symptom of testicular cancer
Appearance of a small, hard lump about the size of a pea on the front or side of the testes; manual examination should begin at 14 and done after the shower by palpating the testes and cord to look for a small lump; swelling may also be a sign of testicular cancer
Cancer of the prostate
Rarely occurs rarely before 40 years of age, but it is the second leading cause of death from cancer in American men; high risk groups include those with a history of multiple sexual partners, STDs and certain viral infections
Nursing assessment for prostate cancer
Asymptomatic if confined to gland; symptoms of urinary obstruction ; with metastasis: low back pain, fatigue, aching in legs, and hip pain; elevated prostate specific antigen; elevated prostatic acid phosphatase; digital rectal examination revealing palpale nodule; transrectal ultrasound to visualize nonpalable nodule; definitive diagnosis by biopsy
Elevated prostate specific antigen
Should be considered prior to a digital rectal exam so that manipulation of the prostate does not give a false positive reading; rise and consistently high levels is more reliable than a single assay; can rise with inflammation, benign hypertrophy, or irritation
Nursing plans and interventions for prostate cancer
Early detection; preoperative bowel preparation to prevent fecal contamination of operative site; post-op care
STDs
Diseases that can be transmitted during intimate sexual contact; occur in adolescents and young adults
Sexual abuse
STDs in infants and children indicate ?? and should be reported; nurse is legally responsible to report suspected cases of child abuse
Chlamydia
Most commonly reported communicable disease in the US
Nursing plans and interventions
Nonjudgmental approach, be straight forward when taking history; all information is condifential and reassure this to the client; complete sexual history; signs and symptoms of STDs, mode of transmission, concise written instructions; avoid sexual contact while infected; report incidents of STDs to appropriate health agencies and departments; instruct women of childbearing age about the risks to a newborn: gonorhheal conjunctivitis, neonatal herpes, congenital syphilis, oral candidiasis; teach safer sex
Burn
Tissue injury or necrosis caused by transfer energy from a heart source to the body; can be thermal, radiation, electrical, chemical; tissue destruction results from coagulation, protein denaturation, ionization of cellular contents; critical symptoms affected include the respiratory, integumentary, cardiovascular, renal GI, neurological
First degree burn
Deep partial thickness; sunburn; leaves the sin pink or red; dry; painful; slight edema; healing occurs in 3-6 days
Second degree burn
Deep partial thickness destruction of the epidermis and upper layers of the dermis; injury to deeper portions of the dermis; painful; appears red, white, weeping with fluid, blisters present; hair follicles intact; very edematous; blanking followed by capillary refill; heals without surgical intervention; usually doesn’t scar; healing occurs 10-21 days
Third degree
Full thickness; involves total destruction of dermis and epidermis; skin cannot regenerate; requires skin grafting; underlying tissue is involved; wound appears dry and leathery as eschar develops; painless; cannot heal on own
Severity
Determined by the extent of surface area involved
Rule of nines
Head and neck 9%, upper extremities 9% each, lower extremities 18% each, front trunk 18%, back trunk 18%, perineal area 1%
Lund and browder
Critical body areas are face, hands, feet and perineum
Stage 1: emergent phase
Begins at the time of injury and concludes with the restoration of capillary permeability; characterized by fluid shift from intravascular to interstitial and shock; focus of care is to preserve vital organ functioning; expect to administer large volumes of fluids
Stage 2: acute phase
Beginning of dieresis to near completion of wound closure; characterized by fluid shift from interstitial to intravascular
Stage 3: rehabilitation phase
Major wound closure to return to optimal level of physical and psychological adjustment; grafting and rehab
Nursing assessment of Burns
Absence of BS indicating paralytic ileus; radically decreased urinary output in the first 72 hours after injury, increased SG; radically increased UOP (dieresis) 72-2 weeks after initial injury; inadequate hydration; signs of inhalation burn
Signs of inhalation burn
Singed nasal hairs, circumoral burns, conjunctivitis, sooty or blood sputum, hoarseness, asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia; rales, wheezing and rhonchi denoting smoke inhalation
ABCs of assessment
Airway, breathing, circulation
Nursing plans and interventions of a burn in the emergent phase
Efforts are directed toward stabilization with ongoing assessment; assist with admission care: extinguish source of burn, provide open airway, determine baseline data, determine depth and extent of burn; administer tetanus toxoid; initiate fluid and electrolyte therapy; IV pain medication; monitor hydration status; provide wound care; monitor respiratory function
Nursing plans and interventions of a burn in the acute phase
Characterized by fluid shift from interstitial to intravascular; dieresis begins; occurs from 72 hours to 2 weeks after initial injury to near completion of wound closure; provide infection control; splint and position client to prevent contractions, avoid use of pillows; perform ROM exercises; provide fluid therapy; adequate nutrition; high-calorie, high protein, high carb; burn care
Dressing change
Very painful; medicate client prior to procedure
Silver sulfadiazine and mafenide acetate
Prevent infection on burn sites
Preexisting conditions
Might influence burn recovery age, chronic illness, physical disabilities, disease, medications used routinely and drug/alcohol abuse
Nursing plans and interventions of a burn in the rehabilitation phase
Characterized by the absence of infection risk; client may return home when the danger of infection has been eliminated; high protein fluids with vitamin supplements are recommended; pressure pressings may be worn continuously to prevent hypertrophic scarring and contractures
Jobst garments
Pressure dressings used
6 months
birth weight doubles
12 months
Birth weight triples
12 months
Birth length increases by 50%
8 weeks
Posterior fontanel closes
2 months
Social smile
3 months
Head turns to locate sounds
4 months
Moro reflex disappears
4 months
Steady head control is achieved
5-6 months
Turns over completely
6 months
Plays peek a boo
7 months
Transfers objects from hand to hand
7-9 months
Develops stranger anxiety
8 months
Sits unsupprted
10 months
Crawls
10-12 months
Fine princer grasp appears
10 months
Waves bye-bye
10-12 months
Walks with assistance
Birth to one year
Explores environment by motor and oral means
Developing a sense of trust; trust vs mistrust
Erikson’s theory from birth to one year
Toys for a child from birth to one year
Mobiles, rattles, squeaking toys, pictures books, balls, colored blocks and activity boxes
30 months
Birth weight quadruples
2 years
Achieves 50% of adult height
1-3 years
Bowlegged and potbellied
1-3 years
All primary teeth are present
12-18 months
Anterior fontanel closes
18 months
Throws a ball overhead
24 months
Kicks a ball
2 years
Feed self with spoon and cup
2 years
Daytime toilet training can be started
2 years
Two to three word sentences are spoken
3 years
Three to four word sentences are spoken
2.5-3 years
Own first and last name can be stated
Developing a sense of autonomy; autonomy vs. doubt and shame
Erikson’s theory at 1-3 years
Nursing implications from 1-3 years
Brief explanations before procedures; enforced separation from parents is the greatest threat to the toddlers psychological and emotional integrity; security objects or favorite toys from home should e provided for a toddler’ expect regression; learning names of body parts; provide choices
Toys for a 1-3 year old
Board and mallet, push-pull toys, toy telephones, stuffed animals, and story books with pictures
2.5 – 3 years
Each year a child gains about 5 pounds
3-5 years
Stands erect with more slender posture
3-5 years
Learns to run, jump, skip and hop
3 years old
Can ride a tricycle
3-5 years
Handedness is established
4 years
Uses scissors
5 years
Ties shoelaces
3-5 years
Learns colors, shapes
3-5 years
Visual acuity approaches 20/20
3-5 years
Egocentric and concrete
3-5 years
Uses sentences
3-5 years
Learns sexual identity (curiosity and masturbation are common)
3-5 years
Imaginary playmates and fears are common
4 & 5 years
Aggressiveness is replaced by more independence
Developing a sense of initiative; initiative vs. guilt
Erikson’s theory at 3-5 years
Nursing implications for a child 3-5 years
Emphasize understanding of the child’s egocentricity; questions should be answered at the child’s level, use simple words; therapeutic play and medical play that allows the child to act out his or her experiences is helpful; fear of mutilation by procedures is common; handle equipment or models of the equipment
Toys for a 3-5 year old
Coloring books, puzzles, cutting and pasting, dolls, building blocks, clay and stuff that allows the preschooler to work out hospitalization experience
6-12 years
Each year, a child gains 4-6 pounds and 2 inches in height
6-12 years
Experience menarche
6-12 years
Loss of primary teeth occurs
6-12 years
Fine and growth motor skills mature
8 years
Able to write script
6-12 years
Dress self completely
6-12 years
Egocentric thinking is replaced by social awareness of others
6-12 years
Learns to tell time and understands past, present and future
6-12 years
Learns cause and effect relationships
6-12 years
Socialization with peers becomes important
6 years
Molars erupt
Developing a sense of industry (industry vs. inferiority)
Erikson’s theory at 6-12 years
Nursing implications for 6-12 years
More support from parents than they wish to admit; contact with peers and school activities is important during hospitalization; explanation of all procedures is important; learn verbal explanations, pictures and books and by handling equipment; privacy and modesty are important and should be respected; participation in care and planning with staff fosters a sense of involvement and accomplishment
Toys for a 6-12 years
Board games, card games, and hobbies, stamp collecting, puzzles, videogame
12-19 years
Girls’ growth spurts during adolescence begin earlier than boys
14 years
Boys catch up around this age and continue to grow
15 years
Girls finish growth around this age
17 years
Boys finish growth around this age
12-19 years
Secondary sex characteristics develop
15 years
Adult thinking begins at this age; they can problem solve and use abstract thinking
12-19 years
Family conflicts develop
Develops a sense of identity (identity vs. role confusion)
Erikson’s theory 12-19 years old
Nursing implications for 12-19 years old
Share room with others of the same age; illnesses, treatments and procedures that alter the body image can be viewed by the adolescent as being devastating; teaching about procedures should include time without the parents being present; need consent for treatment; need to maintain identity; focus should be on the here and now
Pain assessment and management in the pediatric client
Untreated pain may lead to complications, such as delayed recovery, alterations in sleep patterns, and alterations in nutrition; often referred to as the 5th vital sign
Nursing assessment for pain management of pediatric client
Verbal report; as young as 3 can verbalize and report the location and degree of pain; nonverbal signs of pain such as grimacing, irritability, restlessness, and difficulty in sleeping or feeding; include the childs parents in the assessment
Physical assessment to pain
Increased HR, increased RR, diaphoresis and decreased oxygen levels
Pain rating scale
Pain scale to be used with children 1-3 months of age
Faces pain scale and poker chip scale
Can be utilized by children of preschool age and older for pain
Numeric pain scale
Can be used by children 9 years of age and older
FLACC
Nonverbal child can be assessed using this pain assessment tool.
Child health promotion
Immunization of children against communicable diseases is one of the greatest accomplishments of modern medicine. Childhood mortality and morbidity rates have greatly decreased
Rubeola (measles)
Highly contagious viral disease that can lead to neurologic problems or death; transmitted by direct contact with droplets from infected persons; contageious mainly during the prodromal period, characertized by fever and upper respiratory symtoms; classic symptoms include photophobia, koplik spots on buccal mucosa; confluent rash that begins on the face and spreads downward
Varicella (chicken pox)
Viral disease characterized by skin lesions; lesions begin on the trunk and spread to the face and proximal extremities; transmitted by direct contact, droplet spread or freshly contaminated objects; communicable prodromal period to the time all lesions have crusted; progress through macular, popular, vesicular, and pustular stages
Rubella (German measles)
Common viral disease that has teratogenic effects on fetus during the first trimester of pregnancy; transmitted by droplet and direct contact with infected person; discrete red macropapular rash that starts n face and rapidly spreads to entire body; rash disappears within 3 days
Pertussis (whooping cough)
Acute infectious respiratory disease usually occurring in infancy; gram-negative bacteria; begins with upper respiratory symptoms; paroxysmal stage characertized by prolonged coughing, and crowing or whooping upon inspiration; lasts from 4-6 weeks; transmitted by direct contact, droplet spread or freshly contaminated objects; treated by erythromycin; complications include pneumonia, hemorrhage and seizures
Paramyxovirus (mumps)
Incubation: 14-21 days; symptoms are fever, headache, malaise, parotid gland swelling and tenderness; manifestations include submaxillary and sublingual infection, orchitis, and meningoencephalitis; transmitted by direct contact or droplet spread; analgesics used for pain and antiseptics for fever; bed rest maintained until swelling subsides
Nursing care for children with communicable diseases
Isolate child during period of communicability; treat fever with non-aspirin product; report occurrence to the health department; prevent child from scratching skin; administer diphenhydramine HCL (Benadryl) for itching; wash hand after caring for child and handling secretions or child’s articles
German measles
Pose a serious threat to unborn siblings; counsel all expectant mothers; aware of the serious consequences of exposure during pregnancy
Nutritional assessment
Profile of the child’s and family’s eating habits; iron deficiency occurs most commonly in children 12-36 mohts old, in adolescents females, and in females during their childbearing years; vitamins most often consumed in less than appropriate amounts by preschool and school age children are vitamin A, B6, B12, C
Nursing plans and interventions for nutrition
24 hour recall; food diary; food frequency record; assess skin, hair, teeth, gyms, lips, tongue, and eyes; use anthrometry; obtain biochemical analysis
Anthropometry
Measurement of height, weight, head circumference in young children, proportion, skin fold thickness, and arm circumferences
Height and head circumference
Reflect past nutrition
Weight, skinfold thickness and arm circumference
Reflect present nutritional status as well as protein and fat reserves
Skin fold thickness
Provides a measurement of the body’s fat content; one half of the body’s total fat stores are directly beneath the skin
Biochemical analysis
Plasma, blood cells, urine or tissues from liver, bone, hair or fingernails can be used to determine nutritional status; lab testing of HGB, HCT, albumin, creatinine, and nitrogen are also commonly used to determine nutritional status
Diarrhea
Increased number or decreased consistency of stools; serious, potentially fatal illness; can be caused by bacterial or viral infections, malabosption problems, inflammatory diseases, dietary factors
Conditions associated with diarrhea
Dehydration, metabolic acidosis, shock
Nursing assessment for diarrhea
History of exposure to pathogens, contaminated food, dietary changes; signs of dehydration; larboratory signs of acidosis; signs of shock
Signs of dehydration
Poor skin tugor, absence of tears, dry mucous membranes, weight loss, depressed fontanel, decreased UOP, increased SG
Laboratory signs of acidosis
Loss of bicarbonate; serum pH <7.33; loss of sodium and potassium through stools; elevated HCT, elevated BUN
Signs of shock
Decreased blood pressure; rapid, weak pulse; mottled to gray skin color; changes in mental status
Nursing plans and interventions for diarrhea
Hydration status and VS frequently; I&O; do not take temperature rectally; rehydrate; calculate IV hydration to include maintenance and replacement fluids; collect specimens to aid in diagnosis; check stools for pH, glucose, and blood; administer antibiotics; check urine for SG; wash hands; teach home care: pedialyte or Lytren, lactose free diet, should not receive anti-diarrheals, do not give grape juice orange juice apple juice cola or ginger ale
Potassium
This can only be added to IV fluids when there is adequate UOP
Burns
Tissue injuries caused by heat, electricity, chemicals, or radiation
1-2 ml//kg/hour
UOP for infants and children should be this
Children under 2 years
Has a higher mortality rate due to greater central body sirface area; a greater part of their body surgace area is concentrated in the head and trunk as compared to an older child or an adult, therefore this age child is more likely to have serious effects from burns to the trunk and head; greater fluid volume; less effective cardiovascular responses to fluid
Child abuse
Includes physical and mental injury, sexual abuse, and emotional and physical neglect
Poisoning
Ingesting, inhaling, or absorbing a toxic substance; occur in children <6 with peak age being 2; due to their exploratory behavior, curiosity, and oral motor activity of early childhood place the child at risk
Nursing assessment for poisoning
Child found near source; GI disturbances such as NVD and abdominal pain, burns of mouth or pharynx, respiratory distress, seizures, changes in LOC, cyanosis, shock
Nursing plans and interventions for poisoning
Identify the poisonous agent quickly! Assess the child’s respiratory, cardiac, and neurologic status; bring any emesis, stool to ER; child’s age and weight; removal may require gastric lavage, activated charcoal or naloxone HCL (narcan)
Syrup of ipecac
No longer recommended for poisonings; this is because inducing vomiting may cause more damage
signs of respiratory distress in children
Restlessness, increased RR, increased HR, diaphoresis, flaring nostrils, retractions, grunting, adventitious breath sonds, use of accessory muscles, head bobbing, alterations in blood gases: decreased PO2, elevated PCO2; respiratory failure before cardiac
Asthma
An inflammatory reactive airway disease that is commonly chronic; airways become edematous; airways become congested with mucus; smooth muscles of the bronchi and bronchioles constrict
Nursing assessment for asthma
History of family asthma, history of allergies; tight cough; breath sounds that are course, expiratory wheezing, rales, crackles; chest diameter enlarged; signs of respiratory distress
Nursing plans and interventions for asthma
Rapid acting bronchodilators and steroids for acute attacks; maintain hydration; monitor blood gas values for signs of respiratory acidosis; oxygen or nebulizer therapy; monitor pulse oximetry; monitor theophylline levels; administer cromolyn sodium prophylactically to prevent inflammatory response
Cystic fibrosis
An autosomal-recessive disease that causes dysfunction of te exocrine glands; tenacious mucus production obstructs vital structures; lung insufficiency, pancreatic insufficiency, increased loss of sodium and chloride in sweat
Nursing assessment for cystic fibrosis
Meconium ileus at birth in 10-20% of cases; recurrent respiratory infection; pulmonary congestion steatorrhea; foul-smelling bulky stools; delayed growth and poor weight gain; skin that tastes salty when kissed; cyanosis, nail bed clubbing and CHF
Nursing plans and interventions for cystic fibrosis
Monitor respiratory status; assess for signs of respiratory function; IV antibiotics; administer pancreatic enzymes; administer fat soluble vitamins in water soluble form; administer oxygen and nebulizer treatments; evaluate effectiveness of respiratory treatments; teach family percussion and postural-drainage techniques; diet that is high in calories, high in protein, moderate to high in fat, and moderate to low in carbohydrates
Cotaztm-S pancrease
Pancreatic enzyme medication
150%
Child needs this much of the usual calorie intake for normal growth and development
Epiglottitis
Severe, life-threatening infection of the epiglottis; progresses rapidly, causing acute airway obstruction organisms include Haemophilus influenza
Nursing assessment for Epiglottitis
Sudden onset, restlessness, high fever, sore throat, dysphagia, drooling, muffled voice, assuming upright sitting position with chin out and tongue protruding
Nursing plans and interventions for Epiglottitis
Prevention with the Hib vaccine; maintain child in upright position; prepare for intubation or tracheostomy; IV antibiotics; hospitalization in ICU; restrain as needed
Bronchiolitis
A viral infection of the bronchioles that is characterized by thick secretions; usually caused by RSV and is found to be readily transmitted by close contact with hospital personnel, families and other children; occurs primarily in young infants
Nursing assessment for bronchiolitis
History of upper respiratory symptoms; irritable, distressed infant; paroxysmal coughing; poor eating; nasal congestion; nasal flaring; prolonged expiratory phase of respiration; wheezing, rales can be auscultated; shallow, rapid respirations
Nursing plans and interventions for bronchiolitis
Isolate child; monitor respiratory status; observe for hypoxia; clear airway of secretions using a bulb syringe; provide care in mist tent; administer oxygen; maintain hydration; evaluate response to respiratory therapy; administer synagis (palivizumab) to provide passive immunity against RSV to high risk children
Otitis media
Inflammatory disorder of the middle ear; may be suppurative or serous; anatomic structure predisposes children to this; risk for conductive hearing loss if untreated or imcompletely treated
Nursing assessment for otitis media
Fever, pain, infant may pull at ear; enlarged lymph nodes; discharge from ear; upper respiratory symptoms; vomiting, diarrhea
Nursing plans and interventions of otitis media
Administer antibiotics; reduce body temperature with tepid baths and Tylenol; position child on affected side; warm compress on affected ear; finish all antibiotics, follow up visit, monitor for hearing loss; smoking and bottle feeding when child is in supine position are predisposing factor
Tonsillitis
Inflammation of the tonsils; viral or bacterial; related to infection by streptococcus species; treatment is very important due to the risk for developing acute glomerulonephritis or rheumatic heart disease
Nursing assessment for tonsillitis
Sore throat; fever; enlarged tonsils; breathing may be obstructed by kissing tonsils; throat culture to determine viral or bacterial causes
Nursing plans and interventions for tonsillitis
Collect throat culture; warm saline gargles; provide ice chips; administer antibiotics; manage fever with acetaminophen
Signs of postoperative bleeding with tonsillectomy
Frequent swallowing; vomiting fresh blood; clearing throat; highest risk is during the first 24 hours and then 5-10 days after surgery
Congenital heart disease
Heart anomalies that develop in utero and manifest at birth or shortly thereafter
Acyanotic congenital heart disorders
Ventricular septal defect; atrial septal defect; patent ductus arteriosus; coarctation of the aorta; aortic stenosis; left to right shunts or increased pulmonary blood flow; obstructive defects
Cyanotic congentical heart disorders
Tetralogy of fallot, truncus arteriosus; transposition of the great vessels; right to left shunts or decreased pulmonary blood flow; mixed blood flow
Ventricular septal defect
Increased pulmonary blood flow; hole between the ventricles; oxygenated blood from left ventricle is shunted to the right ventricle and re-circulated to the lungs; small defects may close spontaneously; large defects cause Eisenmenger syndrome of congestive heart failure and require surgical closures
Arterial septal defect
Increased pulmonary blood flow; there is a hole between the atria; oxygenated blood from the left atrium is shunted to the right atrium and lungs; do not compromise children seriously; surgical closure is recommended before school age; can lead to congestive heart failure or atrial dysrhythmias later in life if not corrected
Patent ductus arteriosus
Increased pulmonary blood flow;anormal opening between the aorta and the pulmonary artery; closes within 72 hours after bith; if it remains patent, ocygenated blood from the aorta returns to the pulmonary artery; increased blood flow to the lungs causes pulmonary hypertension; medical intervention with indomethacin (indocin) or surgical closure
Coaractation of the aorta
Obstruction of blood flow from ventricles; there is an obstructive narrowing of the aorta; most common sites are the aortic valve and the aorta near the ductus arterisus; common finding is hypertension in the upper extremities and decreased or absent pulses in the lower extremities
Aortic stenosis
Obstruction of blood flow from the ventricles; obstructive narrowing immediately before, at, or after the aortic valve; oxygenated blood flow from the left ventricle into systemic circulation is diminished; symptoms are caused by low cardiac output; require surgical correction
Traditional three T’s of cyanotic heart disease
Tertralogy of fallot, truncus arteriosus, transposition of the great arteries
Tetralogy of fallot
Decreased pulmonary blood flow; combination of 4 defects: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy; aorta placed over and above the ventricular septal defect; cyanosis occurs because unoxygenated blood is pumped into the systemic circulation; decreased pulmonary circulation occurs because of the pulmonary stenosis; experiences tet spells; needs surgery
Tet spells
Hypoxic episodes; relieved by the child squatting or being placed in the knee-chest position
Polycythemia
Common in children with cyanotic defects
Truncus arteriosus
Pulmonary artery and aorta do not separate; one main vessel receives blood from the left and right ventricles together; blood mixes in right and left ventricales through a large ventricular septal defect, resulting in cyansis; requires surgical correction
Transposition of the great vessels
Missed blood flow; the great vessles are reversed; the pulmonary circulation arises from the left ventricle, and systemic circulation arises from the right ventricle; incompatible with like unless coexisting VSD, ASD, and/or PDA is present; medical emergency; given prostaglandin E to keep the ductus open
Nursing assessment for children with congenital heart disease
Murmur; cyanosis, clubbing of the digits; poor feeding, poor weight gain, failure to thrive; frequent regurgitation; frequent respiratory infections; activity intolerance, fatigue; assess quality and symmetry of pulses; BP of upper and lower extremities;; history of maternal infection during pregnancy
Nursing plans and interventions for children with congenital heart disease
Maintain nutritional status; feed small, frequent feedings, provide high calorie formula; maintain hydration ; neutral thermal environment; frequent rest periods; digoxin and diuretics; monitor for signs of deteriorating condition; assist with diagnostic tests and family support; prepare child for surgery as appropriate to age
Acyanotic
Has abnormal circulation; however, all blood entering the systemic circulation is oxygenated
Cyanotic
Has abnormal circulation with unoxygenated blood entering the systemic circulation
Congestive heart failure
More often associated with acyanotic defects
Congestive heart failure
Condition in which the heart is unable to pump effectively the volume of blood that is presented to it; common complications of congenital heart disease; increased workload of the heart caused by shunts or obstructions; reduce the workload of the heart and increase cardiac output
Nursing assessment for congestive heart failure
Tachypnea, shortness of breath; tachycardia; difficulty feeding; cyanosis; grunting, wheezing, pulmonary congestion; edema of the face, eyes of infants, weight gain; diaphoresis; and hepatomegaly
Nursing plans and interventions for congestive heart failure
Monitor VS frequently and report signs of increasing distress; assess respiratory functioning; elevate HOB; administer oxygen; administer digoxin and diuretics; weigh frequently; strict I&O; report any unusual weight gain; provide a low sodium diet or formula
Rheumatic fever
An inflammatory disease; most common cause of acquired heart disease in children; usually affects the aortic and mitral valves of the heart; associated with an antecedent beta hemolytic strep-infection; a collagen disease that injures the heart, blood vessels, joints and subcutaneous tissue
Nursing assessment for rheumatic fever
Chest pain, shortness of breath; tachycardia, even during sleep; migratory large joint pain; chorea; rash; subcutaneous nodules over bony prominences; fever; elevated erythrocyte edimentation rate; elevated ASO titer;
Nursing plans and interventions for rheumatic fever
Monitor VS; assess for increasing signd of cardiac distress; encourage bed rest; assist with ambulation; chorea is temporary; administer penicillin or erythromycin and aspirin for anti-inflammatory and anticoagulant actions
Down syndrome
The most common chromosomal abnormality in children; evidenced by various physical characteristics and mental retardation; results from a trisomy of chromosome 21; associated with maternal age > 35
Nursing assessment for down syndrome
Flat, broad nasal bridge; inner epicanthal eye folds; upward, outward slant of eyes; protruding tongue; short neck; transverse palmer crease; associated with cardiac defects, respiratory infection, feeding difficulties, delated developemental skills, mental retardation
Nursing plans and interventions for down syndrome
Assist and support parents during the diagnostic process; assess and monitor growth and development; bulb syringe for suctioning; signs of respiratory infection; assist family with feeding problems; feed to back and side of mouth; monitor for signs of cardiac difficulty or respiratory infection; early intervention program
Cerebral palsy
A nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity or dyskinesia (involuntary movements); associated with mental retardation and seizures
Causes of cerebral palsy
Anoxic injury before, during or after birth, maternal infections, kernicterus, low birth weight
Nursing assessment for cerebral palsy
Persistent neonatal reflexes after 6 months; delayed developmental milestones; poor suck, tongue thrust; spasticity; scissoring of legs; involuntary movements; seizures
Aspiration
Feed infant or child with cerebral palsy using nursing interventions to prevent this. Position the child upright and support the lower jaw
Spina bifida occulta
A defect of vertebrae only; no sac is present and it is usually a benign condition; bowel and bladder problems may occur
Spina Bifida
A malformation of the vertebrae and spinal cord resulting in varying degrees of disability and deformity; screened for latex allergies; prevented by the mother consuming 0.4mg of folic acid daily three months prior to pregnancy and 0.6mg/day during pregnancy
Meningocele and myelomeningocele
A sac is present at some point along the spine
Meningocele
Contains only meninges and spinal fluid and has less neurlogic involvement
Myelomeningocele
More severe because the sac contains spinal fluid, meninges and nerves
Spina bifida occulta nursing assessment
Dimple with or without hair tuft at base of spine
Nursing assessment for spina bifida
Presence of sac in myelomeningocele is usually lumbar or lumbosacral; flaccid paralysis and limited or no feeling below the defect; head circumference at variance with norms on growth grids
Hydrocephalus
A condition characertized by an abnormal accumulation of CSF within the ventricles of the brain; caused by an obstruction in the flow of CSF between the ventricles; most often associated with spina bifida; can be a complication of meningitis
Nursing assessment hydrocephalus
LOC changes; irritability, vomiting; headache on awakening; motor dysfunction; unequal pupil response; seizures; decline in academics; change in personality; irritability, lethargy; increasing head circumferences; bulging fontanels; widening suture lines; sunset eyes; high pitched cry
Nursing plans and interventions for hydrocephalus
Monitor for signs of increased ICP; seizure precautions; elevated HOB; shunt is inserted into ventricle; tubing it tunneled through skin to peritoneum where it drain excess CSF
seizures
Uncontrolled electrical discharges of neurons in the brain; more common in children <2 years; associated with immatureity of CNS, fevers, infections, neoplasms, cerebral anoxia, and metabolic disorders
Generalized seizures
Tonic-clonic, absence (petit mal(, myoclonic
Tonic clonic seizure
Grand mal seizure; consciousness is lost
Tonic phase
Generalized stiffness of the entire body
Clonic phase
Spasm followed by relaxation
Absence (petit mal)
Momentary loss of consciousness, posture is maintained, has minior face, eye, hand movements
Myoclonic
Sudden, brief contactures of a muscle or group of muscles, no postictal state, may or may not be symmetric or include LOC
Partial seizures
Arise from specific area in the brain and cause limited symptoms; focal and psychomotor seizures
Nursing assessment for toninc clonic seizures
Aura; loss of consciousness; generalized stiffness of entire body; apnea, cyanosis; spasms followed by relaxation; pupils dilated and nonreactive to light; incontinence; post-seizure disoriented, sleepy
Nursing assessment for absence seizures
Usually occur between 4-12 years of age; last 5-10 seconds; appears to e inattentive, day dreaming; poor performance in school
Medication noncompliance
The most common cause for increased seizure activity
Seizure nursing plans and interventions
Maintain airway: turn client on side to aid ventilation; don’t restrain; protect from injury; support head; document; reduce environmental stimuli; pad side rails or crib rails; have suction and oxygen nearby; tape oral airway to the HOB; EEG, CT scan; septic work up;
Bacterial meningitis
Bacterial inflammatory disorder of the meninges that cover the brain and spinal cord; caused by haemophilus influenza; streptococcus pneumoniae. Or neisseria meningitides; usual source of bacterial invasion is the middle ear or the nasopharynx, fractures of the skull, LP, and shunts; exudates covers the brain and cerebral edema occurs
LP of bacterial meningitis
Increased WBC, decreased glucoe, elevated protein, increased ICP, positive culture for meningitis
Nursing assessment for bacterial meningitis for children
Signs of increased ICP; fever, chills, neck stiffness, opisthotonos; photophobia; positive kernig sign; positive brudzinski sign
Kernig sign
Inability to extend leg when thigh is flexed anteriorly at the hip
Brudzinski sign
Neck flexion causing adduction and flexion movements of the lower extremities
Nursing assessment of bacterial meningitis for infants
Absence of classic signs; ill, with generalized symptoms; poor feeding; vomiting, irritability; bulging fontanel; seizures
Nursing plans and interventions for bacterial meningitis
Administer antibiotics and antipyretics; isolate for at least 24 hours; VS and neurologic signs frequently; keep environment quiet and darkened to prevent overstimulation; implement seizure precautions; measure head circumference daily in infants; I&O;
Meningitis
Monitor hydration status and IV therapy carefully; may be inappropriate ADH secretion causing fluid retention and dilutional hyponatremia
Reye syndrome
Acute, rapidly progressing encephalopathy and hepatic dysfunction; antecedent viral infections, such as influenza and chicken pox; associated with aspirin usage
Nursing assessment for Reye Syndrome
Occurs in school age children; lethargy, rapidly progressive to deep coma; vomiting; elevated AGOT/AST, AGPT/ALT, LDH, serum ammonia, decreased PT; hypoglycemia
Reye syndrome nursing plans and interventions
Critical care early in syndrome; neurologic status; maintain ventilation; monitor cardiac parameters; administer mannitol; monitor I&O
Brain tumors
The second most common cancer in children; infratentorial, maing them difficult to excise surgically; occur close to vital structures; gliomas are the most common childhood tumors
Brain tumor nursing assessment
Headache upon awakening (most common symptom of this); vomiting in the morning without nausea; loss of concentration; change in behavior or personality; vision problems, tilting of head; widening structures, I ncreasing frontal occipital circumference, tense fontanel
Nursing plans and interventions for brain tumor
Identify baseline neurologic functioning; monitor I&O carefully; administer steroids and osmotic diuretics
Increased ICP
Suctioning, coughing, straining, and turning cause ??
Muscular dystrophy
An inherited disease of the muscles, causing muscle atrophy and weakness; most serious and most common of the dystrophies is Duchenne
Duchenne muscular dystrophy
an x-linked recessive disease affecting primarily males; appears in the early childhood; rapidly progresses causing respiratory or cardiac complications and death usually by 25 years of age
Nursing assessment for muscular dystrophy
Waddling gait, lordosis; increasing clumsiness, muscle weakness; gowers sign; pseudohypertrophy of muscles; muscle degeneration especially of the thighs and fatty infiltrates; cardiac muscle is involves; delayed cognitive development; elevated CPK and SGOT/AST; scoliosis, respiratory difficulty and cardiac difficulty
gowers sign
Difficulty rising to standing position; has to walk up legs using hands; occurs in Muscular dystrophy
Acute glomerulonephritis
An immune complex response to an antecedent beta hemolytic streptococcal infection of skin or pharynx; antigen antibody complexes become trapped in the membrane of the glomeruli. Causing inflammation and decreased glomerular filtration
Nursing assessment for Acute glomerulonephritis
Recent streptococcal infection; mild to moderate edema that is often confined to the face; irritability, lethargy; hypertension; dark colored urine; slight to moderate proteinuria; elevated antistreptolysin titer, elevated BUN/creatinine
Nursing plans and interventions for Acute glomerulonephritis
Supportive care; monitor VS frequently; I&O; weigh daily; low sodium diet with no added salt; low potassium if oliguric; bed rest during acute phase; administer antihypertensives; monitor for seizures (hypertensive encephalopathy); signs of CHF; signs of renal failure
Acute glomerulonephritis
Follows a streptococcal infection; edema is mild and usually around the eyes; the blood pressure is elevated; the urine is dark, tea colored (hematuria) with slight to moderate proteinuria; blood has a normal serum protein and a positive ASO titer
Renal failure
Decreased UOP is the first sign of ?
Nephrotic syndrome
A disorder in which the basement membrane of the glomeruli becomes permeable to plasma proteins; most often idiopathic in nature; occurs between the ages of 2-3; involve execration and remissions over several years
Nursing assessment for Nephrotic syndrome
Edema that begins insidiously, becomes severe and generalized; lethargy; anorexia; pallor; frothy-appearing urine; massive proteinuria; decreased serum protein; elevated serum lipids
Nursing plans and interventions for Nephrotic syndrome
Supportive care; monitor temperature, assess for signs of infection; protect from persons with infection; provide skin care; bed rest during edematous phase; administer steroids (prednisone) and cholinergics (Urecholine); I&O; abdominal girth daily; administer cytoxan; small, frequent feedings of a normal protein, low salt diet; IV albumin followed by diuretic;
Nephrotic syndrome
The cause is usually idiopathic; edema is severe and generalized; blood pressure is normal; urine is a dark frothy yellow color with massive proteinuria; blood has a decreased serum protein and a negative ASO titer
Urinary tract infection
A bacterial infection anywhere along the urinary tract
Nursing assessment for UTI
Infants: vague symptoms, fever, irritability, poor food intake, diarrhea, vomiting, jaundice, strong smelling urine; children: urinary frequency, hematuria, enuresis, dysuria, fever; Escherichia coli in cultures
Nursing plans and interventions for UTIs
Suspect and assess UTI in infants who are ill; clean voided or cathertized specimen; administer antibiotics
Vesicoureteral reflex
Result of valvular malfunction and backflow of urine into the ureters (and higher) from the bladder (severe cases are associated with hydronephrosis
Nursing assessment for Vesicoureteral reflex
Recurrent UTIs; reflux; reflux noted on voiding cystourethrogram
Nursing plans and interventions for Vesicoureteral reflex
Medication compliance, which usually leads to resolution of mild cases; provide support for children and families requiring surgey; explain the goal of ureteral reimplantation which is to stop reflux and prevent kidney damage; assess dressing and incision for drainage; maintain hydration with IV or oral fluids
Wilms Tumor (Nephroblastoma)
A malignant renal tumor; embryonic in origin; encapsulated; occurs in preschool children; with early detection, surgery, adjuvant chemotherapy, as well as radiation therapy postoperatively, the prognosis is good
Nursing assessment of Wilms Tumor (Nephroblastoma)
Mass in the flank area, confined to midline; often discovered by parents when bathing child; fever; pallor, lethargy; elevated BP; hematuria
Nursing plans and interventions for Wilms Tumor (Nephroblastoma)
Support family during diagnostic period; project from injury and no abdominal palpation; prepare family and child for imminent nephrectomy; monitor for increased BP; monitor for kidney function: I&O and SG; maintain NG tube and chesck for bowel sounds
Hypospadias
Congenital defect of urethral meatus in males; urethra opens on ventral side of penis behind the glans
Surgical correction for hypospadias
Usually done before preschool years to allow for the achievement of sexual identity, to avoid castration anxiety, ad to facilitate toilet training
Nursing assessment for hypospadias
Abnormal placement of meatus; altered voiding stream; presence of chordee; undescended testes and inguinal hernia
Nursing plans and interventions for hypospadias
Prepare child and family for surgery; assess circulation to tip of penis postopertively; monitor urinary drainage after urethroplasty; restrain child; maintain hydration;
Cleft lip and or Cleft palate
Malformation of the face and oral cavity that seem to be multifactorial in hereditary origin
Cleft palate
May not be identified until the infant has difficulty with feeding; closure is usually performed at 1 year of age to minimize speech impairment
Cleft lip
Readily apparent; initial closure of this is performed when infant weighs 10lbs and has an HGB of 10g/dl
Nursing assessment for cleft lip and/or cleft palate
Failure of fusion of the lip, palate or both; difficulty sucking and swallowing; parent reaction to facial deficit
Nursing plans and interventions for cleft lip and/or cleft palate
Promote family bonding and grieving during newborn period; successful corrective surgery is available; assist with feeding – feed in upright position, feed slowly with frequent bubbling, use soft large nipples lamb’s nipples prosthetic palate or rubber tipped asepto synringe;
Cleft lip post-op care
Place on side or upright in infant seat
Cleft palate post-op care
Place client on side or abdomen
Post-op care for cleft lip and/or cleft palate
Remove oral secretions carefully; apply elbow restraints; minimize crying to prevent strain on lip suture line; maintain logan bow to lip; remove one restrain at a time and to ROM’ age appropriate stimulation; resume feeding
Typical parent and family reactions to child with deformity
Grief, guilt, disappointment, sense of loss, anger
Esophageal atresia with tracheoesophageal fistula
Congenital anomaly in which the esophagus doesn’t fully develop’ upper esophagus ends in a blind pouch and the lower art of the esophagus is connected to the trachea; clinical and surgical emergency
Nursing assessment for Esophageal atresia with tracheoesophageal fistula
Three C’s: choking, coughing, cyanosis; excessive salivation; respiratory distress; aspiration pneumonia
Nursing plans and interventions for Esophageal atresia with tracheoesophageal fistula
Pre-op care: monitor respiratory status, remove excess secretions, elevate infant into antireflux position of 30 degrees, provide oxygen, NPO, administer IV; post-op care: NPO, IV fluids, I&O, gastrostomy tube care and feedings, pacifier to meet developmental needs
Pyloric stenosis
A narrowing of the pyloric canal; the sphincter hypertrophies to twice the normal size
Nursing assessment for pyloric stenosis
Usually occurs in first born males; vomiting (free of bile) usually begins after 14 days of life and becomes projectile; hungry, fretful infant; weight loss; failure to gain weight; dehydration with decreased sodium and potassium; metabolic alkalosis; palpable olive shaped mass in URQ of the abdomen; visible peristaltic waves
Metabolic alkalosis
Decreased serum chloride, increased pH and bicarbonate or CO2 content
Nursing plans and interventions for pyloric stenosis
Pre-op care: assess for dehydration; administer IV fluids and electrolytes as prescribed, weigh daily, monitor I&O, provide small frequent feedings; hypertrophied muscle will be split and prognosis is excellent; post-op care: continue IV fluids, provide small oral feedings with electrolyte solutions or glucose, position on right side in semi-fowler position after feeding, burp frequently to avoid stomach’s becoming distended and putting pressure on surgical site, weight daily, monitor I&O
Intussusceptions
Telescoping of one part of the intestine into another part of the intestine, usually the ileum into the colon; partial to complete bowel obstruction occurs; blood vessels become trapped in the telescoping bowel, causing necrosis
Nursing assessment of intussusceptions
Child <1year; acute, intermittent abdominal pain; screaming with legs drawn up to abdomen; vomiting; “currant jelly stools: mixed with blood and mucus; sausaged shaped mass in URQ which LRQ is empty
Nursing plans and interventions for intussusceptions
Monitor carefully for shock and bowel perforation; administer IV fluids; I&O; prepare family for emergency intervention; prepare child for barium enema because in 2/3 cases it will respond to this treatment
GI disorders
Nutritional needs and fluid and electrolyte balance are key problems for children with these disorders
Congenital aganglionic megacolon (hirschsprung disease)
Congenital absence of autonomic parasympathetic ganglion cells in a distal portion of the colon and rectum; lack of peristalsis in the area of the colon where the ganglion cells are absent; fecal contents accumulate above the aganglionic area of the bowel; correction is with a series of surgical procedures: temporary colostomy and later a reanastomosis and closure of the colostomy
Nursing assessment for Congenital aganglionic megacolon (hirschsprung disease)
Suspicion of newborn who fails to pass meconium within 24 hours; distended abdomen, chronic constipation alternating with diarrhea; nutritionally deficient child; enterocolitis that occurs as an emergency event; ribbon-like stools in the older child
Nursing plans and interventions for Congenital aganglionic megacolon (hirschsprung disease)
Pre-operative care: begin preparation for abdominal surgery; provide bowel cleansing program; insert rectal tube; observe for symptoms of bowel perforation; post-op care: VS and axillary temperature; administer IV fluidsm; I&O; care for NG tube with connection to intermittent suction; abdominal and perineal dressings; bowel sounds
Symptoms of bowel perforation
Abdominal distension; vomiting; increased abdominal tenderness; irritability; dyspnea and cyansis
Anorectal malformations
Congenital malformation of the anorectal section of the GI tract (imperforate anus); associated with a fistula; associated with urinary tract anomalies
Nursing assessment for anorectal malformations
Unusual appearing anal dimple; newborn who doesn’t pass meconium within the first 24 hours; meconium appearing from perineal fistula or in urine
Nursing plans and interventions for anorectal malformations
Determine newborn’s first temperature, typically usually a rectal thermometer to assess for imperforate anus; assess newborn for passage of meconium; after surgery position infant in side lying prone position with hips elevated
Iron deficiency anemia
Hemoglobin levels below normal range because of the body’s inadequate supply, intake or absorption of iron; leading hematologic disorder in children; need is greater due to accelerated growth
Causes of Iron deficiency anemia
Inadequate stores during fetal development; deficient dietary intake; chronic blood loss; poor utilization of iron by the body
Nursing assessment for Iron deficiency anemia
Pallor, paleness of mucous membranes; tiredness, fatigue; seen in infants 6-24 months and toddlers/female adolescents are more affected; overweight ” milk baby”; dietary intake low; milk intake greater than 32 oz/day; pica habit;
Lab values for Iron deficiency anemia
Decreased HBG; low serum iron level; elevated total binding capacity
14-24
HBG norms for newborn
10-15
HBG norms for infant
11-16
HBG norms for child
Nursing plans and interventions for Iron deficiency anemia
Need to limit activities; provide rest periods; administer oral iron; limit milk intake; eat: meat, green leafy vegetables, fish, liver, whole grains, legumes
Administration of oral iron
Give on empty stomach; give with citrus juices for increases absorption; use dropper or straw to avoid discoloring teeth; stools will become tarry; can be fatal if overdose; don’t give with diary products
Hemophilia
Inherited bleeding disorder; transmitted by an X-linked recessive chromosome (mother is the carrier, her ons may express the disease); normal individual has between 50-200% factor activity in the blood – the person with this disorder has from 0-25% activity; usually missing is either factor VIII or factor IX
Nursing assessment for hemophilia
First red flag may be prolonged bleeding following circumcision; prolonged bleeding with minor trauma; hemarthrosis; spontaneous bleeding into muscles and tissues; loss of motion in joints; pain
Lab values for hemophilia
PTT is prolonged and factor assays less than 25%
Nursing plans and interventions for hemophilia
Administer FFP, cryoprecipitate of fresh plasma, or lyophilized concentrated as prescribed; pain medication; blood precautions; teach to recognize early bleeding into joints; local treatment for minor bleeds; administration of factor replacement; discuss dental hygiene; provide protective care; wear medic alert ID; genetic counseling
Autosomal recessive
Both parents must be heterozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring; 1 in 4 chance that the infant will have the disease; all children of parents can get the disease; transmission pattern of sickle cell anemia, cystic fibrosis and phenylketouria
X-linked recessive trait
The trait is carried on the X chromosome; usually affects male offspring; hemophilia; child is male, has 50% chance of having hemophilia; if the child is female, she has a 50% chance of being a carrier
Sickle cell anemia
Inherited autosomal recessive disorder of hemoglobin; African and eastern Mediterranean descent; appears after 6 months of age; hemoglobin S replaces all or part of the normal hemoglobin, which causes red blood cells to sickle when oxygen is released to the tissues; sickled cells cannot flow through capillary beds, dehydration promote sickling; HGBS has a less than normal lifespan which leads to chronic anemia; tissue ischemia causes widespread pathologic changes in the spleen, liver, kidney, bones and CNS
Hydration
Very important in the treatment of sickle cell disease because it promotes hemodilution and circulation of RBCs through the blood vessels
Heterozygous gene
HgbAS – sickle cell trait
Homozygous gene
HbSS sickle cell disease
Abnormal hemoglobin
HGBS disease and trait
Nursing assessment of sickle cell anemia
African decent, usually over 6 months; parents with trait or disease; frequent infections; tiredness; chronic hemolytic anemia; delayed physical growth; vaso-occlusive crisis; leg ulcers; cerebral vascular accidents; Hgb electrophoresis
Vaso-occlusive crisis
Fever; severe abdominal pain; hand-foot syndrome; painful edematous hands and feet; arthralgia
Nursing plans and interventions for sickle cell anemia
Prevent crisis; keep child from exercising strenuously; keep away from high altitudes; avoid letting child become infected and seek care at first sig of infection; prophylactic penicillin; keep hydrated; do not withhold fluids at night; administer pneumococcal vaccine, meningococcal vaccine, and haemophilus B vaccine, Hep B vaccine
Nursing care for child in vaso-occlusive crisis
Administer IV fluids and electrolytes two times maintenance levels to increase hydration and treat acidosis; mnitor I&O; administer blood products; administer analgesics; warm compressed; prescribed antibiotics
Supplemental iron
Not given to clients with sickle cell anmia; it is not caused by iron deficiency
Folic acid
Given to patients with sickle cell anemia to stimulate RBC synthesis
Acute lymophocytic leukemia
A cancer of the blood forming organs; 80% of childhood leukemia; noted for the presence of lymphoblasts which replace normal cells in the bone marrow; blast cells are also see in the peripheral blood; null cell type has best prognosis
Acute lymophocytic leukemia
Classified according to whether it involves T lymphocytes, B lymphocytes, or null cells (neither T or B)
Acute lymophocytic leukemia treatment
Four phases: induction, sanctuary, consolidation, maintenance
Nursing assessment for Acute lymophocytic leukemia
Pallor, tiredness, weakness, lethargy due to anemia; petechia, bleeding, bruising due to thrombocytopenia; infection, fever due to neuropenia; bone joint pain due to leukemic infiltration of bone marrow; enlarged lymph nodes; hepatosplenomegaly; headache and vomiting (signs of CNS involvement); anorexia, weight loss
Lab data for Acute lymophocytic leukemia
Bone marrow aspiration that reveals 80-90% immature blast cells
Nursing plans and interventions for Acute lymophocytic leukemia
Private room; reverse isolation; age-appropriate explanations for diagnostic tests, treatments, and nursing care; infection of skin, needle stick sites and dental problems; administer blood products; antineoplastic chemotherapy; provide care toward managing side effects and toxic effects of antineoplastic agents
Care toward managing side effects and toxic effects of antineoplastic agents
Antiemetics; monitor fluid balance; monitor for signs of infection; monitor for signs of bleeding; montiro for cumulative toxic effects of drugs such as hepatic toxicity, cardiac toxicity, renal toxicity, and neurotoxicity; small, appealing meals; increased calories and protein; promote self esteem and positive body image; prevent infection
Prednisone
Frequently used in combination with antineoplastic drugs to reduce the mitosis of lymphocytes.
Allopurinol
An xanthine-oxidase inhibits is also administered to prevent renal damage caused by uric acid buildup and cellular lysis
Congenital hypothyroidism
A congenital condition resulting from inadequate thyroid tissue development in utero. Mental retardation and growth failure occur if it is not detected and treated early in infancy
assessment for congenital hypothyroidism
Low T4 and high TSH levels; symptoms in the newborn: long gestation, large hypoactive infant, delayed meconium passage, feeding problems, prolonged physiologic jaundice, hypothermia; symptoms in early infancy: large, protruding tongue, coarse hair, lethargy, sleepiness, flat expression, constipation
Congenital Hypothyroidism
Child with this condition is often described as a good, quiet baby
Nursing plans and interventions for congenital hypothyroidism
Newborn screening programs before discharge; assess newborn for signs; lifelong need for therapy; give child a single dose in the morning; check pulse daily before giving medication; periodic testing is necessary
Signs of thyroid medication overdose
Rapid pulse, irritability, fever, weight loss, diarrhea
Signs of thyroid medication under-dose
Lethargy, fatigue, constipation, poor feeding
Phenylketonuria (PKU)
An autosomal recessive disorder in which the body cannot metabolize the essential amino acid phenylalanine; the build up of serum levels of phenylalanine leads to CNS damage, most notably mental retardation; decreased melanin produces light skin and blond hair
Nursing assessment for PKU
Guthrie test; frequent vomiting, failure to gain weight; irritability, hyperactivity; musky odor of urine
Guthrie test
Positive is serum phenylalanine levels of 4mg/dl
Hypothyroidism and PKU
Early detection is essential in preventing mental retardation
Nursing plans and interventions for PKU
Perform newborn screening at birth and again at 3 weeks of age; strict adherence to low phenylalanine diet; special formulas for infant such as lofenalac and/or phenex-1; phenyl free milk after 2 years; avoid foods high in phenylalanine; diet must be maintained at least until brain growth is complete
Foods high in phenylalanine
Meat, milk, dairy products, eggs, high protein foods
Foods low in phenylalanine
Vegetables, fruits, juices, cereals, breads, starches
Nutrasweet
Contains phenylalanine and should not be given to a child with PKU
Insulin dependent diabetes mellitus (Type 1 diabetes)
A metabolic disorder in which the insulin producing cells of the pancreas are nonfunctioning as a result of some insult; heredity, viral infections, and autoimmune processes are implicated; causes altered metabolism of carbohydrates, proteins and fats; insulin replacement, dietary management and exercise are the treatments
Nursing assessment for IDDM
Polydipsia, polyphagia, polyuria, enuresis; irritability, fatigue, weight loss, abdominal complaints, nausea, and vomiting; usually occurs in school age children
Fractures
Traumatic injury to the bone; if it occurs in the epiphyseal plate, growth may be affected
Complete fractures
Bone fragments are completely separate
Incomplete fractures
Bone fragments remain attached
Comminuted fractures
Bone fragments from the fractured shaft break free and lie in the surrounding tissue; rare in children
Compartment syndrome
Results in permanent damage to the nerves and vasculature of the injured extremity due to compression
Skin traction
Should never be removed unless the MD prescribes is removal
Traction
Note bed position, tape, weights, pulleys, pins, pin sites, adhesive strips, ace wraps, splints and casts
Skin traction
Force is applied to the skin; buck extension traction, Russell traction, Bryant traction
Buck extension traction
Lower extremity, legs extended, no hip flexion
Russell traction
Two lines of pull on the lower extremity, one perpendicular one longitudinal
Bryant traction
Both lower extremities flexed 90 degree at hips; rarely used because extreme elevation of lower extremities causes decreased peripheral circulation
Skeletal traction
Pin or wire applies pull directly to the distal bone fragment; 90-degree traction
90 degree traction
90-degree flexion of hip and knee; lower extremity is in a boot cast; can also be used on upper extremities
Pin sites
A source of infection; monitor for signs of infection; cleanse and dress the sites as prescribed
Skeletal disorders
Affect the infants or child’s physical mobility
Congenital dislocated hip
Abnormal development of the femoral head in the acetabulum; conservative treatment consists of splinting; surgical intervention is necessary if splinting is not successful
Nursing assessment for congenital dislocated hip
Infant: positive ortolani sign, unequal folds of skin on buttocks and thigh, limited abduction of the affected hip, unequal leg lengths; older child: limp on affected side and trendelenburg sign
Nursing plans and interventions for congenital dislocated hip
Newborn assessment at birth; apply abduction device or splint; teach parents application and removal of the device, skin care and bathing, diapering, follow up care involves frequent adjustments;
Bryant traction
Used if splinting the congenital dislocated hip was unsuccessful; maintain hips in 90 degree flexion; elevate buttocks off bed; monitor circulation to feet; meet developmental needs of immobilized infant; spica cast application
Scoliosis
Lateral curvature of the spine; if severe, it can cause respiratory compromise; surgical correction by spinal fusion or instrumentation may be required if conservative treatment is ineffective
Nursing assessment of scoliosis
Adolescent females 10-15 years old are more frequently affected; elevated shoulder or hip; head and hips are not aligned; a rib hump is apparent when bending forward
Nursing plans and interventions for scoliosis
Screen all adolescent children; prepare child and family for conservative treatment
Milwaukee brace
Needs to be work 23/24 hours; wear a t-shirt under the race to decrease skin irritation; check skin for areas of irritation or breakdown; clothing modifications to camouflage brace; reinforce prescribed exercise for back and abdominal muscles
Log rolling
Requires 2+ persons depending on the size of the client; carefully moved to a draw sheet to the side of the bed away from which they are going to be turned; client is then turned in a simultaneous motion, maintaining the spine in a straight position; pillows are arranged for support and comfort, and they assist the client to maintain alignment; 5 days after surgery of spine;
Brace
Doesn’t correct the spines curve in a child with scoliosis, it only stops or slows the progression
Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis
Chronic inflammatory disorder of the joint synovium; single or multiple joints may be involved; systemic presentation; occurs between 2-5 years and 9-12 years
Nursing assessment for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis
Joint swelling and stiffness; painful joints; generalized symptoms such as fever, malaise, rash; periods of exacerbations and remissions; varying severity
Lab data for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis
Latex fixation test and elevated ESR
Nursing plans and interventions for Juvenile rheumatoid arthritis/ juvenile idiopathic arthritis
Prescribe exercise, splinting and activity; identifying adaptations in routine; support maintaining school schedule and activities; administer NSAIDS, antirheymatic drugs, corticosteroids, cytotoxic drugs; teach SE of drugs
Menstrual cycle
Composed of four phases: normal cycle is 21-45 days in length. Mean age is 12.87 years or 1-3 years after breast budding; pregnancy can occur after the very first menstrual cycle
Menstrual phase
Days 1-5 of cycle; shedding of the endometrium occurs in the form of uterine bleeding
Proliferation (follicular) phase
Day 5 to ovulation; endometrium is restored under primary hormone influence of estrogen; follicle stimulating hormone is secreted by the anterior pituitary; pre-ovulatory surge of leuteinizing hormone affects the follicle and ovulation occurs
Secretory (luteal) phase
Ovulation to approximately 3 days before the menstrual cycle; estrogen levels level off; progesterone levels increase
Ischemic phase
Approximately 3 days before menstruation to onset of menstruation
Menstruation
If fertilization did not occur, the corpus leuteum degenerates; estrogen and progesterone levels drops; endometrium becomes blood starved leading to onset of menstruation
14 days
Between ovulation and the beginning of the next menstrual cycle there is this many days; ovulation occurs this many days before the next menstrual period
Prevent pregnancy
Avoid unprotected intercourse for several days before the anticipated ovulation and for 3 days after ovulation; sperm live 3 days and eggs live 24 hours
Indications of ovulation
Slight drop in temperature occurs 1 day before this; 0.5-1 degree rise occurs at ovulation and remains elevated for 10-12 days; cervical mucus is abdundant, watery, clear and more alkaline; cervical os dilates slightly, softens and rises in the vagina; spinnbarkeit (egg white stretchiness of cervical mucus) occurs; ferning is seen under microscope
Conditions for fertilization
Postcoital test demonstrates live, motile, normal sperm preset in cervical mucus; fallopian tubes are patent; endometrial biopsy indicates adequate progesterone and secretory endometrium; semen is supportive to pregnancy which is 2mL semen or atleast 20 million sperm per ML, >60% are normal and >50% are motile
Implantation
Fertilization takes place in ampulla section of the fallopian tube; zygote takes 2-4 days to enter the uterus; it takes 7-10 days to complete the process of nidation/implantation
Zygote
12 to 14 days after fertilization; from the time the ovum is fertilized until it is implanted in the uterus;
Embryo
3-8 weeks after fertilization; most vulnerable to teratogens which can cause major congenital anomalies
Fetus
9 weeks after fertilization to term; few major anomalies caused by teratogens
Pregnancy length
Counted from the first day of the last menstrual period; 280 days, 40 weeks, 10 lunar months, 9 calendar months
First trimester
From the first day of the LMP through 13 weeks
Second trimester
14 weeks through 26 weeks
Third trimester
27 weeks through 40 weeks
Fetal development at 8 weeks
Development is rapid; heart begins to pump blood; limb buds are well develops; facial features are discernible; major divisions of the brain are discernible; ears develop from skin folds; tiny muscles are formed beneath this skin embryo; weight is 2g
Maternal changes at 8 weeks
Nausea persists up to 12 weeks; uterus changes from pear to globular shape; hegar sign occurs; goodell sign occurs; cervix flexes; leucorrhea increases; ambivalence about pregnancy may occur; no noticeable weight gain; Chadwick sign occurs as early as 4 weeks
Fetal development at 12 weeks
Embryo becomes a fetus; heart is discernible by ultrasound; lower body develops; sex is determinable; kidneys produce urine; weight <1oz
Maternal changes at 12 weeks
Uterus rises above the pelvic brim; Braxton hicks contractions are possible; potential for UTI increases; weight gain is 2.5-4lb during first trimester; placenta is fully functioning and producing hormones
Fetal development at 20 weeks
Vernix protects the body; lanugo covers the body and protects it; eyebrows, eyelashes, head hair develop; fetus sleeps, sucks and kicks; 11-14oz
Maternal changes at 20 weeks
Fundus reaches level of umbilicus; breasts begin secreting colostrums; areolae darken; amniotic sac holds 400ml fluid; postural hypotension may occur; quickening may be felt; nasal stuffiness; leg cramps may begin; varicose veins and constipation may develop\
Fetal development at 28 weeks
Fetus can breathe, swallow, regulate temperature; surfactant forms in lungs; fetus can hear; fetus’ eyelids open; period of greatest fetal weight gain begins; fetus weighs 2.5lbs
Maternal changes at 28 weeks
Fundus is halfway between the umbilicus and xiphoid process; thoracic breathing replaces abdominal breathing; fetal outline is palpable; more introspective and concentrates interest on the unborn child; hemorrhoids and heartburn may begin
Fetal development at 32 weeks
Brown fat deposits develop beneath the skin to insulate baby following birth; 15-17 inches in length; storing iron, calcium and phosphorus; weights 4-5lbs
Maternal changes at 32 weeks
Fundus reaches xiphoid process; breasts are full and tender; urinary frequency returns; swollen ankles may occur; sleeping problems may develop; dyspnea may develop
Fetal changes at 38 weeks
Occupies the entire uterus; activity is restricted; maternal antibodies are transferred to fetus; lecithin/sphingomyelin ratio is 2:1; weights 7+ lbs
Maternal changes at 38 weeks
Lightening occurs; placenta weights 20oz; mother is eager for birth, may have burst of energy; backaches increase; urinary frequency increases; Braxton hicks contractions intensify
First trimester psychosocial responses to pregnancy
Ambivalence, financial worries, career concerns
Second trimester psychosocial responses to pregnancy
Quickening occurs; pregnancy becomes real; pregnant women accepts pregnancy; ambivalence wanes
Third trimester psychosocial responses to pregnancy
Becomes introverted and self-absorbed; begins to ignore partner
Activities during first prenatal visit
Medical history, obstetric history, history of current pregnancy; determine gravidity and parity; perform physical exam; calculate EDB; VS; Lab work
Gravida
Refers to the number of times a woman has been pregnant, regardless of the outcome
Para
Refers to the number of deliveries that have occurred after 20 weeks of gestation
Abortions
Pregnancy losses occurring before 20 weeks are counted as this; add to the clients gravidity count
Term births Preterm births Abortions Living children
TPAL
Count 3 months from the first day of the LMP and add 7 days
Nagele rule
Vital sign changes
BP should rise no more than 30 points systolic and no more than 15 points diastolic; HR: 60-90; RR: 16-24
11
Hgb values during pregnancy33
Hct values during pregnancy
Evaluate nutritional status
Hgb and Hct can do this during pregnancy
Activities during subsequent pregnancy visits
Check urine; graph weight gain; check fundal height; check fetal heart rate; provide anticipatory guidance
Albumin
No more than a trace in a normal finding in urine; related to preeclampsia
Glucose
No more than 1+ in a normal finding in the urine; related to gestational diabetes
Weight gain
3.5-5lb in the first trimester is recommended; 2-4 is the average; 0.9lb per week thereafter is normal (>2lb per week is related to preeclampsia edema); total should be 25-35 pounds
Fundal height
12-13 weeks: rises out of the symphysis; 20 weeks: at umbilicus; 24 weeks: measured in cm, with the number of cm above the symphysis equal to the number of weeks of gestation
Side lying position
Increases perfusion to the uterus, placenta, and fetus
Fetal heart rate
10-12 weeks: detectable using Doppler; 15-20 weeks: detectable using fetoscope; 110-160 is normal range
Fetal well being
Determined using fundal height, fetal heart tones and rate, fetal movement, and uterine activity
Report these changes immediately!!
Visual disturbances; swelling of the face, fingers, or sacrum; severe continuous headache; persistent vomiting; infection; chills, temperature >100.4; dysuria, pain in abdomen; fluid discharge from vagina; changes in fetal movement of increased FHR
Symptoms of malnutrition
Glossitis, cracked lips, dry brittle hair, dental caries, peridontitis, weight
Nursing plans and interventions for malnutrition
Increased intake my 300 calories above basal and activity needs; increase protein by 30g/day; increase intake of iron (30+) and folic acid (800-1000mcg) through diet and supplements; increased intake of vitamin A, C ad calcium; 8-10 glasses of fluid per day; provide a copy of daily food guide to post on refrigerator
1 quart of milk or yogurt per day
Ensure that the daily calcium needs are met and help alleviate the occurrence of leg cramps
Serum alphafetoprotein levels or amniotic fluid AFP levels
Screen for neural tube defects
Ultrasonography
High-frequency sound waves are beamed onto the abdomen; echoes are returned to a machine that records the fetus’ location and size; used in first trimester to determine number of fetuses, presence of fetal cardiac movement and rhythm, uterine abnormalities, gestational age; used in the second and third trimesters to determine fetal viability and gestational age, size-date discrepancies, amniotic fluid volume, placental location and maturity, uterine anomalies and abnormalities, results of amniocentesis
Ultrasonography findings
FHR is apparent as early as 6-7weeks; serial evaluation of biparietal diameter and limb length can differentiate between wrong dates and true IUGR; BPP
Biophysical profile (BPP)
Fetal breathing movements, gross body movements, fetal tone, reactivity of fetal heart rate, and amniotic fluid volume; 10 = fetus is well
Chornic villi sampling
Removal of a small piece of villi during the period of 8-12 weeks gestation under ultrasound guidance; determines genetic diagnosis early in first trimester; obtained in 1 week; informed consent; lithotomy position using stirrups; slight sharp pain upon catheter insertion; results should not be given over the phone
Amniocentesis
Removal of amniotic fluid sample from uterus as early as 14-16 weeks; fetal genetic diagnosis; fetal maturity; fetal well being; performed when uterus rises out of symphysis at 13 weeks and amniotic fluid has formed; takes 10 days to 2 weeks to develop cultured cell karyotype
Karyotype
Determined down syndrome, other trisomies, and sex chromatin (sex-linked disorders)
Biochemical analysis
Determines more than 60 types of metabolic disorders
AFP
Elevations may be associated with neutral tube defects; low levels may indicate trisomy 21
Lecithin:sphingomyeline
Ratio indicates fetal lung maturity unless mother is diabetic or has Rh disease, or fetus is septic
L:S ratio and phosphatidylglycerol (PG)
Most accurate determination of fetal maturity. Present after 35 weeks gestation
Lung maturity
Best indicator for fetal extrauterine survival
Creatinine
Renal maturity indicator >1.8
Orange staining cells
Lipid containing exfoliating sebaceous gland maturity; >20% stained orange indicates 35+ weeks
Bilirubin delta optical density assessment
Should be performed in mother previously sensitized to fetal Rh+ RBC and having antibodies to the RH+ circulating cells; measures the change in optical density of the amniotic fluid caused by staining with bilirubin; done at 24 weeks gestation
Amniocentesis nursing care
VS and FHR; supine position with hands across chest; shave area and scrub with betadine; draw maternal blood sample before and after procedure to determine maternal bleeding; if bilirubin test is prescribed, darken room and immediately cover the tubes with aluminum foil; FHR for 1 hour post; report changes in fetal movement or fluid leaking from vagina
Bladder must be full
Requirement when an amniocentesis is done early in pregnancy to help push the uterus up in the abdomen for easy access
Electronic fetal monitoring
Monitors contractions of FHR
Duration
The length of each contraction from beginning to end
Frequency
Beginning of one contraction to beginning of the next
Intensity
Measured not by external monitoring but in mmHG by internal monitoring after amniotic membranes have ruptured; ranges from 30mmhg-70mmhg
FHR
Measures the balance between parasympathetic and sympathetic impulses usually produces no observable changes in the FHR during uterine contractions; most important indicator of the health of the fetal CNS
Short term variability
Change in FHR from one beat to the next; monitored by a fetal scalp electrode; if present, the fetus is not experiences cerebral asphyxia, and therefore is not a reassuring sign
Long term variability
averages 6 to 10 changes per minute; evaluated by external or internal monitoring
Accelerations
Changes in relation to uterine contractions; caused by sympathetic fetal response; occur in response to fetal movement; indicative of a reactive healthy fetus
Early Decelerations
Changes in relation to uterine contractions; benign pattern caused by parasympathetic response (head compression); heart rate slowly and smoothly decelerates at beginning of contraction and returns to baseline at end of contraction
Nursing actions for early decelerations
No nursing interventions; monitor progress of labor; document process of labor
Non-reassuring warning signs
Variability, bradycardia, tachycardia, variable deceleration pattern
Variability
FHR is absent or minimal; short term variability is absent; long term variability is minimal; caused by hypoxia, acidosis, maternal drug ingestions, fetal sleep
Bradycardia
Baseline FHR <110 for 10 minutes; caused by late manifestations of fetal hypoxia, medication induced, maternal hypotension, fetal heart block, prolonged umbilical cord compression
Tachycardia
Baseline FHR is >180 for 10 minutes; causes are: early sign of hypoxia, fetal anemia, dehydration, maternal infection, maternal fever, maternal hyperthyroid disease, medication induced
Variable deceleration
Common periodic pattern; occurs in 40% of all labors and is caused mainly by cord compression but could also indicate rapid fetal descent; abrupt transitory decrease in the FHR that is variable in duration, depth of fall, and timing relative to the contraction cycle
Nursing actions for variable decelerations
Change maternal position; stimulate fetus if indicated; discontinue oxytocin if infusing; administer oxygen at 10 liters by tight face mask; perform a vaginal exam to check for cord prolapse
Non-reassuring (Ominous) signs
Severe variable decelerations and late decelerations
Severe variable decelerations
FHR below 70 lasting longer than 30-60 seconds; slow return to baseline; decreasing or absent variability
Late decelerations
An ominous and potentially disastrous non-reassuring sign; indicative of utero-placental insufficiency; shape of deceleration is uniform and the FHR returns to baseline after the contraction is over; depth of the deceleration is uniform and does not indicate severity; rarely falls below 100bpm
Nursing actions of late decelerations
Turn client to the side; discontinue oxytocin if infusing; check scalp stimulation for accelerations; oxygen by 10 liters by tight face mask; fetal blood sampling; maintain IV; elevate legs to increase venous return; correct any underlying hypotension by increasing IV rate or with prescribed medications
Early deceleration
Caused by head compression and fetal descent usually occurs between 4-7cm and in the second stage. Check labor progress if these are noted
Cord prolapsed
If this is detected, the examiner should position the mother to relieve pressure on the cord or push the presenting part off the cord until immediate C-section can be accomplished
Late or variable decelerations
Associated with decreased or absent variability and tachycardia, the situation is ominous and requires immediate intervention and fetal assessment
Decrease in uteroplacental perfusion
Results in late decelerations
Cord compression
Results in variable decelerations
Non stress test
Used to determine fetal well being in high risk pregnancy and especially useful in postmaturity (notes response of fetus to own movements); a health fetus will usually response to its own movement by means of an FHR acceleration of 15 beats, lasting for at least 15 seconds after the movement, twice in a 20 minute period; the fetus that response with the 15/15 acceleration is considered reactive and healthy
Contraction stress test
Also called oxytocin challenge test; fetus is challenged with the stress of labor by the induction of uterine contractions and the fetal response to physiologically decreased oxygen supply during uterine contractions; unhealthy fetus will develop nonreassuring FHR patterns in response to uterine contractions’ late decelerations are indicative of UPI; contractions can be induced by nipple stimulation or by infusing a dilute solution of oxytocin; negative if there is no occurrence of late decelerations = negative test
Contraindications of contraction stress test
Prematurity, placenta previa, hydramnios, multiple gestation, and previous uterine classical scar, Rupture of membranes
Nipple stimulation
Causes some danger because you cannot control the dose of oxytocin delivered by the posterior pituitary; change of hyper-stimulation or tetany is increased
Biophysical profile
Ultrasonography is used to evaluate fetal health by assessing 5 variables: fetal breathing movements, gross body movement, fetal tone, reactive FHR, qualitative amniotic fluid volume
Fetal pH blood sampling
Performed only in the intrapartum period when the fetal blood from the presenting part can be taken; when the membranes have ruptures and the cervix is dilated 2-3cm; used to determine true acidosis when non-reassuring FHR is noted; place client in lithotomy position; sterile procedure; prepare ice in cup or emesis basin to carry pipette filled with blood to units pH machine or lab
Percutaneous umbilical blood sampling (PUBS)
Can be done during pregnancy under ultrasound for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis and some genetic testing can be done using this method
Intrapartum nursing care
Begins with true labor and consist of four stages
Stage 1 of Intrapartum nursing care
From the beginning of regular contractions or rupture of membranes to 10cm of dilation and 100% effacement
Stage 2 of Intrapartum nursing care
10 cm to delivery
Stage 3 of Intrapartum nursing care
Delivery of the placenta
Stage 4 of Intrapartum nursing care
First 1-4 hours following delivery
True labor
Pain in the lower back that radiates to the abdomen; pain accompanied y regular rhythmic contractions; contractions that intensify with ambulation; progressive cervical dilation and effacement
False labor
Discomfort localized in abdomen; no lower back pain; contractions decrease in intensity or frequency with ambulation
Nursing assessment for Intrapartum nursing care
Prodomal labor signs such as lightening, Braxton hicks contractions, cervical softening and slight effacement, bloody show or expulsion of mucous plug, and burst of energy “nesting”; gravidity and parity; gestation age; FHR; maternal VS; contraction characteristics; vaginal exam to determine fetal position, cervical dilatation, effacement, position and consistency as well as fetal station; assess for status of membranes, comfort level, labor and delivery preparation, presence of support person, presence of true or false labor
Vaginal examination
Preceded by antiseptic cleansing with client in modified lithotomy position; sterile gloves are worn; exams are not done routinely; prior to analgesia/anesthesia, done to determine progress of labor (dilation of cervix, cervical effacement, and cervical position), done to determine whether second stage pushing can begin
Cervical dilation
cervix opens from 0-10 cm
Cervical effacement
Cervix is taken up into the upper uterine segment; expressed in percentages from 0-100%; the thinning of the cervix
Cervical position
Cervix can be directly anteroir and palpated easily or posterior and difficult to palpate
Cervical consistency
Is the cervix firm to soft
Fetal station
Location of the presenting part in relation to the midpelvis or ischial spines; expressed as cm above or below the spines; station 0 is engaged, station -2 is 2 cm above the ischial spines
Fetal presentation
The part of the fetus that presents to the inlet
Vertex
Head , cephalic
Acromion
Shoulder
Breech
Buttocks
Mentum
Chin
Sinciput
Brow
Fetal position
The relationship of the point of reference on the fetal presenting part to the mothers pelvis; most common is LOA
Leopold maneuvers
Abdominal palpations used to determine the fetal presentation, lie, position and engagement; supine position place both cupped hands over the fundus and palpate the determine fetal position;
Fetal lie
The relationship of the long axis of the fetus to the long axis (spine) of the mother; longitudinal, transverse, or olique
Fetal attitude
Relationship of the fetal parts to one another; flexion or extension; flexion is desirable so that the smallest diameters of the presenting part move through the pelvis
Nursing plans and interventions for Intrapartum period
Take BP between contractions, in side lying position at least every hour unless abnormal; take temperature q4h until rupture of membranes then every hour; FHR q30 minutes in latent stage; FHR q15-30 minutes in midactive stage; FHR q15 minutes in transition stage; assess urine q8h unless abnormal; assess contractions when assessing FHR; sips of clear fluid; offer anesthesia or analgesia in midactive phase
Rupture of membrane
Nitrazine paper turns black or dark blue; vigainal fluid ferns under microscope; color and maount of amniotic fluid should be noted; allowed to ambulate as long as the FHR is normal and the fetus is engaged
Meconium stained fluid
Yellow-green or gold yellow and may indicate fetal stress
Breathing techniques
Deep chest, accelerated and cued; not prescribed by the stage and phase of labor but by the discomfort level of the laboring woman
Hyperventilation
Results in respiratory alkalosis that is caused by blowing off too much CO2; dizziness, tingling of fingers, stiff mouth; have woman breathe into cupped hands or rebreath CO2
Second stage of labor
Heralded by the involuntary need to push, 10 cm dilation and rapid fetal descent and birth; averages 1 hour for a primi and 15 min for a multi; addition of the abdominal focus to the uterine contraction force enhances the cardinal movements of the fetus: engagement, descent, flexion, internal rotation, extension, restitution and external rotation
Nursing assessment during the second stage of labor
Assess BP and pulse q5-15min; FHR with every contraction; observe perineal area for increase in bloody show, bulging perineum and anus, visibility of the presenting part; palpate bladder for distention; assess amniotic fluid for color and consistency
Nursing plans and interventions for the second stage of labor
Maternal BP and pulse q15 between contractions; FHR with each contraction or by continuous fetal monitoring; mouth care, linen change, positioning; decrease outside distractions; squatting, side lying or high-fowler/lithotomy for pushing; hold breath for no longer than 5 seconds during pushing; exhale when pushing or use gentle pushing technique; set up delivery table, including bulb syringe, cord clamp, and sterile supplies; at crowning, put gentle counter-pressure against the perineum. Do not allow rapid delivery over woman’s perineum; record exact delivery time
Third stage of labor
From complete expulsion of the baby to complete expulsion of the placenta; average length of this stage is 5-15 minutes; the longer this stage the greater change of uterine atony or hemorrhage to occur
Nursing assessment of the third stage of labor
Sigs of placental separation: lengthening of umbilical cord outside vagina, gush of blood, uterus change from oval to globular; full feeling in vagina; firm uterine contractions continue
Nursing plans and interventions of the third stage of labor
Place hand under drape and palpate fundus of uterus for firmness and placement at or below the umbilicus; maternal BP before and after placental separation; check patency and site integrity of infusing IV; administer oxytocic medication immediately after delivery of the placenta; document EBL; dry and suction, perform Apgar assessment, place blanket on mother’s abdomen or allow skin to skin contact with mother after delivery; place stockinette cap on the newborns head or cover head to prevent heat loss; gently cleanse vulva and apply sterile perineal pad; remove both legs simultaneously if the lefts are in stirrups; clean gown and warm blanket; lock bed before moving mother, and raise side rails during transfer
Application of perineal pads after delivery
Place two on perineum; don’t touch inside; do apply from front to back, being careful not to drag pad across the anus
Fourth stage of labor
the first 1-4 hours after delivery of the placenta
Nursing assessment for the fourth stage of labor
Postpartum hemorrhage, uterine hyperstimualtion; uterine over distension; dystocia; antepartum hemorrhage; magnesium sulfate therapy; bladder distension
Nursing plans and interventions of the fourth stage of labor
Bed rest for 2 hours to prevent orthostatic hypotension; ass VSq15min, then q30min until stable; assess temp at the beginning of fourth stage and prior to discharge to postpartum room; assess fundal firmness, height, bladder, lochia, and perineum q15min for 1 hour then q30min for 2 hours; change perineal pads and cleanse vulva and perineum with each change; warm blanket on abdomen; analgesics; PO fluids when alert and able to swallow; ice pack to perineum to minimize edema
Full bladder
One of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery.
Fundus
Firm, midline at or below the umbilicus. Massage if soft or boggy. Suspect full bladder if above umbilicus and to the right of the abdomen
First degree tear
A tear that involves only the epidermis
Second degree tear
A tear that involves the dermis, muscle and fascia
Third degree tear
A tear that extends into the anal sphincter
Fourth degree tear
A tear that extends up the rectal mucosa
Newborn care
Care provided to the newborn, usually performed by the nurse
Nursing assessment of newborn
Maternal history and labor data indicating potential problems with newborn; apgar scores; brief physical examination performed in delivery room
Nursing plans and interventions for newborn
Immediately dry infant under warmer or skin to skin with mother; suction mouth and nose with syringe; keep head slightly lower than body; assess airway status; apgar score at 1 and 5 minutes; allow maternal/parent contact; keep head covered; gestational age assessment; examine cord for presence of 2 arteries and one vein; make sure cord blood is collected for analysis and sent to lab; document passage of meconium and urine after delivery; two identity bands on neonate and one on mother; newborn footprints and maternal thumb and finger prints; physical exam of the newborn; eye prophylaxis in delivery room
5 symptoms of respiratory distress
Retractions, tachypnea, dusky color, circumoral cyanosis, expiratory grunt, flaring nares
Labor with analgesia or anesthesia
Usually withheld until the mid-active phase of labor; given in the early latent phase of the first stage of labor, it may retard the progress of labor; if given late in transition or in the second stage, it may depress the newborn; most drugs used for systematic pain relief and relaxation cause CNS depression; regional blocks cause a temporary interruption of nerve impulses
Nursing assessment for patient Labor with analgesia or anesthesia
Acute pain is experienced during active labor; birth plan includes use of analgesic and anesthetic agents; decreased coping and increased anxiety are observed; VS and FHR, labor gross, last time and amount of food or fluids infested; lab values; hydration status; S&S of infection
Nursing plans and interventions for patient Labor with analgesia or anesthesia
Document baseline maternal VS and FHR prior to administration of narcotics or sedatives; assess phase and stage of labor; obtain MD orders; don’t give PO medications; medications IV; push IV bolus into line slowly at the beginning of a contraction because this is when uterine blood vessels are constricted so less analgesic reaches the fetus
IV administration of analgesics
Preferred method for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter
IV administration
Onset: 5 minutes; peak: 30 minutes; Duration: 1 hour
IM administration
Onset: 30 minutes; peak: 1-3 hours; duration: 4-6 hours
After administration of analgesia or anesthesia
Record woman’s response and level of pain; monitor maternal VS, FHR and characteristics of contractions q15min for 1hr after administration; monitor bladder; decrease environmental stimuli; note time between administration of drug and delivery of baby; if baby delivers at peak, notify pediatrician or neonatologist
Tranquilizers
Phenergan and vistaril; used in labor as analegesic potentiating drugs to decrease the amount of narcotic needed to and to decrease maternal anxiety
Agonist narcotic drugs: Demerol or morphine
Produce narcosis and have a higher risk for causing maternal and fetal respiratory depression.
Antagonist drugs: Stadol, Nubain
Have less respirator depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately
General anesthesia
Rarely used in today’s OB units. Might be used as an emergency delivery or when regional block anesthesia is contraindicated or refused; administer drugs to reduce gastric secretions; assist with speedy delivery; assess closely for uterine atony; check fundal firmness and uterine contractions
Regional block anesthesia
Used for relief of perineal and uterine pain; usually safe for mother and infant unless severe hypotension occurs
Pudendal block
Given in second stage to deaden pudendal nerve plexus, thus deadening pain in the perineaum and vagina; has no effect on pain of uterine contractions; safe for mother and infant
Peridural (epidural, caudal) block
Give in first or second stage of labor to block nerve impulses from T10-S5; thereby deadening pain of contractions; used in conjunction with local or pudendal block for delivery; given in single dose or continuously through catheter threaded into epidural space; moderately associated with hypotension; associated with prolonged second stage due to decreased effectiveness of pushing
Intradural (subarachnoid, spinal) block
Given in second stage of labor to deaden uterine and perineal pain; rapid onset, but highly associated with maternal hypotension which can cause maternal and fetal distress; client must remain flat for 6-8 hours after delivery
Contraindications to subarachnoid and peridural blocks
Client’s refusal or fear; anticoagulant therapy or presence of bleeding disorder; presence of antepartum hemorrhage causing acute Hypovolemia; infection or tumor at injection site; allergy to -caine drugs; CNS disorders, previous back surgery, or spinal anatomic abnormality
Pedendal block and subarachnoid (saddle) block
Only used in the second stage of labor.
Peridural and epidural blocks
Can be used in any stage of labor
Nursing assessment for regional blocks
No contracindications; experiencing severe pain; possible need for C-section; BP >100/70; status of maternal fetal unit
Nursing plans and interventions for regional block anesthesia
Ensure that the health care provider has explained the procedure, the risks, the benefits, and the alternatives; prehydrate to counteract possible hypotension: 500-1000mL IV fluid (isotonic) infused 20-30 minutes before initiation; sims position or sitting on the side of bed with head flexed; describe symptoms after test dose of medication is given; BO q1-2 min for 15 min after injection; BP q15min during continuous infusion; assess level of pain; report return of pain sensation; assist client with pushing technique once complete dilatation occurs
What to do if hypotension occurs
Immediately turn client onto left side; increase IV infusion; begin O2 at 10L/min by face mask; notify health care provider stat and have ephedrine available; assess FHR
Nerve block anesthesia
Blocks motor as well as nerve fibers. Vasodilation below the level of the block results in blood pooling in the lower extremities, causing maternal hypotension. 20 min prior to this, the client should be hydrated with 500-1000mL lactated ringers solution IV; monitor maternal vital signs and FHR q15min
Normal postpartum
Period after pregnancy and delivery (usually 6 weeks) when the body returns to the nonpregnant state; care during this period is focused on wellness and family integrity
Normal postpartum changes: reproductive system
Uterus: myometrial contractions occur for 12-24 hours post-delivery, involution occurs 1-2 cm/day, placenta site contracts and heals without scarring; Cervix: becomes parous with a transverse slit, heals within 6 weeks; vagina: rugae reappear within 3 weeks, walls are thin and dry; breasts: nonlactating: nodules are palpable, engorgement occurs 2-3 days postpartum. Lactating: milk sinuses are palpable, colostrums is expressed first then milk, breasts may feel warm, firm, tender for 48 hours
Normal postpartum changes: cardiovascular system
At delivery: maternal vascular bed is reduced by 15%. Pulse decreases to 50, hypothesized results to shivering, BP and pulse return to pre-pregnant levels; First 72 hours: 24-48 hours postpartum, CO is elevated and will return to normal with 2-3 weeks, plasma loss> RBC loss, diaphoresis occurs at night to restore normal plasma level
Normal postpartum changes: hematologic system
HCT rises, WBC is elevated (12,000 up to 25,000), difficult to use WBC for determination of infection; blood-clotting factors are elevated; increases risk for thromboembolism
Normal postpartum changes: urinary system
Dieresis occurs; excretes up to 3000ml/day; bladder distention and incomplete emptying are common; persistent dilatation of ureter and renal pelvis increase risk for UTI; urine glucose, creatinine and BUN levels are normal after 7 days
Normal postpartum changes: GI system
Excess analgesia and anesthesia may decrease peristalsis; no bowel movements are expected for 2-3 days
Normal postpartum changes: integumentary system
Chloasma and hyperpigmentation areas regress; palmar erythema declines quickly; spider nevi fade
Normal postpartum changes: musculoskeletal system
Pelvic muscles regain tone in 3-6 weeks; abdominal muscles regain tone in 6 weeks unless diastasis recti occur
Lochia ruba
Blood tinged discharge, including shreds of tissue and deciduas; lasts 2-3 days postpartum
Lochia serosa
Pale pinkish to brownish discharge lasting 1 week postpartum
Lochia alba
Thicker, whitish yellowish discharge with leukocytes and degenerated cells; lasts up to 4 weeks
Placenta fragments
After the first postpartum day the most common cause of uterine atony is this. Must check for fragments in lochia
Subinvolution
Placental site dose not heal; lochia persists, with brisk periods of lochia rubra; D&C may be necessary
Breast care
Assess nipples for cracks, fissures, redness and tenderness; assess breasts for engorgement; palpate breasts for lumps and nodules; if not breast feeding, teach to wear a supportive bra or binder, ice packs and avoid breast stimulation; assess for change in size and shape; dimpling, puckering, scaling, redness, swelling of any part of the breast
Episiotomy care
Perineal care; fill a squeeze bottle with warm water and an ounce of povidone/iodine solution; lavage perineum with several squirts and blot dry instead of rubbing; avoid anal area
4 hours
Client should void within this many hours pose delivery; suspect retention if voiding is frequent and <100ml
Kegal exercises
Increase the integrity of the introitus and improve urine retention. Alternate contraction and relaxation of the pubococcygeal muscles
Thromboembolism
Examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch
Taking in phase
Dependency behaviors for 24-48 hours; asking for help on the simplest tasks
Taking hold phase
Less focus on physical discomforts, beginning confidence with infant care taking; feeling inadequate caring for infant is normal; praise efforts of parents; most receptive to teaching about infant care
Letting go phase
Total separation of newborn from self; confident in care taking activities of self and newborn
Mother-infant bonding behaviors
Eye contact between mom and baby; exploration of infant from head to toes; stroking, kissing, and fondling the baby; smiling, talking, singing to the neonate; use of claiming expressions; absence of negative statements; naming the newborn quickly and calling it by name
Mom should notify health care provider
Heavy, vaginal bleeding with clots; temperature on >100.4 lasting >24 hours; red, warm lump in breast; pain on urination; tenderness in calf
Sibling rivalry
18months – 3 years; warn that sibling may regress; present to toddler from the newborn and encourage mother to hug toddler; plan time alone with siblings; abstain from sexual intercourse until lochia has ceased
The normal newborn
During the immediate transitional period (6-8 hours of life) and the early newborn period (first few days of life) the nurse assesses, plans and provides nursing interventions based on the outcomes of the individual newborn’s exam
Nursing assessment of the newborn
Review L&D report of neonatal history to determine risks during newborn transition caused by medical and obstetric complications such as C-section, prematurity, diabetic mother, prolonged rupture of membrane, Rh isoimmunization, traumatic delivery; drugs used in labor and delivery; risks during newborn transition caused by degree of birth asphyxia; apgar scores at 1and5 minutes; significant social history of mom; VS q30minx2hours then q1hrx5hours; measure the neonate; physical examination of the newborn; neuromuscular assessment; gestational age assessment; behavioral assessment
Brazelton Neonate behavioral assessment scale
Evaluates the newborn;s behavioral uniqueness; wait 2-3 days to allow the neonate to rid the body of analgesia, anesthesia, and birth trauma; six categories include habituation, orientation, motor activity, self-quieting ability, social behaviors, sleep and awake states
Aspiration
Keep bulb syringe or suction immediately available: suction mouth, then nose; turn neonate on side or stomach and pat firmly on back holding the head 10-15 degrees lower than the feet
Mouth; nose
Suction this first and then ? because stimulating the nares can initiate inspiration, which could cause aspiration of mucous
Infection
Hand washing; provide scrupulous cord care by swabbing the cord with alcohol at each diaper change or keep clean with mild soap and water; cover circumcision with petrolatum gauze and change gauze at each diaper change; don’t allow visitors or personnel to attend to newborn if active infection is present or if newborn has diarrhea, open wounds and infectious, skin rash, or herpesvirus; encourage breast feeding for immunologic factors
Hypothermia
Keep newborn dry and warm; place stockinette cap on the head because the head is the greatest place for heat loss through the scalp; newborn’s temperature falls below 97, place the radiant warmer and apply skin temperature probe to regulate isolette temperature
Hypothermia
Leads to depletion of glucose and to the use of brown fat for energy; this results in ketoacidosis and possible shock. Prevent by keeping warm!!!
Hypoglycemia
Heel-stick blood glucose assessment on all SGA or LGA babies, on infants of diabetic mothers, on jittery babies, and on babies with high pitched cries; report any levels under 40; normal levels is 40-80; prevents cold stress which leads to this
Hemorrhagic disorders
Give vitamin K to prevent this
Hyperbilirubinemia
Evaluate for RH isoimmunization and for ABO incompatibility; RH+ newborn, RH- mother; maternal RH+ antibodies are passed to the fetus and cause RBC hemolysis; RBC destruction binds to protein for excretion or metabolism; promote stolling by early feeding of milk which protein binds bilirubin for excretion; assess for the presence of jaundice; give adequate fluids; monitor bilirubin levels; phototherapy if >12mg/dl
Physiologic jaundice
Occurs at 2-3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic; mainly due to the immature livers normal inability to keep up with RBC destruction and to bind bilirubin; unconjugated bilirubin causes jaundice
Nursing plans and interventions for the newborn
Document the infant;s elimination pattern daily – meconium stool within the first 24 hours to transitional to milk stool, should void within 4-6 hours of birth; screen for PKU after 2-3 days of breast milk or formula ingestion; demand feeding is preferred; bottle fed infants eat q3-4hours, breast fed infant eats q2-3 hours; should gain 1oz per day; needs 50 calories/lb or 108 calories/kg of body weight for the first 6 months; teach not to submerge baby in water for bath until cord falls off
S&S of sick newborn
Lethargy; difficulty waking; temp above 100; vomiting; green, liquid stools; refusal of two feedings in a row
RR>60
Don’t feed infant if this occurs; anticipate gavage feedings in order to prevent further energy utilization and possible aspiration
Evaluating exact urine output
Weight dry diaper before applying. Weight the wet one after infant has voided. Calculate and record each gram of added weight as 1ml of urine
Spontaneous abortion
Indicated by bleeding between conception and 20 weeks gestation; 75% of spontaneous abortions occurs between 8-13 weeks; they are usually related to chromosomal defects; considered a medical emergency;
Nursing assessment of a spontaneous abortion
Gestational age of 20 weeks or less; fetal viability absent; uterine cramping, backache, and pelvic pressure; vaginal, bright red bleeding
Nursing plans and interventions of a spontaneous abortion
Type of abortion and subsequent management; monitor vital signs, LOC qhour until stable; save all peripads and linens; IV with at least an 18g over the needle catheter; RhoGAM if indicated (RH-Mother);
Threatened abortion
Spotting without cervical changes; treated with bed rest for 24 hours; no sex for 2 weeks
Inevitable or incomplete abortion
Moderate to heavy bleeding with tissue and products of conception present; open cervical os; treatment is hospitalization, dilation and curettage
Complete abortion
All products of conception passed; cervix closed; no need for treatment
Septic abortion
Fever, abdominal pain and tenderness; foul-smelling vaginal discharge; bleeding from scant to heavy; treated with termination of pregnancy, antibiotic therapy and monitoring for septic shock
Missed abortion
Fetus is dead; placenta atrophied but passage of products of conception has not occurred; cervix is closed; treated with watchful waiting, check clotting factors and possibly terminate pregnancy to lessen the changes for developing DIC
Recurrent abortions
Loss of three or more previable pregnancies; treatment varies based on the cause; if premature cervical dilation is cause, prophylactic cerclage may be done
A McDonald Suture (cerclage)
Placed around the cervix to constrict the internal os. This is removed prior to labor if labor is planned or left in place if Csection is planned; done to client with prior traumatic delivery history, history of D&C, multiple abortions
Gestational trophoblastic disease (hydatidiform mole)
Chorionic villi degenerate into a bunch of clear vesicles in grape-like clusters; hydatidiform mole is a developmental anomaly; embryo is rarely present; predisposes to choriocarcinoma;
Nursing assessment for Gestational trophoblastic disease (hydatidiform mole)
Vaginal bleeding usually in the first trimester; size and date discrepancy (uterus larger than expected for gestational age); anemia, excessive NV, abdominal cramping, early symptoms of preeclampsia
Nursing plans and intervention
Gestational trophoblastic disease (hydatidiform mole) Preoperative and postoperative D&C care: VS, vaginal discharge, uterine cramping; prevent pregnancy for 1 year, obtain monthly serum human chorionic gonadotropin levels for 1 year;
HCG levels that don’t diminish
Choriocarcinoma may develop. Pregnancy may mask the signs and symptoms of choriocarcinoma
Ectopic pregnancy
Fertilized ovum is implanted outside the uterine cavity, usually in a fallopian tube; occurs in 1/200 pregnancies; occurs as a result of tubular obstruction or blockage that prevents normal transit of the fertilized ovum; considered a medical emergency
Nursing assessment for ectopic pregnancy
Possible absence of early symptoms of pregnancy; missed period; full feeling in the lower abdomen, lower quadrant tenderness; positive pregnancy test; signs of acute rupture: vaginal bleeding, adnexal or abdominal mass, sharp unilateral or bilateral pelvic pain; abdominal pain, referred shoulder pain, syncope, shock
Nursing plans and interventions for ectopic pregnancy
VS stat; check for vaginal bleeding; IV to administer fluids; perform gentle, moderate abdominal palpation and percussion; abdominal ultrasound; prepare client or possible laparotomy; type and crossmatch for 2 units pack RBCs
Ectopic pregnancy
Suspect this in any women of childbearing age who presents at an emergency room, clinic or office with unilateral or bilateral abdominal pain
Abruptio placentae
Partial or complete premature detachment of the placenta from its site of implantation in the uterus; 1/200 pregnancies; occurs late in the third trimester; cause of 15% of maternal deaths; ½ of infants born die; a medical emergency; cause is unknown but r/t hypertensive disorders, high gravidity, abdominal trauma, short umbilical cord; cocaine abuse
Placenta previa
Abnormal implantation of placenta in the lower uterine segment; 1/250 pregnancies; bleeding usually begins in the third trimester; previous uterine scars, surgery and fibroid tumors are associated with this; medical emergency
Partial placenta previa
Placenta lies over part of the cervical os
Complete placenta previa
Placenta lies over the entire cervical os
Marginal placenta previa
Edge of the placenta meets the rim of cervical os
Lower lying placenta previa
Placenta implants in the lower uterin segment with a placental edge lying near the cervical os
Abruptio placenta
Dark, red vaginal bleeding; FHR 100; abdomen is rigid and board life; severe pain
Nursing assessment for Abruptio placenta
Bleeding: concealed or overt (dark red); uterine tenderness; persistent abdominal pain; rigid, board life abdomen; FHR abnormalities
Nursing assessment for placenta previa
Plainless, bright red vaginal bleeding in third trimester; soft uterus; possible signs of shock; placenta in lower uterine segment; FHR is normal
Nursing plans and interventions for Abruptio placenta
Institute bed rest with no vaginal or rectal manipulation, notify MD immediately; monitor BP and pulse q15min; external uterine and fetal monitor; place client in side lying position to increase uterine perfusion; monitor contractions and FHR; IV infusion with 16-18 gauge catheter; review results of CBC, clotting studies, Rh factor and type/crossmatch stat; sighs for developing DIC
DIC signs & symptoms
Bleeding gums or nose; reduced lab values for platelets, fibrinogen, and prothrombin; bleeding from injection sites, IV sites; ecchymosis
Nursing plans and interventions for placenta previa
Use bed rest to extend the period of gestation until fetal lung maturity is achieved; then delivery is accomplished; monitor BP and pulse q15min; IV to administer fluids; review results of CBC, clotting studies, Rh factor and type/crossmatch stat; monitor contractions and FHR; side lying position; continue monitor blood loss: save pads and linens; ultrasound diagnosis; possible C-section if placenta previa is complete
DIC
Syndrome of abnormal clotting that is systematic and pathologic. Large amounts of clotting factors are depleted, causing widespread external and internal bleeding. Related to fetal demise, infection and sepsis, pregnancy induced hypertension and abruption placentae
Abruptio placentae and placenta previa
Should no undergo any abdominal or vaginal manipulation; no Leopold maneuvers; no vaginal exams; no rectal exams, enemas or suppositories; no internal monitoring
Anemia
Decrease in the oxygen carrying capacity of blood; often related to iron deficiency and reduced dietary intake; 20% of pregnant women; associated with increased incidence of abortion, preterm labor, preeclampsoa, infection, postpartum hemorrhage, and intrauterine growth retardation
Nursing assessment for anemia
Fatigue, pallor; HGB<11, HCT <37% in first trimester; HGB < 10.5, HCT < 35% in second semester; HGB<10, HCT<32% in third trimester; poor nutritional intake; noncompliance with prenatal vitamin
Nursing assessment for infections
Multiple sex partners; previous history of STD or vaginal infections; employment involving high exposure to infection; nonspecific symptoms such as fever or malaise; general symptoms of STDs such as vaginal discharge, genital lesions, dysuria, and dyspareunia; lab studies show antibody titers, TORCH, VDRL, RPR, gonorrhea screen, vaginal wet mouth
Psychosocial concerns: teenage pregnancy
Pregnancy occurring at age 19 or younger; associated with anemia, preeclampsia, cephalopelvic disproportion, STDs, IUGR, and ineffective parenting
Preterm labor
Onset of labor between 20 to 37 weeks gestation; predisposing factors to preterm labor include diabetes, cardiac disease, preeclampsia, placenta previa, infection, over distention of uterus due to multiple pregnancies, hydramnios, LGA, working outside home, 2+ children <5 years, financial stress, no social support system, smoking >10 cigarettes per day; responsible for 2/3 neonatal deaths; neonates >4.5lbs or >32 weeks have best chance for survival
Warning signs of labor
Uterine contractions q10min or more often; menstrual like cramps; low, dull backache and pelvic pressure; increase or change in vaginal discharge; rupture of membranes
Glucocorticoids
betamethasone ; Enhances fetal lung maturation or surfactant production if fetus is <35 weeks gestation
Dystocia
Difficult birth resulting from any cause; can result from any one or all of the 5Ps (powers, passage, passenger, psyche, position)
Powers
Primary uterine contractions and secondary abdominal bearing down efforts
Passage
Matneral pelvis, uterus, cervix, vagina, perineum
Passenger
Fetus and placenta
Psyche
Response to labor by woman
Position
Position of the laboring woman
Dystocia
Suspected when there is a lack of progress in cervical dilation; lack of fetal descent; lack of change in uterine contraction characteristics
Nursing assessment for Dystocia
Hypertonic or hypotonic uterine contractions; inability to bear down or push efficiently; prolonged labor patterns
Nursing plans and interventions for Dystocia
Assist with diagnostic procedures; assist with amniotomy; initiate oxytocin
Dystocia
Often requires oxytocin for augmentation or induction of labor; uterine tetany is a serious complication; want contractions q2-3 min lasting no longer than 90 seconds
What to do if tetany occurs
Turn off oxytocin, turn client to a side lying position, administer O2 by face mask
Oxytocin
Most important side effect is ADH effect which can cause water intoxication
Gestational hypertension
BP elevation occurs for the first time after midpregnancy
Transient hypertension
Gestational hypertension, with no other signs of preeclampsia, is present at time of birth; resolves by 12 weeks after birth
Preeclampsia
Pregnancy specific syndrome that usually occurs after 20 weeks gestation’ gestational hypertension + proteinuria
Hemolysis, elevated liver enzymes, low platelets
HELLP – preeclampsia
Eclampsia
Seizures that occur in a woman with preeclampsia
Chronic hypertension superimposed on chronic hypertension
Chronic hypertension with new onset proteinuria and worsening of the already present hypertension, thrombocytopeniam or increased liver enzyme values
Preeclampsia and eclampsia
Most common hypertensive disorder; develops during pregnancy and is characterized by elevated blood pressure, edema and proteinuria; characterized by an increase BP of 30mmHg systolic and/or diastolic increase of 15mmHg diastolic; 10 weeks gestation or 48 hours post delivery; major cause of maternal death, fetal hypoxia and death; predominately primigravida
Pathophysiology for preeclampsia
Generalized vasospam and vasoconstriction leading to vascular damage over time; loss of plasma protein into the interstitial spaces; Hypovolemia, which results in decreased perfusion to major organs
Mild preeclampsia
Bp rise to 30mmHg systolic and 15mmHg diastolic over previous baseline, or 140/90 or greater; presence of associated conditions; weight gain >1+; edema around the eyes, face and fingers; hyperreflexia 3+; CNS symptoms such as possible mild headache, slight irritability; IUGR, evidence by size date discrepancy
Severe preeclampsia
Bp rise to 30mmHg systolic and 15mmHg diastolic over previous baseline, or 140/90 or greater; presence of associated conditions; weight gain >1+; edema around the eyes, face and fingers; hyperreflexia 3+; CNS symptoms such as severe headache, visual disturbances, and epigastric pain ; IUGR, evidence by size date discrepancy; BP of 160/110 on 2+ occasions; proteinuria 3-4+; DTRs 3+ and clonus; elevated serum creatinine, thrombocytopenia, marked liver enzyme elevation (SGOT)
HELLP syndrome
Characterized by hemolysis, elevated liver enzymes, and low platelets; increased risk for abruption, acute real failure, hepatic rupture, preterm birth, and fetal or maternal death or both; aside from changes that occur with preeclampsia; history of malaise, epigastric or RUQ pain, NV; normotensive and do not have proetinuria; treated prophylactically with magnesium sulfate; high risk for deloping the syndrome again in future pregnacies as well as for developing preeclampsia in other pregnancies not complicated by this
Home management for patient with preeclampsia
Absolute bed rest; weigh daily and report >2lb/week; test urine daily for protein; report the following symptoms to the PCP immediately:: visual disturbances, headache, NV, hyperreflexia, convulsions, epigastric pain, oliguria, proteinuria, decreased or absent fetal activity, vaginal bleeding, abdominal pain; high protein diet with limited salt intake, maintain the minimum 35cal/kg of body weight;
S&S of preeclampsia
History of malaise, epigastric or RUQ pain, NV
Hospital management for patient with preeclampsia
If severe preeclampsia is present, hospitalization will be necessary; monitor LOC, BP, VSq4h; continuous fetal assessment; assess for vaginal bleeding and abdominal pain; bed rest in left lying position; catheter; I&O hourly; maintain quiet, slightly darkened environment and limited visitors; administer magnesium sulfate and antihypertensive drugs; assess for signs of coagulopathy; assess DTR and clonus every shift
Signs of coagulopathy
Petechiae under BP cuff; platelet decrease or increase; fibrinogen increase or decrease
Patient with preeclampsia intrapartum
When client begins labor, control the amount of stimulation in the labor room; nurse to client ratio at 1:1; keep room darkened, quiet, private room; absolute bed rest, side lying with side rails up; disturb as little as possible; limit visitors except for support person; explain rationale for procedures and care; IV line with 16-18 gauge; BP q15-30min; check urine for protein q1h; DTR q1h; administer magnesium sulfate;
Magnesium sulfate administration
Given IV with loading dose of 4g in 100ml to 250ml solution; administer over 20-30 minutes to get blood level up to therapeutic serum level (5-8mg/dl);
Magnesium sulfate toxicity
Urinary output <30ml/hour; RR<12; DTRs absent; deceleration of FHR, bradycardia
Major goal for patient with patient preeclampsia
Maintain utereoplacental perfusion and prevent seizures; administration of magnesium sulfate; withhold magnesium sulfate if signs of toxicity exist
Convulsion risk
Up to 48 hours post delivery
Antihypertensive drugs
Rarely used in preeclamptic client; given only in the event of diastolic BP >110 due to the risk of CVA; hydralazine HCL
Maternal cardiac disease
Impaired cardiac function usually results from a congential defect or history of rheumatic heart disease with valve prolapse or stenosis; dangerous because of plasma volume increase that accompanies pregnancy
Class I of cardiac disease
Unrestricted physical activity; ordinary physical activity does not cause cardiac symptomatology
Class II of cardiac disease
Ordinary activity causes fatigue, palpitations, dyspnea, and angina; physical activity is limited
Class III of cardiac disease
With less than ordinary activity, cardiac decompensation symptoms ensure; moderate to marked limitation or activity
Class IV of cardiac disease
Symptoms of cardiac insufficiency occur even at rest; no activity is allowed
Nursing assessment for Maternal cardiac disease
History of preexisting cardiac disease; fatigue, dyspnea, feeling of smothering, dry hacking cough, racing heart, swelling of feet legs ad fingers; HR>100, crackles, orthopnea, RR>25; anemia
Nursing care for cardiac maternity client: antepartum
8-10 hours of sleep; self administration of heparin; diet plan: high iron, high protein, and adequate calorie intake; notify doctor at first signs of infection
Nursing care for cardiac maternity client: intrapartum
Calm atmosphere; semi-fowler, side lying position; prevent valsalva maneuver; avoid hypotension; avoid stirrups in delivery room; pain relief and supportive measures because pain can contribute to cardiac distress
Nursing care for cardiac maternity client: postpartum
Continue semi-fowler position with side-lying position; progress ambulation: dangling, sitting, standing, short to long ambulation according to tolerance and absence of symptoms; stool softeners; watch for signs of urinary infection; report any signs of cardiac decompensation
Nursing care focus for mother with cardiac disease
Prevention of cardiac embarrassment, maintenance of uterine perfusion and alleviation of anxiety
Preterm labor for mothers with cardiac disease
The use of beta-adrenergic agents such as terbutaline (brethine) and ritodrine HCL (yutopar) are contraindicated because of the risk for myocardial ischemia
Normal dieresis
This normally occurs in postpartum period but it can pose serious problems to the new mother with cardiac disease because of increased cardiac output
Nursing assessment for the newborn with congenital heart disease
Weak cry, cyanosis worsening with crying; lethargy, hypotonia and flaccidity; persistent bradycardia or tachycardia; tachypnea or other signs of respiratory distress; decreased or absent femoral pedal pulses
Nursing plans and interventions for the newborn with congenital heart disease
Decrease energy utilization immediately: no nippling; NICU
Coumadin
May not be given during pregnancy due to its ability to cross the placenta and affect the fetus; heparin is the drug of choice
hyperemesis gravidarum
Inability to control NV during pregnancy; inability to keep down fluids and solid foods for 24 hours; linked to maternal hormones
Nursing assessment for hyperemesis gravidarum
Weight loss during pregnancy; signs of dehydration; psychological distress; fluid and electrolye imbalance; metabolic acidosis
Signs of dehydration
Increased urine SG and oliguria
Nursing plans and interventions for hyperemesis gravidarum
Weigh daily; check urine 3x for ketones; monitor electrolytes and hydration status; clear liquids bland full diet; check FHR; psychological support
Helicobater pylori
Another possible causative factors in hyperemesis
Hyperemesis gravidarum
Provider may prescribe antihistamines, vitamin B6, or phenothiazines to relieve nausea; also provide metoclopramide (Reglan) to increase the rate at which the stomach moves food into the intestines or antacids to absorb stomach acid and help prevent acid reflux
Hyperemesis gravidarum
Often deficient in thiamin, riboflavin, vitamin B6, Vitamin A and retinol binding proteins
Diabetes mellitus
Hormonal changes during pregnancy act to increase maternal cell resistance to insulin so that an abundant supply of glucose is available to the fetus; if insulin cannot move glucose into maternal cells, the mother will begin to metabolize fat and protein for energy-producing ketones and fatty acids, which result in ketoacidosis
Diabetes mellitus nursing assessment
Family history of diabetes; history of more than 2 spontaneous abortions; previous baby with weight over 4000g; previous baby with congenital anomalies; high parity; obesity; recurrent monilial vaginitis; abnormal glucose screen; elevated glycosylated hemoglobin; polyphagia, polydipisia, and polyuria; hyperglycemia; increased incidence of preeclampsia, infection and hydramnios
Abnormal glucose screen
A 1 hour glucose screen is routinely done on all pregnant women between 24-26 weeks gestation
Elevated glycosylated hemoglobin
Evaluate diabetic control by reflecting blood glucose level during the previous 6-8 weeks
Type 1 diabetes
Insulin dependent; hemoglobin A1c test
Type 2 diabetes
Non-insulin dependent; in pregnancy, insulin is required to control maternal blood glucose levels
Type 3 diabetes
Gestational diabetes; onset during pregnancy and return to normal glucose tolerance after delivery
Glucose screen
Client does not have to fast for this test; 50g of glucose is given and blood is drawn after 1 hour; >135mg/dl a 3-hour glucose tolerance test is done
Fetal surveillance
High incidence of fetal anomalies occurs in pregnant diabetic women; this is very important via ultrasound exam, alpha fetoprotein, non-stress and contraction stress test
Oral hypoglycemic
Not taken during pregnancy because of the potential teratogenic effects on the fetus
Diabetes mellitus in pregnant women
She is more prone to preeclampsia, hemorrhage, and infection; delivery is often scheduled for 37-38weeks gestation to avoid the end of the third trimester of pregnancy because this is a very difficult time to maintain diabetic control
Predelivery period for diabetes mellitus in pregnant women
Insert an intravenous line for infusion of insulin and a glucose-containing solution. Insulin doesn’t cross the placenta; titrate regular insulin and glucose containing solution to maintain glucose levels between 60-100 during labor; determine blood glucose hourly; place on left side to avoid pressure on vena cava by large fetus or hydramnios; check urine for ketones hourly; monitor fetus continuously
Postdelivery period for diabetes mellitus in pregnant women
Slide-scale approach to insulin administration because of the precipitous fall in insulin requirements; continue 5% glucose infusion at 100-125; check urine for ketones; breastfeeding decreased insulin requirements; contraception: diaphragm with spermicide
Estrogen – birth control
Pills affect glucose metabolism by increasing resistance to insulin
Discontinue long acting insulin
Discontinue this the day before delivery is planed because requirements are less during labor and drop precipitously after delivery
Assessment for diabetic insulin
Macrosomia, IUGR, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, congenital anomalies, prematurity, infection
Nursing plans and interventions for diabetic insulin
Observe for birth trauma: clavicle fracture or cerebral trauma; perform heel sticks for glucose assessment at 30minutes, 1 hour and as prescribed; hypoglycemia, hypocalcemia; small, frequent feedings at 1 hour of age
Emergency delivery
Rapid, uncontrolled delivery; nonsterile or an unassisted delivery that can be managed without complications to mother or fetus
Nursing assessment for emergency delivery
Bulging perineum; woman screaming that the baby is coming; presenting part visible at introitus
Nursing plans and interventions for emergency delivery
Do not leave the client alone; get precipitous delivery basin; clean towel under mothers buttocks; hee-blow or blow-blow breathing technique to slow expulsion of head over perineum; if amnion is still present, rupture with fingers; apply gentle counter pressure against presenting part; check for cord around the neck; clamp cord in 2 places cut between; placenta separation
Cesarean birth
Delivery of a fetus or fetuses through the abdomen; prone to complications such as anesthesia complications, usual abdominal surgery complications, sepsis, thromboembolism, injury of urinary tract
Nursing assessment for cesarean births
Elective or repeat cesarean birth scheduled; performed to prevent harm to mother or fetus
Nursing care for client with cesarean births: before
If planned, encourage couple to attend cesarean birth class; emergency: informed consent, including health care provider’s explanation of risks, benefits, and alternatives to surgery; anesthesiologist of need for preoperative assessment; assist with anesthesia; preoperative mediations; shave abdomen from xiphoid to one quarter a way down the thigh; foley catheter; type and cross match for unit packed RBCs, CBC and chemistry; catheterized or clean catch analysis; remove: dentures, contact lenses, rings, fingernails polish and support person
Nursing care for client with cesarean births: intraoperative care
Place wedge under one hip to displace uterus laterally; keep client warm with warm blankets; monitor and document fetal heart tones continuously; grounding pad to leg; perform abdominal scrub
Nursing care for client with cesarean births: cesarean birth
Receive complete report; fundal height and consistency assessment; assess temperature q hour in recovery, then q4hx24hours; HR, RR, breath sounds, bowel sounds, and SaO2; pain medications; demonstrate splinting abdomen, coughing, deep breathing, and use of IS; aseptic technique to prevent sepsis;
Low transverse uterine incision
Usually results in less postoperative pain, less bleeding and fewer incidents of ruptured uterus
Vertical incision
May involve part of the fundus, resulting in more PO pain, more bleeding and an increased chance for uterine rupture
Pooling of lochia in the vagina
After C-section, lochia is scant in the delivery room; this is normal when the patient ambulates initially.
Laparomtomy
Predisposes the client to postoperative paralytic ileus. The bowel is manipulated during surgery, it creases peristalsis and this condition may persist
Paralytic ileus
Absent bowel sounds, abdominal distension, tympany on percussion, NV, obstipation (intractable constipation)
Post partum infection
Any clinical infection of the genital canal that occurs within 28 days of delivery
Predispose to puerperal morbidity
Temperature >100.4; temperature elevation on 2 successive days or in 2 successive 4hr assessments
Streptococcal and anerobic organisms
Most common organisms for postpartum infections
Perineal infection
Temperature 101-104; red, swollen, very tender perineum; purulent drainage, induration
Endometritis
Infection of the lining of uterus; temperature 101-102; HR >100; malaise, anorexia; excess fundal tenderness long after it is expected; uterine subinvolution; lochia returning to rubra from serosa; foul smell lochia
Parametritis
Pelvic cellulitis; temperature 103-104l tachycardia, tachypnea; severe uterine and cervical tenderness; WBC>25,000; palpale pelvic abscess
Peritonitis
Chills and temperature to 105; rapid thread pulse up to 140; decreased urinary output; paralytic ileus, abdominal distension, absence of bowel sounds
Thromobophlebitis
Deep vein thrombosis; minimal fever; positive humans sign; pain in calf or dull ache in the leg; swelling
Common physiologic response to anxiety
Increased HR and BP; rapid, shallow RR; dry mouth and tight feeling in throat; tremors and muscle tension; anorexia; urinary frequency; palmar sweating
Anxiety
Very contagious and is easily transferred from client to nurse and from nurse to client
Generalized anxiety disorder
Unrealistic, excessive or persistent anxiety and worry about 2 or more circumstances. Previously coping mechanisms are inadequate to deal with this level of anxiety
Nursing assessment for Generalized anxiety disorder
Severe anxiety; motor tension: restlessness, quickly fatigued, feelings of shakiness, tension; autonomic hyperactivity: SOB, heart palpitations, dizziness, diaphoresis, frequent urination; vigilance and scanning: difficulty concentrating, sleep disturbance, irritability, quick to become angry; on edge, appearance of being nervous; low self-esteem
Nursing plans and interventions for Generalized anxiety disorder
Assess client so as to recognize anxiety and label the feeling? relationship between the stressor and the level of anxiety; learn and test various adaptive coping responses; exercise, DB, visualization, relaxation, biofeedback, decrease stimuli
Urinary tract infection
Slight or no temperaruee; dysuria, frequency, urgency, suprapubic tenderness; hematuria, bacteriuria; cloudy urine
Pyelonephritis
Infection of the kidney; temperature >102, chills; flank pain and costovertebral-angle tenderness; NV; dysuria, urgency, cloudy urine, hematuria, bacteriuria
Mastitis
Infection of the breast; sore cracked nipple; flu-like symptoms: malaise, chills, and fever; red, warm lump in breast
Nursing plans and interventions for postpartum infections
Teach good handwashing; record VS; manage fever by increasing fluids, providing cool baths, administering acetaminophen; assess for signs of dehydration; maintain hydration; include the four basic food groups and increase intake of foods containing vitamin C and protein
Nursing plans and interventions for perineal infection
Stay warm; assess site daily for decrease in redness, pain, and discharge; sitz bath and perineal lamp 2-3x/day; antibiotics and analgesics
Nursing plans and interventions for endometritis
Maintain bed rest in fowler or semi fowler position with BR privileges; palpate fundus and abdomen q8h; antibiotics
Nursing plans and interventions for parametritis
Promote lochial and uterine drainage by instructing client to use semi-fowler position; amount and odor of lochia; development of pelvic thrombophlebitis; IV antibiotics
S&S of pelvic thrombophlebitis
Acute abdominal pain caused by a clot in the ovarian vein Nursing plans and interventions for peritonitis Transferred to ICU; medical emergency; O2 via mask; IV antibiotics; NG tube; assess abdomen 3xd for tympany, distension and BS
Nursing plans and interventions for mastitis
C&S of breast milk; breast feed q2-3hours and make sure breasts are emptied with each feed; do not let client cease breastfeeding abruptly; mother should manually empty breasts and discard milk to maintain milk production and reduce congestion; treated at home by PO antibiotics; bed rest for 48 hours; monitor for abscess
Anticoagulants
If woman take these medications, expect heavy menstrual periods
Postpartum infection
Implied isolation from newborn until organism is identified and treatment begun; phone calls to nursery and viewing window
Risk for postpartum infections
Higher in clients who experienced problems during pregnancy and who experienced trauma during L&D
Postpartum hemorrhage
Leading cause of maternal mortality that demands prompt recognition and intervention; can be caused by uterine atony, lacerations to vagina, hematoma development in the cervix perinea or labia, retained placental fragments, and full bladder
Postpartum hemorrhage nursing assessment
Excessive uterine bleeding during the first hour following delivery; excessive uterine bleeding during the postpartum period; blood loss >500ml during vaginal delivery; signs of hypovolemic shock; signs of hematomas developing in perineum; signs of bleeding from un-repaired laceration; signs of uterine atony
Hemorrhage
More than 1 saturated pad q15min
Signs of hematomas developing in perineum
Intense perineal pain; swelling and blue-black discoloration on perineum; pallor, tachycardia and hypotension; feeling of pressure in vagina, urethra and bladder; urinary retention and uterine displacement
Nursing plans and interventions for postpartum hemorrhage: early
Monitor VS, fundus, lochia, q15minx1hour, q30minx1hr, and q1hourx2hours; LOC; bladder empty; call MD if atony or bleeding continues despite message; increasing pitocin IV infusion and administering ergot preparation IM; count pads saturated and time required to saturate; I&O
Nursing plans and interventions for postpartum hemorrhage: late
Quick hospitalization and determination of cause of bleeding; type and cross match for possible blood transfusion; oxytocic drugs and possibly ergot preparations; antibiotics; keep the client warm
Nursing plans and interventions for hematoma development
Ice pack to perineum to decrease swelling and pain; surgical incision if hematoma is large; monitor VS closely; analgesics and antibiotics
Risk factors for hemorrhage
Dystocia, prolonged labor, over distended uterus, abruption placenta and infection
Immediate nursing actions for postpartum hemorrhage
Perform fundal massage; notify health care provider if the fundus does not become firm with massage; count pads to estimate blood loss; assess and record VS; increase IV fluids; oxytocin infusion
Major danger signals in the newborn
CNS: lethargy, high-pitched cry, jitteriness, seizures, bulging fontanels; Respiratory: apnea, tachypnea, flaring nares, retractions, seesaw breathing, grunting, abnormal blood gases; Cardiovascular: abnormal HR and rhythm, persistent murmurs differentials in pulse, dusky skin color, circumoral cyanosis; GI: absent feeding reflexes, vomiting, abdominal distension, changes in stool patterns, no stool; Metabolic: hypoglycemia, hypocalcemia, hyperbilirubinemia, labile temperature
Jitteriness
A clinical manifestation of hypoglycemia and hypocalcemia; lab analysis is indicated to differentiated between the two causes
Signs of cold infant
Skin mottling, tachycardia, tachypnea, prolonged acrocyanosis
Nursing plans and interventions for newborn resuscitation
Ventilations are done over moth and nose, size 1 mask; 40-60 per minute; HR<60 compressions are done with thumbs side by side; 1/3 the anteroposterior chest diameter; compression/ventilation ration is 3:1 to achieve 120 events/min; IV fluids; administer sodium bicarbonate or epinephrine; glucose
Silverman-Anderson index of respiratory distress
Evaluation of resuscitative efforts; upper chest synchronization; lower chest retractions; xiphoid retractions; nares dilation; expiratory grunt; the lower the score, the better the respiratory status; score of 10 indicates severe respiratory distress; exact opposite of method used for apgar
Oxygen therapy for the newborn
Always administer O2 at the lowest concentration possible when correcting hypoxia; use O2 analyzer to determine the exact amount; hypoxia and hyperoxia are dangerous; perscriped in percentages and represents the fraction of inspired O2 in the air; can be administered via oxy-hood (concentrations up to 100%), nasal prongs (low concentrations), continuous positive airway pressure (reduces work of breathing and keeps alveoli open
O2 toxicity results
Retinopathy of prematurity; bronchopulmonary dysplasia
Extracorporeal membrane oxygenation
Blood is oxygenated outside the body through a bypass procedure
Problems associated with neonatal hypoxia
Respiratory acidosis; necrotizing entercolitis; patent ductus arteriosus; intravascular hemorrhage
Necrotizing entercolitis
Hypoxic-ischemic injury to the mucosa of the intestinal tract that results in abdominal distension, sepsis, and nutritional impairment; caused by neonatal hypoxia
Patent ductus arteriosus
Return to fetal circulation in an attempt to provide O2 to the brain and large organs; results in worsening respiratory distress and pulmonary edema due to increased blood flow to the lungs; caused by neonatal hypoxia
Intravascular hemorrhage
Hypoxia causes vessel damage in the time periventricular capillaries, resulting in symptoms of increased ICP; seizures, decreased or absent reflexes, hypotonia, bulging fontanels, enlarged head circumference, setting-sun eyes, shrill cry, hypothermia, apnea, and bradycardia
HCT
Watch this on an infant. It is difficult to oxygenate either an anemic newborn or newborn with polycythemia (HCT>80%, thick, sluggish circulation)
Signs of respiratory acidosis on a newborn
PH<7.2; Po2 <50; PCO2>60
Po2 < 50
Signifies hypoxia
Po2>90
Signifies oxygen toxicity problems
Neonate with sepsis
Infections can be overwhelming in the neonate because of the immature immune system
Nursing assessment for Neonate with sepsis
Lethargy, temperature instability, difficulty breathing, subtle color changes: mottling and duskiness; just acts funny; subtle changes in behavior; respiratory distress, apnea; hyperbilirubinemia
Nursing plans and interventions for Neonate with sepsis
Prevent infection: hand washing, triple dye antimicrobial to cord, avoid wearing rings, universal precautions, appearance of IV site q30min, watch skin integrity, maintain adequate nutrition; place in incubator; sepsis workup: blood cultures, LP, urine collection, chest x-ray, CBC with diff, chemistry; antibiotics
Preterm newborn care
Neonate born at <38 weeks gestation; based on the level of immaturity identified by gestational age and physical assessment
Nursing assessment for Preterm newborn
Respiratory distress: lung immaturity, lack of surfactant lining alveoli, immature respiratory center, PDA; temperature instability: insufficient SUBCU fat, larger ratio of body surface area to body weight, extended open body position, immature hypothalamus; nutrition problems: poorly developed suck, small stomach, immature digestions process, hypoglycemia, anemia, hyperbilirubinemia; fluid and electrolyte problems: limited concentration/excretion ability of kidneys, metabolic acidosis, hypocalcemia (<7mg/dl); Immunologic immaturity: no IgM antibodies, no phagocytosis, thin skin barrier, intraventricular hemorrhage
intraventricular hemorrhage
Weak, fragile capillaries of the brain
Sepsis
Can be indicated by both a temperature increase and decrease
Closing monitoring
Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. This is essential to monitor therapeutic levels and observations for side effects
Nursing plans and interventions for preterm newborn care
Provide and monitor O2 therapy; monitor thermoregulation; monitor fluid and electrolytes; weigh diapers daily; maintain urine output 1ml/kg/hr and SG 1.005-1.012; maintain nutrition; premie formulas; provide TPN; prevent injury resulting from hyperbilirubinemia; prevent intracranial hemorrhage
110-150 calories/kg/day
Calorie calculation for infant per day
140-160ml/kg/day
Milliliters for infant per day
24 calories/oz
Premie formula calorie/oz; increases calories without increasing fluids
Total parenteral nutrition
Preterm or post-surgical neonate who cannot handle or cannot metabolize enteral feedings; monitor glucose, serum and urine; IV fluids with dextrose content >12.5% through central line; calcium supplement and vitamin D to prevent rickets; vitamin E to enhance cellular integrity
Hypoglycemia S&S in preterm
Jitteriness, tremors, lethargy, hypotonia, apnea, weak or high pitched cry, eye rolling, and seizures
Hypocalcemia S&S in preterm
Jitteriness, apnea, increased muscle tone, edema, abdominal distension, feeding intolerance, and chvostek’s sign
chvostek’s sign
Twitching over tapped parotid gland
Excessive fluid volume S&S in preterm
Edema, tachycardia, bulging fontanels, and rales in lungs
Deficient fluid volume S&S in preterm
Sunken fontanels, poor skin turgor, and dry MM
Gavage feeding in newborn client
Sterile feeding tube (5-8fr); calibrated syringe for formula; stethoscope; sterile syringe without needle; paper tape; formula and medications; head slightly elevated and towel under shoulders; measure distance from bridge of nose to the earlobe and then to a point halfway between the xiphoid process and umibilcus; pass tube along back of tongue, advancing as newborn swallows; aspirate and measure any residual stomach contents and reduce volume of feeding by amount of residual; attach large feeding syringe to tube with plunger removed, pour warmed formula or breast milk and allow to flow by gravity, hold 6-8 inches above newborns head for slow feeding: 20mints or 1ml/min; stop flow at neck of syringe by pinching tubing; clear tubing with small amount of sterile water; pinch tubing and withdraw quickly to avoid administering the feeding nasopharyngeally; burp; position on right side; postpone treatments for 1hr; record amount of residual
Trachea
If gavage tube passes into here the newborn can make no noise (gag, cough) and may become cyanotic
Renal immaturity
In a preterm makes the monitoring of administration of IV fluids and drug therapy crucial; closely monitor BUN and creatinine levels when administering the -mycin antibiotics to treat infections of a neonate
Hyperbilirubinemia
Excessive accumulation of bilirubin (usually unconjugated) in the blood due to RBC hemolysis
How to test the placement of gavage feeding tube
Inject 0.5ml of air using sterile syringe while simultaneously listening for air bubble into the stomach with stethoscope over epigastrium; aspirate small amount of stomach contents and check ph (<3 acid)
Nursing assessment of Hyperbilirubinemia
Risk factors: Rh incompatibility, ABO incompatibility, induction using oxytocin because of IUGR, prematurity, sepsis, perinatal asphyxia, maternal diabetes or intrauterine infections, cephalhematoma; jaundice; total bilirubin determinations increase >5mg/day; positive direct comb test; increased reticulocyte count; anemia; urine and stools are dark
Jaundice
With this issue, there is a problem of kernicterus (bilirubin encephalopathy) resulting from bilirubin deposition in the brain
Term infant
Bilirubin level: >12mg/dl
Preterm infant
Level >5mg/dl – more susceptive to kernicterus at lower bilirubin concentrations
Total parenteral nutrition complications
Hyperglycemia, electrolyte imbalance, infection, and dehydration
Emotional aspects related to care of high risk neonates
Without adequate attention to the emotional and developmental needs of the sick neonate, the following occur: failure to thrive, avoidance of eye contact with people, absent or weak crying; nurses may cuddle, swaddle, sing to and offer pacifiers to infant and put mobiles and decals in the crib of the baby
Nursing plans and interventions for Hyperbilirubinemia
Phototherapy; maintain hydration; promote excretion by feeding in order to produce more stooling; fiber optic blanket for rooming or home phototherapy
Phototherapy
Decomposes bilirubin in the skin through oxidation; place unclothed neonate 18 inches below a bank of lights for several hours or days until levels fall <12; place opague mask over eyes to prevent damage; monitor skin temperature; cover genitals with a small diaper or mask to catch urine and stool; turn q2hrs; turn off lights for 5-15 min q8hr to assess for conjunctivitis; monitor for signs of dehydration
Assessing for jaundice
Apply pressure to bony prominences to blank skin. When thumb is removed, the area will look yellow before normal skin color; nose, forehead, and sternum are best for assessment
Unconjugated indirect bilirubin
Calculated by subtracting the direct from the total bilirubin; dangerous bilirubin
Cigarette smoking neonate effects
Neonate is small; IUGR; increases with the number of substance per day; teach client that IUGR can be minimized or eliminated when smoking is stopped early
Narcotics neonate effects
Irritability, hyperactivity; high-pitched cry; coarsem flapping tremors; poor feeding, frantic sucking, VD; nasal stuffiness; swaddle and minimize handling; decrease environmental stimuli; provide pacifier; prone position with sheepskin; cover elbows and knees to prevent skin breakdown; bulb syringe close at hand
Alcohol intake neonate effects
Fetal alcohol syndrome: microcephaly, growth retardation, short palpable fissures, maxillary hypoplasia; long term complications: mental retardation, poor coordination, facial abnormalities, behavior deviations, cardiac and joint abnormalities; determine how often and how much
Coping styles (defense mechanisms)
Automatic psychological processes that protect the individual against anxiety and from awareness of internal and external dangers and stressors
Milieu therapy
Planned use of people, resources, and activities in the environment to assist in improving interpersonal skills, social functioning and performing the activities of daily living; focus on here and now; use limit setting; involves the client in making decisions about his/her own care; activities that support group sharing, cooperation and compromise
Behavior modification
Used to change ineffective behavior patterns; focused on the consequences of actions rather than on peer pressure; positive reinforcement is used to strengthen desired behavior; negative reinforcement is used to decrease or eliminate inappropriate behavior; role modeling and teaching new behaviors are important
Family therapy
Identifies the entire family as the client; based on the concept of the family as a system of interrelated parts forming a whole; focused in on the patterns of interaction within the family; assist the family in identifying the roles assigned to each member based on family rules; congruent and incongruent communication patterns and behaviors are identified; decrease family conflict and anxiety and to develop appropriate role relationships
Crisis intervention
Direct at the resolution of an immediate crisis, which the individual is unable to handle alone; when previously learned coping mechanisms are ineffective in dealing with the current problem; usually in a state of disequilibrium; panic state as a result of the disorganization, be very directive; focus on the problem, not the cause; identify support system; fast coping patterns used in other stressful situations; goal is to return individual to pre-crisis level of functioning; limited to 6 weeks
Cognitive therapy
Directed at replacing a client’s irrational beliefs and distorted attitudes; focused, problem solving therapy; work together to identify and solve problems and overcome difficulties; short term therapy of 2-3 months
Electroconvulsive therapy
Electrically induced seizures for psychiatric purposes; severely depressed clients who fail to respond to antidepressant medications and therapy. Used with extremely suicidal patients because 2 weeks are needed for antidepressants to take effect; administer anticholinergic 30 min prior to procedure; after procedure maintain airway; VSq15min until alert; reorient; common complaints are headache, muscle soreness, nausea
Group intervention
Used with 2 or more client’s who develop interactive relationships and share at least one common goal or issue; may be closed or open and group may be small or large; common to have nurse-led intervention groups include those that focus on medications, symptom mgmt, anger mgmt and self care.
Initial/orientation phase in group intervention
High anxiety, superficial in interactions; testing the therapist to see if he/she can be trusted
Middle/working phase in group intervention
Problem identification; beginning of problem solving; beginning of the group sense of “we”
Termination phase in group intervention
Evaluation of experience; expression of feelings ranging from anger to joy
Helpful techniques in communication
Acknowledge, clarifying, confrontation, focusing, information giving, open-ended questions, reflecting/restating, silence, suggesting
Acknowledging
Recognizing the client’s opinions and statements without imposing your own values and judgment
Clarifying
The process of making sure you have understood the meaning of what was said
Confrontation
Calling attention to inconsistent behavior; information shared and not shared
Focusing
Assisting the client to explore a specific topic which may include sharing perceptions and theme identification
Information giving
Feedback about the client’s observed behavior
Reflecting/restating
Paraphrasing or repeating what the client has said
Silence
Can be therapeutic or can be used to control interaction; use carefully with paranoid client; may be misinterpreted or could be used to support paranoid ideation
Suggesting
Offering alternatives
Basic communication principles
Establish trust; demonstrate a nonjudgmental attitude, offer self; be empathetic, not sympathetic; use active listening; accept and support client’s feelings; clarify and validate client’s statements; use matter of fact approach
Useful phrases
Useful in therapeutic interaction; keep interaction open, genuine and client centered; keep client as focus; be aware of own feelings and anxiety level; tell me about…; go on…; I’d like to discuss what you are thinking; what are your thoughts? Are you saying that…; what are you feeling…; it seems as if
Forbidden phrases
Phrases that should not be used when interacting with clients; avoid social interactions, clichés, and saying too much; avoid changing subjects; avoid words like good, bad, right, wrong and nice; you should..; you’ll have to…; you can’t…; let’s…; if it were me, I would…; why don’t you…; I think you…; it’s the policy on this unit; don’t worry; everyone…; why…; just a second; I know…
Denial
Unconscious failure to acknowledge an event, thought, or feeling that is too painful for conscious awareness; woman diagnosed with cancer tells her family all the tests were negative
Displacement
The transference of feelings to another person or object; after being scolded by his supervisor at work, a man comes home and kicks the dog for barking
Identification
Attempt to be like someone or emulate the personality, traits, or behaviors of another person; a teenage boy dresses and behaves like his favorite singer
Intellectualization
Using reason to avoid emotional conflicts; the wide of a substance abuser describes in detail the dynamics of enabling behavior, yet continues to call her husbands workplace to report his Monday morning absence of illness
Introjection
Incorporation of values of qualities of an admired person or group into one’s own ego structure; a young man deals with a business client in the same fashion his father deals with business clients
Isolation
Separation of an unacceptable feeling, idea or impulse from one’s thought process; a nurse working in an ER is able to care for the seriously injured by isolating or separating her feelings and emotions related to the client’s pain, injuries and death
Passive-aggression
Indirectly expressing aggression toward others; a facade of overt compliance masks covert resentment; an employee arrives late to a meeting and disrupts others after being reminded of the meeting earlier that day and promising to be on time
Projection
Attributing ones own thoughts or impulses to another person; a student who has sexual feelings toward her teacher tells her friends the teaching is “coming on to her”
Rationalization
Offering acceptable, logical explanation to make unacceptable feelings and behavior acceptable’ a student who did not do well in a course says it was poorly taught and the course content was not important anyways
Reaction formation
Development of conscious attitudes and behaviors that are the opposite of what is really felt; a person who dislikes animals does volunteer work for the Humane society
Regression
Reverting to an earlier level of development when anxious or highly stressed; after moving to a new home, a 6 year old starts wetting the bed
Repression
The involuntary exclusion of a painful thought or memory from awareness; a young man whose mother died when he was 12 cannot tell you how old he was or the year she died
Sublimation
Substitution of an unacceptable feeling by a more socially acceptable one; a student who feels too small to play football becomes a champion marathon swimmer
Suppression
Intentional exclusion of feelings or ideas; when about to lose Tara, scarlet O’Hara says “ill think about it tomorrow”
Undoing
Communication or behavior done to negate a previously unacceptable act; a young man who used to hunt wild animals now chairs a committee for the protection of animals
Anxiety
Unexplained discomfort, tension, apprehension or uneasiness, which occurs when a person feels a threat to self; very subjective experience
Mild anxiety
Associated with daily life; motivates learning; produces increased levels of sensory awareness and alertness; thoughts that are logical; able to concentrate and problem solve
Moderate anxiety
Motivate learning; client to be attentive and able to focus and problem solve; dulls perceptions of sensory stimuli; client becomes hesitant; clients speech rate and volume to increase; client becomes wordy; client becomes restless; may be converted into physical symptoms, such as headaches, nausea and diarrhea
Severe anxiety
Fight-or-flight response; sensory stimuli input to be disorganized; cause perceptions to be distorted; impairs concentration and problem-solving ability; selective attention, focusing only on one detail; verbalization of emotional pain; tremors, increased motor activity
Panic
Perceptions are grossly distorted; unable to differentiate real from unreal; unable to concentrate or problem-solve; loss of rational, logical thinking; feel overwhelmed, helpless; loss of control, inability to function; elicit behavior that may be angry and aggressive or withdrawn, with clinging and crying; immediate intervention
Panic disorders and phobias
Discrete periods of intense fear or discomfort that are unexpected and may be incapacitating; characterized by an irrational fear of an external object, activity or situation; chronic condition that has exacerbations and remissions; transfers anxiety or fear from its source to a symbolic object, idea, or situation; fear is excessive and unrealistic but can’t help it
Nursing assessment of Panic disorders and phobias
Coping styles such as displacement, projection, repression, sublimation; autonomic hyperactivity; panic attacks that usually peak at 10 minutes but can past up to 30 minutes; disruption is personal life as well as work life; alcohol and drugs to decrease
Desensitization
The nursing intervention for phobia disorders; assist client to recognize the factors associated with feared stimuli that precipitate a phobic response; teach and practice with client alternative adaptive coping strategies such as use of thought and relaxation techniques; expose client progressively to feared stimuli, offering support with the nurse’s presence; provide positive reinforcement whenever a decrease in phobic reaction occur
Where there is reduced environmental stimuli
Where should the nurse place an anxious client?
Obsessive compulsive disorder
Anxiety associated with repetitive thoughts or irresistible impulses to perform an action; fear of losing control is a major symptom of this disorder
Nursing plans and interventions
Establish trust; listen, use a calm approach and direct, simple questions. Remain with client; do not leave alone; provide a safe envirorment; draw clients attention away from dreaded object or situation; alternative coping strategies and encourage use of such alternatives; substitution of positive thoughts for negative ones; desensitizing client; gradually and systemically introduce the client to the anxiety producing stimuli; pair the anxiety- producing stimuli with another response such as relaxation or exercise; sharing of fears and feelings with others; anti-anxiety medications; selective serotonin reuptake inhibitors; decrease intake of caffeine and nicotine
Nursing assessment for obsessive compulsive disorder
Coping styles such as repression, isolation, undoing; magical thinking; destructive, hostile, aggressive and delusional thought content; difficulty with interpersonal relationships; interference with normal activities; safety issues involves in repetitive performance of the ritualistic activity; recurring intrusive thoughts; recurring, repetitive behaviors that interfere with normal function
Nursing plans and interventions for obsessive compulsive disorder
Provide for client’s physical needs; allow performance of the compulsive activity with attention given to safety; meaning and purpose of the behavior with client; avoid punishing and criticizing; establish routine to avoid anxiety producing changes; learning alternative methods of dealing with stress; avoid reinforcing compulsive behavior; limit the amount of time for performance of ritual and encourage client to gradually decrease the tiem; anti-anxiety medications; SSRIs and tricyclic
At the completion of a performed ritual
Best time to talk to a patient who has obsessive compulsive disorder. The client’s anxiety is lowest at this time and is the optimal time for learning
Anxiety
Compulsive acts are used in response to this; help alleviate; interfering will only increase this; acknowledge the effects that ritualistic acts have on the client; demonstrate empathy; avoid being judgmental
Post-traumatic stress disorder
Severe anxiety, which results from a traumatic experience (war, earthquake, rape, incest)
Nursing assessment for post-traumatic stress disorder
Anxiety; level of proportional to the perceived degree of threat experienced by the client; manifested by symptomatic behaviors such as intrusive thoughts, flashbacks of experience, nightmares, and emotional detachment; response such as shock, anger, panic, denial; self-destructive behavior; visible reminders of trauma
Nursing plans and interventions for post traumatic stress disorder
Consistent, nonthreatening environment; suicidal and homicidal precautions; listen to client’s details of events to identify the most troubling aspect of events; develop objectivity in perceiving event and identify areas of no control; assist client to regain control by identifying past situations that have been handled successfully; anti-anxiety and antipsychotic medications to decrease anxiety, manage behavior and provide rest
Nursing plans and interventions for post traumatic stress disorder
Actively listen to client’s stories of experiences surrounding the traumatic event; assess suicide risk; assist client to develop objectivity about the event and problem solve regarding possible means of controlling anxiety related to the event; encourage group therapy with other clients who have experienced the same or related traumatic events
Benzodiazepines
Chlordiazepoxide HCL (lithium), diazepam (valium), prazepam (centrax), oxazepam (serax), alprazolam (xanx), clorazepate dipotassium (tranxene), lorazepam (ativan); indications: reduce anxiety; induce sedation, relax muscles, inhibit convulsions; safer than sedative hypnotics; reactions include sedation, drowsiness, ataxia, dizziness, irritability, blood dyscrasias, habituation and increased tolerance; administer at bed time to alleviate daytime sedation, greatest harm occurs when combined with CNS depressants and alcohol, avoid driving or working on equipment, gradually taper, short term drug
Bupirone (Buspar)
Indications: Do not exhibit muscle relaxant or anticonvulsant activity, not effective for management of substance abuse; reactions include dizziness. Several weeks for antianxiety effects to become apparent
Zolpidem (ambient)
Indicated for short-term treatment of insomnia; reactions include daytime drowsiness; give with food 1-1.5 hours before bedtime
Somatoform disorders
A group of disorders characterized by the expression of unexplained physical symptoms that have no physical basis; physical symptom is thought to be an unconscious expression of an internal conflict; occur more often in women and begin before 30 years of age; children may learn that physical complaints are an acceptable coping strategy and are rewarded by receiving attention for this behavior -secondary gain; may abuse analgesics without relief from pain or discomfort; accumulate prescription by doctor shopping to relieve physical symptoms
Somatization disorder
Somatic complaints for which frequent medical attention is sought but no medical pathology is present
Hypochondriasis
Belief in and fear of having a disease, including misinterpretation of physical signs as “proof” of the presence of the disease
Conversion disorder
Transferring a mental conflict into a physical symptom for which there is no organic cause
Nursing assessment for somatoform disorders
Preoccupation with pain or bodily function for at least 6 months’ duration; frequent doctor shopping; absence of emotional concern regarding the physical impairment; report excessive dysmenorrheal; VS may be elevated as in a panic attack; fear of having serious disease; excessive use of analgesics; rumination about physical symptoms; drug abuse; depression and presence of suicidal ideation; social or occupational impairment;
Nursing plans and interventions for somatoform disorders
Nonjudgmental attitude; record duration and intensity of pain with attention to factors that precipitate onset; expression of angry feelings; no one medication is particularly recommended; focus interactions and activities away from self and pain; help client identify connection between pain and anxiety; increase time and attention give to client as reward for not focusing on self or physical symptoms
What the nurse should do for somatoform disorders
The pain is real to the person experiencing it but it cannot be explained medically; result from internal conflict; acknowledge the symptom or complaint; reaffirm that diagnostic test results reveal no organic pathology; determine the secondary gains acquired by the client
La belle indifference
Describe the lack of concern over physical illness; conversion reactions
Primary gain
A decrease in anxiety resulting from the ability to deal with a stressful situation
Secondary gain
Rewards obtained from the sick role
Dissociative disorders
Alteration in the function of consciousness, personality, memory or identity; sudden and temporary or gradual and chronic; handle stressful situations by “splitting” from the situation fantasy
Psychogenic amnesia
A sudden temporary inability to recall extensive personal information; occurs after a traumatic event; most common dissociative disorder
Psychogenic fugue
Person suddenly leaves home or work with the inability to recall his or her identity; flight as well as loss of memory; rarely occurs; excessive use of alcoholic may contribute to this; dissociative disorder
Dissociative identity disorder
Presence of two ro more distinct personalities within an individual; personalities emerge during stress
Depersonalization
Characterized by a temporary loss of one’s reality and the ability to feel and express emotions; expresses a fear of going crazy; describes a sense of strangeness in the surrounding environment
Nursing assessment for dissociative disorders
Depression, mood swings, insomnia, potential for suicide; varying degrees of orientation; varying levels of anxiety; impairment of social and occupational functioning; alcohol or drug use
Nursing plans and interventions for dissociative disorders
Reduce environmental stimulation to decrease anxiety; stay with client during periods of depersonalization; acceptance of client’s behavior during various experiences and personalities; document emergence of different personalities; identify stressful situations; identify effective coping patterns used in other stressful situations; using new alternative coping methods
Dissociative disorders
Avoid giving the patients with this disorder too much information about the past; protect from pain; too much too soon can cause decompensation
Cluster A: paranoid personality disorder
Characterized by suspicious, strange behavior that may be precipitated by a stressful event; paranoid personality; schizoid personality; schizotypal personality
Paranoid personality disorder
Pervasive and long standing suspiciousness; mistrusts others, is suspicious, fearful; projects blame for own problems onto others; in touch with reality; verbally uses hospital, accusatory dialogue that is reality based; non-verbally appears suspicious, tense, distant, watchful and angry
Schizoid personality disorder
Socially detached, shy, introverted; avoids interpersonal relationships, lacks social skills; cold, quit, and aloof, has few friends; emotionally detatched, introverted, unresponsive and has autistic thinking; verbally say little, appears withdrawn and seclusive; nonverbally is dull, humorless and has little expression
Schizotypal personality disorder
Has interpersonal deficits; occentricities and off beliefs; socially isolated
Nursing assessment for cluster A: paranoid personality disorders
Determine degree of suspiciousness and mistrust of others; assess degree of anxiety; determine whether delusions are present such as reference or control, persecution, grandeur, somatic; assess degree of insecurity
Nursing plans and interventions for cluster A: paranoid personality disorders
Establish trust; be truthful and honest; identify situations that provoke anxiety and aggressive behaviors; avoid confrontation; help client to focus on the feelings that cause the delusions; assist in identifying thoughts, perceptions and own conclusions about reality; avoid talking and laughing where the client can see but not hear you; engage in noncompetitive activities that require concentration; involve the client in treatment plan
Cluster B: Dramatic, emotional personality disorders
Antisocial personality, borderline personality, histrionic personality and narcissistic personality
Antisocial personality disorder
Shows aggressive acting out behavior pattern without any remorse; clever and manipulative in order to meet own self centered needs; lacks social conscience and ability to feel remorse; is emotionally immature and impulsive; ineffective interpersonal skills that impair forming of close and lasting relationships; verbally is disparaging, humiliating, belligerent to threats; nonverbally is cold, callous, insensitive, socially gracious
Borderline personality disorder
Disturbances regarding self image and sexual, social and occupational roles; impulsive, self damaging behavior, makes suicidal gestures; other directed, overly dependent on others; unable to problem solve or learn from experience; view others as either all good or all bad; verbally is self critical, demanding, whiny, manipulative, and argumentative and can become verbally abusive; nonverbally has highly changeable and intense affect, impulsive behaviors
Histrionic personality disorder
Seeks attention by overreacting and exhibiting hyper excitable emotions; overly dramatic, seeks attention and tends to exaggerate; chaotic relationships, demonstrates angry outbursts and tantrums; verbally is loud, excitable, over reactive, attempts to draw attention o self; nonverbally is immature, self centered, dependent on attention and care from others, seductive and flirty
Narcissistic personality disorder
Perceives self as all powerful and important, is critical of others, arrogant; exaggerated feeling of self importance and self-love; needs attention and admiration; preoccupied with per ad appearance; exploits others; verbally talks about self incessantly and does whatever necessary to draw attention to self; nonverbally is inattentive and indifferent to others, appears concerned only with self
Cluster C: anxious, fearful personality disorders
Avoidant personality, dependent personality, obsessive-compulsive personality
Avoidant personality disorder
Socially inhibited; feels inadequate; hypersensitive to negative criticism, rejection; longs for relationships
Dependent personality disorder
Unreasonable wishes and wants and expresses needs in a demanding, whining manner while professing independence and denying dependent behavior; passive, without accepting responsibility for consequences of his or her own behavior; has low self-esteem, sees self as stupid, unable to make decisions; dependent on others to meet his or her needs; verbally is self depreciating, demanding in others to meet needs; nonverbally appears dull, uninterested in others, dissatisfied with self
Obsessive-compulsive personality disorder
Attempts to control self through the control of others or environment; shows inattention to new facts or different viewpoints; cold and rigid toward others; perfectionist, inflexible and stubborn; acts with blind conformity and obedience to rules; excessively neat and clean; preoccupied with work efficiency and productivity; verbally and nonverbally expresses disapproval of those whose behaviors and standards are different from own
Nursing assessment for cluster B: dramatic, emotional and cluster C: anxiety, fearful personality disorders
Assess degree of social impairment degree of manipulative behavior; assess degree of anxiety; determine the risk for self or other directed violence
Personality disorders
Long standing traits that are maladaptive responses to anxiety and cause difficulty in relating to and working w/ other individuals
Nursing plans and interventions for cluster B: dramatic, emotional and cluster C: anxiety, fearful personality disorders
Establish trust; protect client from injury to self and others; recognize manipulative behavior; focus on strengths and accomplishments; set limits on manipulative behaviors when necessary; reinforce independent, responsible behaviors; assist to recognize the need to respect the needs and rights of others; encourage socialization
Personality disorders
Persons with this are usually comfortable with their disorders and believe that they are right and the world is wrong; very little motivation to change; think of them as a challenge
Anorexia nervosa
Psychiatric disorder involves a voluntary refusal to eat and maintain minimal weight for height and age; a distorted body image and fear of becoming obese drives the excessive dieting and exercise; 15-20% of those diagnosed die; associated with parent child conflicts about dependency issues; bodies and weight are their only areas of control
Nursing assessment for Anorexia nervosa
Weight loss of at least 15% of ideal or original body weight; excessive exercise; apathy about physical condition and inordinate pleasure in weight loss; skeletal appearance; distorted body image; low self-esteem; hair loss and dry skin; irregular heart bear, decreased pulse and BP from decreased fluid volume; amenorrhea for at least 3 months; delayed psychosexual development or disinterest in sec; dehydration and electrolyte imbalance
Nursing plans and interventions for Anorexia nervosa
Monitor weight, VS, and electrolytes – esp. for K+, thyroid levels, Ca/phosphorus; structured supportive environment; time limit for eating; monitor food and fluid intake; be alert to client’s choosing low calorie foods; be alert to possible discarding of food though others, pockets, wastebaskets or drawers; monitor client after meals for possible vomiting; monitor activity level – prevent excessive exercise; positive reinforcement to build self esteem; behavior medication program; focus interactions away from food and eating; antidepressant mediations; family therapy; snacks between meals; monitor activity and assess for weakness, fatigue, and pathologic fractures; watch for water loading prior to weighing; safe environment
Bulima nervosa
Eating disorder characterized by eating excessive amounts of food followed by self-induced purging by vomiting misuse of laxatives, diuretics or other medications, fasting and/or excessive exercise; usually reports loss of control while binge eating
Nursing assessment for Bulima nervosa
Diarrhea or constipation, abdominal pain and bloating; dental damage; sore throat and chronic inflammation of esophageal lining with possible ulceration; financial stressors r/t food budget; concerns with body shape and weight – usually not underweight
Nursing plans and interventions
Monitor weight, VS, and electrolytes; structured supportive environment; time limit for eating; monitor food and fluid intake; express feelings of anger encouragement; positive reinforcement to build self esteem; discuss strategies to stop vomiting; antidepressant medications;
Syrup of ipecac
Used to induce vomiting; if not vomited and is absorbed, cardiotoxicity may occur and can cause conduction disturbances, cardiac dysrhythmias, fetal myocarditis and circulatory failure; assess for edema and listen to breath sounds
Physical assessment and nutritional support
Priority when caring for a client with bulimia; increase self-esteem and develop a positive body image. Behavior modification. Family therapy is most effective because issues of control are common in these disorders
Depressive disorders
Pathologic grief reactions ranging from mild to severe states
Mild depression
Feelings of sadness; difficulty concentrating and performing usual activities; difficult maintaining usual activity level
Moderate depression
Feelings of helplessness and powerlessness; decreased energy; sleep pattern disturbances; appetite and weight changes; slowed speech, thought and movement; rumination on negative feelings
Severe depression
Feelings of hopelessness, worthlessness, guilt, shame; despair; flat affect; indecisiveness; lack of motivation; change in physical appearance; suicidal thoughts; possible delusions and hallucination; sleep and appetite disturbance; loss of interest in sex; constipation
Depressed mood with a loss of interest in the pleasures in life
The most important S&S of depression other changes include a change in appetite accompanied by a change in weight; insomnia and hypersomnia; fatigue or lack of energy; feelings of hopelessness, worthlessness, guilt or over responsibility; loss of ability to concentrate or think clearly; preoccupation with death or suicide
Exogenous depression
Caused by a reaction to the environmental or external factors
Endogenous depression
Caused by an internal biologic deficiency ; biogenic amines at receptor sites in the brain
Nursing assessment for depression
Determine exogenous/endogenous; degree of depression; current suicide risk; arrange for lab tests such as dexamethasone suppression test and biogenic amines test
Biogenic amines
A decreased serotonin is indicative of depression; a decreased norepinephrine level is also indicative of depression
Dexamethasone suppression test
Indirect marker of depression; considered positive if post-DST cortical level is greater than 5mg/dl
Nursing plans and interventions for patient with depression
Suicide precautions; monitor sleep, nutrition and elimination patterns; assist with ADLs; initiate interaction with client; participation in activities; sudden elevation in mode may indicate suicide; identifying a support system; discussion of feelings of helplessness, hopelessness, loneliness, and anger; silence if client is non-talkative; spend time with client and return when promised
Depressed clients
Have difficulty hearing and accepting compliments because of their lowered self concept; comment on signs of improvement by noting behavior
Depressed patient is improving
When they begin to take an interest in their appearance or begin to perform self-care activities that were previously of little or no interest to them
Major warning signs of impending suicide attempt
Begins giving away possessions; previously depressed client becomes happy
Antianxiety drug side effects
Sedation and drowsiness
Antidepressant drug side effects
Anticholinergic effects, postural hypotension
MAO inhibitor side effects
Hypertensive crisis; need dietary restrictions to prevent this
Lithium
Drug that requires renal function assessment and monitoring
Phenothiazines
Drugs that cause extrapyramidal effects; tardive dyskinesia can be permanent if client is not assessed regularly for signs of this; cause photosensitivity
Tricyclic antidepressant drugs
Amitriptyline HCL (elavil), desorpramine HCL (norpramin), imipramine HCL (tofranil), nortiptyline HCL (aventyl), protiptyline HCL (Vivactil), maprotiline (ludiomil); indicated for depression clients with morbid fantasies don’t respond to these dugs; adverse reactions: anticholinergic effects; CNS effects such as sedation, poor concentration; cardiovascular effects such as orthostatic hypotension, quindine like effect on the heart, tachycardia; administer at bedtime, 2-3 weeks to achieve effects; 1-2 weeks should elapse between discontinusing this and initiating MAO inhibitors; avoid alcohol; avoid concurrent use of antihypertensive drugs; evaluate suicide risk
MAO inhibitors
Isocarboxazid (marplan), phenelzine sulfate (nardil), tranycypromine sulfate (parnate); indicated for depression, phobias and anxiety; adverse reactions include tachycardia, urinary hesitancy, constipation, impotence, dizziness, insomnia, muscle twitching, drowsiness, dry mouth, fluid retention, hypertensive crises; must not be used with tricyclics; dietary restrictions include restriction of high tyramine content such as aged cheese, red wine, beer, beef and chicken, liver, yeast, yogurt, soy sauce, chocolate, bananas; not to take over the counter drugs;
selective serotonic reuptake inhibitors
Fluxetine HCL (Prozac), paroxetine (paxil), sertraline (zoloft), fluvoxamine (luvox), citalopram (celexa), escitalopram (lexapro); indicated for depression, anxiety, panic disorder, aggression, anorexia nervosa, OCD; adverse reactions:drowsiness, dizziness, light-headedness, insomnia, headache, depressed appetite, serotonin syndrome, sexual dysfunction, allergic reaction or rash; effective 2-4 weeks after initiation; should not be used with MAO inhibitors; wait 14 days between discontinuing MAO and starting Prozac; at least 5 weeks should lapse between discontinuing Prozac and initiating MAO inhibitors; give in evening if sedation occurs; monitor for serotonin syndrome; caution about st johns wort
Serotonin syndrome
Rapid onset of altered mental states, agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia, diarrhea
Atypical antidepressant drugs
Trazodone (Desyrel), Mitrazapine (remeron), Bupropion (wellbutrin); indicated for depression trazodone = insomnia, dementia with agitation; adverse reactions: safer than tricyclics and MAO inhibitors in terms of side effects; effective 2-4 weeks after initiation
Serotonion/norepinephrine reuptake inhibitors
Duloxetine (Cymbalta), venlafaxine (effexor); indicated for depression, anxiety, panic disorder, anorexia, aggression, OCD; adverse reactions include nausea, dry mouth, insomnia, headache, fatigue, depressed appetite, increasing sweating, sexual dysfunction, withdrawal symptoms with abrupt cessation; should not be used with MAO inhibitors; wait at least 14 days between MAO inhibitor and starting this; baseline BP and monitor periodically; monitor for worsening of pretreatment symptoms
Bipolar disorder or manic depressive illness
Affective disorder that is manifested by mood swings involves euphoria, grandisotiy, and an inflated sense of self-worth. May or may not include sudden swings to depression; atleast one episode of major depression. May cycle between elevation to depression, with periods of normal activity in between
Mild bipolar disorder
Feeling of being on a high; feelings of well being; minor alterations in habits; usually doesn’t seek treatment because of pleasurable effect
Moderate bipolar disorder
Gradiosity, talkativeness, pressured speech, impulsiveness, excessive spending, bizarre dress and grooming
Severe bipolar disorder
Extreme hyperactivity, flight of ideas, nonstop activity, sexual acting out, explicit language, talkativeness, over responsiveness to external stimuli, easily distracted, agitation and possible explosiveness, severe sleep disturbance, delusions of grandeur or persecution
Nursing assessment for bipolar disorder
Determine level of depression, level of mania; assess nutrition and hydration status; assess level of fatigue; assess danger to self and others in relation to level of impulse impairment present
Nursing plans and interventions for bipolar disorder
Maintain client’s physical health; provide nutrition, rest, and hygiene; provide a safe environment; decrease stimulation; private room; consistent approach to minimize manipulative behavior; frequent, brief contacts to decrease anxiety; avoid giving attention to bizarre behavior; meet needs as soon as possible to keep client from becoming aggressive; small, frequent feedings of food that can be carried; simple, active, noncompetitive activities; avoid distracting or stimulating activities; self-control, acceptable behavior; administer lithium, sedatives and antipsychotics
Lithium carbonate (carbolith)
Indicated for bipolar disorders, especially manic phase; adverse reactions include nausea, fatigue, thirst, polyuria, fine hand tremors, weight gain, hypothyroidism; excreted by kidney, maintain levels 0.5-1.5; assess electrolytes esp. sodium, baseline studies of renal, cardiac and thyroid; keep salt usage consistent; use with diuretics is contraindicated
Valporic acid (depakene)
Used in bipolar disorder alone or with lithium; adverse reactions include NV, anorexia, hepatotoxicity, tremor, sedation, headache, dizziness; administer with food, monitor blood levels (should be between 50-125)
Lithium toxicity
Diarrhea, vomiting, drowsiness, muscle weakness, lack of coordination
Carbamezepine (tegretol)
Used in bipolar disorders and as an alternative to lithium; adverse reactions include dizziness, ataxia, blood dyscrasias; serum levels between 8-12; stop if WBC < 3000 or neutrophil count < 1500; monitor hepatic and renal function
Lamotrigine (lamictal)
Used in biopolar disorder alone or with other mood stabilizers; adverse reactions include headache, dizziness, double vision, rash; give low doses initially then gradually include to 200mg/day
Atypical antipsychotic drugs that are also indicated for mania
Risperidone, olanzapine, quetiapine, aripiprazole and ziprasidone
Schizophrenia
A psychiatric disorder characterized by thought disturbance, altered affect, withdrawal from reality, regressive behavior, difficulty with communication, and impaired interpersonal relationships
Catatonic
Stupor or mutism; rigidity (maintenance of a posture against efforts to be moved); posturing negativism; excitement; potential for violence of self or others during stupor or excitement
Disorganized
Incoherence; flat or inappropriate affect, disorganized, uninhibited behavior; unusual mannerisms; socially withdrawn; no delusions
Paranoid
Systematized delusions, hallucinations related to a single theme; ideas of reference; potential for violence if delusions are acted upon
Residual
Socially withdrawn; inappropriate affect; eccentric or peculiar behavior; absence of prominent delusions and hallucinations; no current psychotic behavior
Undifferentiated
Prominent delusions and hallucinations; incoherence and grossly disorganized behaviors; failure to meet any of the criteria for other types
Nursing assessment for schizophrenia
Assess disturbance of through processes; interpret content of internal and external stimuli: symbolism, delusions, ideas of reference; note form: construction of verbal communication: looseness of association, tangentital or circumstantial speech, echolalia, neologism, preservation, word salad; note process: flow of thoughts: blocking, concrete thinking; assess for disturbance in perception: hallucinations, illusions, depersonalization, delusions; assess for disturbances in affect: blunted or flat, inappropriate, incongruent with context of situation or event; assess for disturbance in behavior: incoherent and disorganized, impulsive, uninhibited, posturing, unusual mannerisms, social withdrawal, neglect of personal hygiene, exhibiting echopraxia; assess for disturbance of interpersonal relationships: difficulty establishing trust, difficulty with intimacy, fear and ambivalence toward others
Symbolism
Meaning given to words by client to screen thoughts and feelings that would be difficult to handle if stated directly
Delusions
Fixed false beliefs that may be persecutory, grandose, religious, or somatic in nature
Ideas of reference
Belief that conversations or actions of others have reference to the client
Looseness of association
Lack of clear connection from one thought to the next
Tangential or circumstantial speech
Failing to address the orginal point, giving many nonessential details
Echolalia
Constantly repeating what is heard
Neologism
Creating new words
Preservation
Repeating the same word or phrase in response to different questions
Word-salad
Speaking a jumbled mixture of real and made-up words
Blocking
Gap or interruption in speech due to absent thoughts
Concrete thinking
Thinking based on fast vs. abstract and intellectual points
Hallucinations
False sensory perception, usually auditory or visual
Illusions
Misinterpretation of external environment
Depersonalization
Perceives self as alienated or detached from real body
Nursing plans and interventions for schizophrenia
Establish trust; sit with mute clients; safe and secure environment; assist with physical hygiene and ADLs’ use matter of fact non-judgmental approach; use clear, simple,,, concrete terms when talking with client; accept and support client’s feelings; reinforce congruent thinking. Stress reality; avoid arguing and avoid agreeing with inaccurate communications; set limits; avoid stressful situations; structure time for activities as to limit time for withdrawal; identify positive characteristics related to self; socially acceptable behavior; avoid fostering a dependent relationship; promote family involvement
Important characteristics of schizophrenia
Autism (preoccupied with self), affect is flat, associations, ambivalence
Delusional disorder
Characterized by suspicious, strange behavior, which may be precipitated by a stressful event
Nursing assessment for delusional disorder
Determine degree of suspicious and mistrust; degree of anxiety; determine if delusions are present, reference or control, persecution, grandeur, somatic; determine degree of insecurity
Client is delusional
Recognition of distorted reality; divert focus from delusional thought to reality, do not permit rumination on false ideas; do not agree with or support delusions; avoid arguing about it; be matter of fact; avoid physically touching client, especially if delusions are persecutioal; administer antipsychotic drugs; monitor and treat side effects of psychotropic drugs; administer antiparkinsonian drugs
Client is hallucinating
Protect client from injury that might result from responding to commands of the voices; pay attention to the content; avoid denying or arguing with client about it; discuss observations with client; make frequent but brief remarks to interrupt; administer antipsychotic drugs; administer antiparkinsonian drugs
Fluphenazine HCL (Proloxin)
Indicated to control psychotic behavior; useful in treatment of psychomotor agitation associated with thought disorders; reactions: drowsiness, orthostatic hypotension, weight fain, anticholingeric effects, extrapyramidal effects, photosensitivity, blood dyscrasias: granulocytosis, leucopenia, neuroleptic malignant syndrome; absorbed slowly; use with noncompliant clients because it can be administered IM once q14day
Phenothiazines
Chloripromazine HCL (thorzine), trifluperazine HCL (stelazine), thioridazine HCL (Mellaril), perphenazine (trilafon), triflupromazine (Vesprin), loxapine (loxitane), molidone (moban), fluphenazine HCL (prolixin); indicated to control psychotic behavior such as hallucinations, delusions and bizarre behavior; adverse reactions: drowsiness, orthostatic hypotension, weight fain, anticholingeric effects, extrapyramidal effects, photosensitivity, blood dyscrasias: granulocytosis, leucopenia, neuroleptic malignant syndrome; extrapyramidal effects are a major concern, monitor elderly, 2-3 weeks to achieve effects, keep client supine for 1hr after administration and advice to change positions slowly, avoid alcohol sedatives and antacids
Nonphenothiazines
Holoperidol (haldol), chlorprothizene (taractan), thiothixene HCL (navene), primodide (orap); indicated to control psychotic bejhavior, less sedative than penothiazines; adverse reactions include severe extrapyramidal reactions, leukocytosis, blurred vision, dry mouth, urinary retention; teach to avoid alcohol; orap is used only for touretts syndrome
Long acting Nonphenothiazines
Fluphenazine decanoate (prolixin decanoate), haloperidol decanoate (haldol decanoate); indicated for clients who require supervision with medications regimes; proloxin can be given q7-28days; haldol can be given q4weeks; several months to reach steady state drug levels
Atypical antiphsychotic drugs
Riperidone (risperdal), olanzapine (zyprexa), Questiapine (seroquel), aripiprazole (ability), ziprasidone (geodon), clozapine (clozaril), aripiprazole (abilify); indicated to treat positive and negative symptoms of schizophrenia without significant EPS, in clients who haven’t responded well to typical antiphychotics or have side effects to typical antiphychotics; monitor WBC weekelyx6month then biweekly; baseline VS, EEG; monitor for symptoms of NMS and EPS, teach to change positions slowly
Risperdal
Neuroleptic malignant syndrome, RPS, dizziness, nausea, constipation, anxiety
Zyprexa
Drowsiness, dizziness, weight gain, EPS, agitation
Seroquel
Drowsiness, dizziness, headache, EPS, anticholinergic effects
Clozaril
Agranulocytosis, drowsiness, dizziness, GI symptoms, NMS
Blood dyscrasias
Agranulocytosis in first weeks, thrombocytopenia (decreased platelets); characterized by sore throat, fever, chills, bruises easily, petechia; protect from infections; comfort measures; safety measures
Extrapyramidal effects: parkinsonism
Within 1-4 weeks after initiation of treatment; rigidity, shuffling gait, pill rolling hand movements, tremors, dyskinesia, mask like face; administer anticholingergic drugs cogentin, artane, Benadryl, symmetrel. Ativan, klonopin, inderal. Vitamin E
Extrapyramidal effects: akathisia
Occurs within 1-6 weeks after initiation of treatment; restlessness, agitation and pacing. Sudden difficulty sitting still; rule out anxiety
Extrapyramidal effects: dystonia
Occurs within 1-2 days after initiation of treatment; limb and neck spasms, uncoordinated, jerky movements; difficulty speaking and swallowing, rigidity and muscle spasms; emergency treatment is with IM anticholinergic drugs. Have respiratory emergency equipment
Extrapyramidal effects: tardive dyskinesia
Develops late in treatment; involuntary tongue and lip movements, blinking, choreiform movements of limbs and trunk; permanent side effect; drugs are of no help in decreasing symptoms; teach client and family to report side effects early
Photosensitivity
Sunlight: exposed skin turns blue and color changes occur in eyes, but does not cause vision impairment; teach client to stay out of sun, wear protective clothing and sunglasses; skin discoloration will disappear within 6 months after drug is stopped
Neuroleptic malignant syndrome
Life threatening emergency: high fever, tachycardia, stupor, increased RR, severe muscle rigidity; increased risk with phenothiazines; early recognition is important; transfer to medical facility for hydration, nutritional support, and treatment of respiratory failure and renal failure
Serotonin syndrome
Confusion, disorientation, autonomic dysfunction; notify health care provider STAT; support system
Anticholinergic effects
Dry mouth, blurred vision, tachycardia, nasal congestion, constipation, urinary retention, orthostatic hypotension; encourage sips of water, chewing sugarless gum or hard candy; increase fiber; change positions slowly; report urinary retention; tolerance to side effects will occur
Antiparkinsonian drugs
Trihexyphenidyl HCL (artane), benztropine mesylate (cogentin), amantadine (symmetrel); indicated for action on the extrapyramidal system to reduce disturbing symptoms; adverse reactions include anticholinergic effects, drowsiness, headaches, urinary hesitancy, memory impairment; given in conjunction with antipsychotic drugs
Alcohol withdrawal symptoms
Shortly after drinking stops, 4-6 hours; anxiety, nausea, insomnia, tremors, hyper alertness, and restlessness
Delirium tremens
Appear 12-36 hours after last drink; tachycardia, tachypnea, diaphoresis, marked tremors, hallucinations, paranoia
Disulfiram (antabuse)
Treatment of alcoholism; aversion therapy; interferes with the breakdown of alcohol causes accumulation of acetaldyhyde ; severe side effects occur if alcohol is consumed: NV, hypotension, headaches, rapid HR and RR, flushed face and blood shot eyes, confusion, chest pain, weakness, dizziness; persons with serious heart disease, diabetes, epilepsy, liver impairment or mental status should not take this
Librium and ativan
Commonly used in alcohol withdrawal patients
Opiates
Heroin, morphine, meperidine, codeine, opium, methadone, cocaine, amphetamines, hallucinogenic
Side effects to opiates
Heroin, morphine, meperidine, codeine, opium, methadone; withdrawal: watery eyes, runny nose, dilated pupils, anxiety, diaphoresis, fever, NVD, achiness, abdominal cramps, insomnia, tachycardia; overdose: respiratory depression leading to respiratory arrest, circulatory depression leading to cardiac arrest, unconsciousness leading to coma, death. Effect is general physical and mental deterioration, rapid tolerance and impaired judgment
Cocaine
Withdrawal: depression, fatigue, disturbed sleep, anxiety, psychomotor agitation; overdose: tachycardia, pupillary dilatation, increased BP, cardiac arrhythmias, perspiration, chills, NV; effect: psychological dependence and occurs within hours or day
Amphetamines
Withdrawal: Depression, fatigue, disturbed sleep; overdose: restlessness, tremors, rapid respiration, confusion, assaultive behavior, hallucinations, panic; effect is paranoid delusions
Hallucinogenic
No withdrawal symptoms; overdose: panic and psychosis; effects: withdrawal occurs with abrupt cessation, temporary psychosis
Harm reduction
Common community health strategy designed to reduce the harm of substance abuse to family, individuals, community and society
Denial and rationalization
Most common defense mechanisms used by chemically dependent clients; use must be confronted so the clients accountability for own behavior can develop
Nutrition
Priority in substance abusers. Alcohol and drugs have superseded the intake of food
Organic disorders
Abnormal psychological or behavioral signs and symptoms that occur as a result of cerebral disease, systemic dysfunction, or use of or exposure to exogenous substances
Delirium
Acute process that if treated is usually reversible. Recognized by sudden onset; occurs in response to specific stressor such as infection, drug reaction, substance intoxication or withdrawal, electrolyte imbalance, head trauma, sleep deprivation; treatment is the correction of the causative disorder
Dementia
Cognitive impairments characterized by gradual, progressive onset; irreversible. Judgment, memory, abstract thinking, and social behavior are affected. Most commonly seen in Alzheimer disease and multiinfarctions; also occurs in huntinton disease, Parkinson disease, MS and brain tumors, wernicke korsakoff syndrome
Nursing assessment for organic disorders
Limited attention span, confusion and disorientation, impaired judgment; delusions, visual hallucinations or sensory illusions, labile affect, sudden anger, anxiety and depression, loss of recent and remote memory, confabulation, impaired coordination, increased psychomotor activity, slurring speech, decreased personal hygiene, sleep deprivation, day-night pattern reversal. Incontinence and constipation
Nursing plans and interventions for organic disorders
Safe, consistent environment; health, nutrition, safety, hygiene, and rest; ADLs; support routine in daily activities; mark the bathroom; reorient; simple, direct statements
Confusion
In the elderly is often accepted as being part of growing old. May be due to dehydration with resulting electrolyte balance. “sudden change” when obtaining history
Confabulation
Making up responses, stories to fill in lost memory; not lying. Used by client to decrease anxiety and protect the ego
Confused elderly nursing interventions
Maintaining health and safety; encouraiing self care; reinforcing reality orientation; consistent, safe environment; engaging client in simple tasks and activities to build self esteem
Consistent caregiver
Priority in planning nursing care for the confused older client; change increases anxiety and confusion
Acetyl cholinesterase inhibitors
Tacrine HCL (cognex), donepezil (Aricept), rivastigmine (Exelon), galantamine (reminyl), extended release (concerta) amphetamine mixture (adderall); Alzheimer medications; adverse reactions: ND; cognex: considerable GI distress and elevated liver enzymes; should not take anticholinergic medications; should not be used in severe liver impairment; take with meals; do not stop abruptly
Conduct disorders
Antisocial behavior characterized by violation of laws, societal norms and basic rights of others without feelings of remorse or guilt
Oppositional defiant disorder
Characterized by behavior that fails to adhere to established norms, but doesn’t violate the rights of others
Nursing assessment for conduct disorder
Physical fighting, running away from home, lying, stealing, cruelty to animals, frequent truancy, vandalism, arson, use of alcohol or drugs
Nursing assessment for oppositional defiant disorder
Argumentativeness, blaming others for own problems, defying rules and authority, using obscene language, acting resentful, vindictive
Childhood depression
Child with headaches, stomachaches and other somatic complaints
ID
Functions on the basic instinct level and strives to meet immediate needs
Ego
In touch with external reality and is part of the personality that makes decisions
Stimulants
Dextroamphetamine sulfate (Dexedrine), methylphenidate HCL (Ritalin), pemoline (cylert); indicated for treatment of ADD/ADHD; methylphenidate is also used to treat narcolepsy; adverse reactions: interact with MAO inhibitors producing fever and hypertensive crisis, nervousness, insomnia, dizziness, tourette syndrome, tachycardia, palpations, angina, dysrhythmias, anorexia, weight loss, nausea and abdominal pain; short acting 2-4 hours; take last does at least 6 hours before bed time; 1-3 doses/day; with or after meals to avoid appetite suppression; monitor HR, rhythm and BP; monitor height and weight to detect growth suppression
12-18
HGB in adults
<11
HGB in pregnant women
14-24
HGB for newborn
12-20
HGB for 0-2 weeks
10-17
HGB for 2-6 months
9.5-14
HGB for 6mo-1yr
37-52
HCT for adults
33
HCT for pregnant women
4.2-6.1 million/mm3
RBC count for adults
5 000-10 000
WBC count in adults
9 000-30 000
WBC count for newborn
150 000-400 000
Platelet count in adults
Male: up to 15; female up to 20
ESR/SED rate mm/hr in adults
11-12.5 second
Prothrombin time
60-70 seconds
Partial thromboplastin time
30-40 seconds
Activated partial thromboplastin time
30-120 IU/I
Alkaline phosphatase for adults
3.5-5g/dl
Albumin levels for adults
0.3-1mg/dl
Bilirubin total for adult
1-12mg/dl
Bilirubin total for newborn
9-10.5mg/dl
Calcium levels in adults
98-106mEq/l
Chloride levels in adults
<200mg/dl
Cholesterol levels in adults
Male: 55-150; female: 30-135
Creatine phosphokinase for adults
0.5-1.2mg/dl
Creatinine for adults
70-110mg/dl
Glucose levels for adults
21-28mEq/l
HCO3 in adults
60-180mcg/dl
Iron in adults
250-460mcg/dl
Total iron binding capacity in adults
100-190 IU/l
Lactic dehydrogenase in adults
3.5-5mEq/l
Potassium levels for adults
6.4-8.3 g/dl
Protein total for adults
0-35 IU/l
Aspartate amino transferase levels in adults (AST/SGOT)
4-36IU/ml
Alanine amino transferase in adults (ALT/SGPT)
136-145 mEq/l
Sodium levels in adults
35-160 mg/dl
Triglyceride levels in adults
10-20mg/dl
Urea nitrogen in adults
Foods high in vitamin A
Liver, egg yolks, fortified margarine and butter; dark green and deep orange fruits and vegetables (apricots, broccoli, cantaloupe, carrots, pumpkin, winter squash, sweet potatoes, and spinach)
Foods high in vitamin D
Fortified and full fat dairy products; fish oil; synthesized in skin when exposed to sunlight
Foods high in vitamin E
Vegetable oils and their products such as salad oils, margarine, nuts, seeds, avocado, and mango
Foods high in vitamin K
Green leafy vegetables such as lettuce, cabbage, spinach, peas, asparagus, meat, milk, and soybean oil
Foods high in sodium
Canned vegetables, carrots, tomatoes, tomato catsup, tomato juice, bouillon cubes, mustard, pickled olives, pickles, cucumber, dill, salad dressing, soy sauce, bacon, cheeses, ready to eat breakfast cereals, peanut butter, soups, corned beef
Foods high in vitamin C
Citrus fruits, cantaloupes, strawberries, tomatoes, potatoes, broccoli, green peppers and spinach
Foods high in vitamin B1
Pork, beef, liver, while grains, legumes, and wheat germ
Foods high in vitamin B2
Liver, milk, milk products, soybeans, and enriched cereals
Foods high in vitamin B3
Meat, poultry, fish, peanuts, and enriched grains
Foods high in vitamin B6
Meat, poultry, grains, seeds and seafood
Foods high in folic acid
Liver, beans, peas, spinach, yeast
Foods high in vitamin B12
Shell fish, liver, fish and lean meat
Foods high in calcium
Milk, cheese, dark green vegetables, dried figs, sot, legumes
Foods high in phosphorus
Milk, liver, legumes, fish, soy
Foods high in magnesium
Whole grains, green leafy vegetables, tea, nuts and fruit
Foods high in iron
Meats, eggs, legumes, whole grains, green leafy vegetables and dried fruits
Foods high in iodine
Marine fish, shellfish, dairy products, iodized salt, some breads
Foods high in potassium
Citrus fruits and dried fruits, bananas, watermelon, potatoes, legumes, tea and peanut butter
Foods high in zinc
Meats, seafood, whole grains
Thiazide diuretics
Chlorthalidone (hygroton), hydrochlororthiazide (esidrix, microzide), indapamide (lozol), metolazone (zaroxolyn); indicated for decreased fluid volume, inexpensive, effective, useful in severe hypertension, effective orally, enhances other antihypertensives; adverse reactions: hypokalemia symptoms, hyperuricemia, glucose tolerance, hypercholesterolemia, sexual dysfunction; observe for postural hypotension, caution with renal failure gout and client taking lithium; hypokalemia increases risk for digitalis toxicity, administer postassium supplements
Hypokalemia symptoms
Dry mouth, thirst, weakness, drowsiness, muscle aches, tachycardia
Loop diuretics
Furosemide (lasix), torsemide (demadex), bumetanide (bumex); indicated for rapid action, potent for use when thiazides fail, cause volume depletion; adverse reactions: hypokalemia, hyperuricemia, glucose intolerance, hypercholesterolemia, hypertriglyceridemia, sexual dysfunction, weakness; volume depletion and electrolyte depletion are rapid; all nursing implications cited for thiazides
Potassium sparing diuretics
Spironolactone (aldactone), amiloride (midamor); volume depletion without significant potassium loss; adverse reactions: hyperkalemia, gynecomastia, sexual dysfunction; watch for hyperkalemia and renal failure in those treated with ACE inhibitors or NSAIDS; increase in serum lithium levels; give after meals to decrease GI distress
Combination loops and potassium sparing diuretics
HCTZ and Triamterene (maxidex), HCTZ + amiloride (moduretic), HCTZ + spinorolactone (aldactazide); decreases fluid volume while minimizing K+ loss; side effects of individual drugs offset or minimized by its partner;no to overdo K+ foods because of K+ sparing component in new drug; follow scheduling doses to avoid sleep disruptions
Combined alpha beta blockers
Labetalol (normodyne), carvedilol (coreg); produces decrease in BP without reflex tachycardia or bradycardia; adverse reactions: HF, ventricular dysrhythmias, blood dyscrasias, bronchospasm, orthostatic hypotension; contraindicated with HF, COPD, block
Calcium channel blockers
Diltiazem (cardizem), nifedipine (procardia, adalat), verapamil HCL (calan, isoptin), nisoldipine (sular); inhibits calcium ion influx during cardiac depolarization; decreased SA/AV node conduction; adverse reactions: headache, hypotension, dizziness, edema, nausea, constipation, tachycardia, HF, dry cough; avoid grapefruit juice
Alpha-adrenergic blockers
Prazosin HCL (minipress), terazosin (hytrin), phentolamine mesylate (regitine), doxazosin (Cardura); peripheral vasodilator which acts directly on the blood vessels, used in extreme hypertension of pheochromocytoma; adverse reactions: orthostatic hypotension, weakness, palpitations; use cautiously in elderly; occasional VD
Beta blockers
Metoprolol tartrate (lopressor), nadolol (corgard), propranolol HCL (inderal), timolol maleate (blocadren), atenolo (tenormin), bisoprolol (zebeta), metropolol (lopressor, tropol); blocks the sympathetic nervous system esp. to the heart, produces a slower HR, lowers BP, reduces O2 consumption during myocardial contraction; adverse reactions: bradycarida, fatigue, insomnia, bizarre dreams, sexual dysfunction, hypertriglyceridemia, decreased HDL, depression; apical or radial pulse daily, monitor GI distress, don’t stop abruptly, don’t vary time taken, may mask symptoms of hypoglycemia or may prolong hypoglycemic reaction
Central acting inhibitors
Clonidine (catapres), guanabenz acetate (wytensin), methyldopa (aldomet); decrease BP y stimulating central alpha receptors, resulting in decreased sympathetic outflow from the brain; adverse reactions: drowsiness, dry mouth, fatigue, sexual dysfunction; watch for rebound hypertension if stopped abruptly; make position changes slowly, avoid standing still and taking hot baths and shower
Vasodilators
Hydralazine HCL (apresoline), Minoxidil (loniten); decreased BP by decreasing peripheral resistance; adverse reactions: headache, tachycardia, fluid retention (HF, pulmonary edema), postural hypotension; monitor BP and HR routinely, peripheral edema, I&O, weigh daily
Angiotensin II receptor antagonists
Losartan (Cozaar), Valsartan (diovan), irbesartan (avapro); blocks the vasoconstrictor and aldosternone-producing effects of angiotensin II at various sites; adverse reactions: hypotension, fatigue, hepatitis, renal failure, hyperkalemia; monitor liver enzymes and electrolytes, monitor angrioedema in those with history of it when on ACE inhibitors previously
Angiotensin-Converting Enzyme inhibitors
Captopril (capoten), enalapril maleate (vasotec), lisinopril (zestril), ramipril (altace), benazepril (lotensin), quinapril (accupril); decreases BP by suppressing rennin-angiotensin aldosterone system and inhibiting conversion of angiotensin I into angiotensin II; useful with diabetics; adverse reactions: proteinuria, neutropenia, skin rash, cough; observe for acute renal failure tests, remain in bed 3 hours after first dose
Heparin sodium
Administered parenterally as an antagonist to thrombin and to prevent the conversion of fibrinogen to fibrin; adverse reactions; hemorrhage, agranulocytosis, leucopenia, hepatitis; assess PTT, HGB, HCT, platelets; assess stools for occult blood; avoid IM injection; antagonist protamine sulfate
Warfarin sodium
(Coumadin, coumain, panwarfin); blocks the formation of prothrombin from vitamin K; adverse reactions: hemorrhage, agranulocytosis, leucopenia, hepatitis; given orall, assess PTT, avoid sudden change in intake of foods high in vitamin K; antagonist: vitamin K
Antiplatelet agents
Ticlopidine (ticlid), dipyridamole (persantine), clopidogrel (plavix); short-term use after cardiac interventions, reduces the risk for thrombolytic stroke for those intolerant to aspirin, and prevention of thrombolytic disorders; adverse reactions: neutopenia, thrombocytopenia, agranulocytosis, leucopenia, hemorrhage, GI irritation, bleeding, pancytopenia; give PC or with food; don’t take antacids w/in 2 hours; CBCq2weeks;
Low molecular weight heparin enoxaparin (lovenox)
Prevention of thrombolytic formation (deep vein); hemorrhage, GI irritation, bleeding, thrombocytopenia; signs of bleeding, give SUBCU, monitor CBC, soft toothbrush
Propranolol HCL (Inderal)
supraventricular and ventricular tachydysrhythmias; adverse reactions: hypotension, bradycardia, bronchospasm; monitor VS, contraindicated in asthma and COPD
Verpamil HCL (isoptin, calan)
Supraventricular dysrhythmias; adverse reactions: hypotension, bradycardia, constipation; monitor BP and HR; change positions slowly
Atropine sulfate (atropisol)
Used to treat bradycaria; adverse reactions: chest pain, urinary retention, dry mouth; monitor HR and rhythm, assess for chest pain, assess for urinary retention, avoid use with glaucoma
Digoxin (lanoxin) and digitoxin (crystodigin)
Indicated for supreventricular dysrhythemias and atrial fibrillation; adverse reactions: bradycardia, dysrhythmias, anorexia, NVD, visual disturbances; monitor HR and rhythm, report signs of toxicity, hypokalemia increases the risk for toxicity, causes hypercalecmia
Epinephrine (adrenaline)
Indicated for cardiac arrest; adverse reactions: tachycardia and hypertension; impaired renal function can cause toxicity, monitor BUN and creatinine; monitor pulse return, monitor VS
Class III antiarrhythmics
Bretylium tosylate (cretylol), amiodarone HCL (cordarone), milrinone (primacor), amrinone (inocor), sotalol (betapace); indicated for ventricular dysrhythmias; adverse reactions: dysrhythmias, hypertension or hypotension, muscle weakness, tremors, photophobia; amidoarone is now one of the first choice drugs, monitor VS and ECG; wear sunglasses and sunscreens
Class I A,B,C antiarrhythmics
Quinidine, disopyramide phosphate (norpace), moricizine (ethmozine), lidocaine HCL (xylocaine), mexiletine (mexitil), tocainide HCL (tonocard), phenytoin sodium (dilantin), propafenone (rythmol), flecainide acetate (tambocor); indicated for premature beats, atrial flutter, atrial fibrillation, contraindicated in heart block, ventricular dysrhythmias, unlabeled use digitalis for induced arrhythmias, and ventricular dysrhythmias; adverse reactions: diarrhea, hypotension, ECG changes, cinchonism, interactions with many common drugs, hypotension, CNS effects, seizures, GI distress, bradycardia, dizziness, slurred speech, ventricular dysrhythemias; monitor HR and rhythm, monitor ECG, monitor for tinnitus an visual disturbances, lidocaine administered IV bolus and by infusion; monitor for confusion, drowsiness, slurred speech, seizures with lidocaine, administer oral drugs with foods, cause digoxin toxicity
Nesiritide (natrecor)
Treatment of acutely decompensated HF in clients who have dyspnea at rest or with minimal activity, and reduces PCWP and reduces dyspnea; hypotension is primary side and can be dose limiting, arrhythmias, HA, dizziness, insomnia, tremors, paresthesias, abdominal pain, NV
Eptifibatide (integrilin)
Acute coronary syndrome (unstable angina or non-Q wave MI, used in combination with heparin, aspirin, and in selected situations, ticlid and plavix; adverse reactions: bleeding, hypotension, thrombocytopenia, acute toxicity that presents with decreased muscle tone, dyspnea, loss of righting reflex; check drug-drug interactions, baseline PT/aPTT, H&H, platelet count and monitor; adjusted by weight for elderly; watch for bleeding; quickly reversible so emergency procedures may still be performed shortly after discontinuing
Norepinephrine bitratrate (levophed)
Indicated for dilated coronary arteries and causes peripheral vasoconstriction for emergency hypotensive states not caused by blood loss, vascular thrombosis, or anesthesia using cyclopropane or halothane; adverse reactions: can cause severe tissue necrosis, sloughing and gangrene if infiltrates; rapidly inactivated by various body enzymes; use cautiously in previously hypertensive clients; check BPq2-5min; large veins to avoid complications; pressor effects potentiated by many drugs; have phentolamine diluted per protocol for local injection if infiltrates
Nesiritide (natrecor)
Treatment of acutely decompensated HF in clients who have dyspnea at rest of with minimal activity; reduces PCWP and reduces dyspnea; adverse reactions: hypotension is primary side effects and can be dose limiting, arrhythmias, HA, dizziness, insomnia, tremors, paresthesias, abdominal pain, NV; monitor BP, monitor K+; watch for over-response to treatment
Eptifibatide (integrilin)
Indicated for Acute coronary syndrome and used in combination with heparin, aspirin, ticlid and plavix; adverse reactions: bleeding, hypotension, thrombocytopenia, acute toxicity: decreased muscle tone, dyspnea, loss of righting reflex; baseline PT/aPTT, H&H, platelet count ad monitor; watch for bleeding; quickly reversible so emergency procedures may still be performed shortly after discontinuing infusion
Digitoxin (crystodigin, Purodigin) & Digoxin (lanoxin, lanoxicaps)
Indicated for HF, increases contractility of heart muscle; slows HR and conduction; adverse reactions: AV block, headache, dysrhythmias, NV, blurred vision, yellow-green halos, hypotension, fatigue; monitor serum electrolytes: hypokalemia; monitor serum levels – range from 0.5-2mg; radial pulse prior to administration
Digoxin-immune fab (digibind)
Indicated as antidote for digitalis toxicity and bind with digitoxin or digoxin to prevent biding at their site of action; adverse reactions: decreased cardiac output, atrial tachyarrhythmias, used with caution in elderly and children; use with 0.22um filter; place client on continuous cardiac monitor; resuscitation equipment at bedside before fiving first dose
Hypokalemia
Side effects of digitalis are increased when the client is
Digitalis toxicity S&S
Bradycardia, tachycardia, dysrhythmias, NV, headache
Digitalis
Medication is to be withheld if HR<60
Antacids
Aluminum hydroxide/magnesium hydroxide (Maalox, Mylanta, riopan, gelusil II); indicated for treatment of peptic ulcers, work by neutralizing or reducing acidity of stomach contents, differences in absorption rate; adverse reactions: drug interactions, diarrhea, constipation; take several times/day; administer after meals; assess for history of renal diseases when client is taking magnesium products; electrolyte readjustment occurs and can result in renal insufficiency and calcinosis
Histamine2 antgonists
Ranitidine HCL (zantac), cimetidine (tagamet), famotidine (pepcid), nizatidine (axid); indicated for treatment of peptic ulcers and as a phrophylactic treatment for clients at risk for developing ulcers; there are multiple drug interactions; cigarette smoking interfers with drug action; expensive
Mucosal healing agents
Sucralfate (carafate); indicated to treat peptic ulcers; adverse reactions include constipation and drug interactions with tetracycline, phenytoin sodium, digoxin, and cimetidine; taken 1 hour before meals; antacids interferes with absorption
Antiulcer drugs
Prokinetic agents, antimetics, cough suppressants, stool softners; treatment of slow peristalsis and increased intraabdominal pressure in client with GERD; adverse reaction: diarrhea
Proton pump inhibitors
Lansoprazole (prevacid), pantoprazole (protonix), esomeprazole (nexium), omeprazole (prilosec), rabeprazole (achipex); indicated for treatment of erosive esophagitis associated with GERD; adverse reactions: constipation, hearbrn, anxiety, diarrhea, abdominal pain, hepatocellular damage, pacreatitis, gastroenteritis, tinnitus, vertigo, confusion, HA, blurred vision, hypokinesia, chest pain, dyspnea; take before meals; don’t crush or chew
Hepatitis A (infectious hepatitis)
Source of infection: contaminated food, water or shellfish; route of infection: oral, fecal, parenteral; incubation period: 15-50 days; onset: abrupt; seasonal variation; autumn, winter; age group affected: children and young adults; vaccine: yes; inoculation: yes; potential for chronic liver disease: no; immunity: yes
Hepatitis B (serum hepatitis)
Source of infection: contaminated blood products, needles, surgical instruments or from mother to child at birth; route of infection: oral, fecal, parenteral, direct contact, breast milk, sexual contact; incubation period: 14-180 days; onset: insidious; seasonal variation; all year; age group affected: any; vaccine: yes; inoculation: yes; potential for chronic liver disease: yes; immunity: yes
Hepatitis C (non-A, non-B hepatitis)
Source of infection: contaminated blood products, needles, IV drug use and dialysis; route of infection: parenteral, sexual contact; incubation period: 14-180 days; onset: insidious; seasonal variation; all year; age group affected: any; vaccine: no; inoculation: yes; potential for chronic liver disease: no; immunity: no
Lactulose (cephulac)
Ammonia detoxicant/stimulant laxative; implications are encephalopathy and used to decrease ammonia levels and bowel pH; adverse reactions: diarrhea; monitor ammonia levels
Thyroid preparations
Levothyroxine (synthroid), liothyronine sodium (cytomel), desiccated thyroid (amout thyroid); indications: increase metabolic rates, synthetic T4; adverse reactions: anxiety, insomnia, tremors, tachycardia, palpitations, angina, dysrhythemias; check serum hormone levels routinely; check BP and HR; weigh daily; avoid foods and products contaiing iodine; initiate cautiously in patients with cardiac disease
Steroids
Hydrocortisone, prednisone, dexmethasone; indicated for hormone replacement, severe rheumatoid arthritis, and autoimmune disorders; adverse reactions: emotional liability, impaired wound healing, skin fragility, abnormal fat disposition, hyperglycemia, hirsutism, moon face, osteoporosis; wean slowly; monitor serum potassium, glucose and sodium; weigh daily and report >5lb/week; administer with antiulcer drugs; prevent injurys; monitor BP and HR
Sulfonylureas
First generation: Tolbutamide (oranase), chlorpropamide (diabinase), second generation: Glyburide (micronase, diabeta), glipizide (glucotrol), glimeprode (amaryl); lowers blood sugar by stimulating the release of insulin by the beta cells of the pancreas + causes tissues to take up and store glucose more easily; first generation are low potency and short acting; second generation are high potency and longer acting; adverse reactions: first generations: hypoglycemia, nausea, heartburn, constipation, anorexia, agranulocytosis, allergic skin reactions; second generation reactions: weight gain, hypoglycemia; first generation: responsiveness may decrease over time; once daily with first meal; monitor blood sugar; hard to detect hypoglycemia; second generation: less likely to interact with other medications
Biguinides
Metformin (glucophage); lowers serum glucose levels by inhibiting hepatic glucose production and increasing sensitivity of peripheral tissue to insulin; adverse reactions: abdominal discomfort and diarrhea; many drug-drug interactions, extended release tablets should be taking with evening meal; use cautiously with preexisting renal or liver disease or HF; wait 48 hours to restart dosage after diagnostic studies requiring IV iodine contrast media
Alpha glucosidase inhibitors
Acarbose (precise), miglitol (glyset); lowers BS by blunting sugar levels after meals; adverse reactions: hypoglycemia; must be taken with the first bite of each meal; taking with other classes of oral hypoglycemic; monitor blood sugar
Thiazolidinediones
Rosiglitazone (avandia), pioglitazone (actos); lowers BS by decreasing insulin resistance of the tissues; adverse reactions: hypoglycemia, increased total cholesterol, weight gain, edema, anemia; skip dose if meal skipped; no known drug interactions; monitor liver function; caution with use in CAD; may precipitate HF
Meglitindes
Repaglinide (prandin); lowers BS by stimulating beta cells in pancreas to release insulin closes K_ channels and opening Ca++ channels; adverse reactions: hypoglycemia, angina, chest pain, arthralgia, back pain, NV, dyspepsia, constipation or diarrhea; give before meals; monitor BS
Rapid acting insulin
Prompt zinc suspension insulin (semilente) onset: 0.5-1 hour peak action: 2-3 hours, human insulin lispro (humalog) onset: 0.5-1 hour peak action: 2-4 hours, insulin aspart (novolog) onset: 5-15 min peak action: 0.75- 1.5 hours; note to be given IV; give within 15 min of a meal
Short acting insulin
Regular insulin (human); onset: 30-60min; peak: 2-3 hours; can be given IV
Intermediate acting insulin
Isophane insulin (NPH), insulin zinc suspension (humulin L); onset: 1-2 hours; peak: 6-12 hours; not to be given IV;
Long acting insulin
Protamine zinc (PZI), extended zinc suspension (ultralene), insulin glargine (lantus); onset: 4-8 hours; peak:: 4-20 hours (some say there is no peak); not to be given IV; give once a day; don’t shake solution; don’t mix other solutions with lantus
Non-steroidal anti-inflammatory drugs (NSAIDs)
Aspirin, Ibuprofen, indomethacin, ketorolac tromethamine, celecoxib (celebrex), etodolac (lodine), diclofenac (voltaren), naproxen; antiinflammtory, antipyretic, analgesic; adverse reactions: GI irritation, bleeding, NV, constipation, elevated liver enzymes, prolonged coagulation time, tinnitus, thrombocytopenia, fluid retention. Nephrotoxicity, blood dyscrasias; take with food or milk to reduce GI symptoms; watch for signs of bleeding; avoid alcohol; administer corticosteroids for severe RA; reduce the effect of ACE inhibitors in hypertensive clients; check renal/liver labs and CBC routinely
Hypoglycemia
Headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmares; occurs rapidly and is potentially life threatening; treat immediately with complex CHO; check BS
Hyperglycemia
Polydipsia, polyuria, polyphagia, blurred vision, weight loss, weakness, syncope; encourage water intake; check BS; assess for ketoacidosis
Burst fracture
Characterized by multiple pieces of bone; often occurs at bone ends or in vertebrae
Comminuted fracture
More than one fracture line; more than two bone fragments; fragments may be splintered or crushed
Complete fracture
Break across the entire section of bone, dividing it into distinct fragments; often displaced
Displaced fracture
Fragments out of normal position at fracture site
Incomplete fracture
Fracture occurs through only one cortex of the bone; usually nondisplaced
Linear fracture
Fracture line is intact; fracture is caused by minor to moderate force applied directly to the bone
Longitudinal fracture
Fracture line extends in the direction of the bones longitudinal axis
Nondisplaced fracture
Fragments alinged at fracture site
Oblique fracture
Fracture line occurs at approx. 45 degree angle across the longitudinal axis of the bone
Spiral fracture
Fracture line results from twisting force; forms a spiral encircling the bone
Stellate fracture
Fracture lies radiate from one central point
Transverse fracture
Fracture line occurs at a 90degree angle to the longitudinal axis of the bone
Avulsion fracture
Bone fragments are torn away from the body of the bone at the site of attachment of a ligament or tendon
Compression fracture
Bone buckles and eventually cracks as the result of unusual loading force applied to its longitudinal axis
Greenstick fracture
Incomplete fracture in which one side of the cortex is broken and the other side is flexed but intact
Impacted fracture
Telescoped fracture, with one fragment driven into another
Colles fracture
Fracture within the last inch of the distal radius; distal fragment is displaced in a position of dorsal and medial deviation
Pott’s fracture
Fracture of the distal fibula, seriously disrupting the tibiofibular articulation; a piece of the medial malleolus may be chipped off as a result of rupture of the internal lateral ligament
Pilocarpine HCL (parasympathomimetics)
Enhances papillary constriction; adverse reactions: bronchospasm, NVD, blurred vision, twitching eye lids, eye pain with focusing; use cautiously with pregnancy, asthma, hypertension’ teach proper drop instillation; need for ongoing use of the drug at prescribed intervals; blurred vision tends to decrrase with regular use; treatment of glaucoma
Beta-adrenergic receptor blocking agents
Timolol maleate optic (timoptic solution), carteolol (ocupress); inhibits the formation of aqueous humor; adverse reactions are insignificant and may cause hypotension; cautious use with hypersensitive, asthmatic, second or third- degree heart block, HF, congenital glaucoma, pregnancy; teach proper instillation; need for ongoing use of the drug at prescribed intervals; blurred vision tends to decrease with regular use
Carbonic anhydrase inhibitors
Acetazolamide (diamox), brinzolamide (azopt), dorzolamide (trusopt); reduces aqueous humor production; adverse reactions: numbness, tingling in hands and feet, nausea, malaise; administer orally or IV, produces dieresis, assess for Metabolic acidosis
Prostaglandin angonists
Latanoprost (xalatan), ravoprost (travatan), bimetoprost (lumigan); lowered intraocular pressure of glaucoma by increasing outflow of aqueous humor; adverse reactions: local irritations, foreign body sensation, increased pigmentation of iris, and increased eyelash growth
Mannitol (osmitrol)
Acts on renal tubules by osmosis to prevent water reabsorption; in blood stream, draws fluid from the extravascular spaces into the plasma; adverse reactions: disorientation, confusion and headache, NC, convulsions and anaphylactic reactions; short term therapy only; never give to clients with cerebral hemorrhage; IV infusion is adjusted to urine output; filter urine and watch for crystals; never give to clients with no urine output, if urine output is <30ml/hr accumulation can cause pulmonary edema and water intoxication
Pyridostigmine bromide (mestinon)
Treatment for myasthenia gravis; inhibits the action of cholinesterase at the cholingeric nerve endings, promotes the accumulation of acetylcholine at zcholinergic receptor sites; adverse reactions: cholinergic crisis can occur with over dose; atropine is antidote for drug induced bradycardia; take with milk or food; dosage regulation is required; observe for symptoms of cholinergic crisis; lifelong therapy
Cholinergic crisis
Fasciculations, abdominal cramps, diarrhea, incontinence of stool/urine, hypotesion, bradycardia, respiratory depression, lacrimation, blurred vision
Anticholinergics
Atrophine sulfate (atropisol), benztropine mesylate (cogentin), trihexyphenidyl (artane); reduces cholinergic activity; adverse reactions: increased HR, postural hypotension, dry mouth, constipation, urinary retention; warn to avoid rapid position changes; avoid extreme heat; provide gum, hard candy and frequent mouth care
Dopamine replacements
Levodopa (dopar), levodopa-carbidopa (sinemet); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness
Dopamine releasing agent
Amantadine HCL (symmetrel); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness
Monoamine oxidase type B inhibitor
Selegiline (eldepryl); used with dopamine agonist when client symptoms don’t response; adverse reactions: confusion, dizziness, nausea, dry mouth, insomnia; not an option with antidepressants
Dopamine-releasing agonists
Bromocriptine mesylate (parlodel), praminpexole (mirapet), pergolide (permax); stimulated dopamine production or increases sensitivity of dopamine receptors; newer drugs require lower dosage; adverse reactions: involuntary movements; NV; drugs may take months to achieve desired effects; avoid sudden position changes; avoid foods high in vitamin B6 (meats, liver, high protein foods); insomnia occurs, suggest taking last dose earlier in the day; may initially cause drowsiness
Left hemisphere disruption in the brain
Language: aphasia, agraphia; memory: no deficit; vision: unable to discriminate words and letters, reading problems, deficits in right visual field; behavior: slow, cautious, anxious when attempting a new task, depression or catastrophic response to illness, sense of guilt, feeling of worthlessness, worries over future, quick anger and frustration; no deficit in hearing
Right hemisphere disruption in the brain
Language: may be alert and oriented; memory: disoriented and cannot recognize faces; vision: visual/spatial deficits, neglect of left visual fields, loss of depth perception; behavior: impulsive, unaware of neurologic deficits, confabulates, euphoric, constantly smiles, denies illness, poor judgment, overestimates abilities, impaired sense of humor; loses ability to hear tonal variations
Hydroxyurea (hydrea) & asparaginase (elspar)
Antineoplastic chemotherapeutic agents; urea-derived antineoplastic agent against solid tumors and CML. Anticancer enzyme against ALL; adverse reactions: drowsiness, renal dysfunction, NVD, hepatitis, myelosuppression; adequate H2O
Alkalating agents
Cyclophosphamide (cytoxan, neosar), mechlorethamine HCL (nitrogen mustard), cisplatin (platinol), busulfan (myleran), procarbazine (matulane), imidazole carboximide (dacarbazine); indicated for Hodgkin’s lymphoma, leukemia, neuroblastoma, retinoblastoma, multiple myeloma; adverse reactions: bone marrow suppression, NV, cystitis, stomatitis, alopecia, gonadal suppression, toxic effects occur slowly with high dosage, toxic to kidneys and ears, pleural effusion, seizures; use immediately after reconstitution; avoid vapors in eyes; vesicant; hydrate well and during treatment with IV fluids and mannitol; monitor renal functioning and watch for signs with cystitis; force fluids; monitor hearing and vision
Antimetabolites
Antineoplastic chemotherapeutic agent; flurouracil (adrucil, 5-FU), methotrexate sodium (mexate) requires leucovorin rescue to prevent toxic effects, metcaptopurine/6-MP (purinethol), cytarabine (cytosar-U, ARA-C), Gemcitabine (gemzar); indicated for ALL, AML, brain tumors, ovarian, breast, prostatic, testicular cancers; adverse reactions: NVD, myelosuppression, proctitis, stomatitis, dermatitis, renal toxicity, hepatotoxicity, anaphylaxis; adminster antiemetics PRN, wear sunscreen, toxic to liver and kidneys; avoid: aspirin, sulfonamide, tetracycline, vitamins containing folic acid; leucovorin used with methotrexate as antidotes for high doses; give allopurinol concurrently with 6-MP to inhibit uric acid production by cell destruction increases drugs potency; monitor liver function
Antitumor antibiotics
Dactinomycin (actinomycin), bleomycin sulfate (blenoxane), daunorubicin I (cerubidine), mitomycin, doxorubicin HCL (adriamycin), idarubicin (idamycin); indicated for: sarcoma, neuroblastoma, head and neck tumors, testicular, ovarian, breast cancer, Hodgkin, lymphocytic leukemia, AML; adverse reactions: bone marrow suppression, anorexia, NV, alopecia, cardiac toxicity, vesicant; monitor for cardiac dysrhythmia; urine will turn red; antiemetic PRN
Plant alkaloids
Vincristine sulfate (oncovin), vinblastine sulfate (velban); indicated for ALL, Hodgkin, Wilms tumor, sarcoma, breast cancer, testicular cancer; adverse reactions: bone marrow suppression, neurotoxicity, weakness, paresthesia, jaw pain, constipation, stomatitis, alopecia, headaches, minimal NV; administer antiemetic, monitor for neurotoxicity
Mitotic inhibitors
Paclitaxel (taxol), docetaxel (taxotere); indicated for breast cancer, ovarian cancer, on-small-cell-lung cancer, Kaposi sarcoma; adverse reactions: decreased WBCs & RBCs, alopecia, NVD, joint, muscle pain; monitor for S&S of infection; administer antiemetics and antidiarrheals
Hormonal agents (corticosteroids)
Prednisone (cortalone), dexamethasone (decadron); indicated for leukemia, Hodgkin, breast cancer, lymphoma, multiple myeloma, cerebral edema due to brain metastasis
Male-specific hormonal agents
Flutamide (eulexin), Leuprolide (lupron), goserelin (zoladex); indicated for prostate cancers and testicular cancers; adverse reactions: HA, paresthesias, cardiac arrhythmias, NV, hypoglycemia, neuropathies; bone pain and voiding problems are possible
Androgens
Testosterone (oreton), fluoxymesterone (halotestin); indicated for breast cancer in post menopausal woman; adverse reactions: fluid retention, nausea, and masculinization; low salt diet is necessary
Female specific hormonal agents
Tamoxifen citrate (nolvadex), megestrol (megace), medroxyprogesterone (provea); indicated for breast cancer; adverse reactions: hot flashes, mild nausea; administer antiemetic PRN
Topoisomerase-I inhibitors
Irinotecan (camptosar), topotecan (hycamtin); indicated for use after failure of initial treatment of ovarian, small cell lung and colorectal cancers; adverse reactions: myelosuppression, moderate NVD; antiemetic PRN
Monoclonal antibodies
Trastuzumab (herceptin), rituximad (Rituxan); targets specific malignant cells with less damage to healthy cells in non-hodgkin lymphoma, breast cancer; adverse reactions: fever, chills, infection, NVD, bronchospasm, dyspnea, ARDS, hypotension, ventricular dysfunction; HF; premedicate with antiemetics
Epoetin (procrit, epogen)
Antianemic medication; indicated for anemia due to chronic renal failure, chemotherapy, HIV related treatment; adverse reactions: seizures, hypertension, pain at injection site; don’t shake vial because it can cause an inactivation of medication; monitor HCT levels; give slowly SC
Filgrastim (neupogen)
Granulocyte stimulating factor; improved immune competence by increasing neutrophils; adverse reactions: medullary bone pain during initial treatment and pain at injection site; monitor WBC/diff and ANC, give SC slowly, assess bone pain and medicate with analgesics
Oprelvekin (Neumega)
Thrombotic growth factor; stimulates production of megakaryocytes and platelets; adverse reactions: dizziness, HA, insomnia, blurred vision, nervousness, pleural effusion, vasodilation, cardiac arrhythmias, bone pain, myalgia, GI upsets, fluid retention; give slowly; assess for fluid retention complications; start within 6-24 hours of chemotherapy and continue for 10-21 days; monitor CBC, H&H, platelets
Aldesleukin (proleukin, interleukin-2)
Interlukin medications; indicated for metastatic renal carcinoma; adverse reactions: RF, pulmonary edema, HF, MI, arrhythmias, stroke, bowl perforation, hepatomegaly, GI disturbances, electrolyte imbalances, coagulation disorders, pancytopenia; monitor for serious side effects
Interferon beta products
Interferon beta -1a (avonex), interferon beta-1b (betaseron); indicated for relapsing multiple sclerosis, AIDS, Kaposi sarcoma, malignant melanoma, hepatitis C; adverse reactions: seizures, HA, weakness, insomnia, depression, suicidal ideation, hypertension, chest pain, vasodilation, edema, palpitations, dyspnea, NV, elevated liverfunction studies, GI disorders, myalgia, flu-like symptoms
Interferon alpha products
Interferon alpha-2a (roferon a), interferon alpha-2b (intron a); 2a – indicated for hairy cell leukemia, Kaposi sarcoma; 2b: indicated for chronic hepatitis B&C, Kaposi sarcoma, hairy cell leukemia
Antiemetics
Prochlorperazine (compazine), promethazine HCL (phenergan); indicated for NV; adverse reactions: drowsiness, dizziness, extrapyramidal symptoms, orthostatic hypotension, blurred vision, dry mouth; dilute oral solution with juice, determine baseline BP, give deep IM, monitor BP carefully
Antiemetics
Metoclopramide HCL (raglan), haloperidol (haldol); indicated for NV; adverse reactions: drowsiness, restlessness, fatigue, extrapyramidal symptoms; caution about decreased alertness, avoid alcohol, discontinue if EPS occurs
Antiemetics
Diphenhydramine HCL (Benadryl); given with raglan and haldol to reduce EPS; adverse reactions: sedation, dizziness, hypotension, dry mouth
Ondansetron HCL (zofran)
Antiemetic; indicated for prevention of NV associated with cancer as well as postoperative NV; adverse reactions: headache; administer tablets 30 min prior to chemotherapy and 1-2 hours prior to radiation therapy; dilute IV injection in 50ml of 5% dextrose or 0.9%NaCl
Antiemetic
Granisteron (Kytril); indicated for NV associated with chemotherapy and abdominal radiation; adverse reactions: hypertension, CNS stimulation, elevated liver enzymes; assess for EPS, monitor liver enzymes, give one on day of chemotherapy or 1 hour before
Treponema pallidum, syphillus
Laboratory diagnosis: VDRL, FTA-ABS; symptoms: primary (local): up to 90 days re-exposure, chancre (red, painless lesions with indurated border), highly infectious; secondary (systematic): 6weeks- 6 months post exposure, influenze-type symptoms, generalized rash that affects palms of hands and soles of feet; lesions are contagious; tertiary: 10-30 years post exposure: cardiac and neurologic destruction; treatment is with penicillin G IM (2.4-4.8 million units)
Neisseria gonorrhoeae, Gonorrhea
Laboratory diagnosis: smears, cultures; symptoms: females: majority are asymptomatic; males: dysuria, yellowish-green urethral discharge, urinary frequency; treated with ceftriaxone sodium plus doxycycline hyclate or streptomycin HCL plus doxycycline hyclate
Chalmydia trachomatis, Chlamydia
Laboratory diagnosis: tissue culture, chlamydiazyme, microtrak; symptoms: females: many asymptomatic, but may exhibit dysuria, urgency, vaginal discharge; males: leading cause of nongonococcal urethritis; treated with doxycycline hyclate or tetracycline HCL
Trichomanas vaginalis, trichomoniasis
Laboratory diagnosis: wet slide; symptoms: female: green, yellow or frothy foul smelling vaginal discharge with itching; males: asymptomatic; treated with metronidazole (flagyl)
Candida albicans, Candidiasis
Laboratory diagnosis: viral culture; symptoms: females: odorless, white or yellow, cheesy discharge with itching; males: asymptomatic; treated with miconazole nitrate (monitstat), clotrimazole (gyne-lotrimin), or nystatin (mycostatin)
Herpes simplex virus 2, herpes
Symptoms: vesicles in clusters that rupture and leave painful erosions that cause painful urinary; characterized by remissions and exacerbations; may be contagious when asymptomatic; treated with acyclovir (zovirax) that partially controls symptoms and palliative care that includes viscous lidocaine topically to ease the pain, and keeping the lesions clean and dry
Human papillomavirus (HPV)
Multiple strains, some of which are implicated in cervical cancer; alarming rate increases in adolescent population; lesions may be small, wart life or clustered. May be flat or raised; treated with podophyllum resin, trichloracetic acid, laser, or cryotherapy
Mafenide acetate (sulfamylon)
Treatment of burns, usually used with open method of wound care; adverse reactions: painful, causes mild acidosis; administer pain medication prior to dressing change; penetrates wound rapidly
Silver sulfadiazine (silvadene)
Treatment of burns; usually used with open method of wound care; used to avoid acid=base complication; keeps eschar soft, making debridement easier; adverse reactions: penetrates wound slowly; administer pain medication prior to dressing change
Nitrofurazone (furacin)
Treatment of burns, used to prevent infections, interferes with bacterial enzymes; adverse reactions: allergic contact dermatitis; may see superinfections; administer pain medications prior to dressing change; monitor S&S of infection
MMR vaccine
Administered 12-15months of age and repeated at 4-6 years or by 11-12 years of age; contraindicated for persons with hx of anaphylactic reaction to neomycin or eggs, those with known altered immunodeficiency, and pregnant women; SC at different sites, may have a light transient rash for 2 weeks after administration of vaccine
Hepatitis B
May be given to newborns prior to hospital discharge; all children up to 18 years of age should be vaccinated; contraindicated for persons with anaphylactic reaction to baker’s yeast
DTaP vaccine
Beginning at 2 months, administer 3 doses at 2 month intervals; booster doses given at 15-18 months and at 4-6 years; administer IM; not fiven to children past the 7th birthday; contraindications to P: encephalopathy within 7 days of previous vaccine, hx of seizures, neurologic symptoms after receiving vaccine, systematic allergic reactions; instructed to begin Tylenol administration after the immunization (10-15mg/kg)
Polio vaccine
Recommended for all persons <18 years; administer at 2 months of age and again at 4 months of age. Boosters are given at 6-18 months and at 4-6 years; SB or IM; contraindicated for those with a history of anaphylactic reaction to neomycin or streptomycin; may be given with all over vaccines
Hib (haemophilus influenze type B) vaccine
Offers protection against bacteria that cause epiglottis, bacterial meningitis, septic arthritis; can be given beginning as early as 2 months of age. Children at high risk who were not immunized previously should be immunized >5years; IM; no contraindications
Varicella
School requirement in 33 states; safe for children with asymptomatic HIV infection; administer at 12-18 months of age; give with MMR on same day or >30 days apart in a separate site
Tuberculosis skin testing
Offers screening for exposure; mantoux test with PPD injected intradermally on the forearm; tine test – 4 prongs pressed into the forearm should not be used to determine the presence of infection; positive reaction represents exposure
Iron
Signs of deficiency: anemia, pale conjunctiva, pale skin color, atrophy or papillae on tongue, brittle ridged spoon shaped nails, thyroid edema; food sources: infant rice cereal, liver, beef, pork, eggs, iron fortified formula, infant high protein cereal
Vitamin B12 (riboflavin)
Signs of deficiency: redness and fissuring of eyelid corners; burning, itching, tearing eyes, photophobita, magenta colored tongue and/or glossitis, seborrheic dermatitis, delayed wound healing; food sources: prepared infant formula, liver, enriched cereals, cow’s milk, cheddar cheese, some green leafy vegetable such as broccoli, green beans and spinach
Vitamin A (retinol)
Signs of deficiency: dry, rough skin, dull cornea, soft cornea, bitot spots, night blindness, defective tooth enamel, retarded growth, impaired bone formation, decreased thyroxine formation; food sources: liver, sweet potatoes, carrots, spinach, peaches, apricots
Vitamin B6 (pyridoxine)
Signs of deficiency: scaly dermatitis, weight loss, anemia, irritability, convulsions, peripheral neuritis; food sources: meats, liver, cereals, yeast, soybeans, peanuts, tuna, chicken, bananas
Vitamin C (ascorbic acid)
Signs of deficiency: scurvy, receding gums that are spongy and prone to bleeding, dry rough skin, petechiae, decreased wound healing, increased susceptibility to infection, irritability, anorexia, apprehension; food sources: strawberries, oranges and orange juice, tomatoes, broccoli, cabbage, cauliflower, spinach
Newborn normal HR & RR
100-160HR; 30-60RR
1-11 months normal HR & RR
100-150HR; 25-35RR
1-3 years normal HR & RR
80-130HR; 20-30RR
3-5 years normal HR & RR
80-120HR; 20-25RR
6-10 years normal HR & RR
70-110HR; 18-22RR
10-16 years normal HR & RR
60-90HR; 16-20RR
Epinephrine HCL (sus-phrine)
Indicated as a rapid acting bronchodilator and is the drug of choice for acute asthma attack; adverse reactions: tachycardia, hypertension, tremors, nausea; give SC, IV, nebulizer; can be repeated after 20 min
Theophylline (theo-dur)
Indicated as a bronchodilator, used in asthma to reverse bronchospasm; adverse reactions: tachycardia, irritability, palpitations, hypotension, NV; auscultate lungs before and after administration; monitor blood levels
Penicillin G (Bicillin)
Prophylaxis for recurrence of rheumatic fever; allergic reactions ranging from rashes to anaphylactic shock and death are the adverse reactions; released very slowly over several weeks giving sustained levels of concentration; emergency equipment available whenever administered; always determine existence of allergies to penicillin and cephalosporins
Phenobarbital (luminal)
Anticonvulsant; tonic clonic and partial seizures; the longest acting of common barbiturates; combined with other drugs; adverse reactions: drowsiness, nystagmus, ataxia, paradoxic excitement; therapeutic levels: 15-60mcg/ml; avoid rapid infusion, monitor BP
Phenytoin (dilantin)
Anticonvulsant; tonic clonic and partial seizures; adverse reactions: gingival hyperplasia, dermatitis, ataxia, nausea, anorexia, bone marrow depression, nystagmus; therapeutic levels: 10-20mcg/ml; monitor drug interactions; meticulous oral hygiene; monitor CBC; report to MD if any rash develops; flush IV before and after with NS only; don’t administer with milk
Fosphenytoin sodium (cerebyx)
Anticonvulsant; indicated for generalized convulsive status epilepticus, prevention and treatment of seizures during neurosurgery, short term parenteral replacement for dilatan; adverse reaction: rapid IV infusion can cause hypotension; severe: ataxia, CNS toxicity, confusion, gingival hyperplasia, irritability, lupus erythematosus, nervousness, nystagmus, paradoxic excitement, stevens-johnson syndrome, toxic epidural necrosis; used for short term parental use; always be prescribed and dispensed in phenytoin sodium equivalents; prior to IV infusion, dilute D5W or NS to administer solution of 1.2-25mg PE/ml; infuse at IV rate of no more than 150mg PE/minute
Valporic acid (depakene)
Indicated for absence seizures and myoclonic seizures; adverse reactions: hepatotoxicity, especially in children less than 2 years old; prolonged bleeding times, GI disturbances; monitor liver function; potentiated Phenobarbital and dilantin; therapeutic levels: 50-100meg/ml
Carbamazepine (tegretol)
Indicated for tonic-clonic, mixed seizures, drowsiness, ataxia; adverse reactions: hepatitis and agranulocytosis; monitor liver function; therapeutic level 6-12mcg/ml
Lamotrigine (lamictal)
Indicated for partial seizures, tonic clonic seizures, and absence seizures; adverse reactions: dizziness, headache, nausea, rash; withhold drug if rash develops; don’t discontinue abruptly
Clonazepam (klonopin)
Indicated for absence seizures, myoclonic seizures; adverse reactions: drowsiness, hyperactivity, agitation, increased salivation; therapeutic levels: 20-80mcg/ml; don’t abruptly stop the drug; monitor liver function, CBC and renal function periodically
Mannitol (osmitrol)
Osmotic diuretic used to reduce cerebral edema and postoperative swelling or trauma; adverse reactions: circulatory overlead, confusion, hypokalemia, hyponatremia; use in-line filter for IV administration, avoid extravasation; monitor I&O; lasix may also be prescribed
Bethanechol chloride (urecholine)
Used in renal disorders; Indicated as a cholinergic used to treat: urinary retention, neurogenic bladder, gastric reflux; adverse reactions: orthostatic hypotention, flushing, asthmatic reaction, GI distress; don’t give IV or IM; monitor VS; empty stomach
Prednisone (deltasone)
Used in renal disorders; Indicated as adrenocorticosteriod used to treat immunosuppression (acts as an anti-inflammatory) and edema (promotes dieresis in nephritic syndrome); adverse reactions: mood changes, increased susceptibility to infection, cushingoid appearance, acne, GI distress, thrombocytopenia, edema, potassium loss, growth failure in children; every other day administration is best to avoid growth failure; taper dose; avoid live virus vaccines
Medications used in renal disorders
Oxybutynin (ditropan), tolterodine (detrol); indicated as a GU smooth muscle relaxant (antispasmodic) used to treated uninhibited neurogenic bladder, reflex urogenic bladder – both are characterized by voiding symptoms of urgency, frequency, nocturia and incontinence; adverse reactions: increased susceptibility to UTI, GI distress, dry eyes, dry mouth, vision changes, dizziness, chest pain, drowsiness; administered orally, don’t administer with other medications that have anticholinergic effects; may exacerbate reflux esophagitis; contraindicated in clients with untreated glaucoma or GI narrowing
Medications used in skeletal disorders
Meperidine HCL (Demerol), infliximad (remicade), methocarbamol (robaxin), cyclobenzaprine (flexeril); indicated as narcotic analgesic used to treat acute pain, non-narcotics to treat pain, stiffness and discomfort; adverse reactions: respiratory depression, NV, fever, chills, dizziness, nausea, drowsiness, chest pain, allergic response that would include rash, difficulty breathing etc. do not give if client has increased ICP, has duration of action of 2-4 hours; review history such as heart disease, thyroid disorders and use of MAOIs; remicade use can worsen TB
Latent phase of the first stage of labor
From the beginning of true labor until 3-4cm cervical dilatation; mildly anxious, conversant; continue usual activities; contractions are milk, initially 10-20 minutes apart, 15-20 seconds’ duration; later 5-7 minutes apart 30-40 seconds duration
Active phase of the first stage of labor
From 4-7cm cervical dilatation; increased anxiety, increased discomfort, unwillingness to be left alone; contractions moderate to severe, 2-3 minutes apart lasting 30-60 seconds in duration
Transitions phase of the first stage of labor
From 8-10cm cervical dilatation; changed behavior, sudden nausea and hiccups; extreme irritability and unwillingness to be touched; contractions are severe 1.5 minutes apart and 60-90 seconds duration
Oxytocin, synthetic (pitocin, syntocinon)
Uterine stimulant; indicated for uterine atony; adverse reactions: severe after pains in multipara and hypertension; give immediately after delivery of placenta to avoid trapped placenta; 10-20 units added to remaining IV fluid (at least 50ml); may stimulate let down milk reflex and flow of milk when engorged
Methylergonovine maleate (methergine)
Uterine stimulant; indicated for uterine atony; adverse reactions: hypertension; usual dose: 0.2mg IM followed by tabs of 0.2mg q4-6 hours; use with caution in clients with elevated BP or preeclampsia; take BP prior to administration and if 140/90 or above, notify MD
Prostaglandin F2 (hemabate)
Uterine stimulant; indicated for uterine atony; adverse reactions:headache, NV, fever, bronchospasm, wheezing; contraindicated for clients with asthma; 0.25IM q15-90min up to 8times; check temperature q1-2 hours; auscultate breasth sounds frequently
28 weeks gestational age assessment
No nipple bud; testes in the inguinal cancal or labia majora widely separated with labia minora prominent open and equal in size; vernix over the entire body; lanugo covers the entire body; full extension of extremities in the resting posture
40 weeks gestational age assessment
Raised nipple with tissue bud underneath; descended testes with large rugae on the scrotum; labia majora large and covering the minora; vernix only increases; lanugo only over the shoulders; hypertonic flexion of extremities in resting posture
Apgar assessment
1 and 5 minutes after birth; assesses heart rate, respiratory effort, muscle tone, reflex irritability and color; maximum score is 10 the baby is in good condition; <6 at 5 minutes needs an additional assessment at 10 minutes
Erythromycin and/or tetracycline
Newborn prophylactic eye care; prevention of ophthalmia neonatorum and Chlamydia trachomatis conjunctivitis; adverse reactions: most commonly used agents and there are none known except for puffy eyes resulting from manipulation; place a thin line of ointment along the entire lower lid in conjunctival sac; one tube per baby and discard; manipulate upper lids to ensure complete eye coverage; after 1 minute, may wipe excess from around eyes
Silver nitrate
Indicated as prevention of ophthalmia neonatorus resulting from gonorrhea exposure through the birth canal in a vaginal delivery; adverse reactions: chemical conjunctivitis (red, puffy eyes), staining of the skin if contact occurs; mandatory in the US, may not kill other organisms such as Chlamydia species, 2gtt in lower conjunctival sac making sure drops spread over entire eye; don’t irrigate eyes after instillation
Analgesics
Meperidine HCL (Demerol, pethidine), fentanyl (sublimaze), morphine sulfate (MS contin); indicated for opiod agonists, natcotic used to produce analgesia, euphoria, and sedation in labor, analgesia during labor; adverse reactions: respiratory depression, fetal narcosis or distress, hypotension, fetus received normeperidine which is linked to fetal compromise, itching, urinary retention; store in cabinet; record use accurately; don’t administer is RR<12; monitor RR, HR and BP closely
Analgesics
Butorphanol tartrate (stadol), nalbuphine (nubain); opioid agonist/antagonists, provision of analgesia in labor, narcotic analgesic; adverse reactions: woman with preexisting narcotic dependency will experience withdrawal symptoms immediate; give IV or IM, obtain drug history before administration; monitor RR and HR
Naloxone HCL (Narcan)
Narcotic antagonist used to counteract narcotic effects on mother/fetus; adverse rections: decreased RR; monitor RR closely; pain returns after administraion; 0.01mg/kg – newborn
Teaching breast feeding
Advantages: low cost, distinct immunologic advantages for newborn; milk production is stimulated by decrease in postpartum estrogen production, which allows release of prolactin from the pituitary; the let down reflex is caused by action of oxytocin released from the posterior pituitary, which stimulates myoepithelial cells around milk ducts and sinuses; avoid dieting, add 500 calories to pre-pregnancy intake, drink 8 glasses of non-caffeinated beverages daily; avoid smoking, intake of drugs, alcohol or caffeine, avoid stress; should remain on first breast 10 minutes, then switch to the second breast and suckle until satisfied; use warm water, not drying soap on nipples, let nipples air dry 15 minutesx2-3/day; for engorgement: nurse more frequently, and manually express milk to soften areola before feeding, wear supportive bra, take warm or hot showers, watch for symptoms of mastitis; incorrect position is the most common reason for sore nipples, make sure the is as much areola in baby’s mouth as possible, break suction with insertion of little finger into baby’s mouth
Bisacodyl (Dulcolax suppository)
Postpartum drug; indicated for constipation; adverse reactions: abdominal cramping; insert suppository into anus past internal rectal sphincter; contact laxative that stimulates rectal mucosa directly, there may be some burning, usually effective 15minutes – 1 hour
Docusate sodium (colace)
Postpartum drug; indicated for constipation and painful defecation due to 4th degree tear; adverse reactions: abdominal cramping; increase fluid intake; effective 1-3days of continual use
Rh0 (D) immune globulin (RhoGam)
Post partum drug; Indicated as prevention of Rh isoimmunization with next pregnancy; adverse reactions: none known; given to RH- woman after miscarriage, abortion or any procedure or complication that increases the risk for maternal fetal blood exchange; given at 28 weeks gestation to RH- mothers with a negative antibody titer; given postpartally to RH- mother after delivery or abortion when fetus is RH+; given within 72 hours of delivery; always give IM; is a blood product: must be checked by 2 nurses; syringe must be returned to lab with label; not given to a mother with positive indirect coombs – she has already been sensitized to fetal cells and has developed antibodies
Rubella vaccine
Postpartum drug; indicated if rubella titer of <1:20 or enzyme immunoassay of <0.10; adverse reactions: transient benign arthralgia, transient rash, hypersenivity if allergic to duck eggs; give SC before hospital discharge to non-immune women; breast feed; do not give if women or other family members are immunocompromised; informed consent; avoid pregnancy for 2-3 months after immunization
Diaphragm
Used with spermicide; must be fitted by a NP or MD; left in place for 6 hours after intercourse; refitted if excessive weight gain or loss occurs; check for integrity
Cervical cap
Used with spermicide; contraindicated if cervical anomalies exist; associated with cervical changes; pap smear 3 months after use
Condom with spermicide
Used with spermicide to increase effectiveness; recommended if any suspicion of STD; penis must be withdrawn while erect or condom may fall off; petroleum jell can deteriorate rubber; water soluble jelly should be used
Symptotjermal, protjermal or fertility awareness
Signs of ovulation should be taught: cervical mucus assessment, basal body temperature assessment, mittelschmerz
IUD
Contraindications: diabetes, anemia, abnormal pap, history of pelvic infections; high association with dysmenorrheal and infection
Oral contraceptives
Estrogen in pills prevents pituitary secretion of FSH, preventing ovulation; woman still menstruates; lowest failure rate of methods; contraindications: history of coagulation problems, thrmoboembolism, liver disease, reproductive cancer, coronary artery disease; compliance is a problem because it must be taken every day
Transdermal contraceptive patch
Mechanism of action, efficacy, contraindications and side effects are similar to those of oral contraceptives; continuous levels of progesterone and estradiol; applied to lower abdomen, upper outer arm, buttock or upper torso; applied on the same day ones a week for 3 weeks followed by 1 week without the patch
Norplant (levonorgestrel implant)
Sustained-release, subdermal, progestin only contraceptive; six thin, flexible capsules made of soft silastic tubing; planed in a fanline pattern just beneath the skin of the upper arm; effective within 24 hours after insertion, effective for 5 years; not dependent on clients compliance; reversible with return to previous level of fertility after removal; menstrual pattern changes, headache, nervousness; works by suppression of ovulation as well as by thickening the cervical mucus
Depo provera
IM injection 300mgq3months for contraception; during the first 5 days of menstrual cycle; efficacy 99%; protection from pregnancy is immediate after injection; experience weight gain and irregular/unpredictable menstrual bleeding; monitor for S&S of thrombophlebitis; contraindications: history of brest cancer, stroke, bloot clots, liver disease; effect: nervousness, dizziness GI disturbances, headaches, and fatigue
Respirations: normal newborn norms
30-60; remember ANCs; count 1 full minute by observing abdomen or auscultating
5 symptoms of respiratory distress in newborn
Tachypnea, cyanosis, flaring nares, expiratory grunt, retractions
Heart rate: normal newborn norms
110-160; 100 during sleep; 180 during crying; auscultate for 1 full minute
Temperature: normal newborn norms
97.7-99.4; measure axillary for 5 minutes; rectal approach can perforate rectum
Blood pressure: normal newborn norms
80/50
Weight: normal newborn norms
7lb 8oz; majority weight between 6-9lbs (2700-4000g); weight at birth and daily; normally loses 5%-15% of birth weight in the first week of life
Length: normal newborn norms
18-21 inches; 46-52.5 cm; crown to rump and rump to heel or from crown to heel at birth
Head circumference: normal newborn norms
33-35cm; normally 2cm larger than chest; tape measure placed above eyebrows and stretched around the fullest part of occiput, at posterior fontanel
Chest circumference: normal newborn norms
31-33cm; tape measure is stretched around scapulae over the nipple line
General appearance: normal newborn norms
Awake, flexed extremities, moves all extremities, stong lusty cry, obvious presence of subcutaneous fat, no obvious anomalies
General appearance: abnormal findings in the newborn
Little subcutaneous fat – intrauterine growth problems, fetal stress; frog position – prematurity; flaccid- asphyxia, prematurity; hard to arouse – sepsis, CNS problems, asphyzia; high pitched cry – CNS damage or anomalies, hypoglycemia, drug withdrawal
Integument: normal newborn norms
Smooth, elastic tugor and subcutaneous fat, superficial peeing after 24 hours; veins rarely visible; milia, vernix increases; lanugo, mottling; harlequin sign (pink-red skin o one side of body); erthema toxicum (pink popular rash), Mongolian spots, telangiectatic nevi
Integument: abnormal findings in the newborn
Extreme desquamation – postmaturity; many visible veins – prematurity; meconium staining – fetal distress; cyanosis – heart disease, asphyxia; jaundice (within 24 hours) – blood incompatibilities, sepsis, drug reactions; vesicles – herpes, syphilis; café-au-lait spots — neurofibromatosis
Head: normal newborn norms
Round or slightly molded, caput succedaneum that crosses suture lines; open, flat anterior and posterior fontanels, sutures slightly separated or overlapping due to molding
Head: abnormal findings in newborn
Bulging fontanel – increased ICP; sunken fontanel – dehydration; widely separated sutures – hydrocephalus; premature suture closure – genetic disorders; cephalhematoma – blood under periosteum due to trauma and does not cross suture lines
Eyes: normal newborn norms
Symmetrically placed, pseudostrabismus, chemical conjunctivitis, clear cornea, white blue sclera, subconjunctival hemorrhage from pressure, absence of tears, dolls eye movement
Eyes: abnormal findings in newborn
Purulent discharge – gonorrhea or chlamydia; brushfield spots in iris – down syndrome; absence of red reflex – congenital cataracts; epicanthal folds – down syndrome; setting sun sign – CNS disorders; absent glabellar reflex (blink) – CNS or neuromuscular problem
Ears: normal newborn findings
Pinna at or above level of line draw from other canthus of eye, well formed and firm with instant recoil if folded against head