NCLEX PN Review

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PUD S/S

Epigastric pain relieved with food
Left epigastric pain may radiate to back

PUD - thing to avoid

Caffeine

Dumping Syndrome

related to stomach surgery, food "dumps" into small intestine rapidly causing severe cramping and pain

Dumping Syndrome onset

5-30 min after eating

Dumping Syndrome Nursing considerations

Small Frequent meals
High-fat, High-protein, low CHO diet
Avoid Liquids with meals

Crohn Disease

Small and Large Intestine
a chronic autoimmune disorder

Crohn specific feature

Stricture of Intestines

CD Interventions

Symptomatic relief (NPO, TPN)
Complete bed rest /w ADL assistance

CD Drugs

Sedatives
Antidiarrheal
Sulfasalazine
Immunosuppressive
Antibiotics (fistulas)

Ulcerative Colitis

a serious chronic inflammatory disease of the large intestine and rectum characterized by recurrent episodes of abdominal pain and fever and chills and profuse diarrhea

UC S/S

Liquid stools 10-20 x's a day
Abd. Pain
Anemia

UC Interventions
-diet?

Low-residue, low-fat, high-protein, high-calorie diet
No Dairy products
Monitor I&O

Bowel Obstruction Auscultation
-Early vs Late

High-pitched bowel sounds with early mechanical obstruction
Absent with Late

Cirrhosis S/S

RUQ Pain
Jaundice
Fruity or musty breath (confused with DKA)
Asterixis

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.

Acute Pancreatitis S/S

Severe pain LUQ
deep, piercing and continuous
-Low-grade fever
Grey Turner spots

Grey Turner sign

24-48 hrs
discoloration over the flanks suggesting intra-abdominal bleeding.

Cullen sign

bruising around umbilicus (pancreatitis or ectopic pregnancy)

Steatorrhea

Passage of fat in large amounts in the feces due to failure to digest and absorb it

Cholecystitis

acute inflammation of the gallbladder

Cholelithiasis

formation of presence of gallstones

Lithotripsy

procedure for crushing a stone and eliminating its fragments either surgically or using ultrasonic shock waves, THEN STRAIN URINE

Calculi

kidney stones

BPH Tx

TURP

TURP post-op assessment
-drainage characteristics

blood-tinged urine normal for first few days
irrigation adjusted to keep urine diluted toa reddish pink, clearing to a pink tinge within 48 hrs.

TURP drainage obstruction

Clear with 20-30ml normal saline

TURP danger signs

Notify physician if client has bright red drainage with large clots

Oliguria

production of an abnormally small amount of urine

Diuretic phase

increased urine (water, not wastes). Kidney unable to conserve Na and H20. High BUN. Deficit of K, Na and H20. Azotemia

Azotemia

(excessive) urea and nitrogenous substances in the blood

Renal Diet

Low protein
Low sodium
Low Potassium
Low phosphate

Sulfonylureas

increase insulin prod. from the pancreas
(glipizide- Glucotrol))

Biguanides

reduce glucose production by the liver and enhance insulin sensitivity
(metformin - Glucophage)

Biguanides
-Diseases contraindicated (4)

Kidney disease
Liver disease
Heart failure
Alcoholism

Rapid Acting Insulin
-Onset/Peak/Duration
-Major Names

Aspart, Lispro
-Give 0-15 min before a meal
-Onset: 15 min
-Peak: 60-90 min
-Duration: 3-4 hrs

Regular Acting Insulin
-Onset/Peak/Duration
Major Name

Humulin R
-Onset: 30min-1hr
-Peak: 2-4 hr
-Duration: 6-8 hrs

Intermediate Acting Insulin

NPH
-Onset: 3-4 hrs
-Peak: 6-12 hrs
-Duration: 18-28hrs

Long Acting Insulin Warning

Cannot be mixed with any other type of insulin.
Usually given in Morning
No not shake solution

Long-Acting Insulin

Lantus
-Onset: 1-5 hrs
-Peak: none
-Duration: 24 hrs

Hyperthyroidism S/S

Tachycardia
Diarrhea
Exophthalmos
Wt. Loss
Goiter

Hyperthyroidism Diet

High Protein, Calorie
Low Caffeine, fiber

Thyroidectomy and Calcium gluconate

Always have a bedisde for acute Hypocalcemia r/t parathyroid (watch for Trousseauand Chvostek)

Thyroidectomy bedside equipment

Trach set
O2
Suction equipment

Hypothyroidism S/S

Bradycardia
Constipation
Periorbital edema

Myxedema

advanced hypothyroidism in adults characterized by sluggishness, slow pulse, puffiness in the hands and face, and dry skin (myx = mucous)

Myxedema Coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure

levothyroxine

hypothyroidism

levothyroxine (Synthroid)
-hold if?

Pulse > 100

Addison Disease

occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone

Addison Disease Causes

Sudden withdrawal from corticosteroids
Hypofxn of Adrenal cortex (infection, cancer, trauma)

Addison Disease S/S

Steroid Abuse/Chronic use
Hypovolemia/glycemia/natremia
Loss of Body Hair
Hyperpigmentation

Addison's Diet

High NaCl
High CHO
Low KCl
3L of fluid per day

Cushing Syndrome

Excess adrenal corticoid activity caused by Adrenal, Pituitary or Hypothalamus Tumors

Cushing's Syndrome S/S

Moon Face
Buffalo Hump
Enlarged Heart/HTN
Thin skin easily bruised
Purple Strae abd. obesity
Osteoporosis
Hirsutism

Cushing's Syndrome Diet

Low NaCl
Low CHO

Hypospadias

an abnormal condition in males in which the urethra opens on the under surface of the penis

Epispadias

a congenital abnormality in males in which the urethra is on the upper surface of the penis

Cryptorchidism

undescended testicles

Hydrocele

disorder in which serous fluid accumulates in a body sac (especially in the scrotum)

Cushing Triad

sign of increased ICP
-Widening of pulse pressure,
-Slowing HR
-Slowing Respiration

Cheyne-Stokes

Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea)

Suctioning time limit

15 seconds

Normal ICP

< 20 mm Hg

Decorticate Posturing

-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation)
-adduction of arms (arms fold to chest); flexion of elbows and wrists

Decerebrate Posturing

posturing in which the neck is extended with jaw clenched; arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. MOST SEVERE!!!

Parkinson's Disease

a neurological disorder that seems to be caused by dopamine depletion, marked by muscular rigidity, tremors, and difficulty initiating voluntary action

Parkinson's Nursing Plan

Take Medication with meals
Thicken Liquids
Soft ground foods

Guillian-Barre Syndrome

Self-limiting polyneuropathy of peripheral motor, sensory & autonomic nerves (not CNS)
Distal to Proximal
Usually occurs after an upper respiratory infection

GBS Tx

Intubation when paralysis ascends into thoracic space
Plasmapheresis over 10-15 days
Reposition frequently
May need TPN

Multiple Sclerosis

Demyelination of the CNS myelin
Characterized by periods of remissions and exacerbations

Bulbar muscle

Muscles of the mouth and throat
choke risk with MG

Myasthenia Gravis Dx

Tensilon test (2mg IV)
Brief improvement in local area for a few min

Myasthenic Crisis

inadequate medication.
+tensilon

Cholinergic Crisis

overdose medication. - Tensilon test.

Autonomic Dysreflexia

Hypertensive crisis (elevated systolic pressures of 160-300mm Hg), bradycardia, severe headache, stroke or seizure activity

Autonomic Dysreflexia Causes

Noxious stimuli such as full bladder, fecal impaction, wrinkle in clothing, menstrual cramps, erection, ingrown toenail, bladder infection, sitting on catheter tubing.

Amputation Post-Op
-stump positioning 24 vs 48 hrs

Prone 24hr

Detached retina S/S

described as curtain falling over visual field
Painless
may have black spots of floaters (indicates bleeding has occurred with detatchment

Ototoxic drugs
-three

Gentamicin
Vancomycin
Lasix

Respiratory assessment order

Inspection
Palpation
Percussion
Auscultation

Auscultation location

Hypoglycemia S/S

palpitations, tachy., sweat, fatigue, hunger

Hyperglycemia S/S

Fruity odor, headache, N/V, abd. pain, Rapid Pulse

Peak and Trough

used for drugs with narrow therapeutic index
trough-draw blood 30 min prior to next dose, peak is hour after admin

Stages of Shock

Initial
Compensatory
Progressive
Irreversible

Initial stage of Shock

Agitation
Restlessness
Increased HR
Cool pale skin

Compensatory stage of Shock

Confusion
Decreased urinary output
BP systolic < 100

Progressive stage of Shock

Weak thready pulse
Excessively low BP
Edema
Dysrhythmia

Irreversible stage of Shock

Profound hypotension
HR slows
Multi organ failure
Severe hypoxemia

Hypoxemia

deficient amount of oxygen in the blood

Hypovolemic shock

Most Common
r/t internal or external blood/fluid loss
(Post-op, OB)

Cardiogenic Shock

Pump Failure
decreased cardiac output

Vasogenic Shock

Failure of arteriolar resistance
Massive vasodilation and pooling of blood

Septic Shock

Endotoxins released from bacteria
Massive vasodilation and pooling

DIC

disseminated intravascular coagulation
-Abnormal Clotting then lack of clotting due to used up clotting factor.

ARDS definition

A disorder of the lung tissue caused by infection, shock, burns, or other insults in which the capillaries became leaky and the air spaces fill with fluid.

ARDS S/S

Refactory hypoxemia, decrease pulmonary compliance (elasticity); dyspnea, noncardiac-associated bilateral pulmonary edema; dense pulmonary infiltrates on x-ray (ground-glass appearance

ARDS Tx

ventilation, pressure support, and positive end-expiratory pressure (PEEP)

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Evisceration

wound separation with protrusion of organs

Pain Medication Assessments
-what changes

IV admin = 15 min
Peds = 30 min
Oral = 1 hr

Fluid Volume Excess causes

CHF, renal failure, cirrhosis, over-hydration

FVE S/S

Perpheral edema
periorbital edema
Elevated BP
Dyspnea
Altered LOC

FVE Labs

Decreased BUN, Hgb, Hct

FVE Tx

Diuretics
Fluid restriction
Daily weights
Monitor K+

FVD causes

Inadequate fluid intake
Hemorrhage
Vomiting
Diarrhea
Massive edema

FVD S/S

Wt. Loss
Oliguria
Postural Hypotension

FVD Labs

Increased BUN, Creatinine, Hgb, Hct

FVD Tx

Strict I&O
replace with isotonic fluids
Monitor BP
Daily Wt.

Hyponatremia S/S
-level

<135
Muscle Cramping
Confusion
Check BP Frequently

Hypernatremia S/S
-level

>145
Pulmonary Edema
Seizure
Thirst

Hypokalemia S/S
-level

< 3.5
DYSRHYTHMIAS,
Muscle Cramping

Hyperkalemia S/S
-level

>5
Muscle Weakness
Diarrhea

Hypocalcemia
-level

< 8.5
Trousseau/Chvostek sign
Numbness
Convulsions
Diarrhea

Trousseau's sign

carpal spasm result when a blood pressure cuff is inflated above the client's systolic pressure, and left in place for three minutes.

Chvostek sign

Cheek twitching

Hypercalcemia S/S
-level

>10.5
Muscle weakness
N/V
Behavioral changes
Constipation

HIV and Pregnancy
-Transmission

transmission possible
during pregnancy
time of delivery
after birth through breast feeding

HIV Tests

Screen = ELISA
Confirm = Western blot

ELISA

If Positive = Retest
If second Positive = Western Blot

Wound Intentions

Primary
Secondary
Tertiary

Primary Intention

Surgical Wound, wound edges are brought together (well-repaired lacerations, well reduced bone fractures, healing after flap) surgery

Secondary Intention

Commonly used in the management of contaminated or infected wounds.
The wound is allowed to granulate
Surgeon may pack the wound with a gauze or use a drainage system
(Stage 3 Pressure Ulcer)

Tertiary Intention

The wound is purposely left open due to heavy infection or contamination
initially cleaned, debrided and observed
(Tissue Graft, Stage 4 Pressure ulcer with necrotic tissue and infection)

ALL
-age

Acute lymphocytic leukemia
- before 14years

Hodgkin Lymphoma Dx

presence of Reed-Sternberg cells
-Painful

Non-Hodgkin Lymphoma

Non-painful enargement
MRI/CT

Colorectal Cancer S/S

Change in bowel habits
Ribbon-like stool

Loop Stoma

A loop stoma can be made in the ileum ("loop ileostomy") or colon ("loop colostomy"). A loop stoma often is made when the stoma will be temporary. However, not all loop stomas are temporary

Double-barrel Stoma

the surgeon divides the bowel completely. Each opening is brought to the surface as a separate stoma.
-Permanent

End Stoma

is formed when the proximal end of the bowel is brought to the outside abdominal wall.
-Permanent

Hemovac

Closed wound drainage system connected to a suction often used for mastectomy and total knee/hip replacement.

Jackson-Pratt

Closed wound suction drainage system often used for neurosurgery, neck surgery, abdominal surgery and urologic problems

Stoma Assessment

Should be Pink
-Blue = compromised circulation(notify M.D.)
-Red = skin irritation (non stoma skin exposed to gastric contents, ensure tight fit of bag seal)

Mammogram start age

40 = q1-2 years
50 = q Year

Mastectomy post-op

Position arm on operative side on a pillow

Dysplasia

abnormal development (of organs or cells) or an abnormal structure resulting from such growth

PSA age

prostate-specific antigen
50 and older

Chronic Bronchitis

Chronic sputum with cough production on a daily basis for a minimum of 3 months/year

Chronic Bronchitis Inspection

Right-sided heart failure
Cyanosis
Distended neck veins

Emphysema Inspection

Pursed-lip breathing
Noncyanotic

Chronic Bronchitis Auscultation

Crackles
Rhonchi
Expiratory Wheezes

Emphysema Auscultation

Distant breath sounds
Quiet breath sounds
Wheezes

Tuberculosis S/S

Low-Grade fever
Nigh Sweats
Anorexia
Wt. loss

TB Medication time till done

9-12 months

Definitive Dx of TB

1 positive TB screen and Chest X-ray

Left-sided Heart Failure effects

Inspiratory rales beginining at lung bases
Expiratory Wheezes (mis-DX as Asthma)
Dyspnea
Cough

Right-sided Heart Failure effects

Edema
JVD (jugular vein distention)
Dyspnea on exertion

Cholesterol Lower Drug

"statin"
atorvastatin(Lipitor)
simvastatin(Zocor)

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