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161 terms

NCLEX PN Review

STUDY
PLAY
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)
Statin admin time
At night when peak production of cholesterol occurs
Streptokinase
Thrombolytics
tPA
Thrombolytic agent that is given in the event of a thrombosis or TIA. Increases chance of full recovery by 30%.
Endocarditis S/S
Fever, weigh loss, joint pain, changing heart murmur, splenomegaly, petechiae, clubbing, CHF signs
Pericarditis S/S
chest pain worse when lying down, cough, fever, anxiety, FRICTION RUB,
Arterial Disorders
Weak peripheral pulses
Cool to touch
Painful, nonedematous ulcers
Venous Disorders
Bluish purple skin discoloration
Normal peripheral pulses
Warm to touch
Monitor for hx of DVT
Slightly painful ulcers /w marked edema
Thrombophlebitis
Calf pain, Positive Homans sign
Edema in calf
Homan's Sign
Pain in the calf when the foot is passively dorsiflexed, can indicate DVT
(not very reliable)
Heparin Therapy Test
PTT (Range 25-35 sec) Antidote: Protamine Sulfate
Coumadin Therapy Test
INR <3
PT
Antidote: Vit K
Parenteral Iron
Given via Z-Track to reduce leak/stain