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Compilation NOTES NCLEX I from Tashi
Terms in this set (100)
the early sign of increased ICP
The earliest sign of increased ICP is change in level of conscious (restless, confusion, drowsiness)
headache, nausea, vomiting, pupil changes
The late sign of ICP
cushings triad (increased systolic, widened pulse pressure, bradycardia and irregular respirations,
The gastric pain occurs right after an hr or 30 mins after eating and is located on the left midline upper, and may be excarcebated by food, pain never occurs at nigth
pain occurs at right side of the epigastrium and occurs after 90 mins to3 hrs after eating often awakens at night.
meniere disease: disoder of inner ear
: over production or defective absorption of endolymph (fluctuation in the production or reabsorption of fluid in the inner ear. The cause unknown.
Meniere disease medical surgical management
aim to reduction fluid production facilitating in drainage. Low sodium diet. Drug therapy: meclizine(Antivert), Diazepam(Valium), Promethazine(phenergan) antiemetic, hydrochlortiazide diuretics.
Meniere's disease nursing management
Assess grow hearing through Rinne and weber test. during an attack nurse prescribed medication, limits movement, and promotes client safety, least amount of motion on ADL risk for vertigo.
Meniere's disease nursing advise
low sodium diet & MSG, alcohol, caffeine.
Insulin lantus( glargine)
is long acting has 24 hr duration of action at administered at bed time.
onset 2-4hours, no peak.
Air embolism causes
chest pain,dyspnea, hypoxia, tachycardia and hypotension
Fluid overload increases peripheral vascular volume thereby increasing the BP and pulse rate
also causes neck vein distension shifting fluid to the lungs and crackles are heard.
is a anti-inflammatory action and immunomodulatory agent.used to relieve symptoms caused by rheumatoid arthritis, such as inflammation, swelling, stiffness, and joint pain. This medicine works by stopping the body from producing too many of the immune cells that are responsible for the swelling and inflammation.skip the missed dose and go back to your regular dosing schedule. Do not double doses.
after immediate postpartum should expect some clots and red in color, after 2hr it should be like that of heavy menstrual bleeding. Than it changes to pinkish red or reddish brown. Passage of mucus plug appears pink or as blood tinged mucus. Ruptured amniotic sac would include findings such as watery vaginal drainage
Lochia according to days
lochia rubra is red lasts 3 days after birth
lochia serosa is pinkish blood and mucus content, third to tenth day.
lochia alba is mucus, clear colorless white, tenth to 21day.
Diagnostic findings ICP
skull radiography, CT, MRI, lumbar puncture, and cerebral angiography.
ICP medical management
administers isotonic normal saline, lacatted ringer's or hypertonic 3% saline solutions.
hypotonic is prohibited, it will increase ICP. Administering acetaminophen (tylenol) or applying cooling blanket to maintain normothermia. To control seizure, diazepam (Valium) and fosphenytoin(cerebyx) parenterally anticonvulsant. Benzodiazepine such as midazolam (versed) to sedate agitated client because of hyperactivity.
Narcotic is contraindicated. Mannitol and fluid restriction is used. In addition, stool softener and pepcid to prevent stress ulcer.
ICP surgical management techniques for monitoring ICP
1. a fiberoptic
2. subarachnoid screw
3. intraparenchymal sensor
4. subdural bolt.
Normal ICP in the ventricles
1-15 mm Hg, moderate elevation value range from 15-40mm Hg, and high level exceed 40 mm Hg. A rise of 2 mmHg from previous measurement is cause of concern. Normal ICP below 20 mm Hg is desirable.
Nursing management for ICP for ineffective tissue perfusion related to increased ICP AVB decreased LOC, sluggish pupil response, papilledema and posturing.
ICP will be between 1-15 mm Hg, GCS will be 9 or greater.
Bed slightly elevated, promotes drainage venous blood & CSF from cranium.
Limit movement: activities increase BP, use valsalva manuever, etc.
Avoid extreme hip flexion, compress femoral blood vessel.
keep client quiet, avoid ROM
give O2 before and after suctioning.
placenta development in lower part of uterus. Manifestation by painless vaginal bleed usually bright red. Uterus soft.
Visible dark vaginal bleeding or concealed bleeding within the uterus. enlargement of uterus with gradual or abrupt onset of pain and uterine tenderness possibly low back pain. Uterus firm boardlike, brief contraction.
renal involvement leading to proteinuria in hypertensive disorder. when GH (gestational hypertension) includes proteinuria. The cause is unknown but birth is its cure. Vasospasm is the main characteristic in GH.
Chronic hypertension is considered moderate if the systolic reading is between 140 and 160 mm Hg and diastolic reading is below 11o mm Hg.
However, an increase over baseline blood pressure of 30 mm Hg or more systolic and 15 mm Hg diastolic will place the women in a high risk category. A women with a baseline 90/60 may be at risk for GH if her blood pressure rises to 120/80. Blood pressure normally decreases during the first two trimesters.
Hypertensive medication is not given for mild to moderate levels of high level blood pressure because it may delay the growth.
instead frequent prenatal visit urinalysis to detect proteinuria and fetal assessment are the standard of care and medication in moderate range. Drugs of choice is methyldopa(Aldomet).
notify doctor, gain of more than 1 lb in a week, protein in urine, and increased in BP, decreases fetal movement less than 3 in an hour.
not painful may feel the pressure.
client can pump the breast milk from the affected breast. regular emptying is necessary to avoid abscess formation. If an abscess form the affected breast and ruptures into milk duct then discontinue feeding and pumped milk is discarded.
cardiovascular system fails to provide essential oxygen and nutrients to the cells.
cardiogenic(pulmonary embolism, hypertension)
hypovolemic shock(postpartum hemorrhage, blood clotting problems)
anaphylactic shock(allergic to drug)
volume of blood is depleted with increase heart rate and respiratory rate. Incresed oxygen content of each erythrocyte, more quickly circulate remaining blood. Tachycardia is usually first sign of hypovolemia. To become pale, cold, and clammy moist). suspect has pulse greater than 100 beats per minute
medical management of hypovolemic shock
stop blood loss, giving IV and blood transfusion, giving oxygen, placing the indwelling foley. nursing care: check vital sign every 15 minutes.
early sign: tachycardia, pallor, cold, clammy hands, decreased urine output.
late sign: decreased BP.
In the first hours of postpartum the perineal pad should be weighed
to determine the output amount with 1g equalling 1 ml. Oxygen also monitored.
early postpartum hemorrhage
uterine atony, lacerations, hematomas in reproductive tract.
uterine atony lack of normal muscle tone
muscle are flaccid and do not compress the vessel. normal postpartum changes should be easily felt through abdominal wall a firm mass about the size of a grapefruit
The fundus (top of the uterus) should be at the umbilicus level and begin
descending at a rate of 1 finger width (1cm) each day.
Characteristic uterine atony
it is boggy soft, the fundal height is high often above the umbilicus level. If the bladder is full the uterus is higher and pushed to one side rather than located in the midline of the abdomen.. It should be massage until firm.
mastitis (infection of the breast) signs and symptoms
redness heat in the breast, tenderness, edema heaviness in breast, purulent drainage) usually have fever and chills.
antibiotics and continued removal of milk from the breast are the primary treatment for mastitis. Heat promotes blood flow to the breast. encouraging take fluid 3L perday. wearing good support bra and limit movement should not be too tight.
subinvolution of the uterus
a slower than expected return of the uterus to its nonpregnant condition. typical signs:
fundal height greater than expected since birth.
persistence lochia rubra
subinvolution of uterus medical treatment
Methergine, antibiotics, dilation of the cervix and curretage removal fragments of the placenta from the uterine wall.
anterior fontanels is a triangular shape and closes by 12 to 18 month.
if it bulges during rest suggest increases ICP and should be notified immediately.
Magnesium sulfate infused to iv to manage preeclampsia and signs of toxicity includes
respiratory depression, loss of deep tendon reflex, decrease in FHR and Maternal HR
Nursing consideration in rubela
While taking out NG tube, take a deep breath and hold, while removing chest tube
valsalva maneuver or take a deep breath and hold.
19. Tube feeding, hold if residual is 200ml or more and notify physician.
Continue if less than 100ml.
in infant connects to the inferior venacava
consists of two umbilical arteries and one umbilical vein
before 20 weeks the bladder must be full to support weight of the uterus. After 20 weeks bladder must be emptied to minimize the chance of puncturing the placenta or fetus.
is administered for Rh-ve woman because of risk of immunization from the fetal blood during exam at 28 wk of gestation with 2nd injection within 72 hrs of delivery.
DIC disseminated intravascular coagulation is
a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding, platelet counts are decreased because they are consumed by the process, clotting times are prolonged
Fetal heart rate
is priority while collecting data in early labor.
used to halt preterm labor contraction and prevent preeclampsia (seizure)
Anterior fontanel closes at
12 to 18 months and posterior closes by 2 to 3 years
29. Cough syrup and cold medicine should not be given for a child
positive for more than 10 mm in a child below 5 yrs and 5mm for high risk group
31. S/S of trachoesophageal fistula and esophageal hernia
in infant includes excessive oral secretions
S/S of hialtal hernia in infant includes
vomiting, coughing, wheezing and apnea
foul smelling ribbon like stool
Profuse watery diarrhea and vomiting
in celiac diseases
Intussuception cramp and abdominal pain
blood and mucus in the stool
For hernia in children report if
is a autosomal recessive genetic diseases that needs to avoid phynalaline in diet.
TEF Tracheoesophageial fistula sings three C's
coughing, choking and cyanosis
Pyloric stenosis cardinal sign
After brain tumor surgery colorless drainage would indicate CSF and should be reported to the
Viral hepatitis leads to
food distasteful, fatigue, anorexia, urine color changes.
Taking Dulcolax in the empty stomach will have rapid effects
. Taking at night will leads to BM in the morning
TRimethobenzamide( TIGAN) is med for
Nausea and vomiting
Magnesium Citrate before citrate should be given
Midriatic eye meds dilates the pupil and miotic lessens the IOP,
pilocarpine contricts pupil and increases the out flow of aqueous humor and lowers the IOP. B Adrenergic blocking agents reduces the IOP by decreasing the production of aqueous humor
To minimize the systemic effects of eye drops can have
, occlude the nasolacrimal duct with finger for several mins
Wait 3-5 mins while instilling
2 eye drops
49. ICP increase sign and symptoms
increasing temp and BP
OVARIAN CANCER ss/sx
early vague lower abdominal discomfort and mild digestive complaints. Bowel and bladder functions are also affected in early stage. Late symptoms include pelvic pain, anemia and ascites.
Kawasaki disease is a condition that causes inflammation in the walls of small- and medium-sized arteries throughout the body, including the coronary arteries, which supply blood to the heart muscle. Kawasaki disease is also called mucocutaneous lymph node syndrome because it also affects lymph nodes, skin, and the mucous membranes inside the mouth, nose and throat.
Signs of Kawasaki disease, such as a high fever and peeling skin, can be frightening. The good news is that Kawasaki disease is usually treatable, and most children recover from Kawasaki disease without serious problems. Gamma globulin. Infusion of an immune protein (gamma globulin) through a vein (intravenously) can lower the risk of coronary artery problems.
Aspirin. High doses of aspirin may help treat inflammation. Aspirin can also decrease pain and joint inflammation, as well as reduce the fever. Kawasaki treatment is a rare exception to the rule against aspirin use in children.
elevated blood pressure. BP = CO (Cardiac output) times PR (Peripheral resistance)
systolic BP 120 - 139mm Hg. diastolic BP 80 - 89 mm Hg.
Normal BP ranges from
100/60 to 119/79 mm Hg
below 120 and 80 for diastole.
Stage I hypertension:
systolic BP : 140 to 159 mm Hg or diastolic BP: 90 to 99 mm Hg
AKA 140/90 to 159/99
Stage II hypertension:
systolic BP equals or exceed 160 mm Hg or a diastolic pressure that equals or exceed 100 mm Hg.
Pathophysiology of hypertension
Essential affect african american population higher than any other race. Obesity, inactivity, smoking, excessive alcohol, ineffective stress management are the risk factors. hypernatramia elevate BP. low serum potassium level may cause sodium retention as the kidneys try to maintain number of positive electrolyte: cation.
Hypertension signs and symptoms
may be asymptomatic, "the silent killer." BP becomes elevated clients may identify symptoms such as throbbing, pounding, headache, dizziness, fatigue, insomnia, nervousness, nosebleeds, and blurred vision. angina or dyspnea first clue of hypertension. clients may be overweight and flushed face from engorgement of superficial blood vessels. Peripheral edema may be present. Ophthalmic exam may be reveal vascular changes in the eyes, retinal hemorrhages, or edema known as papilledema.
Diagnostic finding of hypertension
electrocardiography, echocardiography, and chest radiography may reveal enlarged left ventricle. MUGA scan a test detect how well and efficiently heart pump, can detect heart failure. Blood test show elevated BUN and creatinine levels indicating renal function failure. IVP intravenous pyelography may further validate, fluorescein angiography, an ophthalmic test using IV dye often reveals leaking retinal blood vessels.
If cause of hypertension is a renal vascular problem renal arteriography demonstrate narrowing of the renal artery.
If the cause is related to dysfunction of the adrenal gland, a 24 hour collected urine specimen detects elevated catecholamines. Blood studies reveals elevated cholesterol and triglyceride levels indicating that atherosclerosis is an underlying factor.
While taking anticoagulant med, Vitamin K enriched food should be avoided
Antidote anticoagulant meds
Celiac disease symptoms
gluten free diet list
eating disorder characterized by an obsession for thinness that is achieved to self starvation. There are two types of anorexia:
1. severe restriction of caloric intake.
2. bulimarexia: of extended self starvation and a period of extended binging and purging.
BMI (Diagnostic finding of Anorexia Nervosa)
weight (kg) divided by height (meter times meter/ meter square)
Anorexia Nervosa treatment
work with dietitian to provide at least 6 to 8 meals each day with a total caloric value between 1500 to 2000 calories, then gradually increase the total clories between 2,500 to 4000 calories/day.
minimum of two episodes of secret food binges. rapid consumption of a large number of calories per week followed by behaviors intended to prevent weight gain. clients are over weight or normal weight, purging.
Assessment findings of bulimia nervosa
weight can fluctuate as much as 10 lbs in a week. self induced vomiting results in hoarseness, inflammation of esophagus, and oral pharynx, calluses on the back of the hand and fingers, erosion of tooth enamel, swollen parotid glands. A radiograph of the upper gastrointestinal tract shows an overstretched or stenotic esophagus from frequent regurgitation and inflammation followed by scarring.
RUQ-Right upper quadrant
right lobe of liver, gallbladder, duodenum, head of pancreas, hepatic flexure of the colon, portions of ascending and transverse colon.
RLQ-Right lower quadrant
cecum and appendix, portion of ascending colon.
LUQ-Left upper quadrant
Left lobe of liver, stomach, tail of pancreas, splenic flexure of colon, portions of transverse and descending colon.
LLQ- Left lower quadrant
sigmoid colon, portion of descending colon.
Barium swallow or upper gastrointestinal series.
fluoroscopic observation of the client actually swallowing a flavored barium solution and its progress down the esophagus to facilitates identify structural abnormalities as well as swallowing dysfunction.
The client is on low residue diet, takes NPO for 8 to 12 hours before the test. A laxative given clear out GI. med withhold except insulin and anticonvulsant. Its very constipating. drink fluid liberally. Stools will appear white, streaky, or clay colored from the barium. nurse must wait for stool specimen to prevent blockage retained of barium.
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