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Key Concepts for NCLEX - Document preview page 1

Key Concepts for NCLEX - Page 1

Document preview content for Key Concepts for NCLEX

Key Concepts for NCLEX

This document provides essential nursing care notes on Continuous Bladder Irrigation (CBI) post-TURP, including expected outcomes, troubleshooting, complications, and patient instructions.

Alice Edwards
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Key Concepts for NCLEX - Page 1 preview image1IMPORTANT NOTESBladderIrrigation"Continuous Bladder irrigation done mostly in TURF"Thisis a three waycatheter that keeps blood from accumulating•This is done with normal saline•Color of the urine should slowly progress to an amber coloroThe initial voiding following removal may be uncomfortable,, red in color and contain dots. Thecolor of the urine should progress toward amberin2 to 3 days.oOn the fourth day the urine should be clear - 4thday if you see blood this is NOT a good thingoIf bright-red or ketchup-appearing (arterial) bleeding with clots is observed, the nurse shouldincrease the rate"Ifthe catheter becomes obstructed (bladder spasmsrreduced irrigation outflow), turn offthe CBI andirrigate with 50 mL of irrigation solution using a large piston syringe.oContact the primary care provider if unable to dislodge the clot.•Record the amount of irrigating solution instilled (generally very large volumes) and the amount ofreturn. The difference equals urine output"Instruct the client to not try t o push peeoThe catheter has a large balloon (30 to 45 mL) that is taped tightly to the leg, creating tractionso that the balloon will apply firm pressure to the prostatic fossa to prevent bleeding. Thismakes the client feel a continuous need to urinate.oTell patient not to push (muscle spasms) can cause more bleeding§Once an obstruction is ruled out administer an antispasmodic to stop spasms•Expected output 150-200ml q2-3hr (normal is 30ml/hr)oInstruct the client that expectedoutputis 150 to 200mLevery 3 to 4hr. The client shouldcontact the provider if unable to void.•Need to watch out for blockage•Sodium can be absorbed through bladder irrigation•Avoid kinks in the tubing.•Complications:Urethraltrauma,urinary retention, bleeding, and infection are complicationsassociated with TURF. Other complications include re-growth of prostate tissue and reoccurrence ofbladder neck obstruction.Crutches■With crutches elbows should be flexed30degrees."Do not alter crutches after proper fit has been determined. Follow the prescribed crutch gait.•Support body weight at the hand grip with the elbows flexed at 30:.•Position the crutches on theunaffected side when sittingor risingfrom a chair.Climbingthe Stairs with Crutches■Upstairs - Good foot (good up to heaven)"Downstairs-Bad (bad go down hell)
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Key Concepts for NCLEX - Page 2 preview imageCane*Important to always haveTWO CONTACT POINTStouching at all times - two points of support*Keep the cane on theSTRONG SIDEof the body■When moving with the cane:support body weight on both legs, move thecane forward 6 to10inches,then move theweaker leg forwardtoward the cane. Next, advance the stronger leg.Ambulating w / devices*Cane:When ambulating with the cane- have clientkeep the caneon thestrong side ofthe body. Movecane up to 4 inches, thenWEAK LEG-strong leg.oUpstairs with Cane: (UP-STRONG/DOWN- STFLONG)4.Take first stepwiththe strong leg4.Move the affected leg to the same stepoDownstairs with Cane:4.Takefirst stepby placingcaneand unaffected(strong) leg on the step4Lower the affected leg t o the same step■Walker:Adjust walker to client's height. Allow20to 30 degree flexion of the elbows when graspingthe hand grips0Move walker up 6to Binches & move theWEAK LEG& then bring the strong leg equalwiththeweak leg.WWSI*Crutches:Axillary crutch is more commonly used and must be measured to fit anindividual.Crutchshould be2 fingers width from the axillaand15 cm lateral to client's heel. Thebasiccrutchstand isthetripod positionthe crutch is placed 15 cm(6 inches)in front of and 15 cm(6 inches)to the side ofeach foot.Itimproves a person's balance. Theaxilla should not bearweight and client assumestripodposition beforecrutch walking.Types of Crutch Gaits:*Four-point gait- {Alternating Gait)gives stability to client-requires weight bearing on bothlegs. Eachleg is moved alternatively with each opposing crutch.*Three-point gait-requires the client tobearall ofthe weight on one foot.Client will bear all theweight on both crutches and then on the uninvolved leg- affected leg does not touch the ground.*Two- point gait- requires partial weight bearingon each foot .The client moves the crutch at the sametime as the opposing leg.■Swing-through gait- (paraplegics wear weight supporting braces use this gaitJWith weight placed onboth legs, the client will place the crutches one stride in front and thenswings throughthe crutches.Dumping Syndrome"After bariatric surgery observe pt for S/S of dumping syndrome.*Dumping syndrome is a complication of gastric surgery that consists of vasomotor symptoms occurringin response to food ingestion. Symptoms result from the rapid emptying of gastric contents into thesmall intestine.
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Key Concepts for NCLEX - Page 3 preview image•Client Education- DumpingSyndromeoLay down after meal - because it will slow the movement of food within the intestinesoLimit the amount of fluids ingested at one time§Eliminate liquids with meals and for 1 hr prior to and following a mealoConsume a high fat, high proteins, low to moderate carbs dietoAvoidmilk,sweets, and sugars - because these can cause diarrheaoSmall frequent meals rather than large mealsoPernicious anemia is common here- Give Vit BIZCrohn's Disease•Intermittent involvement of throughout the entire lower Gl tract, most commonly in the smallintestine and the terminal ileum.■Inflammation and ulceration throughout the Gl tract - see sporadic lesions and fistulas are common•Diarrhea and colicky abdominal pain•Monitor for Megaloblastic (pernicious Janemia - Give V I T A M I NB12 injectionmonthly for life•UTI -first sign in bowel/bladder fistula(Feces times seen in urine and vagina)•S/S:Abdominal pain/cramping: Often right-lower quadrant painoAnorexia and weight loss, fever, diarrhea, high-pitched bowel sounds, steatorrhea•Acute treatment is fluid and bowel rest•More difficult to cure and manage- Commonly in small intestines•Perineal abscess and fistulas -common in Crohn's disease•Low fiber diet or NPO (severe inflammation)•Longterm treatment is low fiber diet and medicationUlcerative colitis"TOXIN MEGACOLON -common in ulcerative colitis•More acute - see blood and mucus•Bloody and frequent diarrhea and abdominal pain, tenesmus & rectal bleeding-See in theDESCENDING COLON•Common to see joint pain/ arthritis (inflammation}•Antiinflammatory med:oGive suIfasaIazine (AzuIfidine)§May cause yellowish orange discoloration of skin and urine§Avoid sun exposure - wear sun blocked•Low fiber diet or NPO (severe inflammation)Ulcerative Colitis Interventions•PriorityIntervention: NPO (they will have 20 to 25 stools a day]■Diaper & bowel rest/ colitis can lead to TOXIC MEGA COLON•Onlyinthe rectum,.'TREAT WITH SITZ BATH OF WITCH HAZEL COMPRESSION•Medication- antibiotics:SULFASALAZINE (AZULFIDINE} -decrease inflammation of intestinal mucosa(can be given rectally)
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Key Concepts for NCLEX - Page 4 preview imageUlcerative Colitis and Crohn's Disease Nursing Care"Educate the client in eating foods that are high in protein and calories, and low in fiber.■Instruct the client to avoid caffeine and alcohol, and take a multivitamin that contains iron.*Advise the chent that small frequent meals may reduce the occurrence of symptoms.*Inform the client that dietary supplements that are high in protein and low in fiber may be used.*Monitor for an electrolyte imbalance, especially potassium. Diarrhea can cause a loss of fluids andelectrolytes.*Monitor fluids and assess for dehydration.*Educate the client regarding the use of vitamin supplements andBIZinjections,if needed.■Assist the client in identifying foods that trigger symptoms.Diverticulitis*Saccular Dilations or Outpunching of the Diverticula*Abdominal pain -SIGMOID COLON LLO-abd. distension, bloating, flatulence & bowel changes*Increase-High fiber diet & increasefluids- is very important inpreventing future diverticulitisattacksbut duringEXACERBATION OF DIVERTICULITISput patient on LOW fiberdiet■Encourage walk daily for SOmins (for no constipation)- No strenuous exercisesAcute Diverticulitis■Priorityintervention: NPO-Bowel rest!ExampleQ: Which of the following comments made by the patient indicates that additional instruction aboutthe care of a new ileostomy is needed?1. "1 should change the appliance daily t o prevent odors."2. "When I change the appliance. I should check the skin for irritation."3. "I should clean around the stoma with mild soap and water and pat dry."4. "I'll need to alter the appliance opening when the stoma becomes smaller as the areaheals."Rationale:The appliance is changed every 4 to 7 days unless leakage occursHeat and Cold Therapy"First 24hrs- coldoPrevents swelling, decreases inflammation, reduces bleeding, reduces fever, diminishes musclespasms decreases pain by decreasing the velocity of nerve conduction•After 24 hrs - h e a t■Heat increases blood flowoIncreases tissue metabolismoRelaxes musclesoDo not take long showersoEases joint stiffness and pain■Avoid heat application over metal devices to avoid deep tissue burns•Heat-Monitor bony prominences carefully as they are more sensitive to heat applications.oAvoid the use of heat applications over metal devices (pacemakers, prosthetic joints) to preventdeep tissue bums.oDo not apply heat to the abdomen of a pregnant woman to prevent harm to the fetus.
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Key Concepts for NCLEX - Page 5 preview imageoDo not place a heat application under an immobile client as this may increase the risk of burnsCold- Decreases inflammation*Prevents swelling*Reduces bleeding*Reduces fever*Diminishes muscle spasms*Decreases pain by decreasing the velocity of nerve conductionAvoid cold application for cold intolerance*Hyperthyroidism*Peripheral arterial disease*Raynaud's phenomenonH o t compress causes vasodilation and delivers more blood t o the site.*If a patient is in pain, you could apply a hot compress to direct blood, which carries oxygen andnutrients to the area, which will alleviate pain.Cold compresses cause vasoconstriction in the area and divert blood flow.Cognitive Disorders/Alzheimer's*How do you promote hygiene proper care in pt with Alzheimer's?*Alzheimer's disease (AD) is a nonreversible type of dementia that progressively develops throughseven stages over many years*AD is a type of dementia. Dementia is defined as multiple cognitive deficits that impair memory andcan affect language, motor skills, and or abstract thinkingNursing Care for Alzheimer*Assess cognitive status, memory, judgment, and personality changes.*Initiate bowel and bladder program with the chent based on a set schedule.*Encourage the client and family to participate in an AD support group.*Provide a safe environment.*Keep the client on a sleeping schedule and monitor for irregular sleeping patterns.*Provide verbal and nonverbal ways to communicate with the client.*Offer snacks or finger foods if the client is unable to sit for long periods of time.*Check the client's skin weekly for breakdown.*Provide cognitive stimulation: family pics, time place and person*Offer varied environmental stimulations such as walks, music, or craft activities.*Keep a structured environment and introduce change gradually (client's daily routine or a roomchange).*Use a calendar to assist with orientation.*Use short directions when explaining an activity or care the chent needs, such as a bath.■Use therapeutic touch*Place stop signs on the door. Have the chent wear ID. Have chent walk with supervision. Apply physicalrestraints only as a last resort.
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Key Concepts for NCLEX - Page 6 preview imageProvide M e m o r y Training:•Reminisce with the client about The past.•Use memory techniques such as making lists and rehearsing.•Stimulate the client's memory by repeating the client's last statement.•Avoid overstimulation (keep noise and clutter to a minimum and avoid crowds).•Promote consistency by placing commonly used objects in the same location and using a routineschedule.•Reality orientation (early stages)•Easily viewed clock and single day calendar■Pictures of family and pets•Frequent reorientation to time, place, and person•Validation therapy (later stages)•Acknowledge the client's feelings.•Don't argue with the client; this will lead to the client becoming upset.•Reinforce and use repetitive actions or ideas cautiously.•Promote self-care as long as possible. Assist the client with activities of daily living appropriate.•Speak directly to the client in short, concise sentences.•Reduce agitation (use calm, redirecting statements; provide a diversion).■Provide a routine toileting schedule.If patient has CHOLECYSTITIS. What kind of diet restrictions should be on?•Cholecystitis is an inflammation of the gallbladder wall, it is most often caused by gallstones(cholelithiasis) obstructing the cystic and or common bile ducts (bile flow from the gallbladder to theduodenum) causing bile to back up and the gall bladder to become inflamed.•Sharp pain in the Right Upper Quadrant of the abdomen, often radiating to the right shoulder.•Pain with deep inspiration during right subcostal palpation (Murphy's sign ).•Jaundice, clay-colored stools, steatorrhea (fatty stools), dark urine, and pruritus (accumulation ofbile salts in the skin) may be seen in clients with chronic cholecystitis (due t o biliary obstruction).Diagnostic Procedures:•A right-upper quadrant ( RUQ) ultrasound visualizes gall stones and a dilated common bile duct.•An abdominal x-ray or CT scan can visualize calcified gallstones and an enlarged gall bladder.•A hepatobiliary scan (HIDA) assesses the patency of the biliary duct system after an IV injection ofcontrast.Diet:•Encourage a LOW-FAT diet(reduce dairy and avoid fried foods, chocolate, nuts, gravies). Promoteweight reduction.•Avoid gas-forming foods (beans, cabbage, cauliflower, and broccoli).•Small, frequent meals may be tolerated.
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Key Concepts for NCLEX - Page 7 preview imageKegel Exercises*For person with strong risk for urinary incontinence*Tighten pelvic muscles for a count of10:relax slowly for acount of1 0 ,and repeat in sequences of15in the lying-down, sitting and standing positionoPerform four times a day*Keep abdominal muscles relaxed during contractions.*Contract the circumvaginal and or perirectal muscles.Sleep Disorders*Recognizing and reporting sleep disorders*How does it affect medications (cholesterol meds workbetterduring sleep)*fasomfua:the most common sleep disorder, is defined as the inability to get an adequate amount ofsleep and to feel rested. The person may have difficult}-falling asleep, have difficult}' staying asleep,awaken. too early, or not get refreshing sleepoAcute msomnin lasts for only a few days and may be due to personal stressors.oCJjfonrc insomnialasts a month or more. Some people experience intermittent insomnia,where they are able to sleep well for a few days and then experience insomnia for a few days.Women and older adults are more likely to experience insomnia.*Steep apneais a disorder in which there are more than five apneic occurrences lasting longer than10seconds-h rduring sleep, resulting in decreased arterial oxygen saturation levels*Narcolepsy -a disordero fthe sleep and wake mechanism. The person may lose the ability to stayawake. It often happens at inappropriate times and can put the person at risk for injury.*Assesimenr/Dotn CoMectfon:oAxk the client about sleep patterns, history, and if an}' changes have occurred.oAsk the client about sleep problems, which includeoType of problem, symptoms, timing, seriousness, related factors, how the lack of sleep hasaffected the client.oUse a linear scale or visual with "best sleep" on one end and "worst sleep" on the opposite end.Also, the nurse could ask the client to rate sleep on a 0 to 10 scale.oAssess for common factors that interfere with sleep, which include:§Illness - may require more sleep or disrupt sleep, such as nocturia§Current life events (traveling more, change in work hours).§Emotional stress or mental illness (anxiety, fear).§Diet (caffeine consumption, heavy meals before bedtime).oExercise - promotes sleep if done at least 2 hr before bedtime: otherwise, it can disrupt sleepoSleep environment that is too light, the wrong temperature, or too noisy (children, pets, loudnoise, snoring partner).*Amino acid inmilkTRYPTOPHAN-helps in sleep*M ELATONIN-hormone-helps in sleep*Medications - may induce sleepbutinterfere with the restorative sleep cyclesoAxk patient if the}' dream (REM SLEEP)oLoop diuretics should be avoided at night to prevent falls and will most likely interrupt theclient's sleep
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Key Concepts for NCLEX - Page 8 preview imageNonpharmacological Pain Therapy"TENS (Transcutaneous Electrical Nerve Stimulation)■Therapeutic Touch*Pain Pathways -Gate ControlTheory: The theory guided research toward the cognitive behavioralapproaches to pain management. This theory helps to explain how interventions based onsomatosensory (auditory, visual and tactile) stimulation such as friction, music therapy and distractionprovide pain relief.oTwo receptors for opioidsoN i l a n d K a p p a*Distraction-Includes ambulation, deep breathing, visitors, television, and musicoDistraction therapy works best with children*Relaxation-Includes meditation, yoga, and progressive muscle relaxation*Imagery- Focusing on a pleasant thought to divert focusoRequires an ability to concentrate*Acupuncture - vibration or electrical stimulation via tiny needles inserted into the skin andsubcutaneous tissues at specific pointsoReduction of pain stimuli in the environment*Elevation of edematous extremities to promote venous return and decrease swellingStump Pain after Amputation■Elevation for edema*Phantom painoTreated as real painoPatient says they have pain - give them pain medsAcute and Chronic Glomerulonephritis*Glomerulonephritis is an inflammation of the glomerular capillaries, usually following a StreptococcalInfection-It is an immune complex disease, not an infection of the kidney*Duetoswelling and capillary cell deathoAlso get it from SEE, hypotension and diabetes mellitus*Patient will have a spontaneous recover}'*Diet includes:oFluid restriction(24 hr output + 5 0 0 ml).oLOW SODIUM, LOW PROTEIN AND LOW POTASSIUM DIEToPROTEIN restriction (if Azotemia is present = increased BUN).*Important towatchBUN and creatinine levels*CARE after dischargeoAdvise the client to maintain fluid and sodium restriction - a dietar/ consult may be necessary.*ClientEducation: Encourage the client to rest in order to conserve energy.oMaintain prescribed dietary restrictions.Acute Glomerual Nephritis*Strep infection-Ask pt. about sore throat*S/S: body edema. HTN & oliguria
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Key Concepts for NCLEX - Page 9 preview imageRenal Failure*Early symptoms o f Acute Renal Failure:Oliguria (decreased urinary output)*B U N ( 10-20)-increa sed*Creatinine (0.8-1.2)- increased*Anuria: non-passage of urineEnd Stage Renal failure means hemodialysis for life*DAILY weigfats-loss of 2 lbs in 24 hrs, little urine output, fever -sign of infection*DM+HTN are the most risk factorsDiet Teaching Uric Acid- t o prevent hyperuricemia*Avoid -Redmeat (beef. pork and lamb),fatty fish and seafood(tuna, shrimp, lobster and scallopsshellfish l±e scallop, lobster, oyster, clam, and shrimp will have more purine levels than normalfish.)*Avoid beans and legumes*Avoid dark green leafy vegetable, cauliflower, spinach, mushrooms and asparagus*Limit or avoid alcohol & sugar*Choose low-fator fat-free dairyproducts: Drinking skim or low-fat milk & yogurt*Choose complex carbohydrates:whole grains and fruits and vegetablesChronic Kidney Disease*Which priority intervention for CKD can be delegated to LAP?MonitorISO*Canned, pickled and smoked food is prohibited*Know the importance of monitor I&O? LIM IT FLUIDINTAKE*Assess protenuria- teach patienttoAVOID EXCESS PROTEINbecause increased protein intake canaffect mental status & cause confusionPeritoneal dialysis*Therapeutic procedure for CKD utilizes the patient's abdominal cavity lining as a natural filter*Interventions:STERILE-Cloudy Urine dialysisIMMEDIATE INTERVENTION*Abdominal cramping:SLOW THE INFUSION*Assess for infection -clean the pins withHYDROGEN PEROXIDE AND NSKayexalate*Normal potassium level 3.5-5.0*Therapy for elevated potassium (hyperkalemia)"Kayexalate - never give it to patient with PARALYTIC ILEUSAV Shunt*Assess: thrill and bruit (thrill is palpated & bruit is heard)*Take BP on opposite arm of shunt
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Key Concepts for NCLEX - Page 10 preview imageKosher Diet■Prohibits eating meat and dairytogether. This separation includes not only the foods themselves, butthe utensils, pots and pans with which they are cooked, the plates and flatware from which they areeaten, the dishwashers or dishpansinwhich they are cleaned, the spongeswithwhich they arecleaned and the towels with which they are dried."A kosher household will have at least two sets of pots, pans and dishes:one for meat and onefordairy.One must wait a significant amount of time between eating meat and dairy. Opinions differ, andvary from three to six hours after meat. This is because fatty residues and meat particles tend to clingto the mouth. From dairy to meat, however, one need only rinse one's mouth and eat a neutral solidlike bread, unless the dairy productinquestion is also of a type that tends to stick in themouth."All fruitsand vegetables are kosher. However, bugs and worms that maybe found i n some fruits andvegetables are not kosher.Jehovah's Witnesses"Jehovah's Witnesses doNOTaccept blood transfusions.■Clients avoid foods having or prepared with blood.■Can recommend anAUTOLOGOUSblood transfusionoWhen the patient goes in a couple of days before and donates their own bloodStoma Care*An ostomy is a surgical opening from the inside of the body to the outside. Ostomies can be permanentor temporary and are located in various parts of the body.■Ueostomyopening at the small intestineoSee morefluidsand more skin degeneration■Co/ostomy opening at the colonoSee moresolid...change bag more often-%t o K full- change it !*Nursing ActionsoAssess the type and fit of the ostomy appliance.oMonitor for leakage (risk to skin integrity].oFit the ostomy appliance based on:§Type of ostomy.§Location of the ostomy.§Visual acuity and manual dexterity of the client.oVisual acuity and manual dexterity of the client.oAssess peristomal skin integrity and the appearance of the stoma.oThe stoma should appear pink and moist.oApply skin barriers and creams, such as stoma adhesive paste, when applying wafers t o protectthe peristomal skin.oLet the skin sealants dry before applying a new appliance.oEvaluate output from the stoma.Normal post -op output is less than 1000 ml/day. Tohe higher up an ostomy is placed in the small intestine, the more liquid and acidic the outputwill be from the ostomy.oAssess for fluid and electrolyte imbalances, particularly with a new ileostomy.
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Key Concepts for NCLEX - Page 11 preview imageoEducatethe client regarding dietary changes and ostomy appliances that can help manageflatus and odor.§Foodsthat can cause odor includefish, eggs, asparagus, garlic, beans, and dark greenleafy vegetables.§Foodsthat cancause gas includedark green leafy vegetables, beer, carbonatedbeverages, dairy products, and com. Yogurt can be ingested t o help decrease gas.*After an ostomy is placed involving the small intestine, the client shouldoBe instructed t oavoid high-fiber foods forthe first2 monthsafter surgery, chew foodwell,drinkplenty of fluidsoEvaIuate for any evidence of blockage when slow ly adding high-fiber foods.oDo notputanything in the bag to mask odor such as amint.oKeep appliance dean and emptyfrequentIyto decre ase odor.*Normal and Abnormal FindingsoImmediate postoperative stoma should be reddish pink, moist, and may have a small amount ofvisible blood; report any evidence of stoma ischemia or necrosisoIf some skin is hanging off post op that is a normal findingoSigns of stomal ischemia are pale pink or bluish/purple in color and dry in appearance.oIf the stoma appears black or purple i n color, this indicates a serious impairment of blood flowand requires immediate intervention.Spinal Cord Injury"Autonomic Dysreflexia"Stimulation of the sympathetic nervous system causes extreme hypertension, sudden severeheadache, pallor bellow the level of the spinal cord's lesion dermatome, blurred vision, diaphoresis,restlessness, nausea, and piloerection 4goose bumps).*Clients who have lesionsbelow T6 do notexperiencedysreflexiabecause the parasympatheticnervous system is able to neutralize the sympathetic response.*NursingActionsoDetermine and treat the cause.oSit the client up (to decrease blood pressure secondary t o postural hypotension).oNotify the provider.oDetermine The Cause.§DISTENDED BLADDERisthemost common cause(kinked or blocked urinarycatheter, urinary retention, or urinary calculi)§Fecalimpaction§Cold stress or drafts on lower part of the body§Tight clothing§Undiagnosedinjury or illness(kidney infection or stone, lower extremity fracture]oTreatThe Cause§Relieve thekink in thecatheter or irrigate t o remove blockage.§Catheterize the client (use anesthetic ointment on the t i p of the catheter).§Remove the impaction (use anesthetic ointment prior t o removal).§Adjust the room temperature and block drafts.
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Key Concepts for NCLEX - Page 12 preview image§Remove tight clothing.§Assess for injury, such as lower extremity fracture or kidney/bladder Infection.§Monitor vital signs for severe hypertension and bradycardia.§Administer antihypertensives (nitrates or hydralazine).oClient Education:Instruct the client to space out fluid intake and increase frequency ofintermittent catheterizations if fluid intake is temporarily increased.*Perineal CareoDevelopment of a schedule as part of bladder and bowel training is critical for theestablishment of a routineoFlaccid Neurogenic Bladder -Clients who haveLOWER MOTORNEURONINJURIESwill developa flaccid bladder. Bladder management options for males and females include intermittentcatheterization and Crede's method (downward pressure placed on the bladder to manuallyexpress the urine).oSpastic Neurogenic Bladder -ClientswhohaveUPPER MOTOR NEURON INJURIES willdevelopaspastic bladder after the spinal shock resolves. Bladder management options for male clientsInclude condom catheters and stimulation of the micturition reflex by tugging on the pubic hair.Female clients will need to use an indwelling urinary catheter due to the unpredictably of therelease of urine.oNeurogenic bowel functioning does not differ a lot between upper and lower motor neuronInjuries.oDaily use of stool softeners orbulkforming laxativesisrecommended to keep the stool soft. Abowel movement can be stimulated daily or every other day by administration of a bisacodyl(Dulcolax)suppository or digital stimulation (stimulation of the rectal sphincter with a glovedand lubricated finger).§Docusatesodium (Colace)or polycarbophil (Fibercon) to prevent constipation and keepthe stool soft.*A client who has acervical spinal injurywill also have anupper motor neuron injury,which willmanifest itself by creating aspastic bladder.Since the bladder will empty on Its own, acondomcatheter isan appropriate method."Develop a schedule as part of the bowel and bladder training.PharmacologyLeukotriene Modifiers: Montelukast (Singulair), Zileuton (Zyflo), Zafirlukast (Accclate)*Respiratory Drugs*Suppress inflammation, bronchoconstriction, airway, edema and mucus production.■Used for long-term therapy of asthma in adults and children 15 years and older and to preventexercise-induced bronchospasm.*Take these drugs every day- they areNOTrescue inhalersWhat group does Spiriva(Advair) Belong to? Respiratory-Bronchodilator- Leukotriene Modifier"Works in a different way- NOT a rescue inhaler- taking it regularly reduces number of asthma attacks"Control inflammation- prevents it over time
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Key Concepts for NCLEX - Page 13 preview image"Spiriva (tiotropumi)- inhaled anticholinergic-blocks muscarenic receptors of the bronchi, resulting inbronchodilation.*Advair{Fluticasone propionate)- GlucocorticoidsoThese medications prevent inflammation, suppress airway mucus production, and promoteresponsiveness of beta! receptors in the bronchial tree.Antibiotics■Antibiotics that affect the CELLWALLareBACTERICIDAL.This group of antibiotics includes penicillin's,cephalosporin's, carbapenems and monobactams.Penicillin's*Penicillin 6(BicillinLA)*Broad-Spectrum■Amoxicillin-clavulanate (Augmentin)}"Ampicillin (Principen)"Antistaphylococcal■Nafcillin (Unipen)*Methicillin*Antipseudomonas■Carbenicillin (Geoillin)*Ticarcillin-davulanate (Timemtin)*Piperacillin tazobactam (Zoysn)Cephalosporin's•Cepalexin (Keflex)-1stgeneration•Cephradine, Anspor, Velosef-1stgeneration*Cefaclor (Celcor), Cefotetan (Cefotan)- 2ndgeneration"Ceftriaxone (Rocephin), Cefotazime(Claforan), Cefoperazone (Cefobid)- 3rdgeneration*Cefepime (Maxlpime)- 4thgenerationCarbapenems’Imipenem (Primaxin)■Meropenem (MerrernIV)MonobactamsNo cross-hypersensitivity reactions withpenicillinbut like penicillins can trigger seizures inpatients with history of seizures.*Vancomycin (Vancocin)*Aztreonam (Azactam)*Fosfomycin (Monurol)*Penicillin-anaphylactic reaction of antibiotic that breaks theCELL WALL-also cephalosporinoAnaphylaxis:§Interview clients for prlor aIlergy.§Advise clients to wear an allergy identification bracelet."Gentamicin- Interfers with PROTIEN SYNTHESISoCan cause OTOTOKCICTY (ringing in the ears) and NEPROTOXCICTYoPJost common IV medicationoDosage is reduced in the elderly due to decrease in renal clearance- after 65 kidneys function lessoSide Effects/Adverse Effects:§Ototoxicity: Monitorclientsfor symptoms ofTINNITUS (ringing in theears), headache,hearing loss, nausea, dizziness and vertigo. STOP medication if this occurs.§Nephrotoxicity:Monitorl&O, BUN and Creatininelevels. Instruct client to reportsignificant decrease in the amount of urine output.
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Key Concepts for NCLEX - Page 14 preview imageMedications That Cause Nephrotoxicity:•Amphoteracin B (antifungal)•Cyclosporins•ACE inhibitors•Cisplatin {cancer medication)"NSAIDsLithium (Lithane, Eskalith**, and Lithonate): MOOD STABILIZER***Effective i n the treatment ofbipolar Iacute and recurrent manic and depressive episodes.*Itusually takes 7 to 1 4 days to reach therapeutic levels.Antipsychotic or benzodiazepine can be used t o prevent exhaustion., coronary collapse, and deathuntil Lithium reaches therapeutic levelsMETALLIC TASTE-telI patient t o chew hard candy or use oral swabsDuring initial treatment of manic episodes-levels 0.8-1.4 mEq/LInstruct clients to monitor signs of toxicity and when to contact the provider.. Clients should stoptaking medication and seek medical attention if experiencing diarrhea, vomiting, or excessivesweating.Need to watch for HYPONATREMIAReduced serum sodium decreases lithium excretion, which can lead to toxicity.Adequate fluid and sodium intake should be maintained.If taking diuretics- risk for hypokalemiaSide effects:Polyuria and mild thirstIntervention:Use a potassium-sparing diuretic, such as spironolactone (Aldactone).Pharmacological Interventions:Lithium carbonatex’Therapeutic andtoxic levelsoTherapeutic blood level 0.8 t o 1.2 mEq/LoMaintenance blood level 0.4 to 1.3 mEq/LoToxic blood level: 1.5 to 2.0 mEq/LLithium Toxicity: Symptoms of Li ToxicityLevels 1.3 to 1.5 mEq/L -Fine hand tremors, nausea, vomiting, diarrhea, confusion, ataxia, slurredspeech, lethargy, thirst and polyuria, muscle weakness.Nursing Consideration:Medication shouldbewithheld, Assess patient for toxicity symptoms, bloodlevels measured, and evaluate dosage. Dehydration should be addressed.Levels 1.6 to 2.0Course hand tremors, Gl upset, mental confusion, muscle hyperirritability,incoordination, and sedation.Nursing Consideration:Medication should be withheld, Assess patient for toxicity symptoms, bloodlevels measured, and evaluate dosage. Dehydration should be addressed.Levels > 2.1 to 3.0 mEq/L -Ataxia, Confusion, blurred vision, hypotension, Profound CNS depression,arrythmias, seizures, coma, death due to pulmonary complications.Nursing considerations:All of the above & administer emetic to alert the clients or administer gastriclavage.•Greaterthan2.5mEq/L-rapid progression of symptoms leading t o coma & death-NursingConsiderations: All of the above & Hemodialysis may be used in severe cases.
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Key Concepts for NCLEX - Page 15 preview imageLithium levels should be measured at least 5 days after beginning therapy and after any dosage change.Blood should be drawn in the MORNING, 8 to 12 hours after the last dose was taken.*For older adult patients, Start low and go-slow applies. Lithium levels should be drawn every 3 t o 4days f o r t h e m .*Someone can go toxic at any time in treatment - even if they have been taking it for years soitisimportant to teach patient t oget routine blood work done.*Suddenly stopping lithium can lead t o relapse and recurrence ofMANIA.*Two majorlong-term risks of lithiumtherapy areHYPOTHYROIDISMandIMPAIRMENToftheKIDNEY'Sability t oCONCENTRATE URINE.*Before starting therapy, you should assess:Renal Function, Thyroid Status, Dementia AndNeurological Disorders.*Shouldntbe given t o patients with cardiovascular disease, brain damage, renal disease, thyroiddisease, or myasthenia gravis.*It can harma fetus, shouldn't be used when breast feeding, and shouldn't be used for children under12 years of age.’Lithium is a naturally occurring salt - but you need t o teach the patientNOTt o change their diet to oneof low sodium -THEY NEED TOKEEPA REGULAR DIET*Kidney function test- AST & ALT- No NSAIDS such as Ibuprofen use aspirin*Have t o be extremely careful with a patient who is having a manic episode because they might have anelectrolyte imbalance that can lead to lithium toxicity*Lithium with an SSRI for a manic pt. can cause RAPID CYLING!Q: Ifa patient comes i n with a lithium level of 1.6 what do you do?A: Assess the patient, hold the dose and then call the doctor.Digoxin:*Normal lab value- 0.5 to 2.0 ng/mL*Watch for HYPOKALEMIA*Check apical pulse- if less than 60/min in an adult, less than 70/min in children, less than 90/min ininfants- Hold Digoxin & notify provider!*Instruct client t o observe symptoms of toxicity: Anorexia, fatigue, weakness, nausea and vomiting’Management of toxicity:oDigoxin and potassium-sparing medication should b e stopped immediately.oMonitor potassium levels. For levels less than 3.5 mEq/L, administer potassium intravenously.oIf K+ levels greater than5.0 mEq/L- Put pt. on a cardiac monitor.oTreat dysrhythmias with phenytoin (Dilantin) or Lidocaine.oTreat bradycardia with atropine.oFor overdose treat with: activated charcoal, cholestyramine or DIGIBIND can be used to binddigoxin and prevent absorption.*How it interferes with K+oThiazide diuretics, such as hydrochlorothiazide (HCTZ), and loop diuretics, such as furosemide(Lasix), may lead toHYPOKALEMIA-Increase t h e risk ofDYSRHTTHMIAS!oAce inhibitors and ARBS increase the risk ofHYPERKALEMIA-leads to decreased therapeuticeffects of digoxin.oMonitor k+ levels to maintain 3.5 to 5.0 mEq/LoInstruct client to report signs of hypokalemia (nausea, vomiting and weakness)
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Key Concepts for NCLEX - Page 16 preview imageoTesch clients to consume high potassium foods CSpiniach, bananas, potatoes}.*Monitor Digoxin LevelsoSigns of toxicity may appear less than 1.75 ng/mLoTeach clients to monitor apical pulse.Therate maybe irregular with early or extra beats noted.oClients with heart failure respond best to serum levels between 0.5- 0.8 ng/mLoNausea 8< Vomitingare significant toxic symptoms-sign of toxicity!Epogen- Used for Chronic Anemia (Kidney Failure)- Kidney's can't produce erythropoietin■It's working if Hematocrit goes up"Watch HCT if it goes up too much- BP could increase and lead t oHYPERTENSIVE CRISIS"Given SubQ"Adverse Effects:oHypertension secondary to elevation in hematocrit levelsoMonitor clients hemoglobin, hematocrit and BPrif elevated- give hypertensive medicationsoIncreases risk for cardiovascular event (Ml, Stroke, Cardiac Arrest) with an increase in Hgbabove12g/dL or more than 1 g in 2 weeks.oDecrease dosage when these limits are reached.■Nursing Interventions:oObtain client's baseline blood pressure. Clients with chronic renal failure- control hypertensionbefore start of treatment.oAdminister SubQ or IV bolus injection.oDo not agitate the vial of medication. Use each vial for one dose and do not put the needleback into the vial when withdrawing the medication.oDosing is usually 3x/week, but maybe once a week with some types of chemotherapy.oMonitor client's iron levels- RBC growth is dependent on adequate iron, folic acid and vitaminB12.oMonitor Hgb and Het twice a week until target range is reached.Anemia*Anemia is an abnormally low amount of circulating RBCs,Hgb concentration, or both."Anemia results in diminished oxygen-carrying capacity and delivery to tissues and organs.*Nursing Actions for AnemiaoMonitor the client for fatigue, pallor, dizziness, and shortness of breath.oHelp the client manage anemia-related fatigue by scheduling activities with rest periods inbetween and using energy saving measures (sitting during showers and ADLs).oAdminister erythropoietin medications such as erythropoietin alfa (Epogen) and antianemicmedications such as ferrous sulfate (Feosol) as prescribed.oMonitor the client's Hgb to determine response to medications. Be prepared t o administerblood if prescribedoMonitor Hgb and Het closely because you do not want it to rise too quickly = Hypertension§Should not grow by 4 in two weeks§Monitor the client for cardiovascular event if Hgb increases too rapidly ( >lgm/dL in 2weeks).
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Key Concepts for NCLEX - Page 17 preview imageIron supplementation:oStool w i l l be black.oM a y cause gastrointestinal distress; take with f o o d i f this occurs.oTake w i t h vitamin C t o increase absorption.oTake 2 h r before o r after meal o r antacids.oIncrease f i b e r and fluids in diet t o manage constipation.oUse a straw with liquid iron to avoid staining teethAnemiaoI r o n deficiency: food sources rich i n IRON?- Absorption IRON better with Vit C b u t m o r e GldifficultyoFoodssources rich in iron:Red meat. Egg yolks, Dark, leafy greens (spinach, coIlards),Dried fruit(prunes, raisins),Iron-enriched cereals and grains (check t h e labels],Mollusks (oysters, clams,scallopsJTurkey o rchickengiblets, Beans, lentils, chick peas and soybeans. Liver, ArtichokesoMegaloblastic: why d o cells become bigger? B/c Vit B12 is lowoSicklecell: hydration!!!oGood sources o f Vit B l 2-liver, beef, salmon, trout, breakfast cereals.Tuna, milk, cheese, h a m , egg, roasted chickenoAnemia is an abnormally l o w a m o u n t o f circulating RBCs, Hgb concentration, or both.oAnemia results i n diminished oxygen-carrying capacity and delivery to tissues a n d organs.NursingConsiderationsoAdminister parenteral iron t o a client using theZ-track method.oInstruct t o havehemoglobincheckedin4 t o6weeks t o determine efficacy.oVitamin C may increase oral ironabsorption.oInstruct t h e d i e n t t o take iron supplements between m e aIs t o increa se a bsorption, i f tolerate d.oErythropoietin - Epoetin alfa (Epogen, Procrit)oA hematopoietic growth factor used t o increase production o f RBCsoObserve the client for an increase in blood pressure (Hypertension}.oMonitor Hgb and Het twice a weekoM o n i t o r t h e client for cardiovascular event i f Hgb increases t o o rapidly ( > l g m / d L i n 2 weeks).ClientEducationoReinforce the importance of having Hgb and Het evaluated o n a twice-a week basis.oVitamin B12 supplementation (Cyanocobalamin)oVitamin B12 is necessary t o convert folic acid fromitsinactive form t o its active f o r m . All cellsrely o n folic acid f o r DNA production.oNursing Considerations§Give vitamin B12 according t o appropriate r o u t e related t o cause o f Vitamin B12 anemia(parenteral versus oral).§Administer parenteral forms of vitamin B12 intramuscularly o r deep subcutaneous t odecrease irritation. D o n o t mix§The goal o f t r e a t m e n t is t o restore and maintain adequate tissue oxygenation.
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Key Concepts for NCLEX - Page 18 preview image/randeficiencyanemia occurs because of a lack of t h e mineral i r o n in t h e body. Bone m a r r o w i n the center o ft h e bone needs i r o n t o make hemoglobin, the part o f the red blood cell t h a t transports oxygen to the body'sorgans. W i t h o u t adequate i r o n , the b o d y cannot produce enough hemoglobin for r e d blood cells. The result isiron-deficiency anemia.This type of anemia can be caused by:*An iron-poor diet, especially i n infants, children, teens, vegans, and vegetarians"The metabolic demands o f pregnancy and breastfeeding t h a t deplete a woman's iron stores*M enstruation, f reque n t bloo d donation and enduranee training.*Digestive conditions such as Crohn's disease o r surgical removal o f p a r t o f t h e stomach o rsmallintestine*Certain drugs, foods, and caffeinated drinks*Olderadultclients most at risk for developing iron deficiency anemia, chronic blood loss, vitamin B12and folate deficiencies.*Food Sources Rich in Iron -red m e a t , egg yolks, dark, leafy greens (spinach, collards), dried fruit(prunes, raisins), Iron-enriched cereals and grains (check the labels), mollusks (oysters, clams, scallops),turkey o r chicken giblets, beans, lentils, chick peas and soybeans, liver, and artichokesSickle Cell AnemiaPAIN MANAGEMENT AND HYDRATION IS REALLY IMPORTANT*An inherited disorder t h a t affects African-Americans. Red blood cells become crescent-shaped becauseof a genetic defect. They break d o w n rapidly, so oxygen does not get t o t h e body's organs, causinganemia. The crescent-shaped red blood cells also get stuck i n t i n y blood vessels, causing pain."The key interventions for a client in sickle cell crisis is t o promote and maintain oxygenation andtissue perfusion, hydrate the client t o prevent excessive sickling of the red blood cells, manage theclient's pain, and promote neurological function."Administer morphine, administer normal saline, assess hand-grip strength."Clients with sickle cell anemia have problems with the shape of the red blood cells, n o t t h e number, soa blood transfusion w o u l d n o t be indicated.M rcrocy tic Anemia:Vitamin B12 deficiency folic acid deficiency alcoholism.AnemroCaused by Blood Loss*Red blood cells can b e lost through bleeding, which can occur 5lowly over a long period o f time, andcan often g o undetected. This kind o f chronic bleeding commonly results from the following:*Gastrointestinal conditions:ulcers, hemorrhoids, gastritis (inflammation of the stomach) & cancer*Use o f nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin o r ibuprofen"Menstruation and childbirth i n women, especially i f menstrual bleedingisexcessive and i f there aremultiple pregnanciesAnemia Caused by Decreased or Faulty Red Blood Cell ProductionThe bod y m ay produce too few bloo d cel15 o r t h e blood celIs m ay not f unction corre ctly. In either case, anemiacan result. Red blood cells may be faulty o r decreased d u e t o abnormal red blood cells o r the a lack o f mineralsa n d vitamins needed f o r red blood cells t o work properly.Conditions associated with these causes of anemia include the following:■Sickleell anemia■Bone m a r r o wandstem cell problems*Iron deficiency anemia*O t h e r health conditions"Vitamin deficiency
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Key Concepts for NCLEX - Page 19 preview imageVitamin-deficiency anemiamay occur whenvitamin B-12 andfolateare deficient.These two vitamins areneeded to make red blood cells. Conditions leading to anemia caused by vitamin deficiency include:•Megaloblastic Anemia: Vitamin B-12 or folate or both are deficientoCells willbecome bigger because B12islowoGood sources of Vit B12-liver, beef,, salmon, trout, breakfast cereals, tuna,milk,cheese, ham,egg, roasted chicken•Perniciousanemia:Poor vitamin B-12 absorption caused by conditions such as Crohn's disease, anintestinal parasite infection, surgical removal of part of the stomach or intestine, or infection with HIV•Dietary deficiency: Eating little or no meat may cause a lack vitamin B-12, while overcooking or eatingtoo few vegetables may cause a folate deficiency.•During early pregnancy, sufficient folic acid can prevent the fetus from developing neural tube defectssuch as spina bifida.Central Line•Important that you watch forINFECTIONbecause it is a line straight to the heart•Observe the central line insertion site frequently for local infection (erythema, tenderness, exudate).-Change the sterile dressing on a central line per protocol (typically every 72 hrs)"Flush the line at least every 12hr(3 mL for peripheral, 10 mLfor central lines) to maintain patency.•Studies show that 0.9% sodium chloride is as effective as heparinized flush solutions to maintaincatheter patency. Follow facility policy. Leave central lines clamped when not in use.•TPN administrationis usually through acentral line,such as a non-tunneled triple lumen catheter or asingle- or double-lumen peripherally inserted central line (PICC).Magnesium Sulfate•CNS Depressant - USED FOR SEIZURES•Use in early onset of labor - toPrevent Seizureand increase tolerance for seizure activity•Monitor reflexes (Deep Tendon Reflexes) and respirations•Low magnesium,heart rate goesup = TACHYCARDIA•Usedintreatmentof pregnancy induced hypertension and preeclampsia•Magnesium sulfate, lowers BP and depresses CNS- M o n i t o r BP•Signs OfToxicity-absence of patellar deep tendon reflexes, urine output < 30 ml/hr, respirations <12/minoCalcium gluconate-antidcte for Magnesium toxicityCalcium Channel Blockers (CCB)•Nifedipine (Adalat, Procardia)•Verapamil (Calan)•Diltiazem {Cardizem)- used to regulate HR-administer IV*Amlodipine (Norvasc)*Felodiplne (Pkendil)*Nicardipine (Cardene, Cleviprex)*Concurrent use of CCB & Beta blockerscan lead to BRADYCARDIA and HEART FAILURE-space thesemeds- couple hours between•CCB cannot be taken with GRAPEFRUIT JUICE- LEAD TO TOXICITY* ‘When you send a patient home a good beta blocker to give for home management is: Coreg**
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Key Concepts for NCLEX - Page 20 preview imageDopamine - you will see drug calculations and drip rates"Used to treat shock and heart failure*It's a vasoconstrictor*For critical care- in cardiac care-Increase BP- worry about EXTRVASTION (LEAKING OUT OF IV = NECROSIS)oMonitor IV closelyoDiscontinue infusion at the first sign of irritationoRegitineis the antidote!TPN- Bag becomes empty give them10% dextroseNardil (Phenelzine) -MAOI's ainteracts with food (containing TYRAMINE).Monoamine Oxidase Inhibitors (MAOI):"Phenelzine - Nardil (7.5 - 90 mg/d)*Tranylcypromine - Parnate (10 - 60mg/d)*Isocarboxazid - Marplan (20 - 60 mg/d*Selegiline - Emsam (Patch) 6mg - 12mg/d*Modobemide - Manerlx (Canada)*St. John's Wort*Side effects: Dizziness, headache, stiff neck, N/V, restlessness, insomnia, dry mouth, sexualdysfunction, weight gain andhepatic necrosis*Indications**:useful inATYPICAL DEPRESSION (increased sleep/appetite, anxiety & rejection).*Adverse/toxic ef fectsaHypert ensive Crisis(if you eat foods containing tyramine)*Inhibits the breakdown of norepinephrine, serotonin, dopamine, andtyramineaAll of these aredesired except for t h e inhibition of breaking down tyramine.*High tyramine levels can cause high BP, hypertensive crisis, and CVA."Rarely used because of the problems with food interactions*Emsam is a patch & causes severe increase in blood pressure*Food interaction:This will be a question o n the test!vMUST AVOIDFOODS such as avocados, soybean, figs, ripe bananas, fermented, smoked, oraged meats, sausages such as bologna, pepperoni, and salami, smoked fish,allcheeses, beers,red wine, soy sauce, and protein supplements.vQ o nthe test: Why do you teach a patient t o avoid these things like tyramine?A: Because it can result in high blood pressure and intracranial bleeding.*Drug interactionsDON'T ADMINISTER WITH:vOther antidepressants (SSRIs, SNRI's, TCA's), OTC cold & flu medications and DEMEROL."Therapeutic uses:oAtypical Depression, Bulimia, Obsessive compulsive Disorders*Side effects:Dizziness, headache, stiff neck, N/V, restlessness, insomnia, dry mouth, sexualdysfunction, weight gain, hypotension and hepatic necrosis.*Orthostatic HypotensionoMonitor BPoHold medicationoInstruct the client to change positions slowly
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Key Concepts for NCLEX - Page 21 preview image"Other informationforMAOI's:vMonitor BP duringthe first 6 weeks of treatment.vHYPERTENSIVE CRISISmay beginwitha headache, stiff neck, palpitations, increasedordecreased HR, nausea, vomiting, or pyrexia.Immediate medical attention is required.oAdminister Phentolamine (Regitine)oAdminister Calcium Channel Blocker- Nifedipine (Procardia),oIce packs or hypothermic blankets can he used.4*Labs are done early in the morning before the morning dose of medications1Contraindications:oUse cautiously i n clients with diabetes and seizure disorder or those takingTricyclicAntidepressants- can lead t o HYPERTENSIVE CRISIS.oUse withSSRKscan lead t oSERTONINCRISISoTyramine Rich FoodsoConcurrent use of vasopressors (phenlethylam ine, caffeine) mayres uIt in hypertensionoAdvise clientsto avoid,tyramine foods, and foods that contain caffeine, chocolate, fava beansand ginseng.The BIG Deal with MAOI:■Foodinteraction: Pickled, fermented, smoked, or aged foods, such as red wine, preserved food, agedstinky cheese, whichleads to hypertensive crisesresulting in intracranial bleed.■Drug Interaction (Do not give with)0Other antidepressants0OTC cold and flu medications0DemerolAntidepressantDrugs:"Tricyclic Antidepressants (TCAs)oAmitriptyline (Elavil)oImipramine (Tofranil)oDoxepin (Sinequan)oNortriptyline {Aventyl)oAmoxapine (Asendin)oTrimipramine (Surmontil)0Amitriptyline (Elavil)- Do not use with MAOI's§Have more side effects§Take longer t o reach optimal dose§FARMORE LETHAL INOD§Contraindicated for clients with SEIZU RES
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Key Concepts for NCLEX - Page 22 preview imageTCA AmitriptylineSide effectsNursing InterventionsOrthostatic Hypotension’Instruct clients about the signs of postural hypotension(lightheadedness, dizziness), if these occur, advise the client to sit or liedown.■Orthostatic hypotension can be minimized by getting up or changingpositions slowly.■Monitor blood pressure and heart rate for clients in the hospital fororthostatic changes before administration and 1 hr after, if a significantdecrease in blood pressure and/or increase in heart rate is noted, do notadminister the medication, and notify the provider.Anticholinergic Effects-Dry mouth-Blurred Vision-Photophobia-Urinary hesitancy,retention-Constipation-Tachycardia" Instruct clients on ways to minimize anticholinergic effects. Theseinclude:0Chewingsugarless gum0Sipping on wateroWearing sunglasses when outdoors0Eating foods high in fiber0Participating in regular exerciseoIncreasingfluid intake to at least 2 to 3 L/dayoVoiding just before taking medicationSedation•This effect usually diminishes over time."Advise clients to avoid hazardous activities such as driving if sedation isexcessive."Advise clients to take medication at bedtime t o minimize daytimesleepiness and to promote sleep.Fatal Arrhythmias!Toxicity resultingincholinergicblockade and cardiac toxicityevidenced by dysrhythmias,mental confusion, and agitation,followed by seizures, coma, andpossible death.■Give a 1-week supply of medication to clients who are acutelyill.‘Obtain the client's baseiine ECG.•Monitor vital signs frequently."Monitor clients for signs of toxicity.■Notif y the provider if signs of toxicity occur.Decrease seizure threshold"Monitor clients who have seizure disordersExcessive Sweating■Inform clients of side effect.■Assist clients with frequent linen changes.Contraindication•Pregnancy, those who have SEIZUREDISORDERS*Concurrent use of Mao's & St. John's wort may lead toSEROTONIN SYNDROME.
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Key Concepts for NCLEX - Page 23 preview image*Selective Serotonin Reuptake Inhibitors (SSRIs)- Do not take with MAOI's0Fluoxetine (Prozac)0Sertraline (Zoloft)0Paroxetine (Paxil)0Citalopram (Celexa)0Do n o t take SSRI with pimozide (Cirap), thioridazine (Mellaril), o r a monoamine oxidase inhibitor(MAOI) such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil)0Issues with SSRIs:oDizziness, Nausea, Pins and needlesoZappersoProzacdoes notcausediscontinuation symptoms=1 6 weeks half life0PossibleSideEffectsSSRI:o61upset:Nausea and Vomiting, ConstipationoNervousness, sleep disturbancersomnolenceoSexual dysfunction: Iibido and orgasmoWeight gain & Cognitive problems:WORD FINDING■Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs)-Do not use with MAOI's0Venlafaxine (Effexor)0Duloxetine(Cymbalta)-D o n o t use Cymbalta together with thioridazine (Mellaril), o r an M A Oinhibitor.oIndicated for depression and diabetic peripheral neuropathyoNeuropathic pain= nerve injury o r dysfunctiono4" serotonin and NorepinephrineSerotonin Syndrome:Mild inm o s t people, recoverywithin2 4 - 7 2 hours, although i t can cause death under circumstancesSeen i n people taking t w o o r m o r e medicationsthatincrease levels o f serotonin i n t h e CNSSymptoms: 3 of the followingHyperpyrexiaDiaphoresisNausea & Autonomic instabilityAtaxia- lack of muscle control-unsteady gaitShiveringM e n t a l status changesAgitationMyoclonus (hiccups)HyperreflexiaAntipsychotics:*ChIorprom azine (Thora zine)- Low potency*Haloperidol (Haldol)- Hiigh Potency*Fluphenazine (Prolixin)- High Potency"Thiothixine (Navane)- High PotencyAntipsychotics- Adverse Effects of Drugs*Always check BP and pulse with Psych medications*M e dications take 2-3 weeks t o take effect"Have anticholinergics side effects:Blurred vision, dry m o u t h , photophobia, tachycardia, urinaryretention and constipation.
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Key Concepts for NCLEX - Page 24 preview imageIMPORTANT TEACHING: Typical Antipsychotics to Minimise Anticholinergic Effects"Advice client to chew sugarless gum, eat foods in high fiber a drink 2 to 3 L of fluid/day."Instruct client aboutPostural Hypotension(light headednessrdizziness)oAdvise client to get u p slowlyfromlying tosittingposition."Advise client of photosensitivity!Conventional Antipsychotic Medications EPS Side Effects:Acute dystonia:Anticholinergics- Involves bizarre and severe muscle contractions usually of the head andneck. Can be painful and frightening. Occurs within 4B hours of initiation of medication.Intervention:Treat with Cogentin or BenadryI or Symmetrel IMAkathisia:Anticholinergics-Described as feeling like jumping outoftheskin. Inability to sitstill, resultinginrocking, running, or agitated dancing. Regular rhythmic movements usually of lower limbs. Usually occursafter 3 or more weeksoftreatment.Intervenlion:Treat w/Lorazepam or Cogentin or Benadryl or Symmetrel I MPseudoparkinsonism:Anticholinergics- Cogwheel rigidity, tremors at rest, rhythmic oscillations oftheextremities,pillrolling movement of the fingers and bradykinesia.Usuallyoccurs after 3 or more weeks oftreatment.Intervention:Treat with Cogentin or Benadryl or Symmetrel I MTardiveDyskinesia:Abnormal Involuntary Movement Scale (AIMS) - Characterized by abnormal involuntarymovements lip smacking (Guppy like), tongue protrusion, foot tapping St facial tics. Usually occurs late in thecourse of long-term treatment. Avoid typical antipsychotics. Prophylactic use of vitamin E and Omega-3 FFA.Often irreversible.Intervention: AbnormaI Involuntary M ovement Seale (AlMS)- Brief test for detection of t ardive dyskinesiaAnti-Parkinson medications: (to relieve EPS Parkinson side effects}*Trihexyphenidyl (Artane)"Diphenhydramine (Benadryl)"Benztropine (Cogentin}"Amantadine (Symmetrel)Anticholinergic Side Effects: Occur with Typical (Conventional) Antipsychotics"Dry mouth"Blurred vision■Constipation"Urinary retention"Tachycardia•Photophobia
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Key Concepts for NCLEX - Page 25 preview imagePotentially Dangerous Responses to Antipsychotics: TOXICITY*Neuroleptic Malignant Syndrome (NMS)oTypically occursinfirst 2 weeks of treatment or when the dose is increasedoCaused by acute reduction of dopamine in the brainoSymptoms:Muscle rigidity,, tachycardia., hyperpyrexia (elevated temp) altered consciousness(mental confusion), tremors and diaphoresis-lead t o DEATHoWatch patient as soon as temperature spikes- if left untreated a person can die within8hours.oIf pt. is diaphoretic, unable to respond & is motionless eHold the medication, notify thephysician, and begin supportive treatments.oMild cases can be treated with Farlodel (Bromocriptine)oSevere cases can be treated withDantriuin & ECT*Nursing Interventions:oStop antipsychotic medicationsoApply cooling blanketsoAdminister antipyreticsoAdminister diazepam(Valium)t o control anxietyoAdminister Dantrolene (Dantrium] to induce muscle relaxationMethergine -for uterine atony, excessive bleeding post partum*Monitor BPTracheostomy Care*Tracheotomy is a sterile surgicalincisioninto the trachea for establishing an airway*Tracheostomy is the stoma that results from tracheotom y a n d t h e i nsertion and maintenanee of acannula*Provide tracheostomy care every 8 hr■Give frequent oral care, usually every 2 hr.*Forcuffed tubes,keep the pressurebelow 20 mmHgto reduce the risk of tracheal necrosis due toprolonged compression of tracheal capillaries.*Assess/ZWonftoroOxygenation and ventilation (respiratory rate, effort, SaO2) and vital signs hourlyoThickness, quantity, odor, and color of mucous secretionsoStoma and skin surrounding the stoma for signs of inflammation or infection (redness, swelling,drainage)oProvide adequate humidification and hydration to thin secretions and decrease risk of mucusplugging.oDo not suction routinely, because this may cause mucosal damage, bleeding, andbronchospasm.oAssess/monitor the need for suctioning:Suction on a PRN basis when assessment findingsindicate it is needed (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia,mucus in the airway).
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Key Concepts for NCLEX - Page 26 preview imageSuction:oSuction the tracheostomy tube If necessary, using sterile suctioning supplies.oSterile procedure during suctioning, suction 10-15 seconds a t a time§Infant you only suction for 5 secondsoHyperoxygenate the client with oxygen before and afteroYou only suction when you are pulling outoAssess respiratory status every 1-2 hoursoNever turn off the ventilator alarms.oThere are three types of ventilator alarms: volume, pressure, and apnea alarms.§VOLUME (LOW PRESSURE) ALARMS:indicate a low exhaled volume due to adisconnection, cuff leak, and/ortube displacement.§PRESSURE (HIGH PRESSURE} ALARMS:indicate excess secretions, client biting thetubing, kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and/orpneumothorax or obstruction.§APNEA ALARMS:indicate that the ventilator does not detect spontaneous respiration ina preset time period.oAssess the cuff pressure at least every 8 hr.§Maintain the cuff pressure below20mm Hgt o reduce the risk of tracheal necrosisoAssess for an air leak aroundthecuff (client speaking, air hissing, or decreasing SaO2).Inadequate cuff pressure can result in inadequate oxygenation and/or accidental extubation.■Changing TracheotomyoRemove old dressings and excess secretions.oApply the oxygen source loosely if the client desaturates during the procedure.oUse cotton-tipped applicators and gauze pads t o clean exposed outer cannula surfaces.oBegin with half-strength(mixed with sterile 0.9% NaCI) o r full-strength hydrogen peroxidefollowed by 0.9% NaCI. Clean i n a circular motion from the stoma site outward.oUse surgical aseptic technique t o remove and clean the inner cannula (use half-strength or full-strength hydrogen peroxide solution t o clean the cannula and sterile 0.9% NaCI t o rinse it).oReplace the inner cannula if it is disposable.oChange non-disposable tracheostomy tubes every 6 to 8 weeks or per protocol.*Reposition the client every 2 hr to prevent atelectasis and pneumonia.Minimize dust in the client's room;DO NOT SHAKE BEDDING*Ifthe client is permitted to eat, position the client in an upright position and tip the client’s chin to herchest t o enable swallowing. Assess for aspirationBioterrorism*Cutaneous Anthrax - Formsblack scabs*InhalationaI -AnthraxoS/S:Sore throat, Fever, Muscle aches, Severe dyspnea, Meningitis,ShockoTX:IV ciprofloxacin(Cipro]Ergonomic Principles*Assess the client's ability t o balance, transfer, and use assistive devices prior t o planning care.*The closer the line of gravity is to the center of the base of support, the more stable the individualis.
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Key Concepts for NCLEX - Page 27 preview image"To lower the center of gravity, bend the hips and knees.*LiftingoDon't lift with your back - always use your kneesoUse themajormuscle groups t o prevent backstrain, andtighten the abdominal muscles t oincrease support t o the back muscles.oDistribute the weight between the large muscles of the arms and legs to decrease the strain o nany one muscle group and avoid strain o n smaller muscles.oWhen lifting an object from the floor, flex the hips, knees, and back. Get the object t o thighlevel, keeping the knees bent and the back straightened.oStand up while holding the object as close as possible to the body, bringing the load to thecenter of gravity to increase stability and decrease back strain.oUse assistive devices whenever possible, and seek assistance whenever it is needed.■When pushing or pulling a load:oWiden the base of support.oWhen opportunity allows, pull objects toward the center of gravity rather than pushing away.oIf pushing, move thefrontfoot forward, and if pulling, move the rear leg back to promotestability.oFace the direction of movement when moving a client.oUse own body as a counterweight when pushing or pulling t o make the movement easier.oSliding, rolling, and pushing require less energy than lifting and offer less risk for injury.oAvoid twisting the thoracic spine and bending the back while the hips and knees are straight.*Leading the blind - They need to hold onto youoLead themholding onto theelbowPT. IN TRACTION- NEVER TAKE OFF THE WEIGHTSBuck Traction: (Hip Fractures)is a foam boot with Velcro straps applied to the lower leg to helpimmobilize and relieve pain in clients with fractured hip!*To decrease muscle spasms- Placed for longer periods*If patientisSOB/Cyanotic: Give 0 2beforenotifyingHCP*Superficial perineal nerve compression can result if the straps are too tight.*Frequent release of straps prevents this complication.*Buck traction:5 - 10 LBs- must NOT be sitting o n the floor*Keep proper body alignment and change positions slowly with the assistance of unaffected side whenusing BUCK'S traction*Boot should be removed 3 times a day for inspection of skin*Assist client with foot exercises throughout the day t o prevent DVT*NEVER PLACE WEIGHTS ON THE FLOOR- WEIGHTS MUST HANG FREELY TO PROVIDE CONSTANTTRACTIONBryant's traction is used in children under 3 years of age & has a fractured femur
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Key Concepts for NCLEX - Page 28 preview imageSkeletal Traction"Applied directly to the bone to reduce a fracture or to maintain bone alignment"Pins &wires are inserted through the skin and soft tissue andintothe bone*Balanced suspension is uses splints and slings to support the extremity and weights for countertraction"Skeletal:oUsed continuously. The pulling force is applied directly to the bone by weights attached by ropedirectly to a rod/screw placed through the bone."Examples include skeletal tongs (Gardner-Wells] and femoral or tibial pins (Steinmann pin).*Weights up to 25 pounds can be applied as needed*Maintain body alignment and realign if the client seems uncomfortable or reports pain.*Avoid lifting or removing weights.■Assure that weights hang freely.*Ifthe weights are accidentally displaced, replace the weights.Ifthe problem is not corrected,, notify theprovider.Assure that pulley ropes are freeof knots.*Notify the provider if the client experiences severe pain from muscle spasms unrelieved withmedications and/or repositioning."Move the client inhalotraction as aunit,without applying pressure to the rods. This will preventloosening of the pins and pain*Routinely monitor skin integrity and document"Pin Site Care:oPin care is done frequently throughout immobilization (skeletal traction and external fixationmethods)oMonitor for signs of infection including:§Drainage (color, amount, odor).§Loosening of pins.§Tenting of skin at pin site (skin rising up pin).§Pin care protocols (Chlorhexidine)arebased on provider preference and institutionpolicy.§A primary concept of pin care is that one cotton-tip swab is designated for each pin toavoid cross-contamination.§Pin care is provided three times a day or per facility protocol.§Crusting at the pin site should not be removed as this provides a natural barrier frombacteria.Skin Traction■Usedforshortterm: Assessevery B hrs -skin care dressing*Clean pins with NS or hydrogen peroxideSix Ps Are Characteristic of ImpendingCompartment Syndrome*Paresthesia: numbness and tingling*Pain:distal to injury that is not relieved by opioid analgesics and pain on passive stretch of muscletraveling through compartment*Pressure:T1incompartment"Pallor:coolness and loss of normal color of extremity*Paralysis:loss of function
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Key Concepts for NCLEX - Page 29 preview image•Pulselessness: diminished/absent peripheral pulsesIf Compart ment Syndrome Then:•Extremity shouldNOT BE ELEVATEDabove heart level.oElevation may raise venous pressure and slow arterial perfusion.•Application ofcold compressesmay resultin vasoconstrictionand may exacerbate(make worse)compartment syndrome."May be necessary to remove or loosen bandage•Reductionintraction weight may -!■external circumferential pressures.•Surgical decompressionmay be necessary.(Fasciotomy-surgical site left open for several days t oensure adequate soft tissue decompression; risk for infection and delayed wound healing is a potentialproblem following fasciotomyIf a patient has a surgery to repair fractured left tibia and cannot feel the surgical site by stating that it feelsasleep, you should?"Neurovasc uIar assessmentof fractured extremity for any changes•Check peripheral pulses•Check for edema, color & temperature•Notify HCPA patient post-operative walking with a limp could indicate that theHIP ISDISLODGED.f a patient had a hip replacement, you should place anABDUCTION PILLOWbetween the legs.Nursing Implementation for Fractures:"Neurovasc uIar assessment of fractured extremity for any changes.•Check pulse, for edema, color, temperature.•Minimize pain by proper alignment, support of extremity, and positioning of patient.•Keep extremity elevated above heart.■Monitor for bleeding and look over bony prominences for skin integrity."Fractured mandible: Check for patent airway, maintain clean oral hygiene, and adequate nutrition•Because of limited movement, t o prevent constipation, maintain a high fluid intake and fibrous foods.•Assist patient w i t h ambulation t o help determine the patient's abilities. Give referrals to long termrehabilitation programs.•Fractured hip:keep hip i n neutral position when sitting, walking, or laying down.•Fractured humerus:Protect the axilla of skin breakdown duetoconstant sweating with absorptionpads.Nursing Management for Hip Replacement Surgery•ABDUCTIONpillow between legs"Patient should never cross legs or twist to reachbehind•Never bend down/Weight bearing exercisesExample Q: Inidentifying people at risk for fractures, the nurse recognizes that the person at greatest riskforgreenstick fractures is?a.A femaIe client over 40 years old waIking her dogb.A 2 1 year old male who plays basketball 6 times a week for 6 hoursc.A 5 year old male playing at the playground
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Key Concepts for NCLEX - Page 30 preview imaged.A 90 year old female with a history of fallsPelvic Fracture/Hip Replacement*Do not cross legs■No squatting or sitting down‘TeachingisImportant hereHIP REPLACEMENT SURGERYTheDos*Do keep the leg facing forward."Do keep the affected leginfront as you sit or stand.*Do use a high kitchen or barstoolinthe kitchen.*Do kneel on the knee on the operated leg (the bad side).*Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Don't applyice directly to the skin; use an ice pack or wrap it in a damp towel."Do apply heat before exercising to assistwithrangeofmotion. Use aheatingpad or hotrdamp towelfor15to 20 minutes."Do cut back on your exercises if your muscles begin to ache, but don't stop doing them1The Don'ts■Don't cross your legs at the knees for at least 8 weeks.*Don't bring your knee up higher than your hip.*Don’t lean forward while sitting or as you sit down.■Don’ttryt o pick up something on the floor while you aresitting.*Don't turn your feet excessively inward or outward when you bend down.■Don’t reach down to pull up blankets whenlyingin bed.*Don't bend at the waist beyond 9 0 \*Don't stand pigeon-toed.■Don’t kneel on the knee of the unoperated leg (the good side}.*Don't use pain as a guide for what you may or may not do.Toradol (NSAID)The medication is most often used totreat pain following aprocedure,butmay also be used for suchthings as pain caused by kidney stones, back pain, or cancer pain.Elelongs to a class of drugs callednonsteroidal anti-inflammatory drugs.Toradol Side Effects Include:Headache, Abdominal pain (or stomach pain) & NauseaHeartburn or indigestionDiarrhea, Dizziness, Drowsiness & Swelling*Other side effects with Toradol occurring in more than 1 percent of people include but arenot limitedto: Highblood pressure (hypertension), Itching, Unexplained rash, Gas, Constipation,Vomiting,Sweating Pain at the injection siteifinjection.
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Key Concepts for NCLEX - Page 31 preview imageToradol - Serious Side Effects:Allergic reactionsStomach or intestinal problems, including bleeding, ulcers (known as a perforation).Liver damage, which can cause nausea, fatigue, yellowing of the skin or whites of the eyes, andexcessive tiredness.Kidney problems, including kidney failureFluid retention or unexplained weight gainPatient has thick sputum that cannot be expelled by coughing. First thing you should do is provide■Water t o loosen u p the secretions.**Sputum Specimens are best taken in the morning- have client drink some water. fTB testing)f anIVisinfiltrated,this could be a priority given the other options.■Stop the IVand monitor the site & place warm/hot compressesBPH Teaching*BPHisa benign enlargement of the prostate gland- usually men over60"Avoid:Caffeine & Alcohol■The possible cause of this condition is thought t o be attributed t o the increa sed accumulation ofdihydrosytestosterone-Not Cancer*Decreased force of urinary stream, difficulty in urination, Double Voiding (stopping and startingstream several times while voiding and dribbling at the end of the voiding) is an indication of BPH■S/S: FREQUENCY, URGENCY, NOCTURIA & HESITANCY*Teach the patient t o practice Kegal exercises for 10-20 mins daily*The nurse should know and teach patients t o know thatAnticholinergic (COGENTIN)should NOT begiven to patients withBPH*Diagnostics:Digital RectalExam, PSA test > 4ng = Prostate Cancer, Urine test for Nitrates, Blood testfor creatine & Transurethral ultrasound with Biopsy*BPH Medication:oPROSCAR (FINASTERIDE) 5- alpha reductase inhibitor§Cause Orthostatic Hypotension§Slows the growth of the prostate§Can causeERECTILE DYSFUNCTION§Patient teaching:Sexualactivity will decreases-Discuss sexual concernsBPH Teaching- Yearly Check■Kegel exercises 10-20 min daily■Saw pahrietto(herb)can decrease prostate but can increase risk for BLEEDING*Proscar:INCREASE ORTHOSTATIC HYPOTENSIONso risk for falls, not for pregnant women, decreasessize of prostate.■Urine incontinence -dribbling- difficultyurinatlng is indicative if BPH■Cogentin (anticholinergics)should NOT be given to patients withBPH
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Key Concepts for NCLEX - Page 32 preview imageTrans-Urethral Resection of the Prostate (TURP}: Prostate surrounds the urethra; theenlargement cansqueeze the urethra making it difficult topassurine.This may lead tosymptoms that can include:■Weak flowof urine*Needing to strain t o pass urine*Not being able to empty the bladder completely, so needing to use the toilet day and night."To relieve the above symptoms of an enlarged prostate -TURP is carried out■TURP: For males- always check catheters, will be a Foley catheter but a 3-way, so always check.*Ifthe catheter caused infection then change the catheterPriorities forthemost experienced nurses: Only give TURP to experienced nurses!*Don't give a new nurse a complex patient such as one with TURP.TURP- TransurethraI Resection of the Prostate"Use of excision and cauterization t o remove prostate tissue cytoscopically■A surgical treatment using a resectoscope inserted through the urethra*CONTINUOUS BLADDERIRRIGATIONoContinuous bladder irrigation 3 lumen catheter (ZOOOL)-increase flow rate if you see red bloodoIt isusuallydone for the first 24hoursto prevent obstruction from mucus and blood clots.oIt is toPREVENT THE CLOTS,if there is aBRIGHTREDBLEEDINGthat means there is a clot stuckin there so you have theINCREASETHEFLOWrate of CBIHand Hygiene■The No. 1 measure t o reduce the growth and transmission of infectious agents is hand hygiene. TheCenters for Disease Control and Prevention (CDC) states that "hand hygiene has been cited frequentlyas the single most important practice to reduce the transmission of infectious agents in health caresettings. The term "hand hygiene" refers to both hand washing with an antimicrobial or plain soap andwater as well as the use of alcohol based products such as gels, foams, and rinses."*The three essential components of hand washing include:oSoapoWateroFrictionTransmission of Infectious Diseases*Reverse IsolationoDesigned to protecta patientfrom infectious organisms that might be carried by the staff,other patients, or visitors or o n droplets in the air or on equipment or materials.oProtective modified reverse isolation is less restrictive butisnot prolonged needlessly becausethe patient usually feels lonely and sensorial deprived.oHand washing,gowning, gloving, sterilization, or disinfection of materials brought into the areaand other details of housekeeping vary with the reason for the isolation and the usual practicesofthe hospital.*Rotavirus- Contact precautionoProtect visitorsand caregivers against direct dient/environmental contact infections(respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, woundinfections, herpes simplex, scabies, multidrug-resistant organisms).
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Key Concepts for NCLEX - Page 33 preview imageoContact Precautions Require:§A private room or a room with other clients with the same infection§Gloves and gowns worn by the caregivers and visitors§Disposal of infectious dressing material into a single, nonporous bag without touchingthe outside of the bag•Meningitis- Droplet precautionoIsolate the client as soon as meningitis is suspected.oMaintain isolation precautions per hospital policy.oThis should beDROPLET PRECAUTIONSwhich requires a private room or a room with cohorts,wearing of a surgicalmask when within 3 feet of the client,appropriate hand hygiene, and theuse of designated equipment, such as blood pressure cuff and thermometer. Continue untilantibiotics have been administered for 24 hr.oImplement fever-reduction measures, such as a cooling blanket, if necessary.oReport meningococcal infections to the public health department.oDecrease environmental stimuli.oProvide a quiet environment.oMinimize exposure to bright light (natural and electric).oMaintain bed rest with the head of the bed elevated t o 3O':.oMaintain client safety, such as seizure precautions.Home Visit•Child safe home:oAspiration:§Keep all small objects out of reach.§Check toys for loose parts.§Do not feed the infant hard candy, peanuts, popcorn, or whole or sliced pieces of hotdog.§Do not place the infant in the supine position while feeding or prop the infant's bottle.§A pacifier {if used] should be constructed of one piece.oProvide parents with information about prevention of lead poisoning electrical sockets, meds,locking cabinets, poison control center#oSuffocation:§Keep plastic bags out of reach.§Make sure crib mattress fits snugly and that crib slats are no more than 23/8 inchesapart. Never leave an infant or toddler alone while in the bathtub.§Remove crib toys such as mobiles from over the bed as soon as the infant begins to pushup.§Keep latex balloons away from infants and toddlers.§Fence swimming pools and use a locked gate.*Begin swimming lessons when the child's developmental status allows forprotective responses such as closing her mouth under water.§Keep toilet lids down and bathroom doors closed
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Key Concepts for NCLEX - Page 34 preview imageoPoisoning :§Keep house plants and cleaning agents out of reach.§Place poisons, paint, and gasoline in locked cabinet.§Keep medications in child-proof containers and locked up.§Dispose of medications which are not longer used or are out of date,oFalls :§Keep crib and playpen rails up.§Never leave the infant unattended on a changing table or other high surface6Restrain when in high chair, swing, stroller, etc§Place in a low bed when toddler starts to climb.oMotor vehicle/lnjury:§Use backward facing car seat until the infant toddler is 1 vear old and weighs at least 20lb.§All car seats should be federally approved and be placed in the back seatoBums:§Test the temperature of formula and bath water.§Place pots on back burner and turn handle away from front of stove.§Supervise the use of faucetsElderly safe home: fallsoModifications that can be made to improve home safety include:oRemoving items that could cause the client to trip, such as throw rugs and loose carpetsoPlacing electrical cords and extension cords that against a wall behind] furnitureoMaking sure that steps and sidewalks are in good repairoPlacing grab bars near the toilet and in the tub or shower and installing a stool riseroUsing a non-skid mat in the tub or shower & place a shower chair in the showeroEnsuring that lighting is adequate both inside and outside of the home•Red flagoDomestic violence, elder abuse, fall riskoStages of healing of bruises or cutsoMalnutritionoLice on childrenoElectrical socketsoPoisonous substancesRespiratory Therapy- Oxygentherapy*21% 0 2 m air - the rest is nitrogen*Humidified over4L (do not use on patient withanose bleed)*High volume & most precise =VENTURI MASK*40% nasal cannula*60-80%-mask*100%-nonreabreather
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Key Concepts for NCLEX - Page 35 preview image*Pulse OximeteroMeasures light absorption by oxygenated and deoxygenated Hgb in arterial blood.oSaO2 and SpO2 are used interchangeablyoThis is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood. Theexpected reference range is95%to100%,although acceptable levels for some clients rangefrom 91% to 100%.oLess than 85% is abnormaloAdditional reasons for low readings include hypothermia; poor peripheral blood flow, toomuch light (sun or infrared lamps}, low Hgb levels, client movement, edema, and nail polish.oA SaO2 below 91% requires interventions to help the client regain acceptable SaO2 levels.oA SaO2 below 86% is an emergency .oA 5aO2 below 80% is life-threatening.oIf you get a low reading - make sure that it is working!*Ventilation:oHIGHPRESSURE ALARM:obstructionex. Patient needs suctioningoLOWPRESSURE ALARM: something has become disconnected ex. tubing disconnectedRespiratory Drugs■Albuterolusually given in treatment■Give Zopinex to not increase HR as much as Albuterol■Mucomyst for breaking up secretionsCooling Blanket*Place thermal sensor first■Collect vitals more frequentlyAcid Base Imbalances■pH 7.35 to 7.45*PaO2 80 to 100 mm Hg■PaCO2 35 to 45 mm Hg■HCO3- 22 to 26 mEq.L■SaO2 95 to 100%oBlood pH levels below 7.35 reflect acidosis, while levels above 7.45 reflect alkalosis.Respiratory Acfdos/s - Hypoventilation*Change in PaCO2. pH below 7.35*Vital signs:Tachycardia (severe acidosis may lead to bradycardia), tachypnea & dysrhythmias■Neurological:Anxiety, irritability, confusion, coma*Respiratory:Ineffective, shallow, rapid breathing*Skin:Pale or cyanotic
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Key Concepts for NCLEX - Page 36 preview imageRespiratory Alkalosis -Hyperventilation•Change in PaC02, pH above 7.45•Vital Signs:Tachypnea■Neurological:Anxiety, tetany, convulsions, tingling, numbness•CV:Palpitations, chest pain, dysrhythmias•Respiratory: Rapid, deep respirationsMetabolic Acidosis -DIARRHEA•Change in HC0 3, ph below 7.35•D M = metabolic Acidosis- Non-ketotic if blood sugar is over 6 0 0■Vital Signs:Bradycardia, weak peripheral pulses, hypotension, tachypnea and dysrhythmias•Neurological:Muscle weakness, Hyporeflexia. flaccid paralysis, fatigue, confusion•Respiratory:Rapid, deep respirations(Kussmaul's respirations)•Skin:Warm, dry, flushedMetabolic Alkalosis- VOMITING•Change in HCOS. ph above 7.45•Vital Signs:Tachycardia, nonnotensive or hypotensive, dysrhythmias•Neurological:Numbness, tingling, tetany, muscle weakness. Hyperreflexia, confusion, convulsion•Respiratory:Depressed skeletal muscles resulting in ineffective breathing•**anything chronic you will always see compensation***Myocardial Infarction"Troponin levels-normal 0-0.1 (elevated)oTroponin is more important CKMB•Mis are classified based on:oThe affected area of the heart (anterior, anterolateral).oThe EKG changes producedSTELEVATIONoMost M l tend involve the left ventricle (LV)Myocardial Infarction ( M l )■Location-precordial, substemak radiates•Quality-heaviness, crushing pressure, burning"Quantity-severe, sometimes mild•Timing -sudden onset, lasting > 15 min•Aggravat ing & reIieving factors- UNRELIEVED•AssociatedS&S-dyspnea. sweating, weakness, u &v, severe anxiety.■Clinical Manifestations of M loPain§Severe, immobilizing chest painNOT relieved by rest, position change, or nitrateadministration*The HALLMARK of a n M loNausea and vomiting§Can result from reflex stimulation of the vomiting center by the severe pain§Patient in so much pain - reflex stimulation in the brain is stimulated
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Key Concepts for NCLEX - Page 37 preview imageST Elevation = M lST Depression = IschemiaPlanning for Chest Pain*Give themNitroglycerine and Morphine"Emergency treatment chest pain (MONA) - Oxygen comes first]oM orphine sulfate if pain unrelievedoOxygenoNitroglycerine spray, or sublingual or IV if indicatedoAspirin 325mg§2 large gauge IV lines§Cardiac, monitor. 12-lead ECG (gold standard)§Assess contraindications thrombolytic therapy±Recent Surgery, high BP. risk for embolism - DON'T DO§Send t o cardiac cath lab within 3 0 minutesQUESTION:Patient arrives at an urgent care center complaining of substemal and epigastric pain and pressurefor thelast 1 2 hours.The nurse reviews the labs knowing that this point in time MI would be indicated bypeak levels or what?ANSWER: Troponin and CK-MBPeak T wave= HyperkalemiaU wave= HypokalemiaOther Drugs t o Know - Other Uses*Breast cancer drug = tomosiphen*Prostate cancer drug = lupron (can be given to women to stop bleeding)*Pulmonary fibrosis = viagra*Hy perkalemia = CaI c i um G 111c on a t eAngiocardiography*Visualize the interior of the heart & adjacent great vessels"Procedure: using sterile technique, vascular access is obtainedoCatheter inserted that contains a guide wire & is advanced to the Rt atrium, guide wire removed &contrast material is injected. X-ray images are taken & storedoNursing care-similar to conscious sedation, manual pressure for 5 min at insertion site, thenpressure dressing; monitor for hemorrhage or hematoma formation. push fluids afterwards*Preprocedure:oPatient needs t o be NPO, informed consent, contrast (make sure that they are n o t allergic t othe die), conscious sedation (not putting to sleep), when you inject the die important to tell thepatient there will be a FLUSHINGSENSATION -so they don't get scaredoPost procedure- Have to layflatfor 2hoursand on bed restfor4-6hours - CANTGET UP!oImportant to check renal function before the test because of the contrast
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Key Concepts for NCLEX - Page 38 preview imageIntraprocedureoPt receives dye. anti-platelet medication -Aggrastat (don't want tore-occludethe area) -becareful patient might bleed out!!oSee occlusion they will suck it out andstentthe area§Pt haiing stent might have to be onPlavixforone year- good potential that the patientmight re-occludeoIf the patient is onGlucophage (Metformin)for diabetes it can betoxic t o the kidneys - holdthe GLUCOPHAGE (Metformin) for 48 hours post procedureoPt receives contrast - monitor patient creatinine, blood sugars§Ifpt has kidney problems, history of diabetes, high blood sugars are high or GFR are low4. Can give themMucomystPO helps with binding with the irons from the contrastto get it out of the system*PostprocedureoYour FIRSTPRIORITYis to check circulation!Check distal pulse (dorsal pedal pulses)oPatient has no pulse post procedure - need to let someone know right awayoChecking every 15 minutes!!oLook at color of the skin: pale, cool or warmoCheck for bleeding or hematoma at the puncture siteoIf the site has some bleeding -put pressure above site for 5 to10minutes then puta1 0pound sac on the areaoVital signs:monitor Q 5 minutes for an houroMonitor for dysrtythmiasoWatch for s.-'s of pulmonary embolioPush fluids afterwardsoBedrest for 4-6 hours, first two hours flatoIf the patient wants todrink something p u t them in REVERSE TRENDELENBURGposition -head of the bed lower than the feet - not bending the torso•How Do You Take The Catheter Out?oPull out - femoral artery is going to bleedoHaveto putpressure ABOVE the puncture siteo1 0 pound weight pressure - for about 10-15 minutes§Not a sandbag - has to be thenurse putting on pressure§Then later put sandbagoTwo peopleshouldbe inthe room- patient can have avasovagal reaction§Bradycardia and the blood vessels dilate§Tell patient to hear down and not to coughoWhile holding down - have the other nurse check pulses to make sure that you aren't puttingtoo much pressureoSee slight bleeding - put a weight on the incision patient - theyMUST remainflatoPulsation and pain to the site -ifs an aneurysm and has to be fixed by surgeryoPt complaining of back pain -check for bleeding and BPQUESTION:A patient returns from the cardiac cath lab following a coronary angiogram which of the followingassessment would require immediate action?ANSWER: ST Segment Elevation (Infarction)
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Key Concepts for NCLEX - Page 39 preview imageP A W P - Measures the pressures in the LEFT Ventricle via the pulmonary artery•Normal level (PAWP}: 6-12§What if ± e number is2 0- too much volume - give the patientLASIX§What if the number is 5 - give them FLUIDSNormal CVP: 2-8•What if the patient'sCVP is 15 -what should you do? Give the patient's lasix•What if the patientsCVP is0 - give them fluids - anticipate that the patient's BP is going to drop* * * l f stabilizations of ABG is good - patient can be extubatedOnce you take the tube out:Priority- CHECK FOR STRIDOR & OXYGENATION•Give themSalmeterol or AlbuterolM e n t a l HealthDepression•Depression is a mood (affective) disorder that is a widespread issue, ranking high among causes ofdisability.•Depression m a y b e comorbid with the following:oAnxiety disorders§These disorders are comorbid with 70% of major depressive disorders, the combinationof which makes a client's prognosis poorer, with a higher risk for suicide and disability.oSchizophreniaoSubstance abuseSClients often abuse substances in order to relieve symptoms and or self-treat mentalhealth disorders.oEating disordersoPersonality disorders•A client with depression may be at nsk for suicide, especially if he has a family or personal history ofsuicide attempts, comorbid anxiety disorder or panic attacks, comorbid substance abuse or psychosis,poor self-esteem, a lack of social support, or a chronic medical condition•Major depressive disorder ( M D D )is a single episode or recurrent episodes of unipolar depression (notassociated with mood swings from major depression to mania) resulting in a significant change in aclient's normal functioning (social, occupational, self-care)accompanied by at least five of thefollowing specific symptoms,which must occur almost every day for a minimum of 2 weeks, and lastmost of the day:oDepressed moodoDifficulty sleeping or excessive sleepingoIndecisivenessoDecreased ability to concentrateoSuicidal ideationoIncrease or decrease in motor activityoInability to feel pleasureoIncrease or decrease in weight of more than 5% of total body weight over 1 month
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Key Concepts for NCLEX - Page 40 preview imageAnxiety•Anxiety is a response to stress. Higher levels of anxiety result in behavior changes. Anxiety tends to bepersistent and is often disabling.•Anxiety levels can be mild (restlessness, increased motivation, irritability), moderate (agitation, muscletightness), severe (inability to function, ritualistic behavior, unresponsive), or panic (distortedperception, loss of rational thought, immobility)•Interventions for anxiety disorders include:•Providing emotional support that is accepting of regression and other defense mechanisms•Offering protection during panic levels of anxiety by providing for needs•Implementing methods to increase client self-esteem and feelings of achievement•Providing assistance with working through traumatic events or losses to reach an acceptance of whathas happened•Encouraging group therapyPanic Disorder•Episodes typically last 15 to 30 min.•Four or more of the following symptoms are present:oPalpitations & Shortness of breathoChoking or smothering sensationoChest painoNauseaoFeelings of depersonalizationoFear of dying or insanityoChills or hot flashes•The client may experience behavior changes and or persistent worries about when the next attack willoccur.•The client maybegin t o experience agoraphobiadue to a fear of being in places where previous panicattacks occurred. For example, if previous attacks occurred while driving, the client may stop driving. Ifattacks continue while walking or tailing alternative transportation, the client may remain at home•Levels of AnxietyoMild:-restlessness, increased motivation, irritability (its good)oModera te:-agitation, muscle tightnessoSevere: inability to function, ritualistic behavior, unresponsiveoPanic: Distorts perception, loss of rational thought, immobilityPersonality Disorders•All Personality Disorders Share Four Common Characteristics:oInflexibility maladaptive responses to stressoDisability in social and professional relationshipsoTendency to provoke interpersonal conflictoAbility to merge personal boundaries with others•Cluster A -generally described as odd or eccentric•Cluster B -generally described as dramatic, emotional, or erratic•ClusterC - generally described as anxious or fearful
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Key Concepts for NCLEX - Page 41 preview image*ClusterA (odd or eccentric disorders)oParanoid personality disorder : characterized by irrational suspicions and mistrust of others.oSchizoid personality disorder lack of interest in social relationships, seeing no point in sharingtime with others, anhedonia. introspection.oSchizotypal personality disorder): characterized by odd behavior or thinking.*ClusterB (dramatic, emotional or erratic disorders)oAntisocial Personality Disorder:a pervasive disregard for the law and the rights of others.oBorderlinePersonality Disorder:extreme "black and white" thinking, instability inrelationships, self-image, identity and behavior often leading to self-harm and impulsivity.Borderline personality disorder is diagnosed in three times as many females as males.oHistrionic Personality Disorder:pervasive attention-seeking behavior including inappropriatelyseductive behavior and shallow or exaggerated emotions.oNarcissistic Personality Disorder:a pervasive pattern of grandiosity, needforadmiration, and alack of empathy.*Cluster C(anxious or fearful disorders)oAvoidant Personality Disorder:social inhibition, feelings of inadequacy, extreme sensitivity tonegative evaluation aud avoidance of social interaction.oDep endent Personality Disorder:pervasive psychological dependence on other people.oObsessive-Compulsive Personality Disorder:(not the same as obsessive-compulsive disorder)characterized by rigid conformity to rules, moral codes aud excessive orderliness.Bipolar•Recognize s.'s of manic episode of bipolar disorder•M a n i a -an abnormally elevated mood, which may also be described as expansive or irritable; usuallyrequires inpatient treatment•S/S:oPersistent elevated mood (EUPHORIA)oAgitation and irritabilityoDislike of interference and intolerance of criticismoIncrease in talking aud activitiesoFlight ofideas - rapid, continuous speech with sudden and frequent topic changeoGrandiose view of self and abilities (grandiosity)oImpulsivity: spending money, giving away money or possessionsoDemanding and manipulative behavioroDistractibilityoPoor judgmentoAttention-seeking behavior:flashy dress aud makeup, inappropriate behaidoroImpairment in social aud occupational functioningoDecreased sleepoNeglect of ADLs, including nutrition aud hydrationoPossible presence of delusions aud hallucinationsoDenial of illnessoGiving away things, spending a lot of moneyoBeing extremelysexual
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Key Concepts for NCLEX - Page 42 preview imageAnger Management•How to manage aggressive and angry clientNursing Care:•Provide a safe environment not only for the client who is aggressive, but also for the other clients andstaff on the unit.•Follow policies of the mental health setting when working with clients who demonstrate aggression.•Assess for triggers or preconditions that escalate client emotion.•Steps to handle aggressive and or escalating behavior in a mental health setting include:•Responding quickly•Remaining calm and in control•Encouraging the client to express feelings verbally, using therapeutic communication techniques(reflective techniques, silence, active listening•Allowing the client as much personal space as possible•Maintaining eye contact and sitting or standing at the same level as the client•Communicating uith honesty, sincerity, and nonaggressive stance•Avoiding accusatory or threatening statements•Describing options clearly and offering the client choice•Reassuring the client that staff are present to help prevent loss of control•Setting limits for the client:oTell the client calmly and directly what he must do in a particular situation, such as. "I need youto stop yelling and walk with me to the day room where we can talk."oUse physical activity, such as walking, to de-escalate anger and behaviors.oInform the client of the consequences of his behavior, such as loss of privileges.oUse pharmacological interventions if the client does not respond to calm limit setting.oPlan for four to six staff members to be available and in sight of the client as a "show of force" ifappropriate.•Following an aggressive/violent episode:oDiscuss ways for the client to keep control during the aggression cycle.oEncourage the client to talk about the incident and what triggered and escalated the aggressionfrom the client's perspective.oDebrief the staff to evaluate the effectiveness of actions.oDocument the entire incident completely§Medications:Haloperidol (Haldol}*Haloperidol is an antipsychotic agent used to control aggressive and impulsive behavior.Nutrition - Albumin Levels: 3.5-5.0 G/DICaring For a Dying Patient•Normal griefoThis grief is considered uncomplicated.oEmotions may be negative loss, such as anger, resentment, withdrawal, hopelessness, and guiltbut should change to acceptance xvith time.oSome acceptance should be evident by 6 months after the loss.oSomatic complaints may include chest pain, palpitations, headaches, nausea, changes in sleeppatterns, or fatigue.
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Key Concepts for NCLEX - Page 43 preview imageAnticipatory griefoThis grief implies the "letting go" of an object or person before the loss, as in the case of aterminal illness.oIndividuals have the opportunity to grieve before the actual loss.Dysfunctional griefoThis grief involves difficult progression through the expected stages of the grieving process.oUsually the work of grief is prolonged, the symptoms are more severe, and they may result indepression or exacerbation of a preexisting disorder.oThe client may develop suicidal ideation, intense feelings of guilt, and lowered self-esteem.oSomatic complaints persist for an extended period of time.Disenfranchised griefoThis grief entails an experienced loss that cannot be publicly shared or is not sociallyacceptable, such as the loss of a loved one through suicide.Nursing InterventionsoPromote continuity of care and communication by limiting assigned staff changes.oAssist the client and family to set priorities for end-of-life care.oGive priority to the control of symptoms.oAdminister medications that manage pain, air hunger, and anxiety.oPerform ongoing assessment to determine effectiveness of treatment and need formodifications of treatment plan, such as lower or higher doses of medications.oManage side effects of medicationsoReposition the client to maintain airway and comfort.oMaintain integrity of skin and mucous membranes.oProvide an environment that promotes dignity and self-esteem.oRemove products of elimination as soon as possible to maintain a clean and odor freeenvironment.oOffer comfortable clothing.oProvide grooming for hair, nails, and skinoEncourage family members to bring in comforting possessions to make the client feel at homeoEncourage use of relaxation techniques, such as guided imagery and music.oPromote decision making in food selection, activities, and health care to permit the client asmuch control as possible.Support for the Grieving FamilyoSuggest that family members plan visits in a manner that promotes client rest.oEnsure that the family receives appropriate information as the treatment plan changes.oProvide privacy so family members have the opportunity to communicate and express feelingsamong themselves without including the client.oDetermine family members' desire to provide physical care. Provide instruction as necessary.oEducate the family about physical changes to expect as the client moves closer to death.
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Key Concepts for NCLEX - Page 44 preview imageStages of Grief (Kiibier Ross Stages)*Denial Anger, Bargaining. Depression. AcceptancePalliativeCare*Family and pt education-Palliative care improves the quality of life of clients and their families facingend-of-life■Determine family members' desire to provide physical care. Provide instruction as necessary.■Educate the family about physical changes to expect as the client moves closer to*Suggest that family members plan visits to promote the client's rest.*Ensure that the family receives appropriate information as the treatment plan changes.*Provide privacy so family members have the opportunity to communicate and express feelings amongthemselves without including the client*Promote continuity of care and communication by limiting assigned staff changes.*Assist the client and family to set priorities for end-of-life care.■Physical CareoGive priority to controlling symptoms.oAdminister medications that manage pain, air hunger, and anxiety.oPerform ongoing assessment to determine the effectiveness of treatment and the need formodifications of the treatment plan, such as lower or higher doses of medications.oManage adverse side effects of medications.oReposition the client to maintain airway patency and comfort.oMaintain the integrity of skin and mucous membranes.oProvide an environment that promotes dignity and self-esteem.oRemove products of elimination as soon as possible to maintain a clean and odor freeenvironmentoOffer comfortable clothingoMorphineisgiven for comfort!oIf Patient taking morphine and see respiratory depression - GIVE NARCANoOxygen is a comfort measureBody Image*Could be due to burns, stoma, scoliosisoScoliosis: have to wear the back brace 24 hours a day for a year except for the shower - needto give her clothes that she can wear over the brace*Support the client who is experiencing disturbed body image.Domestic Violence*Counseling is very important*Family therapy-maybe useful if the violent episode was recent and if both partners agree to take part.*The perpetrator must first take steps to control violence, such as learning anger managementstrategies*Nursing ActionsoHelp client develop a safety plan, identify behaviors and situations that might trigger violenceand provide information regarding safe places to live.oEncourage participation in support groups.oUse case management to coordinate community; medical, criminal justice, and social services.
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Key Concepts for NCLEX - Page 45 preview imageoUse crisis intervention techniques to help resolve family or community situations whereviolence has been devastatingNursingIntervention:oMust be culturally sensitive.oCounseling is an important nursing intervention for all types of violenceoCase management is needed to coordinate services.oNurses have a legal responsibility and are mandated to report suspected or actual cases of childor elder abuse.Nursing Interventions for domestic partner violence :oMake a safety plan for fast escape when violence occurs.oTeaching empowerment skills to client.oTeaching the client to recognize behaviors and situations that might trigger violence.Nursing Interventions for family violence:oStabilizing the home situation.oMaintaining an environment without violence and a higher quality of life for all family members.oEmpowering the vulnerable members and promoting the growth and development of all familymembers. Teaching and promoting normal growth and developmentoTeaching strategies to manage stress.Psychosis■Verify are they hearing voices, what are their voices telling them- Ask patient about hallucinations*Agoraphobia - fear of crowded places and being in pubhc places- with no escape"Flight of ideas: describes excessive speech at a rapid rate that involves fragmented or unrelated ideas*Abstract thinking: tell someone a cat has nine lives - and they will kill the cat and wait for it to comeback to lifeMust Know DefinitionsNegative Symptoms:Positive Symptoms:Affect- flat or blunted (facial expression neverchanges)Alogia- poverty of thought or speech- mumbleAvolition- (lack of motivation) lack of motivationin activities and hygieneAnhedonia- lack of pleasure or joyAnergia- lack of energyApathy- indifferenceSocial isolationChronic low self-esteemNeologisms-are made up wordsEcholalia- repeating another's wordsEchopraxia - mimicking of movementsClang associations- rhyming words "on thetrack...have a big Mac"Word salad - jumble of words that aremeaningless to the listenerLoose Association- Pattern of thinking isillogical & connections in thought areinterrupted.Delusions- false fixed beliefs thatrs held tobe trueHallucinations-a sense of perception- tactile,gustatory, auditory, olfactory and visual.Disturbed thought processesBizarre behavior- such as walking backward
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Key Concepts for NCLEX - Page 46 preview imageImipramine Tofranil (TCA) antidepressant is used to treat clients with agoraphobia and those underdetoxification of cocaine!Chronic Emphysema•What kind of acid base balance? Respirator}' acidosis and compensator}' metabolic alkalosis■Chronic means compensatedBurns•Priority intervention is airway•Also important hydration, infection control. and a high calorie dietCare of Skin Cancer■SPF cream-sun protection-Hours of day to avoid: 10-2pm•Hours of day to not go out to prevent mosquito bites: during dusk and dawnPulmonary Artery Wedge Pressure•Tosee how much blood is going to lungs - determine how much gas exchange-PAWP 4-12/ Ieft heart |preload}•Swan Catheter - inflate balloon (nurse does NOT inflate balloon)•Can't keep balloon inflated cause it can rupture and damage left ventricleUmbilical Cord Prolapse•The greatest risk to the client and fetus is umbilical cord prolapse leading to fetal distress•During cord prolapse Fetal bradycardia (FHR <110/min for 10 min or more)■When there is suspected rupture of membranes the nurse should first assess the FHR to assure there isno fetal distress from possible umbilical cord prolapse, which can occur with the gush of amniotic, fluid.■In Amniotomythe client is at increased risk for cord prolapse.oIn Amniotomy Assure that the presenting part of the fetus is engaged prior to an amniotomy toprevent cord prolapse.•InterventionoLower the head of the bed and elevate the client's hips on a pillow, or place the client in theknee-chest position to minimize pressure from the cord.oPlaceptin aTrendelenburg position or Knee chest positionUsing gravity to shift the baby offthe pelvisoLift the cord upwardUmbilical Cord Prolapse Intervention■Loop of the cord slips down the presenting part of the fetus and is pulsating•Frank is visible cord•Gloved hand is to hold the presenting part up until deliver}'•Maternal hip are elevated on two pillows•The kneetochest position
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Key Concepts for NCLEX - Page 47 preview imageSee Decelerations on the FUR Monitor - Indication of an Umbilical Cord Prolapsed*Early Decelerations:fetal HEAD COMPRESSION, fundal pressureoInterventions: Nothing*Variable Decelerations: CORD COMPRESSION.Oligohydraminos (not enough amniotic fluids)*Late Decelerations: UTEROPLACENTAL INSUFFICIENCY,maternal hypotensionoInterventions for variable and late:§Discontinue Oxytocin (Pitocin) if it is being infused.§Help the client Into aside-lying positionor to a hands and knees position to take thepressure off the umbilical cord§Administer oxygen (8 to 10 L min by mask).§Start an IV line if one is not in place.§Administer a tocolytic medication as prescribed.§Stimulate the fetal scalp.§Notify the priman-care provider.*Fetal kick countsoPl is instructed to lie on her side & count the number of times she feels the fetus moveso1stmethod:She counts and records 10 fetal movements in a period of 2 hourso2n dmethod: She counts fetal movementsfor1 hour three times week- count is reassuring if itequals or exceeds the established baseline*Assessment of Fetal Well-BeingoDappier ultrasound (see under ultrasound)oFetal Biophysical Profile§Noninvasive fetal physical assessment§Involves feta] heart rate monitor and ultrasound§BPP(biophysicalprofile): uses a real time ultrasound to visualize physical andphysiological characteristics of the fetus and observes for fetal biophysical responses tostimuli.§It measures 5 variables with a score of 2 for each normal finding and 0 for eachabnormal finding:4.Reactive FUR(from reactive NST),4.Fetalbreathing movements(at least 1 episode of 30 sec in 30 min is a normalresponse)4. Gross body movements (atleast 3 body or limb extensions with return to flexionin 30 min is a normal response)4-Fetal tone(atleast 1 episode of extension with return to flexion is a normalreaction)4-Amniotic fluidvolume (atleast 1 pockets of fluid that measures at least 1cm in 2perpendicular planes is a normal reaction).»Total score of 8-10 is normal, less than 4 is abnormal.
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Key Concepts for NCLEX - Page 48 preview imageNon-Stress Test*Noninvasive procedure performed during thethird trimester tomonitorfetal movements*Assess for an intact fetal CNS*NST (nonstresstest): is most widely used technique for antepartum evaluation of fetal wellbeingperformed during the third trimester.■It is a noninvasive procedure that monitors response of the FHR to fetal movement.*A Doppler transducer,used to monitor the FHR. and a tocotransducer used to monitor uterinecontractions. is attached externally to a client's abdomen to obtain paper tracing strips.§The client pushes a button attached t o the monitor whenever she feels a fetal m o v e m e n twhich is then noted on the paper tracing.This allows a nurse to assess the FHRinrelationshipto the fetal movement.§This is indicated for assessing an intact fetal CNS during the third trimester, ruling out the riskfor fetal death in clients who have diabetes mellitus used twice a week or until after 28 weeksof gestation.§NSTisREACTIVEif the FHR is a normal baseline rate with moderate variability accelerates to 15beats min for at least 15 seconds and occurs two or more times during a 20 min period.§If this doesn't happen after 40 minutes, it isconsidered NONREACTIVE,it is further assessedwith a contraction stress test (CST) or biophysical profile (EPP)*ProcedureoPosition at semi-Fowlef a or left lateral positionoClient presses the button when fetus movesoIf there is no movement Vibroacoustic stimulation is activated"If nonstress test is nonreactive- perform aContraction Stress TestoCST is based on the premise that fetal oxygenation is only marginally adequate when the uterusat restoEvaluates the fetal response to uterine contractionsoObtain baselineF H Rfor20minutesoHave mom lightly rub her nipples for 2-3 minutes and watch how the fetus respondsoCSTs are evaluated accordingtothe presence or absence of late decelerationsoLate decelerations is associated with fetal hypoxiaoOxytocin (Pitocin) administration CST is used if nipple stimulation fails and consists of the§IV administration of Oxytocin to induce uterine contractions.*Negative findings (normal):no late decelerations in 10 minutes with 3 contractions"Positive findings (abnormal):late decelerations on more than half the contractionsThe Passageway & Passenger Relationship1Engagement-widest diameter of the presenting part has passed through the pelvic inlet■Station - refers t o level of the presenting part t o the maternal ischial spinescIschialspines—0 stationoAboveischial spines—(-) minus stationcBelow ischial spines — ( - )plus stationo+4cm means that that presenting part is at the pelvic outlet
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