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EXIT HESI Review

Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test

Terms in this set (149)

-1st it's very important to secure the scene and use the one rating system commonly used in the ED consists of three tiers — emergent, urgent, and nonurgent with the categories sometimes identified with color coding or numbers.
-The emergent classification (a.k.a. red or priority 1) is given to clients with life-threatening injuries (here, the clients with respiratory distress [airway] and partial amputation of the foot [bleeding/circulation]) who require immediate attention and continuous evaluation but have a high chance of survival once their conditions have been stabilized.
-The urgent (a.k.a. yellow or priority 2) classification is given to clients whose injuries and complications are not life threatening (here, the client with the fractured humerus), provided that they are treated within 1 to 2 hours; such clients require evaluation every 30 to 60 minutes thereafter.
-The nonurgent (a.k.a. green or priority 3) classification is given to clients with local injuries (here, the clients with the forehead laceration and bruises of the arms and legs) who do not have immediate complications and can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter.
-The overall goal of disaster nursing is to achieve the best possible level of health for the people and the community involved in the disaster. (Think what a nurse would do first when encountered with a disaster situation)

Geriatrics-med admin-prevent med error?

Know 6 rights: pt, dose, med, route, time, documentation
Give clear & simple instructions- Have pt repeat to verify they understand
Provide written material in large print
Assess functional status-LOC
Provide memory aides, calendar, med schedule, pills box (labeled mon-sun)
Monitor pt's responses to med & anticipate dosage adjustments prn
Assess swallowing ability capsule or tablet, if needed order liquid
Educate alternatives to med's such as proper diet instead of vitamins & exercise instead of laxatives
Educate pt to place med on front of tongue & swallow with fluid to help wash it to the back of throat, If pt continues to have trouble swallowing (if allowed crush med) and have pt try using pudding or applesauce.

nursing skills-mobility-Parkinson's disease?

-Chronic, progressive , debilitating neuro disease of the basal ganglia and substantia nigra (michael linares "lack of dopamine"), Affecting motor ability and slowness in the initiation and execution of mov't (bradykinesia) and postural instability (difficulties with gait and balance)
-Schedule activities later in the day to allow sufficient time for client to perform self-care activities without rushing.
-Encourage activities and exercise. A cane or walker may be needed.

integumentary-Pediculosis capitis-school health

-Teaching strategies: educate about basic hygiene practices for hair and scalp care
-Instruct pt's to wash hair with medicated shampoo from drugstore or prescription with cold water in a basin or sink (not in a shower), use the fine comb tooth and repeat tx q 12-24 hours.
-If needed after shampooing pick-out lice with tweezers
-Clean all rugs, pillows, blankets, carpets and clothes with hot water and dry hot heat for 30 min
-If exposed during sexual encounter notify partner

UAP home care?

Some of the responsibilities and duties of a personal support worker include, but are not limited to:
Observing, documenting and reporting clinical and treatment information, including patient's behavioral changes
Assisting with motion exercises and other rehabilitative measures
Taking and recording blood pressure, temperature, pulse, respiration, and body weight
Assisting with ambulating and mobilization of patients
Collecting specimens for required medical tests
Providing emotional and support services to patients, their families and other caregivers
Assisting with personal hygiene
Assisting with meal preparation, grocery shopping, dietary planning, and food and flu

Professional issues/anxiety/Communication//cultural/spiritual-Use of Interpreter?

-Rn to develop transcultural communication skills and be able to work with interpreters.
-On admission the Rn needs to, assess and document language(s) pt speak and write and determine if pt's need an interpreter. Pt's have a right to receive assistance
-Family members are not qualified to be used as interpreters for the pt when discussing health care needs for the pt, however family can assist with ongoing interaction during the pt's care. Health care centers are required to offer free language assistance all hours of the day.

Respiratory-Mechanical ventilator (MV)-aspiration?

-The purposes of MV are to improve gas exchange and to decrease the work needed for effective breathing until lung function is adequate for pt to breath on own.
-The Rn to assess the pt's respiratory status at least q4h for the first 24hrs, then prn:
-V/S q4h
-pt's color (lips and nailbeds), perform mouth care q2h, assess pressure ulcers around mouth.
-pt's chest for bilateral expansion
-assess placement of nasotracheal tube/endotracheal tube
-SpO2
-ABG's
-HOA to 30 - 45 deg when pt is supine to prevent aspiration and ventilator associated pneumonia
-Check alarms
-empty vent tubes when moisture collects, never empty tubing back into the cascade
-suction prn or q2h, listen to lungs for wheezes,crackles, equal breath sounds and or absent breath sounds.

ARDS-chemical paralysis?

-Patho: ARDS is an unexpected, catastrophic pulmonary complications occurring in a person with no previous pulmonary problem.
-Pt's are critically ill and are managed in an ICU setting. Mortality rate is high.
-Interventions to prevent complications: elevate hob 30', assist with daily awaking (sedation vacation), oral hygiene and assist with mobility.
-Monitor client for signs of hypoxemia and o2 toxicity, ABG's, LOC, I&O, and V/S.
-Suction only when secretions are present
-Pt's with ARDS who are briefly chemically induced for paralysis improves survival for critically ill and is used to recovery of. (so they stop fighting the ventilator )

Cardiovascular-Transvenous pacemaker-sensitivity?

-The pacemaker essentially does two things : it senses the patient's own rhythm using a "sensing circuit", and it sends out electrical signals using an "output circuit". If the patient's intrinsic rhythm becomes too slow or goes away completely, the electronic pacemaker senses that, and starts sending out signals along the wires leading from the control box to the heart muscle. The signals, if they're "capturing" properly, provide a regular electrical stimulus, making the heart contract at a rate fast enough to maintain the patient's blood pressure.

-it senses the patient's own rhythm using a "sensing circuit", This sensing and stimulating activity continues on a beat by beat basis.-this was very hard to find??????

Leadership-RN-assigned to critical care?

-Act as a liaison between the patient, the patient's family and other healthcare professionals. Leaders are also encouraged to use briefings, debriefings, and huddles to keep communication lines open throughout a shift (SBAR)

Popliteal BP?

-Located behind both knees, this site is used to assess status of circulation of lower legs. Always assess bilateral.

Ambulate-hemiparesis?

-Hemiparesis (one-sided weakness), when walking an assistive device is used, stand on the patient's affected side and support them with a gait belt. FYI: Never hold them by the arm for support, if pt falls then you might dislocate arm from shoulder.

Restraint 1?

-Physical restraints are only used as a last resort, when pt's behavior places them or others at risk for injury.
-A written order is required for all restraints and must include start/end times.
-Nurses must assess CMS, ABC's, use 2 finger check and know how to properly apply restraints.
-Ex: mitten restraints, freedom elbow restraint, extremity restraint and belt restraint while sitting.
-must never be written as a PRN order; each order must be renewed every 4 hours, for adults up to 24.
-assess the skin for any irritation every 30 min, pad bony prominences , tie to bed frame not rail, release every 2 hrs if not specifically contraindicated and always re- assess for need.

IV Assessment?

-IV assessment is used to maintain safety of the site and pt for, adverse reactions, overdose, and circulatory overload, use 6 rights of med admin, assess site infiltration, assess compatibility of medications, prevent transmission of microorganism's use sterile technique, and record pt's reactions to medication given.
-If IV infiltrates vein or phlebitis occurs: stop infusing medication, tx IV site as indicated per policy, and insert new IV site if continuing IV therapy.
-Never administer medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

PEG tube-Med admin?

-PEG tubes are surgically placed and formed via a fistula in (endoscopic procedure) the Ab wall, into the stomach. It is used for long-term enteral nutrition. This procedure has a high rate of inflections.
-MEDICATIONS: Check order against MAR, check allergies formula type and rate, purpose of administration and medications order (are they finely crushed?) Dissolved in 15-30 ml of warm water.
-Check residual- hold med if residual is >400ml.
-Raise or maintain head of bed 30-45 degrees prior to medications
-Remove plunger from 30-60 ml syringe, attach syringe to PEG tube, open clamp and pour in 15-30 ml water flush tube by regulating rate fast or slow by height of the syringe
-Using the syringe as a funnel, administer each medication separately, flushing after each med with 15-30 ml water. Final flush is 30-60 ml water. Close clamp.
Remove gloves and wash hands.
-Documentation: medication administered, assessments, type of formula and volume administered, pt's response/reactions, and amount of fluid administered on I&O record.

IV fluid tubing/safety

Incompatibility:
-Two incompatible solutions or medications must never come in contact with one another in an IV line.
-KCl is incompatible with many medications.
-When in doubt about compatibility flush, flush, flush with NS.
Pumps:
-Pumps use ccs/hr not gtts/min.
-Do not clear the pump before the change of shift. The number of cc's infused is used to calculate intake and output.
Piggybacks:
-An intermittent volume-controlled infusion (small volume 25-100 ml) connected to a secondary (shorter) tubing that is inserted into the upper Y-port of the primary infusion tubing. The primary infusion does not infuse at the same time as the piggyback but will resume infusion after the piggyback infusion is completed.
-The piggyback must always be higher than the primary to infuse and the piggyback tubing should be primed by back flushing if the medication is compatible with the IV solution that is infusing. Most nurses set IV pump piggyback volumes 5 cc's greater than the amount indicated on the bag so that all the solution in the piggyback tubing will infuse, leaving the tubing empty.
-Some nurses use a different set of piggyback tubing for each IV. This is not necessary if the medications are compatible. If the medications are incompatible back flushing make this unnecessary. If different sets of piggyback tubing are used the access device on the end of the piggyback tubing must be changed each time.

Medication Admin- filled syringe

Only touch the outside of the syringe barrel and the handle of the plunger to maintain sterility.
Inject air BF aspirating fluid.
Review FIG 31-19 pg. 605-608...... comparison of injecting..... angles 15, 45,90
Yellow pages at end of chapter. FYI
pg. 624-626 (preparing injections)
pg. 628-631 (administering meds)

CVA confusion

(CVA) or Stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue.
The following are the symptoms of Cerebrovascular accident:
Headache
Dizziness and confusion
Visual disturbance
Slurred speech or loss of speech
Difficulty of swallowing

Client teaching meds GERI

The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs.
Question: Quizlet nclex
A patient is taking delayed-release omeprazole (Prilosec) capsules for the treatment of gastroesophageal reflux disease (GERD). Which statement will the nurse include in the teaching plan about this medication?"
The entire capsule should be taken whole, not crushed, chewed, or opened."
Web: Polypharmacy
Best action of the nurse will be to continue to completely review all medications taken routinely, randomly, by prescription, from friends and over the counter during all medication reviews. client abuse Look for disorientation, diet and dehydration

Bed position - Nursing Responsibilities of the Nurse in Patient Positioning

Help the patient assume the desired or required bed position. The nurse assists the patient to achieve proper body positioning and alignment.
Support patient's body in correct alignment using pillows or splints.
Assure the proper use of supportive devices.
Frequently monitor and evaluate the position selected.
Provide skin care.
Keep patient beds in a low position rail on one side down etc.

point of maximal impulse (PMI)

Pulses in the Mitral area (the apex of the heart) are considered normal and are referred to as PMI, located at the fifth intercostal space in the midclavicular line. If it appears in more than one intercostal space and has shifted lateral to the midclavicular line, the PT may have left ventricular hypertrophy.
Mosby: Definition:
1. the point on the chest wall at which the maximal cardiac impulse is seen and/or palpated.
Synonyms: point of maximum intensity or Apical impulse
WEB: Now turn your attention to the patient's anterior chest wall, or precordium. Have the patient bare his chest. Inspect for an apical pulsation. This pulse, also called the point of maximal impulse (PMI) occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible and is more easily seen in patients who have thin chest walls or enlarged hearts, or in patients who are in high cardiac-output states, such as with exercise or fluid-volume overload. Having the patient sit upright or lean forward is useful, as it brings the heart closer to the chest wall. Breast tissue, of course, may make the PMI difficult to see. If the PMI is visible, be sure to note its location and size. Normally, the PMI is located near the fourth or fifth intercostal space near the left midclavicular line and covers an area no larger than that of a nickel. If the left ventricle is enlarged, as with left ventricular hypertrophy, the apical impulse may be visible over a larger area or displaced leftward or both. Be sure to inspect for pulsations all over the precordium and upper abdomen for any abnormal findings. Next, palpate the PMI. A visible PMI is usually palpable as a brief thump against your fingers. A pulsation that is so forceful it seems to "lift" your fingers upward is called a lift. A pulsation that feels rolling under your fingers is called a heave. Using a bony part of your hand, palpate for a thrill, or vibration, over the PMI.

Burns positioning

WEB: Joint contractures are one of the most challenging aspects of burn management and are the main source of disability for burn patients. Proper positioning of the patient, range of motion exercises and splinting are vital in bringing about the best functional outcomes in the rehabilitation of the patient. Proper positioning and range of motion exercises should be initiated from the beginning. Initial edema may make movement difficult, but the patient should be encouraged to do daily exercises.
Normally burn contractures only occur in patients with full-thickness burns (third degree burns) but they can occur in superficial burns that get infected and convert to full-thickness and take longer to heal.
Positioning:
Positioning is very important in the prevention of contractures and deformities. For burn patients, the "position of comfort" is the position that most leads to contractures. Scar contractures tend to occur more in areas where skin is loose or more pliable. Because scars continue to mature over a long period, it is critical to continue the positioning long enough to prevent the contractures. Scars in adults do not reach maturation for 6-24 months and in children, the time period is 12-24 months.
In the African context, it is the family members who are available and provide most of the daily care of the patient. It is most beneficial to explain to the family the proper positioning for the patient and then encourage them to help follow through during the day. There are basic items available to help position the patient that the family can use. They can use a rolled up towel to place behind the neck to keep the neck in extension if the burn is over the anterior portion of the neck. They can put pillows at the end of the bed between the patient's feet and the foot board to help keep the ankles at 90 degrees. They can use pillows or a rolled up blanket to put between the arm and the body to help keep the shoulder in abduction.

Muscular dystrophy

Refer family to the local chapter of the Muscular dystrophy Association (www.mda.org) for support, information and services.
Collaborate with physical and occupational health for patient needs.

Coumadin- dietary vitamin K

Eat small amounts of foods rich in vitamin K each day.
Your liver uses vitamin K to make blood clotting proteins. In doing so, vitamin K plays a role in your body's natural clotting process. Warfarin works against vitamin K. Specifically, warfarin reduces your liver's ability to use vitamin K to produce normally functioning forms of the blood clotting proteins. By reducing the liver's ability to use vitamin K to produce normally functioning forms of the blood clotting proteins, warfarin reduces your risk of forming a blood clot.
There are many things that can affect your INR. Because warfarin works against vitamin K, you should try to keep your daily intake of vitamin K consistent. Foods high in vitamin K include Swiss chard, kale, Brussels sprouts, broccoli, and spinach. Green tea is also a source of vitamin K.
Vitamin K can be used to lessen the effects of coumadin in case of over medication.

Osteoporosis- calcium needs

Teach PT and/or caregiver the current recommended dietary allowance for calcium and review foods high in calcium like (Vitamin D milk, leafy green vegetables, yogurt, and cheese).
Supplement: Calcium (with vitamin D if needed)
OS-cal, Citracl: 1-1.5 g in divided doses orally daily

Ulcerative colitis- diet

PT with severe sx- NPO to ensuree bowel rest, TPN for severely ill and malnourished, T.E.N elemental formula.
Avoid caffeine, alcohol, raw veggies and other high fiber foods. BC increase diarrhea and cramping.
Avoid lactose containing foods, carbonated beverages, pepper, nuts, and corn, dried fruits, and smoking.

VTE risk-Venous thromboembolism

PT are at Increased risk for a PE.
Most often seen in legs and upper arm
Highest occurrence in PT after hip surgery, total knee surgery or open prostate surgery.
others are UC heart failure, cancer, oral contraceptives, and immobility. IE bed rest, long flights on a airplane .
African americans are at higher risk BC predisposing factors.

Adverse drug reaction

STOP drug and contact the physician
Drug reactions encompass all adverse events related to drug administration, regardless of etiology.

Aspiration- unilateral weakness

PT with stroke: Dysphagia
NPO until swallowing can evaluated.
Observe for drooping, drooling, impaired voluntary cough, hoarseness, incomplete mouth closure or cranial nerve palsies.
Check Gag reflex, collaborate with SLP and dietician for screening and eval.
Minimize disruptions, watch for fatigue.
Add Thickened to liquids
proper bed position
OCC health consult for self feeding utensils.
WEB: Tucking the chin (neck flexion) or holding the breath before swallowing may reduce aspiration. Turning the head toward the weak side may improve pharyngeal clearance by deflecting the bolus to the strong side in a patient with unilateral pharyngeal weakness.

Hypertonic IV- fluid overload

Hypertonic- cell shrinks, fluid moves out of the cell to the interstitial compartments
Solution is more concentrated than normal blood.
NANDA: The state in which an individual experiences increased fluid retention and edema Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required.

Hypertonic IV- fluid overload - defining characteristics

• Weight gain
• Edema
• Bounding pulses
• Shortness of breath; orthopnea
• Pulmonary congestion on x-ray
• Abnormal breath sounds: crackles (rales)
• Change in respiratory pattern
• Third heart sound S3
• Intake greater than output
• Decreased hemoglobin or hematocrit
• Increased blood pressure
• Increased central venous pressure (CVP)
• Increased pulmonary artery pressure (PAP)
• Jugular vein distention
• Change in mental status (lethargy or confusion)
• Oliguria
• Specific gravity changes
• Azotemia
• Change in electrolytes
• Restlessness and anxiety

IV site pain

Inflammation and clot formation
• Problem: The IV site is swollen, red, and warm.
• Possible cause: Inflammation of the vein with possible clot formation due to trauma, bacteria, or irritating solutions
• Assessment: The patient reports tenderness, burning, and irritation along the accessed vein. The rate of infusion has slowed. (With clot formation, the vein might have a palpable band along its path and the patient might have fever, leukocytosis, and malaise.)
• Intervention: Stop the infusion and discontinue the IV line. If you suspect clot formation, apply a cold compress first to decrease blood flow and to increase platelet aggregation at the site and follow it with a warm compress and elevation of the extremity to help reduce or eliminate the irritation. Establish new IV access proximal to the original site or in the other extremity if IV therapy must continue.
• Prevention: Make sure the medication's concentration is appropriate for peripheral administration. Medications like potassium are more concentrated for central IV access and more dilute for peripheral access. Also be sure to use the appropriate-size catheter for the vein and aseptic technique for IV insertion. Anchor the IV well to prevent movement of the catheter and irritation of the vein. Change and rotate IV sites according to your agency's policy. To prevent clot formation, avoid trauma to the vein at the time of insertion. Make sure all medications and fluids are compatible. Observe the IV site every hour during medication infusions to ensure patency and to watch for early signs of complications.

IV site pain - Infiltration

• Problem: The tissue surrounding the IV insertion site is swollen, pale, and cool to the touch.
• Possible cause: Unintentional administration of solution or medication into the surrounding tissue
• Assessment: Leaking from the IV site with slowing or occlusion of fluid flow. The patient reports tenderness, discomfort, and coolness in the area surrounding the IV insertion site.
• Intervention: Stop the IV infusion and discontinue the IV line. Elevate the extremity, apply warm compresses three to four times per day, encourage active range of motion, and follow your agency's policy for site care and documentation of infiltrated IVs. Establish new IV access proximal to the original site or in the opposite extremity if IV therapy must continue.
• Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein.

IV site pain - Extravasation

Problem: The tissue around the IV site is pale or discolored and cool to the touch.
• Possible cause: Inadvertent administration of an irritant solution or medication into the surrounding tissue. Vasoconstrictors, calcium, and chemotherapy drugs are examples of drugs known to cause tissue necrosis with extravasation.
• Assessment: The pale or discolored tissue surrounding the IV insertion site shows signs of progressing to blistering and inflammation and could ultimately become necrosed.
• Intervention: Extravasation is an emergent situation, as it can cause serious tissue necrosis. Stop the IV infusion and discontinue the IV line. Consult your agency's policy or a pharmacist for specific care of the extravasated tissue or use a medication manual to determine the appropriate care (for example, injection of phentolamine within the extravasation border). Follow your agency's policy for proper documentation. Establish new IV access in the opposite extremity if IV therapy must continue.
• Prevention: Observe the IV site frequently during infusion. Avoid inserting IV access devices in areas of flexion. Secure IV tubing to minimize movement of the IV catheter within the vein. Use the smallest catheter possible for accommodating the vein. If central access is available, infuse solutions and medications known to cause tissue necrosis via central venous access.
Also Phlebitis, infection, and bending at vein puncture site.

/Elimination-Urine C&S Specifics on techniques, what to look for and collection of urine samples

Urinalysis is part of any complete physical examination and is especially useful for patients with suspected kidney or urologic disorders. Ideally the urine sample is collected at the mornings first void, because specimens obtained at other times may be too dilute. The urine specimen may be collected by several techniques.
**Midstream clean catch specimen is preferred for culture and sensitivity testing because of the reduced incidence of cellular and microbial contamination. This method can be collected and anytime of day or night.
C-identifies the microorganism that is causing the issue, such as UTI, and S-determines which antibiotic agent is most effective in killing the bacteria. (Nurse would do the following if the patient was unable to do this themselves)
Patients are required to first cleanse the urethral area with a castile soap towelette or iodine solution, to significantly reduce the opportunities for contaminants to enter the urine stream.
The urine midstream is then collected into a clean/sterile container that should not touch the genitalia. Any excess urine should be voided into the toilet.
Internet

Burns-Parkland Formula

Parkland formula is a starting point for fluid resuscitation and is used in the first 24hours of fluid resuscitation.
Determine the % of BSA that is burned by using Rule of 9's: Head and each arm=18%, Back and chest each=18%, Each leg=18% and Perineum=1%
Determine patient's weight in kg
Parkland formula: 4 X kg X %Burned=Amount of IV fluid to be given in first 24hrs
Administer ½ of the calculated fluid in the first 8hrs and the other ½ in the next 16hrs.
-internet

IV Heparin pump

Infusions prescribed by Unit Dosage per hr
Steps:
Determine the amount of medication per 1ml
Determine the infusion rate or ml/hr
EX- RX=continuous heparin sodium by IV at 1000 units per hour
Available: IV bag of 500 ml D5W with 20,000 units of heparin sodium
How many ml/hr are required to administer the correct dose?
1. known amount of med in solution= Amount of med per ml total volume of diluent
2. doses per hr desired= infusion rate, or ml/hr concentration per/ml
Calculate the amount of medication per ml:
20,000 units = 40 units/1ml
500 ml
Calculate ml/hr:
1000 units= 25ml/hr
40 units

Patho-Protein binding drugs

Protein binding describes the ability of proteins to form bonds with other substances, and most commonly refers to the bonding of drugs to these molecules in blood plasma, RBCs, other components of the blood, and to tissue membranes. It can however, refer to other chemicals that enter the bloodstream. Proteins are large and complex molecules consisting of chains of amino acids joined by peptide bonds, and they can take on a variety of complicated shapes. They can bond with molecules, including other proteins at particular binding sites. The chemical properties of the binding sites are very important because bonding will only take place if it's chemically feasible. A single protein may have more than 1 binding site.
Albumin, lipoproteins and a1-acid-glycoprotein (AGP) are the proteins commonly involved in binding with drugs. Acidic and neutral compounds tend to bind with albumin, which is basic and basic substances will primarily bond to AGP because it is acidic. If the albumin is saturated, acidic compounds may also bond with lipoproteins. Binding is often reversible. The amount of drug that is bound determines how effective it is in the body. The bound drug is kept in the blood stream while the unbound component may be metabolized or excreted, making it the active part. Ex: Drug is 95% bound to a binding protein and 5% is free, the 5% is active in the system and causing pharmacological effects. -internet

Peds-IV safe dosage

Convert child's body weight to kg
There should be a safe dosage range listed regarding the drug in use
Multiply the amount needed to be administered by the child's body weight in kg
Compare the results to the safe dosage range to make sure it falls within it
If it is too low or too high then it is not within the safe dosage range.

Pedi-Basic nursing/Skills/Nutrition/Teaching-Protein Intake

Protein is needed for healing and lack of adequate nutrition can lead to many issues.

Cystectomy with ur division

Preoperative Interventions
Instruct the client in preoperative, operative and postoperative management including diet, medications, ng tube placement, IV lines, NPO status, pain control, coughing, and deep breathing, leg exercises and postoperative activity.
Demonstrate appliance application and use for patient's who will have stoma.
Arrange an enterostomal nurse consult and visit with someone who has a ur diversion.
Administer antimicrobials for bowel prep as prescribed
Encourage discussion of feelings including effects on sexual activities
Postoperative Interventions
Monitor vitals
Assess incision site
Assess stoma every hour for first 24 hours-should be red and moist
Monitor for edema in the stoma-it may be present in the immediate postoperative period
Notify HCP if stoma appears dark and dusky-indicates necrosis
Monitor for stoma prolapse
Assess bowel function. Monitor for expected return of peristalsis (3-4 days)
Maintain NPO as prescribed-until bowel sounds return
Monitor for continuous urine flow (30-60 ml/hr) Notify HCP if urine output is <30 ml/hr or if no urine output for more than 15 min
Monitor urinary drainage pouch for leaks and check skin integrity (Box 52-19)
Monitor urine pH-highly alkaline or acidic urine can cause skin irritation and facilitate crystal formation (do not stick dipstick in the stoma)
Ureteral stents or catheters, if present, maintain stability with catheters to prevent dislodgement-they may be in place for 2-3 weeks or until healing occurs
Monitor for hematuria
Monitor for signs of peritonitis
Monitor for bladder distention following a partial cystectomy
Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity lymphedema after a radical cystectomy.
Instruct the client regarding the potential for UTI or development of calculi
Instruct the client to assess skin for irritation, monitor urinary drainage pouch and report any leakage
Encourage client to express feelings about changes in body image, embarrassment, and sexual dysfunction

Prof Issues-HTN Teaching

Describe importance of compliance w/tx plan
Describe the disease process-explain that symptoms usually do not develop until organs have suffered damage
Initiate and assist the client in planning a regular exercise program, avoiding heavy weight lifting and isometric exercises
Emphasize importance of beginning exercise program gradually
Encourage client to express feelings about daily stress
Teach relaxation techniques and how to incorporate them into their daily living pattern
Assist the client in ways to reduce stress
Instruct the client and family how to monitor bp
Instruct client to maintain a bp diary
Emphasize the importance of lifelong medication and importance of follow-up treatment
Instruct the client and family about dietary restrictions which may include sodium, fat, calories and cholesterol
Instruct client how to shop for and prepare low-sodium meals
Provide list of products that contain sodium
Instruct/Teach client to read labels of products to determine sodium content (sodium, MSG, NaCL)
Instruct the client to bake, roast, or boil foods, avoid salt in prep of foods, and avoid using salt at the table
Instruct client to avoid canned foods; fresh foods best to consume
Instruct client about the actions, side effects and scheduling of medications
Advise the client to contact HCP if uncomfortable side effects occur, but NOT to stop the medication
Instruct client to avoid OTC's
Stress the importance of follow-up care

Geriatrics/Sensory-Hearing

Some hearing loss affects ⅓ of all adults between 65-74yrs
About ½ ages 75-79yrs
Appearance of ear changes-making it appear larger- (especially in men)
Auricle loses flexibility-becomes longer and wider
Tragus enlarges
Lobe sags, elongates and wrinkles
Coarse, wiry, stiff hairs grow at the periphery of the auricle
Auditory canal narrows-hairs that line it become stiffer and coarser
Cerumen glands atrophy, causing wax to become thicker and dryer-ear wax blocking the canal can cause temporary reversible obstructive hearing loss
Presbycusis-loss of the ability to hear high frequency sounds

Geriatrics/Med Surg-Colostomy Home care

Dietary and fluid intake and habits
Presence or absence of N/V
Weight gain/loss
Bowel sounds
Bowel elimination pattern, characteristics, and amount of effluent (stool)
Assess condition of stoma, including:
Location, size, protrusion, color and integrity
Signs of ischemia-dull coloring or dark or purplish bruising
Assess peristomal skin for:
Presence or absence of excoriated skin, leakage underneath drainage system
Fit of appliance and effectiveness of appliance and skin barrier
Assess patient's and family's coping skills, including:
Self-care abilities in the home
Acknowledgement of changes in body image and function
Sense of loss
General:
Assess for ability for self-management within limitations
Home care can be provided for those requiring assistance
Review home situation to aid patient in arranging for care
Ostomy products should be kept in area where it is neither hot nor cold to ensure proper functioning
No changes are needed for sleeping accommodations; they may place a moisture-proof covering over the bed mattress if patients feel insecure about the pouch system
No diet restrictions-usual diet may be resumed after discharge

Adverse drug reaction

STOP drug and contact the physician
Drug reactions encompass all adverse events related to drug administration, regardless of etiology.

Geriatrics Professional Issues- Leadership/teaching

"Interventions to promote independence in ADLs address a person's physical ability, cognitive ability and safety. The physical ability to perform ADLs requires strength, flexibility and balance. you need to make accomodation for impairments of vision, hearing and touch. The cognitive ability to perform ADL requires the ability to recognize, judge, and remember..."

Nursing Process- Hospice

"Hospice care is a philosophy and a model for the care of the terminally ill patients and their family...Pts accepted into hospice are usually have 6 to 12 months to live, nursing hospice services are avaliable in home, hospital, extended care or nursing home settings... Nurses providing hospice care use therapeutic communication, offer psychosocial care and expert symptom management, promote patient dignity and self esteem, maintain a comfortable and peaceful environment, provide spiritual comfort and hope, protect against abandonment or isolation, offer family support, assist with ethical decision making and facilitate mourning... As a patient's death gets closer the hospice team provides intensive support to the patient and family."

Geriatrics/Professional Issues- Medical Surgical- Leadership/Nursing Process-Osteoporosis

-Background: Bone Mineral Density (BDM): Determines bone strength and peaks between 25-30 years of age. BDM, decreases most rapidly in postmenopausal women as serum estrogen levels diminish. Although estrogen does not build bone, it helps prevent bone loss.
-Diagnosis: There are no definitive laboratory test that confirm a diagnosis of primary osteoprosis, although a number of biochemical markers can provide information about bone resorption and formation activity. X-rays can show bone loss, but only after 25%-40% bone loss, mostly seen after a fracture has occurred through x-ray ("silent disease").
-Planning: Expected outcome is that the pt avoids fractures by prevention of falls, managing risk factors, and adhering to preventative measures and treatment for bone loss.
-Intervention: Nutritional therapy (protein, mag, vit k, calcium, and vit D. Pts should avoid alcohol and caffeine consumption
Exercise/Life style changes: Strengthen abdominal and back muscles, muscle tightening, active ROM, improve joint mobility. SWIMMING, LOW IMPACT good resistance and strengthening. Walking for 30 min 3-5 times a week is the single most effective exercise for osteoporosis PREVENTION.

-Drug Therapy:
Calcium and vit D supplements, Biophoshponates (BPs) slow bone resorption (FOSAMAX, BONIVA, ACTONEL) these should be taken early in the morning with 8 oz of water and wait 30-60 min in an upright posistion before eating. If esophageal irritation discontinue (CHOCKING) and consult with HCP.
-Community Based Care:
Pts are typically managed at home, DXA scan done annually, possible long term care facility (but after numerous falls/fractures), refer pts to National Osteoporosis Foundation.

Geriatrics post CVA- Rehab POC

Stroke (CVA) Cerebralvascular accident: caused by change in the normal blood supply to the brain.
Rehab POC: PT and OT, and nursing management
-Managing of impaired swallowing: Pt is expected to avoid aspiration and have adequate nutrition to promote health and prevent complications, including major weight loss
Post CVA, pt should remain NPO until further swallowing ability is assessed and a plan of care is developed for impaired swallowing. Before ANY medciations or liquids are given. The pt swallowing needs to be assessed.
Improving mobility and promoting self care: pt with a CVA is expected to ambulate and provide self care independently with or without assistive devices.
Pts typically have flaccid or spastic paralysis. It is crucial that the nurse supports the affected flaccid side of the stroke patient, and to avoid pulling on the arm to prevent dislocation of the shoulder. Place arm on a pillow while sitting to prevent hanging of the arm, PT or OT may provide sling in order to support the arm during ambulation.
DVT and VT are big risk factors that can lead to PE. Prevent this complication by applying sequential compression stockings (SCDs), changing of the pts position regularly (Q2 Turns), and ambulation of the patient as frequently as possible if possible. Report any indications of DVT to health care provider and document accordingly.
Promoting Effective Communication: pt with CVA is expected to receive, interpret and express spoken, written and nonverbal messages, IF POSSIBLE.
Pictures, assistive devices, reassuring the pt when they become confused, irritated or frustrated when they are unable to express there speech or understand.
Promoting continence: The pt with a stroke is expected to control elimination of urine and stool.
Find the cause of pts incontinence first, may be due to being unconscious, impaired innovation of the bladder, or the inability to communicate the need to urinate or defecate. Before any training is started establish a bowel training program determine any routine that may help the patient with toileting
encourage the pt to drink prune juice and eat foods high in fiber to increase to help promote bowel elimination.
If pt has a cath, remove as soon as possible.
Managing Sensory Perception: pt with a stroke is expected to adapt to sensory changes in vision, proprioception (position sense) and sensation, along with free from injury.
Always approach the pt from the unaffected side, which should face the door of the room. Place objects within the pts field of vision. Mirrors may make it better or easier to visualize the entire room.
To assist with memory impairment that MAY or may not be present after stroke. Reorient the pt to the year, month and day of the week and the circumstances that surround the hospitalization.
Preventing Unilateral Body Neglect: The pt with a stroke is expected to adjust and use technique to compensate for unilateral body neglect.
Most commonly seen in right sided cerebral stroke. Teach the pt to touch and use both side of the body. When dressing, dress the affected side first.

Geriatrics/Nursing Process- Hip fx/Bucks tx-POC

-One of the two most common type of traction is skin tractions, also known s Bucks Tractions. Thi is typically secured around the affected leg. The primary purpose of skin traction is to decrease painful muscle spasms that accompany hip fractures. The weight is used as a pulling force and is limited to 5-10 lbs to precent injury to skin.
- The nurse may set up or assist in the setup of traction if specially educated. Typically physicians assistants set up traction. Once placed weights are not removed unless prescribed. They should not be lifted or placed on the floor. Weights should be freely hanging, at all times. Teach the importatnces to CNAs, other medical members, and family members/visitors. Assess skin every 8 hours for signs of irritation or inflammation. When possible remove the belt or boot that is used for skin traction every 8 hours to inspect under the device.
- Check equipment frequently to ensure proper functioning. If pt reports svere pain from muscle spasm the weights may be to heavy or the pt may need to be realigned. Report pain to HCP, if body realignment does not help, assess affected body part for circulation, compromise and tissue damage. The circulation is usually monitored every hour for the first 24 hours, after traction is applied and every 4 hours after.

Maternity-Antepartum/Preclampsia S&S

Preeclampsia is a pregnancy-specific syndrome that usually occurs after 20 weeks gestational hypertension plus proteinuria. This is the most common hypertensive disorder, occurs during pregnancy and is characterized by elevated BP and proteinuria. Greater or equal to 140/90 mm. No known causes. The major goal of nursing care for a client with preeclampsia is to maintian uteroplacental perfusion and prevent seizures. This reqire the administration of magnesium sulfate if signs of toxicity exist: respirations less than 12/min, absence of DTRs, or urine outsput less than 30ml/hr. Althought delivery is often described as the 'cure' for preeclampsia, the client can convulse up to 48 hour after delivery.
In addition to swelling, protein in the urine, and high blood pressure, preeclampsia symptoms can include: Webmd.com
Rapid weight gain caused by a significant increase in bodily fluid.
Abdominal pain.
Severe headaches.
Change in reflexes.
Reduced urine or no urine output.
Dizziness.
Excessive vomiting and nausea.
Vision changes.

Maternity Signs of Pregnancy

Nausea presists up to 12 weeks, uteru changes from pear to globular shape, hegar sign occurs (softening of the isthmus of cervix), goodell sign occurs (softening of the cervix), cervix flexes, leukorrhea increases, chadwick sign (bluing of vagina) appears as early as 4 weeks.

Maternity- Intrapartum- Early decels-action

Early deceleration of the FHR is a visually apparent, gradual (onset to lowest point greater than or equal to 30 seconds) decrease in and return to baseline FHR associated with UCs. it is thought to be caused by transient fetal head compression and is considered a normal and benign finding. Generally the onset, nadir, and recovery of the deceleration correspond to the beginning, peak, and end of the contraction. For this reason an early deceleration is sometimes called mirror image of the contraction.... because early decelerations are considered to be benign, interventions are not necessary. The value of identifying them is so they can be distinguished from late or variable decelerations, which can be abnormal and for which interventions are appropriate. There is no nursing intervention required due to it being caused from a benign

Maternity- Intrapartum- Oxytocin Contraindications

Contraindications:
where there is significant cephalopelvic disproportion
unfavorable fetal positions or presentations, such as transverse lies, which are undeliverable without conversion prior to delivery
Obstetrical emergencies where the benefit-to-risk ratio for either the fetus or the mother favors surgical intervention
in fetal distress where delivery is not imminent
adequate uterine activity fails to achieve satisfactory progress
where the uterus is already hyperactive or hypertonic
in cases where vaginal delivery is contraindicated, such as invasive cervical carcinoma, active herpes genitalis, total placenta previa etc...
in pts with hypersensitivity to the drug

Maternity- Newborn- Flea bite rash

Erythema Toxicum also known as flea bite dermatitis: appears in neonates during the first 24-72 hours after birth and can last up to 3 weeks. Contains lesions at different stages, papules, vesicles and macules. Lesions may appear suddenly anywhere on the body. The rash is thought to be an inflammatory response. Eosinophils may be prescribed to decrease inflammation, however the rash being alarming it has no significance and requires no treatment.

Maternity- Postpartum- Inverted mipples

Inverted nipples, which can affect the babys ability to successfully latch on to the breast. To determine if nipples are inverted a woman can perform a test on her nipples to determin freedom of protrusion. Exercise to break the adhesions that cause the nipple to invert do not work and may cause uterine contractions. Some clinical recommmend the prenatal use of breast shells during the last trimester for women with flat or inverted nipples, although evidence to support their effectiveness is lacking. they can be uncomfortable and cause irritation to the nipple or areola. breast stimulation is contraindicated in women at risk for preterm labor, there for decision making should be made judiciously.

Maternity- Postpartum- Postpartum Infection

Postpartum infection or puerperal infection, is any clinical infection of the genital tract that occurs within 28 days after miscarriage, including induced abortion or birth. Includes a temp of 38 C (100.4 F) or more on 2 successive days of the first 10 postpartum days. Common postpartum infections include wound infections, UTIs, and endometritis (infection of the lining of the uterus). for predisposing factors for postpartum infections.

Maternity/Medical Surgical- Antepartum- Novel H1N1- admission

Swine flu generated a pandemic in 2009, caused significant morbidity and mortality particularly in Mexico and the US.
Therapeutic management: tylenol, fluids, Symmetrel may help but does not cure the disease.
Prevention: vaccine recommended for children 6months to 18 years.

Medical Surgical- Cardiovascular- Aneurysm

Mostly related to AAA, physical assessment will include abdominal flank or back pain, pain is usually steady, unaffected by movement and lasting for hours or days. Pulsation in the upper abdomen slightly to the left of the midline between the xiphoid process and the umbilicus. Auscultate for a bruit over the mass, but avoid palpating the mass because it may be tender and there is risk for rupture. assess for hemorrhagic shock, signs and symptoms include hypotension, diaphoresis decreased level of consciousness, oliguria, loss of pulses distal to the rupture and dysrhythmias. Rupture into the abdominal cavity causes distention.

Medical Surgical- Cardiovascular- MI-EKG changes

Myocardial Infarction (MI) occurs when myocardial tissue is abruptly and severely deprived of oxygen. when blood flow is quickly reduced by 80-90%, ischemia develops. ischemia can lead to injury and necrosis of myocardial tissue if blood flow is not restored.
-When a infraction occurs, one of the three ECG changes is usually observed: ST-Elevation MI (STEMI), T wave inversion, or non-ST-elevation MI (NSTEMI). An abnormal Q wave (wider than 0.4 seconds or more than one-third the height of the QRS complex) may develop, depending on the amount of myocardium that has necrosed. women having an MI often present with an NSTEMI or T-wave inversion. pp 836 Med Surg

Medical Surgical- Cardiovascular- Mitral Valve

The mitral valve (bicuspid) separates the LA from the LV. During ventricular diastole, these valves act as funnels and help move the flow of blood from the atria to the ventricles. During systole, the valves close to prevent the backflow (regurgitation) of blood into the atria.

Medical Surgical- Cardiovascular/Endocrine- Hypopituitarism

Some of the hormones involved in the pituitary gland could eventually affects BP but nothing that i can see that directly affects the heart.
Hypopituitarism: This type of pt has deficiency of one or more anterior pituitary hormones, resulting in metabolic problems and sexual dysfunction. If only one hormone is affected, the condition is known as selective hypopituitarism. Decreased production of all of the anterior pituitary hormones is an extremely rare condition known as panhypopituitarism. Hormones that are involved, include: growth hormone, luteinizing hormone, follicle stimulating hormone, thyroid stimulating hormone, adrenocorticotropic hormone, and vasopressin (antidiuretic hormone).

Medical Surgical-- Cardiovascular/Immune/Hematology - Prasugrel-ecchymosis

Prasugrel (Effient) - antiplatelet drug. Decreases risk or post-op bleeding
Contraindicated for patients over 75, or with a history of prior stroke.

Medical Surgical - Cardiovascular/Operative/Physical Assessment - DVT-action

DVT (deep vein thrombosis) - Increase risk for PE (pulmonary embolism).
-Most often occurs in legs but can occur in arms with use of central lines.
-May be symptomatic but classic signs are:
Calf/groin tenderness/pain
Sudden onset of unilateral swelling
Positive Homan's sign (pain when dorsiflexing the foot) is not advised because of false positives and low level of effectiveness when assessing this way.
Induration (hardening) along the blood vessel with warmth and edema.
Prefered diagnostic test: Venous duplex ultrasonagraphy.
Treatment:
Rest
Drug therapy (anticoagulants)
IV unfractionated heparin to treat acute issue followed by warfarin therapy.

Medical Surgical - Endocrine - Cushing syndrome-glucose

" Glucose metabolism is profoundly affected by hypercortisolism. Fasting blood glucose levels are high because the liver is stimulated to convert more glycogen to glucose and the insulin receptors are less sensitive, so blood glucose does not move as easily into the tissues. In addition muscle mass loss reduces glucose uptake" (P. 1386). These patients usually are diabetic also.

Medical Surgical - Endocrine - Kussmaul respirations

Kussmaul respirations are usually seen in Metabolic Acidosis.
Specifically: Diabetic ketoacidosis
Breaths are deep and rapid and not under voluntary control Also called "Air hunger

Medical Surgical - GVHepatic - GERD-pantoprazole

Protonix (Pantoprazole) - Proton Pump Inhibitor (PPI)
-Reduces acid production
-Primary treatment for severe GERD
-May be given in IV form to treat or prevent stress ulcers.
-Long-term use may cause community acquired pneumonia/ GI infections.
-Long-term use increases risk for hip fractures
-PPI's interfere calcium absorption and protein digestion reducing available calcium to bone tissue.

Medical Surgical - GI/Hepatic - Peptic ulcers-time

Duodenal ulcer pain is usually located to the right of the epigastrium.
The pain associated with a Duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the patient at night.

Medical Surgical - GI/Hepatic/Oncology - Ondansetmn after chemotherapy

Zofran (Ondansetron)
Prevents/treats nausea/vomiting.
May induce bradycardia, hypotension & vertigo.
Tell patient to change positions slowly to avoid falls.

Medical Surgical - Musculoskeletal - Crutch walking prep

Crutches require balance, coordination, and arm strength. For this reason crutches are not usually recommended for the older adult. (Walkers or canes should be used instead).
2-3 finger width between the top of the crutches and the armpit to prevent nerve damage or bursitis.
Elbow should be flexed no more than 30 degrees.
2-point gait
Requires partial weight bearing on affected leg.
moves crutch at the same time as the opposing leg (similar to normal walking).
3-point gait (most common)
Requires pt. to bear all weight on one foot.
Can advance to touch-down weight bearing of the affected leg.
Pt. will bear weight on both crutches and then on the unaffected leg
4-point gait
Requires weight bearing on both legs.
Each leg moves alternately with each opposing crutch so 3 points of support are on the ground at all times.

Respiratory - Pulmonary embolism
1st action:

oxygen administration

Pg. 743 (box) Saunders/NCLEX (purple)
Notify Rapid response team
Reassure pt. and elevate head of bead.
Prepare to administer oxygen.
Obtain vital signs and check lung sounds.
Prepare to obtain ABG
Prepare for administration of heparin therapy.
Document the event, interventions taken, and the client's response to treatment.

Musculoskeletal/TraumaÆmergency - Emergency treatment

In the case of a possible fracture:
Immobilize affected extremity with cast or slpint.
Assess neurovascular damage For example, color, sensation, motion, temperature.

Neurological - Huntington's

The 2 defining characteristics of huntington's disease are
Progressive mental status changes
Leading to dementia
Following directions becomes difficult as the disease progresses.
Choreiform movements, ie: Rapid, jerky movements

Neurological - Naloxone-CNS depression

Naloxone (Narcan) does not produce analgesia or Respiratory depression.
Drug of choice for complete or partial reversal of opioid induced respiratory depression.
Only available in injectable form (IV or IM).
Patients with long acting opioid overdose may need numerous doses and should be reassessed frequently.
rapid acting (less than 2 minutes)
also relatively short duration of action (30 min. to 2 hours)

Neurological - Neuropathic pain

Pain resulting from damage along a nerve.
Divided into 2 categories by location
Peripheral
central
Symptoms:
Decreased sensation
Pain-aching/burning/tingling "pins & needles"
skin breakdown
Complications:
non-healing ulcers
gastric paresis
erectile dysfunction
Treatment:
Antidepressant
duloxetine (cymbalta)
Elavil
nortriptyline (Pamelor)
Anticonvulsants
gabapentin (neurontin)
pregabalin Lyrica
Treating the underlying cause
such as in diabetes (keeping blood sugars under control to prevent worsening of the pain.
***None of these drugs should be stopped abruptly. Pt. must gradually reduce dose.

SCI- assess lumbosacral plexus

Lumbosacral plexus L1-S2
Assessment:
Assess how injury occurred (sport, car accident, trauma etc)
After nerve(s) is damaged or cut, the nerve distal to injury degenerates and retracts within 24 hrs
Perform physical assessment to determine which nerve(s) are involved
assess for weakness, flaccid paralysis, abnormal movement (tremor, atropy, contractions, paresis, or absent deep tendon reflex)
Assess pain, sensation,
assess perfusion by checking cap refill of nail beds. check skin for discoloration (cyanotic), check for edema
Pt may report burning sensation below injury site.

Seizure Care

During seizure: AIRWAY!
Loosen all restrictive clothing
Maintain airway and suction PRN
IV push Drugs:
Lorazepam (Ativan) and Diazepam (Valium) Drug list in box on page 934
At completion of seizure:
check VS
Neuro assessment
keep patient on side
allow pt to rest
document seizure (green box 44-6 pg 936)
Simple Partial seizure: observe and document time seizure occurred & how long it lasted.
Generalized Tonic Clonic or complex partial seizure: turn pt on side during seizure (pt may lose consciousness, and to prevent aspiration)
Pt may become cyanotic--this is common and is usually self limiting > 02 is given during postictal phase
Status Epilepticus: AIRWAY
Start IV > Normal Saline started
To prevent additional tonic clonic seizures or cardiac arrest, a loading dose of IV phenytoin (Dilantin) administered (dosages on PG 936). PO Dilantin given as follow-up after emergency is resolved
Alternative to phenytoin (Dilantin) is fosphentoin (Cerebyx) > compatible with most IV solutions and causes fewer cardiovascular complications than phenytoin, also can be given in IV dextrose
serum drug levels drawn Q6-12 hrs after loading dose given

Skull Fracture finding

assessment findings depend on type of fracture (linear, depressed, compound, comminuted)
clinical manifestations usually result from increased ICP
changes in neuro status
CHANGES IN LOC
airway and breathing pattern changes
VS changes (reflecting increased ICP)
HA, N/V
visual disturbances, pupillary changes, and papilledema
CSF drainage from ears
posturing
decreased sensation or numbness
seizure activity

Morphine RR

Opioid analgesics (Morphine) depress the CNS thereby causing respiratory depression and hypotension
assess the pt's VS and effectiveness of the drug within 5-10 minutes after administering IV Morphine
if respiratory depression occurs or pt experiences opioid overdose, administer 1-2 mg IV naloxone hydrochloride (Narcan) > repeat Q 2-3 minutes PRN up to 10 mg

Operative/ Respiratory - Postoperative pain

S/Sx of postop pain:
increase HR, BP, RR
diaphoresis (sweating)
restlessness
confusion
grimacing, wincing
Ask pt to rate pain on 0-10 scale
Assess surgical site
Assess for bleeding
Assess airway
lung assessment (stridor)
VS > if Pulse ox drops below 95% notify MD > if it drops 10 points at any time, call Rapid Response Team

Renal - ARF - Best diet

Acute Renal Failure (Acute Kidney Injury > AKI)
Pt's with AKI have a high rate of protein breakdown, causing breakdown of muscle protein leading to increase in BUN
Pt's with AKI have individualized nutritional needs, and are calculated based upon degree of remaining kidney function and whether the patient is on dialysis or not

Renal - UTI - S&S

urinary frequency pyuria
urgency bacteruria
dysuria retention
difficulties initiating urine stream suprapubic tenderness or fullness
low back pain feeling of incomplete emptying of bladder
nocturia
hematuria
incontinence
Older adult manifestations
onset may be vague > increased confusion, frequent falls
sudden onset of incontinence or worsening incontinence
fever, tachycardia, tachypnea, hypotension without urinary symptoms
loss of appetite, nocturia and dysuria are most common symptoms

Renal/Respiratory - Pyelonephritis-medicate

broad spectrum antibiotics (abx) prescribed once pt diagnosed with Pyelo, after urine and blood cultures are known, then more specific abx is administered
IV abx administered for first 24-48 hrs. Duration 10-14 days
Urinary antiseptic medications are usually prescribed (nitrofurantoin {Macrodantin}) for comfort
nitrofurantoin (Macrodantin) > Macrobid
PG 862 NCLEX
analgesics, antipyretics, abx, urinary antiseptics and antiemetics are administered as ordered

Respiratory - COPD-chest pain

increased amounts of air is trapped in the lungs > caused by loss of elastic recoil in alveolar walls > overstretching and enlargement of alveoli is called bullae
these changes increase work of breathing, the overinflated lung causes the diaphragm to flatten > pt's use accessory muscles to aid in breathing which then causes fatigue and chest pain
Cardiac Failure (Cor pulmonale) Right sided heart failure
air trapping, airway collapse and stiff alveolar walls increase the lung tissue pressure, making blood flow through the tissues more difficult
this increased pressure causes an increased workload on the right side of the heart
The chambers of the right side of the heart enlarge from the increased workload, backup of blood into the venous system occurs
oxygenation decreases as the disease progresses
Cardiac dysrhythmias are also common in pt's with COPD resulting from hypoxia

Hemopneumothorax-chest tube

Collection chamber
monitor drainage, notify MD if drainage is greater than 70-100 Ml/hr or if drainage suddenly becomes bright red or increases in volume
To monitor volume output, mark chest tube on collection chamber Q1-4 hr
Monitor fluctuation of fluid level in chamber > fluctuation stops if tube is obstructed, suction not working properly or if the lung has re-expanded
Intermittent bubbling in chamber is expected, but continuous bubbling indicates air leak in system> notify MD if this occurs
Keep drainage system below level of the chest and tubes free of kinks
Assessment/random interventions
assess respiratory status and listen to lung sounds
assess chest tube dressing for drainage around tube insertion
assess pain level
ensure pt does coughing and deep breathing exercises
change pt's position frequently to promote drainage and ventilation
DO NOT strip/milk tubing unless specifically asked by MD and if policy allows
keep clamped and sterile occlusive dressing at bedside
never clamp chest tube without written prescription from MD
if chest tube is pulled out accidentally, pinch skin opening together, apply occlusive sterile dressing and notify MD STAT

Respiratory - Priority-hemodynamic alarms

If the hemodynamic system begins alarming, CHECK THE PATIENT. This is just the monitors the pt is hooked up to (blood pressure, SP02, HR)
The Sp02 could be dropping due to ET tube displacement, the patient is apneic, or poor reading.

Musculoskeletal/Operative - Postop femur fracture patho

femur fractures mostly result from trauma such as car accidents only patho i could find... rest is just info
seldom immobilized > large muscles of thigh become spastic
extensive hemorrhage may occur with femur fractures
healing time = 6 months or longer

Neurological - MS-patho

Inflammatory response resulting in random or patchy areas of plaque in white matter of CNS > myelin sheath is damaged and becomes demyelinated
Nerve impulses still transmitted, but not as effective > over time may become completely blocked
Areas affected: optic nerves, pyramidal tracts, posterior columns, brainstem nuclei, ventricular region of brain and axons connecting neurons to brain and spinal cord
clinical manifestations
muscle weakness and spasticity, fatigue, intention tremors, parasthesia, hypalgesia, ataxia, dysarthria, dysphagia,diplopia, nystagmus, scotomas,decreased visual and hearing acuity, tinnitus,bowel and bladder dysfunction, impotence, cognitive changes > memory loss, impaired judgment, decreased ability to solve problems
4 types of MS
Relapsing-Remitting MS (RRMS) > occurs in most MS case
symptoms develop and resolve in a few weeks to months, pt then returns to baseline
during relapsing phase pt reports loss of function and continues to develop new symptoms
Primary Progressive MS (PPMS)
steady and gradual neurological deterioration without remission
no acute attacks occur
pt's age of onset tends to be between 40-60 yrs old
Secondary Progressive MS (SPMS)
begins as relapsing-remitting type MS, then later becomes steadily progressive
about half of all people with RRMS develop SPMS within 10 yrs
Progressive Relapsing MS (PRMS)
characterized by frequent relapses with partial recovery, but pt does not return to baseline
only seen in small % of patients
progressive, cumulative symptoms and deterioration over several years

Endocrine/Physical Assessment - DM

Type 1 DM
weight loss with increased appetite during weeks before diagnosis are common
Type 2 DM
excess weight and obesity are risk factors for type 2 DM
ask women how large their children were at birth because those who develop type 2 DM often had gestational diabetes or were glucose intolerant during pregnancy
ask women about frequent yeast infections (increased sugar = infection)
assess the patient for change in vision
CHECK A BLOOD SUGAR > fasting sugars normal range is <100
hemoglobin A1C normal range is 4-6%

GI-Hepatic - Pancreatitis-hydration

Patients with acute pancreatitis are kept NPO in order to rest the pancreas and reduce pancreatic enzyme secretion.
Isotonic IV fluids are given (NS) to maintain hydration

Neurological - Epidural hematoma

Results from arterial bleeding into the space between the dura and the inner skull.
often caused by a fracture of the temporal bone
patients with epidural hematomas have "lucid intervals" during which the patient is awake and talking, these last a few minutes > this follows momentary unconsciousness that occurs within minutes of the injury

Teaching - PCN allergy

teach the patient to inform healthcare providers about their allergy to PCN.
patient should be aware of the type of reaction they have to PCN (anaphylaxis, rash, N/V, wheezing, pruritus, etc)
Teach the patient and their families the drugs action, side effects and toxic effects

Pediatrics - Cardiovascular/Trauma - Shock - IO access

insert IO below and medial to the tibial tuberosity
aspiration of bone marrow and blood confirms correct placement

Pediatrics- Endocrine/Immune/Hematology-Digoxin and potassium levels

Digoxin is a potentially dangerous drug because of its narrow margin of safety for therapeutic, toxic and lethal doses.
Primarily used for systolic heart failure and atrial fibrillation, in children used to help improve heart pump efficiency
therapeutic level 0.5 to 2
hypokalemia=potassium level lower than 3.5mEq/L, normal 3.5-5.0 mEq/L
Closely monitor serum electrolytes, specifically potassium levels because low levels or hypokalemia may precipitate digoxin toxicity
Digoxin toxicity is manifested in children by nausea, vomiting, bradycardia, anorexia and dysrhythmias.

Pediatrics-GI/Hepatic/Operative-pylorotomy-pain

Hypertrophic pyloric stenosis- the circular muscle of the pyloric thickens, causing severe narrowing of the pyloric canal between the stomach and the duodenum. Causing partial obstruction and over time complete obstruction
Surgical relief of the pyloric obstruction is the standard therapy for this disorder
Appropriate analgesics should be given around the clock because pain is continuous.

Pediatrics-Growth and development/physical assessment/sensory-assessment diversion

Performing pediatric physical examination: observe behavior that signals child's readiness to cooperate:
talking to the nurse
making eye contact
allowing physical touching
choosing to sit on exam table rather than parents lap
If signs of readiness are not observed, use the following techniques:
talking to parent while essentially "ignoring" child; gradually focusing on child or a favorite object (doll)
make complimenting remarks about child
tell a funny story or play a simple magic trick
have a nonthreatening "friend" available (puppet)

Pediatrics-Neurological-tetanus-POC

Tetanus is an acute, preventable, but often fatal disease caused by gram-positive bacillus clostridium tetani
Characterized by painful muscle rigidity involving the masseter and neck muscles
primary prevention occurs through immunization and boosters
after an injury has occurred further preventive measures are based on the child's immune status and the nature of the injury
Specific prophylactic therapy after trauma is administration of tetanus toxoid
an unprotected or inadequately immunized child should receive tetanus immunoglobulin
Concurrent administration of both TIG and tetanus toxoid at separate sites is recommended both to provide protection and to initiate the active immune process
TIG and tetanus toxoid given IM, never by IV
antibiotic treatment with penicillin G (or erythromycin or tetracycline in older children allergic to penicillin) is important in the management of tetanus
In acute phase-treated in ICU with general supportive care:
monitoring adequate airway
fluid and electrolyte balance
pain management
adequate caloric intake
local care of wound by surgical debridement and cleansing
reduced external stimuli

Pediatrics-Oncology-Leukemia-MTX

Leukemia-broad term given to a group of malignant diseases of the bone marrow and lymphatic system
Is the most common form of childhood cancer
more common in boys and caucasians, peak onset between 2-5 years of age
Methotrexate-a chemotherapy drug used to treat leukemia
given IV, PO, IM and IT
Intrathecal chemotherapy- given through a lumbar puncture(spinal tap)
usually given twice (or more if leukemia cells found in CNS) during the first month and 4-6 times during the next 1-2 months. Then repeated less often during remainder of treatment.
Maintenance therapy- methotrexate given PO weekly
total length of therapy is 2-3 years
Must wear sunscreen and sunglasses outside when on methotrexate

Pediatrics-Physical assessment-Bulging fontanel-6 months

Fontanels-the areas where more than two bones meet, membrane filled spaces where the sutures intersect, also known as soft spots
Anterior fontanel closes at 18 months
Posterior fontanel closes at 6-8 weeks
Bulging is a sign of brain swelling or fluid buildup on the brain
common causes
Encephalitis
hydrocephalus
meningitis
hypoxic-ischemic encephalopathy
intracranial hemorrhage
Other causes
brain tumor or abscess
lyme disease
addison's disease
congestive heart failure
leukemia
electrolyte disturbances
hyperthyroidism

Pediatrics- Respiratory- infant chest thrusts

Give 5 back blows: firm back blows with the heel of one hand between the infant's shoulder blades
Give 5 chest thrusts: place 2 or 3 fingers in the center of the infant's chest just below the nipple line and compress the breastbone 1 ½ inches
Continue sets of 5 blows to 5 chest thrusts until:
object is forced out
infant can cough forcefully, cry or breath
infant becomes unconscious
Support the head and neck- keep head lower than the chest

Pediatrics- Respiratory-sickle cell crisis-position

Place patient in semi-fowlers with legs extended on the bed
This provides the best oxygenation for the patient

Pediatrics-Respiratory/reproduction

Many antibiotics interact with birth control pills. They do this by increasing the rate at which the birth control hormones are metabolized in the blood stream
This may decrease the effectiveness of hormone birth control
It is recommended to use a backup form of birth control(condom) while on hormone birth control and antibiotics

Pediatric/Professional issue- Teaching- asthma triggers

Allergens:
outdoor: trees, shrubs, weeds, grasses, molds, pollens, air pollution, spores
indoor: dust or dust mites, mold, cockroach antigen
irritants:
tobacco smoke, wood smoke, odors, and sprays
exposure to occupational chemicals
exercise
cold air
changes in weather or temperature
environmental changes:
new home, new school, etc
cold and infections
animals
cats, dogs, rodents, and horses
medications
aspirin, NSAIDs, antibiotics, and beta blockers
strong emotions
anger, fear, laughing, crying
conditions
reflux, and tracheoesophageal fistula
food additives
sulfite preservatives
foods
nuts, and dairy
endocrine factors
menses, pregnancy, and thyroid disease

Pediatric/Professional issue- Teaching- diaper rash- skin care

This dermatitis or skin inflammation appears as redness, scaling, blisters or papules
parents are instructed in measures to help prevent and treat diaper rash
diapers should be checked often and changes as soon as the infant voids or stools
plain water with mild soap is used to cleanse the diaper area; if baby wipes are used, they should be unscented and alcohol free
the infant's skin should be allowed to dry completely before applying another diaper
exposing the buttocks to air can help dry up diaper rash
zinc oxide ointments can be used to protect the infant's skin from moisture and further excoriation
most cases resolve within a few days
use good hand hygiene

Pediatric/professional issue- Teaching- Pavlik harness-evaluate teaching

Dysplasia of the hip newborn to 6 months: hip joint is maintained by dynamic splinting in a safe position with the proximal femur centered in the acetabulum in an attitude of flexion
Pavlik harness is the most widely used device
worn continuously until the hip is proved stable on clinical and ultrasound examination
Primary nursing goal is teaching parents to apply and maintain the reduction device
parents are instructed to not adjust the harness straps, this is done every 1-2 weeks by the health care provider
skin care is important:
always put on an undershirt and knee socks under feet and leg pieces
check for red areas under harness often
always place diaper under the straps
avoid lotions and powders
gently massage healthy skin under straps to stimulate circulation
Parents are encouraged to hold and nurture infant

Professional issue- documentation/leadership/legal/ethical- MI- living will

written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this legal document the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state

leadership- blood transfusion

National patient safety goals requires agencies to ensure that blood components are properly ordered, handles and dispensed and administered and that patients are appropriately monitored. med surg pg 212
nursing actions during transfusions aim at preventing or early recognition of adverse transfusion reaction.
Each patient must be matched for compatibility
Before starting: explain the procedure, assess vital signs, begin infusion slowly, remain with the patient for 15-30 minutes, ask patient to report any unusual sensations, recheck vital signs within 15 minutes
If no reaction noted, infusion rate may be increased to 1 unit in about 2 hours
primary action is to determine that the blood component delivered is correct and that identification of the patient is correct

leadership/legal/ethical- advanced directives-DPAHC

advanced directives are based on values of informed consent, patient autonomy over end of life decisions, truth telling and control over the dying process
DPAHC: is a legal document that designates a person or persons of one's choosing to make health care decisions when the patient is no longer able to make decisions on their own behalf. This agent makes healthcare treatment decisions based on the patient's wishes

Leadership/legal/ ethical- medical records- privacy fund

HIPAA: creates patient rights to consent to the use and disclosure of their protected health information
It establishes the basis for privacy and confidentiality
privacy: is the right of patients to keep personal information from being disclosed
confidentiality: protects private patient information once it has been disclosed in a healthcare setting

Professional issue- leadership/nursing process- bariatric surgery- vomiting

Nausea and vomiting are the most common complaints after bariatric surgery
typically associated with inappropriate diet or noncompliance with a gastroplasty diet (overeating or not chewing food adequately)
Gastroplasty diet:
eat undisturbed
chew meticulously
never drink with meal
wait 2 hours after solid food to drink
can also be associated with strictures and stomal stenosis

Profession issue- legal/ethical- malpractice- prevent legal action fund

document, document, document
get informed consent
report abuse of elders and children
keep all patient records and personal information private
avoid/prevent medication errors-know the 5 rights, dose, route, drug, patient, time
maintain patient safety
effective communication
know scope of practice and standards of care

Documentation- Heart Sounds- S3

The S3 is a ventricular filling sound. It occurs in early diastole during the rapid filling phase. It sounds after S2, is a dull soft sound, and is low-pitched, like "distant thunder".
Location- heard at the apex or lower left sternal border; the split S2 is at the base
Respiratory variation- does not vary in timing with respirations, the S2 does
Pitch- lower pitched.

MedSurg-Documentation- Unna Boot- venous stasis ulcer

compression dressing (gauze) with zinc oxide and calamine to promote healing
For venous stasis ulcers, the paste-impregnated wrap is covered by an elastic layer, generally an elastic wrap ("ACE" bandage) or self-adherent elastic bandage such as Coban; this is referred to as a 2-layer compression bandage. An alternative treatment is a 4-layer, graduated compression wrap (Pro-Fore is an example). Evidence indicates that both are equally effective in healing venous stasis ulcers — a slow process in the best of circumstances, often taking 2-6 months.[2] Wikipedia- i know but i couldn't find it anywhere and this was the most to the point explanation :0

MedSurg- Leadership- ORIF (open reduction internal fixation) complications

One of the most common methods of reducing and immobilizing a fracture
Open reduction allows the surgeon to directly view the fracture site & internal fixation uses metal pins, screws, rods, plates or prostheses to immobilize the fracture to heal. Hardware isn't always removed, but most frequently it is removed in ankle fractures.
Because bone is a vascular, dynamic body tissue, the pt is at risk for complications specific to fractures and muscoskeletal surgery.
toradol is often given in PACU to reduce inflammation & pain
aggressive pain management starts asap to avoid chronic pain & promote early mobility Med Surg pg 1155
risk of fat embolism is greatest in the first 36 hrs after fracture
bone fractures predispose pts to anemia- check hematocrit every 3-4 days
Hematocrit MALES- 42-52% & FEMALES- 37-47%
clients with fractures, edema or casts after on extremities need frequent neurovascular assessment- distal to the injury SKIN, COLOR, TEMP, SENSATION, CAPILLARY REFILL, MOBILITY, PAIN & PULSES

Leadership/Legal/Ethical - Terminal cancer family issues

offer physical & emotional support by "being with" the pt
respect cultural preferences
be realistic
encourage reminiscence
promote spirituality
foster hope
avoid explanations of the loss
communicate with the pt
provide referrals to bereavement specialists
teach about the physical signs of death
ensure that the pt is receiving palliative care, with an emphasis on symptom management, especially pain.

Leadership/Legal/Ethical- ventricular fibrillation- actions

When Vfib begins-
the patient becomes faint,
loses consciousness,
no pulse and
apneic (not breathing,
no BP,
heart sounds are absent-
death results without prompt action.
Priority action is to defibrillate to organized rhythm- use AED & if not available , begin CPR & keep doing CPR until AED is available.

Hemoglobin

Adults: Male: 14-18 & Female: 12-16
Child: 1-6 yrs: 9.5-14 & 6-18 yrs: 10-15.5
Newborn: 14-24
Older Adult: Values slightly decrease
Nursing Implications: High altitude increases values, drug therapy can alter values & slight Hgb decreases normally occur during pregnancy

HEMATOCRIT %:

Adults: Male: 42-52 & Female: 37-47, Pregnant >33
Child: 1-6 yrs: 30-40 & 6-18: 32-44
Newborn: 44-64
Older Adult: Values slightly decreased
Nursing Implications: Abn in RBC size may alter Hct values

WBC

5-10 (1000/mm3) both sexes
Child: <2 yrs: 6.2-17 & >2 yrs: 5-10
Newborn: 9-30
Older Adults: Same as Adult
Nursing Implications: Anesthesia, stress, exercise & convulsions can Increase values,
Drug therapy can decrease values for 24-48 hrs

136-145 Both sexes
Child: 136-145
Newborn:134- 144 & Infant: 134-150
Older Adults: same as adults
Nursing Implications: Do not collect from an arm with an infusing IV solution

3.5-5 both sexes
Child: 3.4-4.7
Newborn: 3-5.9 & Infant: 4.1-5.3
Older Adults: Same as adults
Nursing Implications: Hemolysis of specimen can result in false High levels & exercise of the arm with tourniquet in place may result in High K levels

BUN

7-18

GLUCOSE

70-110 both sexes
Child: < 2 yrs: 60-100 & >2 yrs 70-110
Newborn: 30-60 & Infant: 40-90
Older Adult: Decrease in muscle mass may cause Decrease in values
Nursing Implications: Pt to be NPO except for water 8 hrs prior to testing
caffeine can cause increased values
stress (MI, infection, general anesthesia) can cause iatrogenic hyperglycemia

ABG

pH: 7.35-7.45
CO2: 35-45
HCO3: 21-28

Bilirubin in Newborns

1-12

PT

prothrombin

11- 12.5 & pregnant: slightly lower - both sexes
Child: same as adults
Infant/Newborn: same as adults
Older Adults: same as adults
Nursing Implications: Used in regulating Coumadin therapy
Therapeutic Range: 1.5 - 2

INR

0.8 - 1.1 both sexes
Child: same as adults
Infant/Newborn: same as adults
Older Adults: same as adults
Nursing Implications: Used to monitor anticoagulation therapy. INR must be individualized

Higher if on Coumidin (2-3, I think)

PTT

60-70 both sexes, pregnant is slightly lower
Child: same as adults
Infant/Newborn: same as adult
Older Adults: same as adult
Nursing Implications: Used to regulate Heparin therapy.
Therapeutic Range: 1.5-2.5

Teaching- Asthma

Avoid environmental, medications and foods that are triggers for pts asthma
If get exercise asthma- use bronchodilator 30 mins before exercise
Know proper dose & sequence when using MDI (metered dose inhalers)
Plenty of rest and sleep
Reduce stress & anxiety- relaxation techniques, coping mechanisms
Wash all bedding in hot water to destroy mites
Monitor peak expiratory flow rates at least DAILY
Go to ER, if: grey, blue lips or fingertips, difficulty breathing, walking or talking, retractions of neck, chest or ribs, nasal flaring, failure of medications to control worsening symptoms, flow rate 50% below normal or declining.

Teaching- COPD

Very similar to Asthma- avoid stressors that can worsen disease
Teach pt pursed lip breathing, diaphragmatic breathing, positioning, relaxation therapy, energy conservation, coughing and deep breathing.

Diabetes 2 teaching, adult

Type 2- progressive disorder, combination of insulin resistance and decreased secretion of insulin by pancreatic beta cells
Teach:
tight control of blood glucose
regular eye check ups
check urine for ketones & microalbumin
monitor K+ levels closely - vary depending on hydration
adopt a low-calorie diet to lose weight, increase exercise while taking antidiabetic drugs
recognize symptoms of hypoglycemia or hyperglycemia & treatments & when to call PCP
proper foot care

Teaching- Metformin

take with food
report symptoms of lactic acidosis: malaise, unusual muscle pain ,respiratory distress, increased somnolence, and abdominal distress
instruct pt to report illness that causes severe vomiting, diarrhea or fever
tablets must be swallowed whole- never crushed or chewed

Teaching- Pneumonia discharge

review all drugs with the pt and family
emphasize completing anti-infective therapy
notify PCP if fever,chills, persistent cough, dyspnea (shortness of breath), wheezing, hemoptysis (coughing up blood), chest discomfort, increased sputum production, increased fatigue
plenty of rest and gradually increase activity
avoid URI/viruses- avoid crowds
immunizations against influenza and pneumonia
no smoking or around irritants such as smoke

Teaching- Tadafil (Cialis)

When used for- Erectile dysfunction drug - Cialis & when used for-Pulmonary hypertension - Adcirca.
headache
flushing
seizure
do not take with nitrates - cause drop in BP- causing MI or stroke

Psychiatric/Mental Health/Abuse/Anxiety/Communications- Therapeutic Communication

communication is the primary tool used in the delivery of psychiatric nursing care
therapeutic interaction is to assist the client in gaining insight into thoughts, feelings & behavior
establish trust
demonstrate a non-judgemental attitude
offer self; be empathetic, not sympathetic
use active listening
accept and support client's feelings
clarify and validate pts statements
use matter of fact approach
remember a nonverbal communication may be more impt than a verbal

Communications- OCD reduce anxiety

best time for interaction with pt is at the completion of the a ritual- pts anxiety is lowest at this point
compulsive acts are in response to anxiety- it is RN responsibility to alleviate the anxiety
RN Intervetions:
provide for pt physical needs
allow performance of compulsive activity with attn given to safety
explore meaning & purpose of the behavior
avoid punishing
establish routine to avoid anxiety - producing changes
limit the amt of time for performance of ritual
avoid reinforcing compulsive behavior
administer anti-anxiety meds & SSRIs and tricyclic antidepressants

Depression/Grief- Depression, 1st priority

At all times when caring for a pt with depression, the RN must be cognizant of the potential for suicide; assessment of risk for self-harm or harm to others is ongoing

Depression/Grief- SSRI contraindications

SSRIs: Prozac, Paxil, Zoloft, Luvox, & Celexa
Hypersensitivity Drug Book (Skidmore) pg 460
Adverse Rxn:drowsiness
dizziness, headache, insomnia, and depressed appetite
Do not take with MAO inhibitors bc may cause hypertensive crisis- wait at least 14 days discontinuing MAO inhibitors and starting Prozac (fluoxetine) Hesi, pg 320
Side effects of MH medications
Anti-anxiety drugs- sedation, drowsiness
Antidepressants- anticholinergic effects, postural hypotension
MAO inhibitors- hypertensive crisis
Problems and concerns in DRug Therapy
Lithium requires renal fx assessment & monitoring
Phenothiazines causes extrapyramidal effects (EPS)- tardive dyskinesia can be permanent if client is not assessed regularly for signs of tardive dyskinesia
Patient teaching about drugs
Phenothiazines cause photosensitivity, so pts must wear protective clothing & sunglasses
MAO inhibitors require dietary restrictions to prevent hypertensive crisis

Depression/Grief- Suicide attempt

most important S/S of depression = depressed mood with loss of interest in the pleasures of life
most significant risk factor= previous suicide attempt
major warning signs of impending suicide attempt: 1. pt is giving away possessions; 2. pt becomes happy

Psychoses- Disruptive Behavior

redirect negative behavior or verbal abuse in a calm, firm, nonjudgmental, non defensive manner
suggest a walk or other physical activity
set limits on intrusive behavior:" when you interrupt, I cannot explain the procedure to others. Please wait your turn."
if necessary, seclude or administer meds if pt totally out of control.

Psychoses- Extrapyramidal Symptoms

Extrapyramidal Effects, side effects of psychotropic drugs ( Haldol, Geodon, Zyprexa, Seroquel)

Psychoses- Hallucinations

are false sensory perceptions, usually auditory or visual in nature
if pt has hallucinations:
protect client from injury that may result from responding to commands of the voices; pay attention to the content
use matter of fact, non-judgemental approach
avoid denying or arguing with pt about the hallucination
discuss your observations with the client ( you appear to be listening to..)
make frequent but brief remarks to interrupt the hallucinations. stress reality
set limits on behavior
administer antipsychotics
monitor and treat side effects
administer anticholinergics

Nutrition/ Anorexia

Anorexia Nervosa- priority problem- nutritional support. Do not allow anorexia pt to plan or prepare food for unit-based activities. These behaviors reinforce their perception of self-control.

Nutrition/Magnesium diet- Chronic Alcoholism

A clinical syndrome characterized by muscle tremor, twitching and more bizarre movements, occasionally by convulsions and often by delirium, has been described and is considered to be a manifestation of magnesium deficiency

Alzheimer's wandering

provide safe, consistent environment
confusion may be due to dehydration/UTI
reorient client to reality as needed

Cocaine exposed newborn

the effects on the fetus are secondary to maternal effects- hypertension, decreased uterine blood flow , increased vascular resistance, consequently the fetus experiences decreased blood flow and oxygenation
the newborn can have either neurobehavioral depression or excitability
elevated heart rate and increased respirations at birth

Cirrhosis of Liver

chronic alcohol ingestion- Laennec's cirrhosis

Adrenal crisis

aka addisonian crisis, life threatening event in which the need for cortisol and aldosterone is greater than the available supply
often occurs in response to a stressful event( surgery, trauma, severe infection)

Preop teaching- anxiety

encourage patient to speak about feelings that cause anxiety

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