verify with another nurse, use infusion pump, monitor daily weights, I & O, fluid balance, serum glucose q4 to 6 hrs, infection, change dressing q48 to 72 hrs, change tubing and fluid q24 hours, if TPN is unavailable, administer dextrose 10% in water to prevent hypoglycemia POST TERM, IUGR, ASPHYXIA, COLD STRESS,
Maternal diabetes, Gestational hypertension, Tocolytic therapy, Prematurity, LGA, SGA, Perinatal hypoxia, Infection, Hypothermia
being African American, Hispanic, or Asian
obesity and fat distribution, inactivity, family history, race, age, pre-diabetes, Overweight, family hx, ethnicity, HTN, gestational diabetes, age, viruses, lifestyle, disease of pancreas.
children-s/s diarrhea, steatorrhea, anemia abdominal distention, impaired growth, lack of appetite and fatigue. Adults- diarrhea, abdominal pain, bloating, anemia, steatorrhea, and osteomalacia. Dietary Foods that are gluten free-milk, cheese, rice, corn, eggs, potatoes, fruit, veg, fresh poultry, meats, fish, dried beans. Gravy mixes sauces,cold cuts, and soups, have gluten. Increase fluid consumption 1500-3000 ml at least preferably h20, at night because that's when urine is most concentrated.
Foods high in oxlate such as spinach,rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries., Avoid mega doses of vitamin c, and limit foods high in purine lean meats, organ meats, whole grains and legumes.
Severe HA,deteriorating loc, restlessness, irritiability, dilated pinpoint pupils, asymmetric pupils, slow to react or non reactive, alteration with breathing patterns, cheyne stokes respirations, hyperventilation, apnea, deteriation in motor function, abnormal posturing, decerebrate, decorticate, or flaccidity, cushing reflex, htn, widening pulse pressure, and bradycardia, csf leakage, halo sign, seizures,. nabdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased heart rate, hallucinations, illusions, anxiety, increased blood pressure, respiratory rate, temp, and tonic clonic seizures.
May occur 2-3 days after cessation of alcohol, and may last for 2-3 days, *THIS IS A MEDICAL EMERGENCY. severe disorientation, severe htn, psychotic symptoms, cardiac dysthymias, delirium. Meds- valium, Ativan, carbamazepine (tegretrol) seizures, clonidine (catapres) Librium (chlordiazepoxide)
Expressive and receptive aphasia, agnosia, (unable to recognize objects), alexia (difficulty to reading), a graphic (writing difficulty), hemiplegia,(paralysis), or hemiparesis (weakness), slow behavior, depression, anger, visual changes(hemianopsia). Call for assistance ASAP, notify MD, use a sterile gloved hand, insert 2 fingers in vagina, and apply finger pressure on on either side of the cord, to fetal presenting part to elevate it off cord, reposition knee chest position, or trendelenburg, or side lying with a rolled towel under the pt. right or left hip, to relieve pressure on cord. Apply a warm saline soaked sterile towel to cord to prevent from drying. Provide cont electronic monitoring of FHR for variable decels. O2 at 8-10 liters, IV access, prepare for c-section, educate and inform pt. on interventions. Fullness, faintness, diaphoresis, tachycardia, palpitations, hypotension, nausea, abdominal distinction, cramping, diarrhea, weakness, and syncope. New onset of diabetes, or loss of glucose control in pets. With diabetes, weight gain, increased cholesterol with HTN, orthostatic hypotension, anticholinergic effects such as urinary hesitancy or retention, and dry mouth. agitation, dizziness, sedation, and sleep disruption, mild eps such as tremor. Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
protect visitors & caregivers when 3 ft of the pt.
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag
PMGG= Private room/ share same illness, mask, gown and gloves
◯ Stage I - Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
◯ Stage II - Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
◯ Stage III - Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
◯ Stage IV - Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).
◯ Unstageable - No determination of stage because eschar or slough obscures the wound.
excessive diuresis, monitor for dehydration, output less than 30ml/hr, hypotension, ototoxcity (irreversible w/ ethacrynic acid), hypokalemia, avoid in pregnancy, digoxin can increase toxicity, monitor BP, lithium, NSAIDs decrease effect used in: heart failure, HTN, MI, nephropathy. stop diuretic 2-3days before ACE, dry cough, hyperkalmeia, rash and alter taste-report, angiodema, neutropenia, can increase lithium levels, avoid use of NSAIDs metoprolol, atenolol, metoprolol succinate, esmolo, propranolol, nadolol, carvedilol, labetalol: HTN, agnina, migrain, glaucoma decrease LDL, increase HDL, hepatotoxic, myopathy, monitor CK, no grapefruit juice, erythromycin, ketoconazole, ezetimibe, gemfibrozil, fenofibrate bradycardia, heart failure, dizziness, weakness, monitor HR, chest pain edema. contraindicated in clients w/ AV block, severe heart failure, severe hypotension, and cardiogenic shock, use cautiously w/ heart, liver, kidney, failure. respiratory orders, older clients hypotension, bradycardia, heart failure, fatigue, contraindicated in AV clock, heart failure, bradycardia, diabetes, liver, thyroid, respiratory, Wolff-parkinson white pulmonary toxicity, sinus bradycardia and AV block, monitor BP, HF, visual disturbances, liver and thyroid dysfunction, phlebitis with IV admin, hypotension, bradycardia, contraindicated in patients w/ AV block, pregnancy risk: av block, bradycardia, newborns and infants, HF, fluid and electrolyte imbalance bradycardia, hypotension (therapeutic level: .5-.8) nausea, vomiting, dyrhythmias, hypokalemia, contraindicated: tachycardia, fibrillation, not use AV block, bradycardia, renal disease, hypothyroidism, cardiomyopathy antacids and metoclopramide decrease digoxin, amiodarone, quinidine, verapamil, diltiazem, propafenone, flecainide increase digoxin levers, cortico, diuretics, thiazides, amphotericin B may decrease K levels- monitor HR- report is less than 60, eat high K diet CONTACT: "MRS WEE"
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staph)
-Enteric infections (C-Diff)
-Eye infections (conjunctivitis)
Management: gown, gloves, goggles, private room
VRSA - contact and airborne precautions (private room, door closed, negative pressure)
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material) Lactose intolerance results from an inadequate supply of lactase, the enzyme that digests lactose.
Symptoms include distention, cramps, flatus, and diarrhea.
Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk, sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings.
Pre-ESRD, or diminished renal reserve/renal insufficiency, is a predialysis condition characterized by an increase in serum creatinine.
Goals of nutritional therapy for pre-ESRD are to:
Help preserve remaining renal function by limiting the intake of protein and phosphorus.
Control blood glucose levels and hypertension, which are both risk factors.
Protein restriction is key for clients with pre-ESRD.
Slows the progression of renal disease.
Too little protein results in breakdown of body protein, so protein intake must be carefully determined.
Restricting phosphorus intake slows the progression of renal disease.
High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys.
Dietary recommendations for pre-ESRD:
Limit meat intake.
Limit dairy products to ½ cup per day.
Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some whole grains).
Restrict sodium intake to maintain blood pressure.
Caution clients to use vitamin and mineral supplements ONLY when recommended by their provider.
End Stage Renal Disease (ESRD):
ESRD, or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, or dialysis or transplantation is required.
The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries.
A high-protein, low-phosphorus, low-potassium, low-sodium, fluid restricted diet is recommended.
Calcium and vitamin D are nutrients of concern.
Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate.
Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).
Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores.
Phosphorus must be restricted.
The high protein requirement leads to an increase in phosphorus intake.
Phosphate binders must be taken with all meals and snacks.
Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form.
This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia, hypocalcemia, and hypermagnesemia.
Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium.
Potassium intake is dependent upon the client's laboratory values, which should be closely monitored.
Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, and urine output.
Achieving a well-balanced diet based on the above guidelines is a difficult task. The National Renal Diet provides clients with a list of appropriate food choices.
Prioritization includes clinical care coordination such as clinical decision making, priority setting, organizational skills, use of resources, time management, and evaluation of care.
Clinical decisions are made by completing a thorough assessment which will help you make good judgments later when you see a changing clinical condition. A poor initial assessment can lead to missed findings later on.
Priority setting refers to addressing problems and prioritizing care. It is critical for efficient care. The RN uses his/her knowledge of pathophysiology when prioritizing interventions with multiple clients.
Orders of prioritization:
1. Treat first any immediate threats to a patient's survival or safety.
Ex. obstructed airway, loss of consciousness, psychological episode or anxiety attack.
2. Next, treat actual problems. Ex. nausea, full bowel or bladder, comfort measures.
3. Then, treat relatively urgent actual or potential problems that the patient or family does not recognize. Ex. Monitoring for post-op complications, anticipating teaching needs of a patient that may be unaware of side effects of meds.
4. Lastly, treat actual or potential problems where help may be needed in the future.
Ex Teaching for self-care in the home.
Here are some great principles to help you as you prioritize:
Systemic before local
Acute before chronic
Actual before potential
Listen don't assume
Recognize first then apply clinical knowledge
Maslow's Hierarchy of Needs:
Prioritize according to Maslow with physiological and safety issues before psychological esteem issues.
Admittance of a pregnant client to a medical-surgical unit:
You may have a pregnant client admitted with a diagnosis unrelated to her pregnancy and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to assist you in performing important assessment elements for these clients is FETUS.
* F: Document fetal heart tones every shift. To assess fetal heart tones, use a handheld Doppler ultrasound and place it in an area corresponding to uterine height. For example, for a client who's less than 20 weeks' pregnant, the most likely area to find fetal heart tones is at the pubic hairline or the symphysis pubis. For a client whose pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most probably be heard midline between the symphysis pubis and the umbilicus. As the pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly above the umbilicus.
* E: Provide emotional support. Pregnant women who are experiencing unexpected medical conditions are at a high level of anxiety related to how the current medical problem may affect the fetus. You should take extra care to alleviate and reduce your client's anxiety by explaining all medications and treatments. Additionally, be prepared to listen for fetal heart tones anytime the client requests it to further reduce her worry of the fetus' well being.
* T: Measure maternal temperature. Because your client's core body temperature is higher than you can detect through oral or tympanic thermometers, be alert to the presence of a fever. A high maternal temperature can lead to fetal tachycardia and distress. An order for antipyretics on admission to ensure their quick availability will be a prudent request you should make to the admitting physician.
* U: Ask about uterine activity or contractions. Make it a normal part of your routine to ask about any type of uterine pain, tightening, or discomfort throughout your shift. Be aware that early contractions often present as lower back pain. Don't attribute complaints of lower back pain to the hospital bed. If your client reports any unusual activity, take care to softly palpate the lower abdomen for periods of greater than 2 minutes while conversing with her. Watch for subtle changes of facial expression while simultaneously detecting a change in uterine tone. If contractions are suspected, your client will need to be monitored with continuous fetal monitoring in the labor and delivery unit.
* S: Assess for the presence of and changes in sensations of fetal movement. After 20 weeks' gestation, all women should be able to report feeling the fetus move. This is an important assessment to perform and document at least every shift, easily accomplished by asking "How often are you feeling the baby move?" By asking this as an open-ended question, you'll receive more information about the quantity of fetal movement such as, "I haven't felt the baby move as much as usual today."
There are times when a woman may be hospitalized during the postpartum period for a medical condition. When this occurs, she'll most likely be placed on a general medical-surgical unit. Her admission will cause you to ask: "What's normal during the weeks following the birth of a baby?"
* Breasts. Within the first 24 hours postpartum, colostrum appears and is followed by breast milk within the first 72 hours. Breast engorgement is most likely to occur around day 4 postpartum. The engorged breast will appear full, taut, and even shiny. Although this is normal, it may be very uncomfortable for your client. In contrast, a woman with mastitis will usually run a fever higher than 100° F, report feeling "ill," and have one breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your client is breastfeeding her newborn, she'll require a breast pump. Depending on the medications ordered, the milk may need to be disposed of and not used for the baby.
* Lochia. Sometimes women will experience lochia (vaginal discharge) until the time of their 6-week postpartum visit. Immediately after delivery, the lochia is red and heavy enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia should be lighter in color (pink to red) and amount, requiring a pad change every 4 hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain isn't a normal finding and requires immediate intervention.
* Perineal care. For the first 2 weeks following delivery, clients will need to perform perineal hygiene as taught during the immediate postpartum period. This may include perineal water rinses following elimination using warm water or medicinal rinses, use of sitz baths, and comfort medications to the perineal and anal area.
* Cesarean section. If your client delivered her baby via cesarean section, continued assessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum. Redness and warmth around the incision, excessive bruising around the incision, or incisional drainage requires immediate intervention. If the surgeon used staples to close the incision, they're usually removed approximately 5 days post-delivery.
Remember, the hospitalized postpartum client is likely to be very emotional. Not only will she be experiencing the normal hormonal fluctuations of the postpartum period, she'll may also be distraught leaving her newborn at home and feeling that she's missing bonding time with her child. Visitation between the mother and her infant may be very limited to minimize the infant's risk of infection, but visits should be arranged if at all possible.
PP--> Low implantation of the placenta
AP--> Premature separation of the placenta
PP--> It occurs in approximately 5 in every 1000 pregnancies
AP--> It occurs in about 10% of pregnancies and is the most common cause of perinatal death
PP--> increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation,
AP--> high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, pregnancy-induced hypertension, direct trauma, vasoconstriction from cigarette use, thrombic conditions that lead to thrombosis such as autoimmune antibodies
PP--> Always present
AP--> May or may not be present
Color of blood in bleeding episodes:
PP--> Bright red
AP--> Dark red
Pain during bleeding:
AP--> Sharp, stabbing pain
PP--> Place the woman immediately on bed rest in a side-lyon position. Weight perineal pads. NEVER attempt a pelvic or rectal examination because it may initiate massive blood loss.
AP--> Fluid replacement. Oxygen by mask. Monitor FHR. Keep the woman in a lateral position. DO NOT perform any vaginal or pelvic examinations or give enema. Pregnancy must be terminated because the fetus cannot obtain adequate oxygen and nutrients. If birth does not seem imminent, cesarean birth is method of choice for delivery.
Ophthalmic medications are drugs used for the eye. These medications are typically prescribed for clients who have Glaucoma, Macular Degeneration. Other ophthalmic medications are used to treat allergic conjunctivitis, inflammatory disorders, dyes to visualize the eye, and to treat infections or viruses.
Beta-Adrenergic Blocking Agents
Prescribed for clients who have open-angle glaucoma. These agents decrease the production of aqueous humor. Block beta 1and beta 2 receptors.
Common Beta-Adrenergic Ophthalmic Blocking Agents:
beta xolos ( Bet optic ) (see the form of beta in the drug names?) See optic in Betoptic? Opthalmic medication.
levo beta xolol ( Beta xon) (see the form of beta in the drug names?)
levobunolol ( Beta gan) (see the form of beta in the drug name?)
timolol ( Bet imol) (see the form of beta in the drug name?)
First line treatment for glaucoma. Fewer side effects and just as effective as the beta-adrenergic Ophthalmic blocking agents.
These drugs lower IOP by facilitating aqueous humor outflow by relaxing the ciliary muscle.
Common Prostaglandin Analogs:
latanoprost (Xal atan ) (see the suffix atan in this drug and the drug below, they are the same)
Travoprost (trav atan ) (see the suffix atan in this drug and the drug above; they are the same)
These drugs lower IOP by reducing aqueous humor production and by increasing outflow. Also delays optic nerve degeneration and protects retinal neurons from death.
Common Alpha2-Adrenergic Agonists:
Brimon idine (Alphagan) (see the similarities with idine in the name of the drug)
Apraclon idine (Iop idine ) (see the similarities with idine in both of the names of the drug)
Direct Acting Cholinergic Agonist/Muscarinic Agonist (parasympathomimetic agent)
These drugs stimulate the cholinergic receptors in the eye, constricts the pupil (miosis), and contraction of the ciliary muscle. IOP is reduced by the tension generated by contracting the ciliary muscle and promotes widening of the spaces within the trabecular meshwork, thereby facilitating outflow of aqueous humor.
Common Direct Acting Cholinergic Agonist Agents:
Key points of ophthalmic medications:
· Cylo plegics are drugs that cause paralysis of the ciliary muscle...plegic-like paraplegic, paralysis
· Mydriatics are drugs that dilate the pupil.
· Drug therapy for glaucoma is directed at reducing elevated IOP, by increasing aqueous humor outflow or decreasing aqueous humor production.
· Oculus Dexter: OD (right eye)
· Oculus Sinister: OS (left eye)
· Oculus Uterque: OU (both eyes)
Remember BAD POCC: Ophthalmic Medication Classes for treatment of Glaucoma
B -beta adrenergic blocking agents
A -Alpha-Adrenergic Agonists
D -Direct Acting Cholinergic Agonists
P -Prostaglandin Analogs
O -Osmotic Agents
C -Carbonic Anhydrase Inhibitors
C -Cholinesterase Inhibitor; An indirect acting Cholinergic Agonist
Remember BAD POCC for key points or side effects of Opthalmic Medications:
B -Blurred vision
A -Angle closure glaucoma (medications are used for this kind of glaucoma)
D -Dry eyes
O -Ocular pressure (used to treat OP from glaucoma)
C -Can Cause systemic effects
C -Ciliary muscle constriction
Gout is a type of arthritis. In healthy people the body breaks down dietary purines and produces uric acid. The uric acid dissolves and is excreted via the kidneys. In individuals affected with gout the body either produces too much uric acid or is unable to excrete enough uric acid and it builds up. High uric acid levels results in urate crystals which can now collect in joints or tissues. This causes severe pain, inflammation and swelling. Treatment is both lifestyle adjustment and medication.
First Line: NSAIDs and prednisone (Deltasone)
Purpose: Used as a first line defense to treat the pain and inflammation of gout attacks.
Purpose: Treat the inflammation and pain associated with gout.
Just like NSAIDs, these meds can lead to GI distress and should be taken with foods.
HINT: The word gout is right in the name Colgout.
This is the only medical preventative treatment for gout. Allopurinal prevents uric acid production. This can be an effective means of preventing gout attacks when diet alone is not effective.
HINT: Examine the name allopurinol and you can see the word PURINE in the middle of the name.
Note: There are many drug and food interactions associated with allopurinol:
Potential serious interactions with the use of saliscylates, loop diuretics, phenylbutazamines and alcohol and potential for drug interactions with Warfarin (Coumadin).
Teach client with gout to avoid the following:
· Anchovies, sardine in oil, fish roe, herring
· Organ meat (liver, kidneys, sweetbreads)
· Legumes (dried beans and peas)
· Meathextracts (gravies and consommé)
· Mushrooms, spinach, asparagus, cauliflower