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During peritoneal dialysis- client suddenly begins to breathe more rapidly, what do you do? Elevate the
HOB! Will decrease the pressure fo the dialysate on the diaphragm and increase the vital capacity of
the lungs, draining the cavity will further decrease the pressure.
Normal platelet = 150,000- 400,000. Decreased platelet= increase risk for bleeding. No IM injections,
use sm. gauge needle to prevent trauma, apply firm pressure to needlestick site for 10 min, soft
bristled toothbrush , do not floss, and no hard fards
Femoral to popliteal bypass graft= report if client becomes clammy. Hypovolemic shock is caused by
an inadequate volume of blood caused by hemorrhage, severe dehyradtion, or burns. skin will be cold
and clammy b/c the body redirects blood from the skin, kidneys, and GI tract to the brain and heart.
Dear God,
Today I will have my examinations. You know how important they are to me. So I am humbly asking
Your gracious help and divine assitance. I pray to you, my dear God, please neve rlet me be at ease
and give my very best. Please never let me guess nor rely on pure luck, but enlighten my mind and let
me think clearly. Please never let me resort to chances nor to dishonesty, but let me work to the
fullest of my ability. I pray for Your guidance that i as i think, I may find the right solutions, I may be
able to correctly answer the questions, I may solve those difficult problems. I ask, O God, Your
intercession, that as I write, I may not be careless nor overconfident, I may not be distracted but be
more concentrated, I may not be in a hurry nor take the exams too lightly. Today, O my Lord, I will
take my examinations Let me, with Your help, give my best effort. Let me, because of You, receive the
best and fruitful results. This I pray in Jesus name. Amen.
My tips:
Stages of Dying:
DABDA
Denial
Anger
Bargaining
Depression
Acceptance
Normal growth and development
Most People Can Get Stuff
BIRTH to 1 year- Mobiles
1-3 years- Push and pull toys
3-5 years - Coloring
6-12 years- Board Games
12-19 years- own Stuff
Can Not eat = - 2 amps D50 IV push; (Glucagon alternative option if no IV access is available,
however is of no use in prolonged hypoglycemia because stores of glycogen are depleted)
Points to remember:
For high sugar (DKA, HHNS) most of the signs and symptoms are from polyuria, so look for
dehydration and electrolyte imbalances...remember High and Dry
For low sugar most of the signs and symptoms are from the release of epinephrine, so look for
things that would happen when someone was high on adrenaline, such as hypertension, sweating,
tachycardia and tremors.
Imperative that you can recognize the difference between these two, as you are almost guaranteed
to see a question relating to this difference!
Re: Anyoone up for random FACT THROWING??
PULMONARY EDEMA:TX "MAD DOG"
Morphine
Aminophylline
Digitalis
Diuretics
Oxygen
Gases in blood(ABG'S)
drugs to treat viral respiratory infections
"you'd get a respiratory infection if you shoot an ARO (arrow)
laced with viruses into the lungs
ARO
Re: Anyoone up for random FACT THROWING??
d1206,thanks for the correction
back to facts:
Pnuemothorax symptoms
P-THORAX
Pleuritic pain
Trachea deviation
Hyper resonance
Onset sudden
Reduced breath sounds(dyspnea)
Absent Fremitus
X-ray shows collapse
As we all know, Maslow's hierarchy is important to know and understand. Yet there are examples
where Maslow's hierarchy is contraindicated. With that being said, here is to refresh your memory
on Maslow's hierarchy. PLEASE HELP GIVE EXAMPLES.
--------------------------------------------------------------------------------IMAGINE that this is the pyramid:
1st (most) important (located at the bottom of the pyramid): BASIC PHYISIOLOGICAL NEEDS:
airway, respiratory effort, heart rate, rhythm, and strength of contraction, nutrition, elimination
2nd most important (located above physiological on the pyramid): SAFETY AND SECURITY:
protection from injury, promote feeling of security, trust in nurse-client relationship
PSYCHOSOCIAL NEEDS
3rd most important: LOVE and BELONGING: maintain support systems, protect from isolation, fear
4th: SELF ESTEEM: control, competence, positive regard, acceptance/worthiness
5th (top of the pyramid): SELF ACTUALIZATION: hope, spiritual well-being, enhanced growth.
----------------------------------------------------------------example of when it is contraindicated:
-a dehydrated and extremely suicidal client: safety comes before hydration
-----------------------------------------------------------example of when physiological is more important than safety
-cataract client: disturbed sensory perception (visual) is more important than risk of injury related to
decreased vision
)In myocardial infarction...MORPHINE first BEFORE OXYGEN...
cataract client: disturbed sensory perception (visual) is more important than risk of injury
related to decreased vision
hhmmm physiologic need IS more important than safety/security.
that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting your butt
along the way (safety/security)
phyisiologic needs always come before safety, except in psy. When you think about these needs, you
need O2, water, food. Also, think about ABC's then safety
example of when oxygen is not administered first....
that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting
your butt along the way (safety/security)
yes but risk for is a potential diagnosis and altered sensory perception is an actual diagnosis. Priority
would be a diagnosis that is present not one that has the potential to be.
Just remember that underneath that Maslow's triangle there is an imaginary "additional" line below
the whole thing that is LIFE or DEATH.
In other words, if the "safety" factor is a life or death issue, that takes priority over every other need.
A client being hydrated isn't going to mean a hill of beans if he's dead.
always draw up clear to cloudy when mixing insulin.
2. do not add potassium to the diet of someone who is taking potassium sparing diretics.
3. Give diretics in the am to avoid nocturia.
4. always check for tube placement with 10 cc of air before instilling ANYTHING in an NG tube.
5. An infant should double there birth weight by 6 months old.
mother/baby stuff
1. Rh negative mom gets Rhogam if baby Rh positive. Mom also gets Rhogam after
aminocentesis, ectopic preganancy, or miscarriages.
2. fetus L/S Ratio less than 2= immature lungs......2-3=borderline....greater than
3=good lung maturity dude!! may give dexamethasone to speed up maturity if baby
needs to be delivered soon.
3. prolasped cord position knee chest or trend..call for help!! GET THAT BOTTOM
OFF THE CORD! SUPPORT CORD WITH YA HAND
4. decelerations early vs late----always good to be early but dont ever show up
late. early mirrors the contraction, late comes after the contraction
5. LOCHIA SEQUENCE...lochia rubra- red, clotty....lochia serosa...pink,
brown....lochia alba..white.........SHOULD NEVER HAVE A FOUL ODOR!
VEAL CHOP
Variable deceleration -Cord compression
Early deceleration - Head ompression
Acceleration - O.k
Late deceleration - Position change
Pt with asthma - FIRST give bronchodilators (opens airways) and then stuff them with steroids
2. Antepartum client c/o leg cramps - teach client to dorsiflex foot
3. Pt who had thyroidectomy - assess for signs of hypocalcemia (muscle twitching: positive
Chvostek's/Trousseau's sign, tetany)
4. NORMAL FINDINGS for a 6 month old child - sits up without support
5. DELEGATION/SUPERVISION
RN's can assess (initial for sure, MOST IMPORTANTLY), teach, administer blood products, planning,
evaluation, infusion of IV meds,
LVN's can do dressing changes, administer enemas/antibiotics, oral care and routine observation, perform
fingerstick glucose readings, gathering data and observations: breath sounds and pulse oximetry, set up
equipment for oxygen and suctioning, checking and observing client for signs of infection, irrigating the ear,
reminding client about post-op instructions given by RN, assisting with procedures in stable clients with
predictable outcomes
Nursing assistant's can do VS's, baths, ambulate client, brush/floss client's teeth, record intake and output,
can remind client to perform actions that are already part of the plan of care, weighing the client, taking pulse
and blood pressure, reinforce dietary and fluid restrictions after the RN has explained them to the client
Remember that long-term corticosteroid use causes adrenal atrophy, which will decrease the ability of
the body to withstand stress. Therefore, when a pt is made NPO before surgery, check with the MD
because this medication may still need to be given. Sometimes you may also see the the dosage of a
corticosteroid increased before surgery
Diet= Calorie Carb protein / TPN may be used monitor BS / Sliding Scale for insulin
supplments: Vit B, Vit C, Iron
FyI: Most concern is a burn that does not blanch.
Degree of Burns
1 = Pink to red; epidermis damage (superfical) ;uncontrollable painful
2 = red to white with blisters and edema; epidermis and dermis (partial thickness) ;
painful
= charred, waxy white and edema; damage skin, nerves, muscle, bones(called deep
thickness burn), painless
3 = usually dry darkbrown or has a leathery appearence.
;damage to all the Epidermis and Dermis Skin grafting is recommended.( Full Thickness
Burn)
4= The tissue beneath the skin is burned/destroyed. includes the muscles, tendons,
ligaments and bones. Skin grafting is usually needed to close up the areas.
Endocrine Glands
Hypothalamus (Regulator)
Pituitary Gland (Growth, Reproduction, Melanin, F&E)
Pineal Gland (Melatonin, Circadan Rhythms)
Thyroid (Metabolism, Energy, Growth)
Parathyroid (Calcium Regulation)
Thymus (Immune Response)
Adrenal Glands (Stress Response, Metabolism, F&E)
Pancreas (Fat, Protein, Carb Metabolism)
Ovaries (Reproductive System, Sex Organs)
Testes (Reproduction, Muscles, Bones, Skin, Hair)
Hormones
Hypothalmus (Releasing/Inhibiting Hormones)
Ant. Pituitary (TSH, Growth Hormone, LH, FSH, ACTH)
Posterior Pituitary (ADH, MSH, Oxytocin)
Pineal (Melantonin)
Thymus (Thymopoietin)
Thyroid (T4, T3, Calcitonin)
Parathyroids ( PTH)
Adrenal Medulla (Epi, Norepi)
Adrenal Cortex ( Glucocorticoids, Mineralocorticoids)
Pancreas (Insulin, Glucagon)
Addissons Disease Assessments
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium Addissons Disease
Implementations
An infant experiencing vomiting and/or diarrhea should be seen before an older child, young
adult, or adult experiencing vomiting/diarrhea.
* Blood sample shows microcytic and hypochromic anemia (small RBC diameter with decreased
pigmentation) and an increase in red cell size distribution width (RDW)
* Decreased MCV, MCH, and MCHC; analyzed only when hemoglobin is low
* Low serum iron level and elevated serum iron-binding capacity or low serum ferritin levels
Therapeutic management
* Examine stools for occult blood; endoscopic examination and other diagnostic procedures may be
performed to detect possible sources of bleeding
* Increase intake of iron-rich foods, such as organ meats, meat, beans, green leafy vegetables,
molasses, and raisins
* Administer iron supplements
* Administer parenteral iron dextran (InFed) by deep IM route via Z-track method
* Determine stool color, consistency, frequency, and amount; may appear greenish black and tarry;
caution client that iron supplements usually cause constipation and client should take preventive
measures (fluids, fiber)
Client teaching
* Take iron on an empty stomach; absorption of iron is decreased with food; ab*sorption may be
enhanced when taken with an acidic beverage (such as one with vitamin C), but avoid grapefruit Mice
* Foods high in iron include organ meats (beef or calf liver, chicken liver), other meats, beans (black,
pinto, and garbanzo), leafy green vegetables, raisins, and molasses
MEGALOBLASTIC ANEMIA
* Vitamin B12, deficiency anemia
* A type of anemia characterized by macrocytic RBCs
Nursing assessment
* Pallor or slight jaundice with a complaint of weakness
* Smooth, sore, beefy red tongue (glossitis), and cheilosis (cracking of lips)
* Diarrhea
* Paresthesias (numbness or tingling in extremities)
* Impaired proprioception (difficulty identifying one's position in space. which may progress to
difficulty with balance)
* Clients with this anemia tend to be fair-haired or prematurely gray Macrocytic (megaloblastic)
anemia (RBC diameter >8) with increase in MCV and MCHC
* Gastric secretion analysis reveals achlorhydria: absence of free hydrochloric acid in a pH maintained
at 3.5
* Twenty-four-hour urine for Schilling test (a vitamin B12 absorption test th indicates if client lacks
intrinsic factor by measuring excretion of orally ad-ministered radionuclide-labeled B12) confirms
diagnosis of pernicious anemia
Therapeutic management
* Medication therapy: parenteral vitamin B12,100 to 1000 mcg subcutaneously daily for 7 days, then
once a week for 1 month, then monthly for lifetime is usually prescribed; a nasal form is now available
also
Client teaching
* Dietary sources of vitamin B12 include dairy products, animal proteins
Folic aciddeficiency anemia
Nursing assessment
* Pallor, progressive weakness, fatigue
* Shortness of breath
* Cardiac palpitations
* GI symptoms are similar to B12 deficiency but usually more severe (glossitis, cheilosis, and
diarrhea)
* Neurological symptoms seen in B12 deficiency are not seen in folic acid deficiency and therefore
assist in differentiating these two types of anemia
* RBC analysis shows macrocytic (megaloblastic) anemia (RBC diameter, high MCV with low
hemoglobin, low serum folate level
Therapeutic management
* Includes dietary counseling and administration of folic acid
Client teaching
* Dietary sources of folic acid such as green leafy vegetables, fish, citrus yeast, dried beans, grains,
nuts, and liver
APLASTIC ANEMIA
Nursing assessment
*
*
*
*
*
*
*
*
*
Therapeutic management
* Institute reverse isolation to protect client from infection
* Monitor for evidence of bleeding
* Avoid invasive procedures including rectal temperatures
Client teaching
* Methods to prevent infection such as avoiding crowds, maintaining good hygiene, hand washing, and
elimination of uncooked foods from the diet
* Methods to prevent hemorrhage such as using a soft toothbrush, avoiding contact sports, and use of
an electric razor
* Avoid drugs that increase bleeding tendency, such as aspirin
Sickle Cell Disease
Nursing assessment
* Pallor and jaundice
* Fatigue and possible irritability
* Large joints and surrounding tissue may become swollen during crisis
* Priapism (abnormal, painful, continuous erection of penis) may occur if penile veins are obstructed
* Severe pain
* Anemia with sickle cells noted on a peripheral smear
* Hemoglobin electrophoresis to detect presence and percentage of hemoglobin is used for a definitive
diagnosis
* Elevated serum bilrubin levels
* Elevated reticulocyte count
Therapeutic management
* Care of client in sickle cell crisis
o Recognize that client may have severe pain and medicate accordingly, usually with opioid analgesics
o Administer 02 to increase oxygenation to cells
o Promote hydration to decrease blood viscosity; provide oral intake of at 6 to 8 quarts daily or IV
fluids of 3 liters daily
o Monitor for complications such as vaso-occlusive disease (thrombosis), hy*poxia, CVA, renal
dysfunction, priapism leading to impotence, acute chest syndrome (fever, chest pain, cough,
pulmonary infiltrates, and dyspnea), an substance abuse
o Manage infection if appropriate
Medication therapy
* Narcotic (opioid) analgesics during the acute phase of sickle cell crisis, often at large doses
Client teaching
* Ways to prevent sickle cell crisis
* Maintain an oral intake of at least 4 to 6 quarts a day; avoid conditions that might predispose to
dehydration
* Avoid high altitudes
* Prevent and promptly treat infections
* Use stress-reduction strategies
* Avoid exposure to cold
* Avoid overexertion
Anemia
* Children with persistent anemia might experience frequent bouts of otitis media and upper
respiratory infections.
Pernicious Anemia
* For the exam, you should know the names for the various B vitamins and realize that they can be
used interchangeably in test items;
* B1 (Thiamine)
* B2 (riboflavin)
* B3 (niancin)
* B6 (pyridoxine)
* B9 (folic acid)
* B12 (cyanocobalamin)
* Morphine is the drug of choice for acute pain in sickle cell anemia. Meperidine is contraindicated due
to the possibility of central nervous system stimulation in these clients that could lead to seizure
activity.
* An easy to remember general nursing care for clients with sickle cell anemia is to remember the
following
* H - heat
* H hydration
* O oxygen
* P pain relief
Polycythemia Vera
This disorder is characterized by thicker than normal blood. There is an increase in the clients
hemoglobin to levels of 18 g/dL, RBC of 6 million/mm or hematocrit at 55% or greater and increased
platelets)
* With polycythemia, the client is at risk for cerebrovascular accident (CVA), myocardial infarction,
(MI) and bleeding due to dysfunctional platelets.
Hemophilia
* Intracranial bleeding is the major cause of death in clients with hemophilia
* Cryoprecipitates are no longer used for treatment of hemophilia because HIV and hepatitis cannot
be removed.
Transfusion Therapy
* Severe reactions occur during the first 50mL of blood transfused. Stay with the patient for the initial
15-30 min of infusion
Client with Burns
BURN INJURY
* An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity,
or radiation
* There are several types of burn injury: thermal, chemical, electrical, and radiation
* Thermal burn: results from dry heat (flames) or moist heat (steam or hot liq*uids); is most common
type; causes cellular destruction that results in vascu*lar, bony, muscle, or nerve complications;
thermal burns can also lead to inhalation injury if head and neck area is affected
* Chemical burn: caused by direct contact with either acidic or alkaline agents; alters tissue perfusion
and leads to necrosis
* Electrical burn: severity depends on type and duration of current and amount of voltage; electricity
follows path of least resistance (muscles, bone, blood vessels. and nerves); sources of electrical injury
include direct current, alter*nating current, and lightning
* Radiation burn: usually associated with sunburn or radiation treatment for cancer; usually
superficial; extensive exposure to radiation may lead to tissue damage and multisystem injury
o Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history
and medication history including date of last tetanus pro*phylaxis; assess for other concurrent injuries
o Systemic effects of severe burns include asphyxia from smoke inhalation that causes edema of
respiratory passages; shock from fluid shifts; renal failure from shock; protein loss from open wound;
potassium excess from tissue destruction and renal failure
o Diagnostic and laboratory test findings: may have elevated hematocrit (Hct) and decreased
hemoglobin (Hgb) caused by fluid shift, decreased sodium (Nat) and increased potassium (K+) caused
by damage to capillary and cell mem*branes, elevated BUN and creatinine caused by dehydration,
myoglobin in urine, and possible deterioration of arterial blood gases (ABGs) and oxygen (02)
saturation readings depending on respiratory status
o Therapeutic management
* First aid: douse flames with water or smother them with a blanket, coat, or other similar object; cool
a scald burn with cool water; flush chemical burns copiously with water or other appropriate irrigant
after dusting away any dry powder if present; remove client from contact with an electrical source
only after current has been shut off
* Priority care is on ABCs: airway, breathing, and circulation; assess for smoke inhalation injury
(singed nares, eyebrows or lashes; burns on face or neck; stridor, increasing dyspnea) and give 02
(up to 100% as prescribed), being prepared for possible intubation and mechanical ventilation if
severe inhala*tion injury or carbon monoxide inhalation has occurred; assess for signs of shock
caused by fluid shifts (increased pulse, falling BP and urine output, pal*lor, cool clammy skin,
deteriorating level of consciousness [LOC])
* Fluid resuscitation: Brooke formula uses 2 mL/kg/% TBSA burned (3/4 crys*talloid plus 1/4 colloid)
plus maintenance fluid of 2,000 mL D5W per
o Medication therapy: analgesicsusually morphine sulfate IV, tetanus booster (> 5-10 years since
last dose), topical antimicrobials, systemic antibiotics
o Acute phase of burn management: begins with start of diuresis (usually 48 to 72 hours postburn)
Burn Classifications
+ Pain medication is given intravenously to provide quick, optimal relief and to prevent overmedication
as edema subsides and fluid shift is resolving.
+ The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours
following the injury to detect changes in electrical conduction of the heart.
+ Full thickness burns can damage muscles, leading to the development of myoglobinuria in which
urinary output becomes burgundy in color. The client with myoglobinuria require hemodialysis to
prevent tubular necrosis and acute renal failure.
Burn Measurement with TBSA
+ It will be beneficial to review your nursing textbooks for local and systematic reactions to burns
because these injuries affect all body systems and cardiovascular and renal functions in particular.
Nursing Care for Burn Victims
+ The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with
an ophthalmologists is important because burns of the eyes can result in corneal ulceration and
blindness.
+ Important Steps in treating a burn client include the following:
* Treat airway and breathing Traces of carbon around the mouth or nose, blisters in the roof of the
mouth, or the presence of respiratory stridor, indicate the client has respiratory damage
* Ensure proper circulation Compromised circulation is evident by a drop in normal blood pressure,
slowed capillary refill, and decreased urinary output. These symptoms signal impending burn shock.
o It is important to remember that the actual burns might not be the biggest survival issue facing burn
clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon
monoxide combines with hemoglobin to form carboxyhemoglobin which binds to available hemoglobin
200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasolidating effect
causing the client to have a characteristic cherry red appearance. Interventions for carbon monoxide
poisoning focus on early intubation and mechanical ventilation with 100% oxygen.
o Enzymatic debridement should not be used for burns greater thatn 10% TBSA, for burns near the
eyes, or for burns involving muscle.
Dressing for Burns
o Dressing for burns include standard wound dressings (sterile gauze) and biologic or biosynthetic
dressings (grafts, amniotic membranes, cultured skin, and artificial skin)
o Biologic dressings are obtained from either human tissue (homograft or allograft) pr animal tissue
(heterograft or xenograft). These dressing which are temporary are used for clients with partial
thickness or granulating full thickness injuries.
o Hemografts and allografts are taken from cadaver donors and obtained through a skin bank. These
grafts are expensive and there is a risk of blood-borne infection. Heterografts and xenografts are
taken from animal sources. The most common heterograft is pig skin (porcine) because of its
compatibility with human skin.
o Muslims and Orthodox Jews are two religious/ethnic groups who might be offended by the use of
porcine grafts since the pig is considered an unclean animal. Christian groups such as Seventh Day
Adventists might also reject the use of procine grafts.
* Teach client and family how to care for tracheostomy and feeding tube (if applicable)
* Provide access to communication devices, such as writing supplies, picture or word board, speaking
tracheostomy valve
* Provide emotional sunnort to client and family: make annronriate referrals
Respiratory Isolation
* Droplet precautions (transmission-based precautions)
* In addition to standard precautions, persons should wear mask when near client who has known or
suspected pathogen transmitted by droplet route
* Limit client transport within facility; when transport is necessary, place mask on client
* Limit contamination of equipment and/or environment
* Place client in private room or with a cohort (client with same diagnosis)
NURSING MANAGEMENT OF CLIENT HAVING THORACIC SURGERY
Preoperative period
* Reduce anxiety through preoperative teaching about procedure and postopera*tive course and care
* Assess client's support systems and ability to care for self after surgery
* Administer preoperative medications, such as antibiotics, opioid analgesics, and anti-anxiety agents,
as ordered
* Obtain baseline vital signs, oxygenation status, and cognitive status for compari*son postoperatively
Postoperative period
* Maintain patent airway
* Position client for optimal ventilation and perfusion; note any specific surgeon-s orders for
positioning; be prepared to initiate respiratory support (intubation. emergency tracheostomy,
mechanical ventilation) as needed
* Maintain client safety
* Assess for and report possible surgical complications to maintain oxygenation
* Change in level of consciousness (LOC) ranging from restlessness and agitation to lethargy or
unresponsiveness
* Increase in respiratory rate, unequal chest expansion, decreased breath sounds, and/or use of
accessory muscles for breathing
* Loss of water seal drainage in closed chest drainage system
* Greater than desired volume of chest drainage (75-100 mL drainage over 1 hour is an average
acceptable upper limit); orders should specify volume acceptable chest tube drainage; should
decrease over first 24 hours
Positioning client after lung surgery: orders should specify turning parameters for indvidual client
* Lobectomy: positioning includes lying on back or turned to either side
* Segmental resection: positioning includes lying on back and turned onto nonl erative side;
positioning on operative side may place tension on sutures and mote bleeding
* Pneumonectomy
* Positioning includes lying on back and turned toward operative side
* Avoid complete lateral turning to either side, which changes pressure dynam*ics within chest and
could lead to mediastinal shift
OBSTRUCTIVE PULMONARY DISEASES
Emphysema
a. Progressive destruction of alveoli related to chronic inflammation
Assessment
* "Pink puffer" is a classic clinical description characterized by barrel chest, pursed-lip breathing
(caused by forced exhalation), obvious use of accessory muscles when breathing, and underweight
appearance
* Exertional dyspnea progresses with advancing disease
* Persistent tachycardia is related to inadequate oxygenation
* Overall diminished breath sounds, and possible wheezes or crackles
* ABGs: slightly decreased P02; PCO2 is not elevated until later stages
* Chest x-ray: hyperinflated lungs with a flattened diaphragm; heart size is nor*mal or small
* Pulmonary function tests: low vital capacity and forced expiratory volume (FEVi)
Therapeutic management
* Goals are to improve ventilation and promote patent airway by removing se*cretions
* Remove environmental pollutants and encourage smoking cessation
* Prescribed treatments include bronchodilator therapy, beta-adrenergic ago*nists, corticosteroid
therapy, oxygen and nebulization therapy, chest physio*therapy, intermittent positive-pressure
breathing (IPPB), possibly mechanical ventilation, and possible surgical procedures such as
bullectomy, lung volume reduction surgery, or lung transplantation
* Provide education and referrals for clients with behaviors (such as smoking) that increase risk for
COPD
* Refer clients to a structured pulmonary conditioning program and provide reinforcement as
appropriate
* Teach clients to avoid pulmonary irritants
* Assist clients to develop appropriate nutritional plans to provide ade*quate calories
Chronic bronchitis
A disorder of chronic airway inflammation with a chronic productive cough lasting at least 3 months
during 2 years; is a form of COPD
Assessment
* Frequent cough, occurring during winter season, with foul-smelling sputum
* Frequent pulmonary infections
* Classic appearance of "blue bloater" includes tendency for obesity and bluish-red skin discoloration
from cyanosis and polycythemia
* Dyspnea and activity intolerance occurs as disease progresses
* Increased anteriorposterior chest diameter
* Elevated red blood cell count; hemoglobin and hematocrit elevated in later stages
* Chest x-ray reveals enlarged heart, congested lung fields, and normal or flattened diaphragm
* Pulmonary function indicates increased residual volume, decreased vital capacity, FEVi, and
FEVi/FVC ratio
Therapeutic management
* Includes measures previously described in section on emphysema
* Provide education or referrals to clients with behaviors that increase the risk of developing COPD
Dyspnea
Tracheal deviation toward unaffected side
Diminished breath sounds on affected side
Percussion dullness on affected side
Unequal chest expansion (reduced on affected side)
Crepitus over chest
Chest x-ray reveals pneumothorax
ABG shows decreased P02
Therapeutic management
* In mild cases, no chest tube is required; if pneumothorax is significant, a chest tube is inserted and
attached to water seal drainage
* Spontaneous pneumothorax: in otherwise healthy client, may resolve without in*vasive treatment
* If spontaneous pneumothorax occurs repeatedly, may require pleurodesis, an in*stillation of an
agent (such as talc or tetracycline) in pleural spaces to allow pleura to adhere together; other
procedures include partial pleurectomy, sta*pling, or laser pleurodesis for pleural sealing
* Care of client with a chest tube:
* Monitor respiratory and oxygenation status
* Provide supplemental oxygen as indicated
* Maintain infection control practices
* Medication therapy: analgesics and antibiotics
ATELECTASIS
* Incomplete expansion or collapse of the lung resulting from obstruction of air*way by secretions or a
foreign body
Assessment
* Low-grade fever
* Breath sounds diminished or absent in affected area
* Diminished rate and depth of respiration
PULMONARY TUBERCULOSIS
* Lung infection caused by Mycobacterium tuberculosis
Assessment
* Frequent cough with copious frothy pink sputum; nonproductive cough devel*ops first as an early
symptom (especially in early morning)
* Night sweats
* Anorexia
* Weight loss
* History may indicate recent exposure to infected individual
* Positive tuberculin skin test (indicates exposure)
* Appearance of characteristic Ghon tubercle on chest x-ray
* Positive acid-fast bacillus sputum cultures (provides definitive diagnosis of infection)
Therapeutic management
* Monitor respiratory and oxygenation status
* Provide adequate nutrition and hydration
* Institute standard precautions (Centers for Disease Control [CDC] Tier 1) and airborne precautions
(Tier 2, transmission-based precautions
* Use a private room with negative air pressure that has 6 to 12 full air exchanges per hour and is
vented to the outside or has its own air filtration system
* Wear specially fitted mask (N95 respirator) whenever entering client's room; fit-test the mask with
each use
* Provide visitors with appropriate masks
* Wear gown and masks if client does not reliably cover mouth during cough*ing or sneezing to
reduce risk of transmission to others
* Provide client with a surgical mask if it is necessary to bring client to another department; choose
shortest and least busy route and alert that department ahead of time about client's status; schedule
tests for least busy times of day
* Administer antimicrobial therapy as prescribed
* Provide supplemental oxygen as indicated
* Obtain periodic sputum cultures following onset of antimicrobial therapy
Client education
* Infection control measures, including handwashing, coughing into tissues disposing of them in a
closed bag
* Teach client, family, and close contacts about mechanisms of transmission antimicrobial therapy,
including need to take medication for full course of apy to prevent recurrence and/or development of
drug-resistant organisrm
PULMONARY EMBOLISM
* Emboli lodge in pulmonary vasculature and impede blood flow through pulmonary capillaries
Assessment
*
*
*
*
*
*
*
*
*
*
Therapeutic management
* Supplemental oxygen therapy; maintain patent airway
* Be prepared to initiate mechanical ventilation
* Maintain IV access and provide circulatory support as needed
* Anticoagulant and/or thrombolytic therapy
* Opioid analgesies and anti-anxiety agents as needed
* Embolectomy
* To prevent future pulmonary emboli, a vena cava filter may be inserted to trap emboli from a known
source
BRONCHOGENIC CARCINOMA
* Lung cancer is leading cause of death from malignancy
Assessment
*
*
*
*
*
*
*
*
*
*
*
*
Therapeutic management
*
o
o
o
o
*
*
*
Surgical resection
Pneumonectomy: removal of entire lung
Lobectomy: removal of a lobe of lung
Segmentectomy (segmental resection): removal of a segment or segments of a lung
Wedge resection: dissection and removal of a defined area in lung
Chemotherapy
Radiation therapy
Laser therapy
* Immunotherapy
CANCER OF THE LARYNX
* Most laryngeal tumors are benign
Assessment
* Hoarseness and/or change in voice characteristics
* Palpable jugular nodes
* Pain when swallowing
* Unexplained earache
* Diagnostic test results: laryngeal biopsy findings, x-ray visualization, MRI findings, barium swallow
visualization
Therapeutic management
* Depends on stage of disease and general condition of client
* Radiation therapy or brachytherapy (placement of a radioactive sow next to tumor)
* Chemotherapy
* Laryngectomy
* Radical neck dissection
* Maintain patent airway (tracheostomy performed with laryngectomy)
* Pain management
* Provide adequate hydration and nutrition (temporary or permanent alter route for nutrition)
* Provide alternate means for communication and plan for permanent mea communication (artificial
larynx or esophageal speech)
* Monitor respiratory and oxygenation status
* Provide oxygen supplementation as indicated
* Medication therapy: opioid analgesics and antipyretics
THORACIC TRAUMA
* Alteration of breathing mechanics and/or gas exchange caused by respiratory. system trauma
Assessment
*
*
*
*
*
*
*
Ventilation support
Be prepared to initiate mechanical ventilation
Maintain IV access
Possible placement of chest tube with water seal drainage
strict I & 0
* Strict handwashing; avoid exposure to respiratory infections
* Cluster nursing care to minimize 02 requirements and caloric expenditure
* Plan quiet stimulation and activities to foster normal infant development and parental bonding with
extended and often repeated hospitalizations of in*fants with BPD
Medications
*
*
*
*
LARYNGOTRACHEOBRONCHITIS (LTB)
* Viral infection that causes inflammation, edema, and narrowing of chea, and bronchi; usually LTB is
preceded by a recent upper respira% fection (URI)
Assessment
* Onset is gradual after URI
* Child awakens with low-grade fever, barking cough, and acute stridor; noisy breathing and use of
accessory muscles increase
* Child is agitated, restless, has a frightened appearance, sore throat, and rhinorrhea
* Pulse oximetry is used to detect hypoxemia; anteroposterior (AP) and lateral upper airway x-rays
are ordered
Therapeutic management
* Monitor child's respiratory effort continuously to ensure a patent airway; ob*serve for diminished
breath sounds, circumoral cyanosis, diminishing noisy breathing, and drooling
* Quiet respiratory effort is a sign of physical exhaustion and impending respira*tory failure
* Provide humidity and supplemental 02; IV fluids prevent dehydration and help liquefy secretions
* Assist child to assume upright position or any position of comfort; promote a calm, quiet
environment; keep parents nearby to decrease child's stress and to lessen crying
* Keep emergency intubation equipment available at bedside; readily respond to call bell or requests
for assistance
* Assess parental and child's anxiety level; provide emotional support
* Medications
* Bronchodilators decrease mucosal constriction and laryngeal edema; nebu*lized racemic epinephrine
has a rapid onset with improvement of symptoms, although relapse may occur within 2 hours
* Corticosteroids decrease inflammation and edema
Child and family education
* Cool mist humidifier and parental presence can be initial treatment of crisis; comforting measures
include cuddling, rocking, singing, and any calming mea*sures until breathing becomes easier
* Instruct parents to seek medical attention immediately if breathing becomes la*bored, child seems
exhausted or very agitated, or if symptoms do not improve after cool air humidity treatment
EPIGLOTTITIS
* Cluster nursing care to allow for rest; assess anxiety level of parents and provide support; maintain
a calm environment
* IV fluids may be needed if oral intake is compromised; monitor strict I & 0; weigh daily to assess
fluid loss
* Maintain strict handwashing and contact precautions; caregivers should not care for other high-risk
children
* Medications: bronchodilators and steroids are sometimes used; prevention of bronchiolitis in highrisk children under age 2 may be achieved with use of palivizumab (Synagis) or IV RSV
immunoglobulin
FOREIGN BODY ASPIRATION
* Inhalation of an object into respiratory tract, intentional or otherwise
* The type and shape of object, as well as small diameter of an infant's airway, de*termines severity
of problem; round objects such as hot dogs, round candy, nuts, and grapes do not break apart and are
more likely to occlude airway; latex bal*loons are particularly hazardous; objects with irregular shapes
may irritate air*way and partially obstruct airflow
Assessment
* Sudden coughing and gagging is first sign, and objects in upper airway may be expelled by coughing
* Partial obstruction may cause symptoms of respiratory infection for days or even weeks; child may
have hoarseness, croupy cough, wheezing, and dyspnea
Therapeutic management
* Assess respiratory status to determine severity of problem and degree of ob*struction; continuously
monitor and provide assistance if obstruction worse
* If total airway obstruction occurs, perform back blows and chest thrusts for infants and Heimlich
maneuver in children older than 1 year
* Keep NPO; foreign body is usually removed in surgery
* Position for comfort and to optimize airway; provide emotional support to parents and child and
alleviate anxiety
* After removal of object, assess for additional obstruction that may result from laryngeal edema and
tissue swelling
Asthma
* When both antibiotics and aminophylline are administered intravenously, the nurse should check for
compatibility. If only one IV site is used, the nurse should use the SAS procedure (saline, administer
medication, saline) for administering medications. Administer IV doses using a controller.
* Clinets receiving aminophylline should be maintained or cardiorespiratory monitoring because
aminophylline affects cardia and respiratory rates as well as blood pressure. Because toxicity can
occur rapidly the nurse should monitor the clients aminophylline level. Symptoms of toxicity are
nausea, vomiting, tachycardia, palpitations, hypotension. In extreme cases, the client could progress
to shock, coma and death.
* The therapeutic range for aminophylline is 10-20 mcg/mL.
Pneumonia
I would just like to say thanks to everyone who has posted here. I take my NCLEX on September 10 and I have
gotten alot of great info! It is amazing how much you sort of forget once you have gotten past them
...so I
I - Influenza
D - Diptheria (Pharyngeal)
E - Epiglottitis
R - Rubella
M - Mumps
M - Meningitis
M - Mycoplasma or meningeal pneumonia
An - Adenovirus
Private room
Mask
CONTACT PRECAUTION
MRS.WEE
M - Multidrug resistant organism
R - Respiratory infection - RSV
S - Skin infections
W - Wound infections
E - Enteric infections - clostridium defficile
E - Eye infections
Skin Infections:
V - Varicella zoster
C - Cutaneous diptheria
H - Herpes simplex
I - Impetigo
P - Pediculosis
S - Scabies, Staphylococcus
Private room
Gloves
Gown
Someone mention in another thread of having a
Botox question on the nclex, so Botox it is:
Botulinum Toxin (Botox)
Produced by the Clostridium Botulinum bacteria,
which temporarily weakens/paralyzes facial muscles.
Used to reduce wrinkles (facial lines), last 90-120 days.
It is also used to TX strabismus (cross eye), abnormal neck
and shoulder contraction and vocal spasm.
May relieve migrane and tension H/A symtoms.
Most common SE: H/A, nausea, brusing, flu like symtoms,
ptosis (eye drooping),
other SE: Temporary facial pain, redness at injection site,
reduced blinking, and weakness in facial muscles.
Extreme cases: muscle weakness can limit facial expressions
Rare occasions: sore may develope on the white of the eye (corneal ulceration)
This is GREAT! Here's some I got from a review class I went to several months ago...
*Change in color is always a LATE sign!
*Incentive Spirometry steps:1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 seconds,
and then HOLD for 10 seconds
*Aminoglycocide (__Mycin ; except erythromycine) Adverse Effects are bean shaped - Nephrotoxic
to Kidneys and Ototoxic to Ears
*MRSA - Contact precaution ONLY
*VRSA - Contact AND airborne precaution (Private room, door closed, negative pressure)
*LITHIUM
L-level of therapeutic affect is 0.5-1.5
I-indicate mania
T-toxic level is 2-3 - N/V, diarrhea, tremors
H-hyrdrate 2-3L of water/day
I-increased UO and dry mouth
U-uh oh; give Mannitol and Diamox if toxic s/s are present
M-maintain Na intake of 2-3g/day
*All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased.
*SNS- Increase in BP, HR and RR (dilated bronchioled), dilated pupils (blurred vision), Decreased GUT
(urniary retention), GIT (constipation), Constricted blood vessels and Dry mouth.
*Blood transfusion- sign of allergies in order:
1)Flank pain
2)Frequent swallowing
3)Rashes
4)Fever
5)Chills
*Thrombocytopenia -Bleeding precautions!
1)Soft bristled toothbrush
2)No insertion of anything! (c/i suppositories, douche)
3)No IM meds as much as possible!
*Iron deficiency anemia - easily fatigued
1)Fe PO - give with Vitamin C or on an empty stomach
2)Fe via IM- Inferon via Ztrack
*Pernicious Anemia - Red, Beffy tongue; will take Vit.B12 for life!
*BURNS
1st Degree - Red and Painful
2nd Degree - Blisters
3rd Degree - No Pain because of blocked and burned nerves
*Meniere's Disease - Admin diuretics to decrease endolymph in the cochlea, restrict Na, lay on
affected ear when in bed. Triad:
1)Vertigo
2)Tinnitus
3)N/V
*Gastric Ulcer pain occurs 30 minutes to 90 minutes after eating, not at night, and doesn't go away
with food
Collection Chamber- This is the patient fluid Collection Chamber. Located on the Right
Side.
(2 things to Know): Notify Physician IF:
1. ABOVE 100 ML/Hr drainage
2. BRIGHT-RED drainage color.
Water Seal- This is the Middle Chamber.
Fluctuation Fluid inside chamber, indicates that client is breathing. (respirations) This is
NORMAL.
If the Fluid inside chamber stops fluctuating (moving up and down) this can mean 2 things:
- Lung Reexpansion
- Blocked Occluded Tube.
PRIORITY: Always check for KINKS in the tubing BEFORE notifying the physician.
- Intermittent Bubbling (On and Off) is Normal
Suction Control Chamber- Left Chamber
- Intermittent Bubbling (on and Off) is Normal especially for Pneumothorax patients.
- Notify Physician for Continuous Bubbling.
* Note: all drainage systems shouldn't have Continuous Bubbling. Notify physician if you
notice this.
Antacid that contains magnesium may cause diarrhea
Antacid that contains aluminum may cause constipation
During colostomy irrigation bag should be hung 18 inches (45 cm) above the stoma
stress incontinence = involuntary leakage that is triggered by a sudden physical strain such as cough,
sneeze or quick movement
urge incontinence = inability to suppress a sudden urge to urinate
total incontinence = continuous leakage resulting from the bladder's inability to retain urine.
Right sided failure:
Edema (peripheral)
Liver /spleen enlargement
jugular vein distention
bounding pulses
decrease or absent of urinary output
Left Sided Failure:
Cyanosis
Wheezes
anxiety
pulmonary crackes
apical murmurs
decrease BP/periheral pulses
increase res.p. rate
s3/s4 gallop
Schizophrenia
Positive symptoms:
1. hallucinations
2. delusions
3. loose associations
4. agitated or bizarre behavior
Negative symptoms:
1. apathy
2. anhedonia
3. poverty of speech
4. poor social functioning
5. social withdrawal
Treament:
Typical and atypical meds
Antiparkinsonian meds
Nursing Care:
- protect client and other from harm including suicide prec.
-administer meds as ordered
-monitor s/e
-establish trust and reduce anxiety
-encourage or reinfore
* clients sense of control
* reality orientation
*self care
-help clients set realistic goals
-provide safe environment
do not....
with them....
Not sure if this stuff was allready addressed but things I learned that helped me pass in July were:
In NCLEX hospital (the imaginary hospital where you pretend you are when you take your test) you
HAVE:
1 AN UNLIMITED BUDGET
2 AN UNLIMITED AMMOUNT OF TIME TO SPEND WITH EACH PATIENT
3 UNLIMITED STAFFING
If you have a answer as an option, YOU HAVE
1 the order to do it
2 the option to use it (Family to stay all night or delegating a person to do it)
3 the time to quietly sit with a patient for 12 hours holding their hand
You CANNOT
1 Delegate upward or horizontally, you cannot have your boss start an IV. You cannot delegate a fellow
nurse to do this either.
2 treat the machinery! STAY WITH THE PATIENT and treat THEM!
3 delegate aides or lpn's to ASSESS or TEACH
Ok my points are Priority points that i have learned over the months.
Tricky points if you see a pat with blood sugar or 222 and K+ of 59 WHO do you see first. ?
Also you have a patient going into a seizure do you move all the furniture away first of do you put the
patient on its side First these the things and points you need to know. What do you do first.
if you see a pregnant woman come into the Er with a umbilical cord protruding out the belly wht
position do you put her in
Just incase anyone else was as confused about triage systems as I was...
listed by prioritization
1. Immediate (emergent) - seriously injured but have a reasonable chance for survival once in stable
condition
2. Delayed (nonemergent) - can wait for 1-2 hours after recieving simple first aid
3. Expectant - extremely critical or dying
4. Minimal (nonemergent) - no impairment of function; can treat on their own or recieve treatment
from a non-professional
I hope this helps!
hate to say this, but in working on Suzanne's Tip #1, I saved lab values until close to the
end, as I did not do well the first time I took the practice test. In fact, I had to take it
five times before I was finally able to pass the chapter test! Here are some things that
helped me remember some lab values:
BUN: Normal 8-25 I pictured 8 buns on one cookie sheet. For the upper limit of 25, I
picture three times that many on three pans and an extra bun squeezed on the third pan,
making a total of 25 buns.
Calcium: Normal 8.6 - 10. I picture 8-10 cups of milk to provide calcium instead of drinking
8-10 cups of water. (We DO need our water!)
Chloride: Normal 98-107 mEq/L: I picture 10 rows of 10 bottles of bleach, or Chlorox,
making a total of 100 gallon jugs, making a total of 100, which is about the norm for
chloride.
DigOXin: Normal 0.5 - 2 ng/L: I picture half of a pair of oxen up to one pair of oxen pulling
a cart (The ox is from the "ox" in Digoxin).
Iron ranges from 50 to 175 in males & females, so I picture an athlete pumping from 50
pounds to 175 pounds of iron weights
I haven't thought of a good way to remember lithium, but the low range is the same as for
digoxin.
Magnesium: 1.6 to 2.6 mg/dL (Think magnesium1.6 2.6 si in magnesium stands for
six)
Phosphorus: Normal value: 2.7 to 4.5 mg/dL (little higher than magnesium)
Serum AMylase: Normal = 25 - 151 units/L (remember 25-150 yards of AMber lace)
Serum creatinine: 0.6 1.3 mg/dL (A specific indicator of renal function). (Think
creatinine1.6, higher level about double the lower normal level)
Serum Lipase: 10 -140 units/L (Lipase LIES all over the place from 10 to 140)
Serum potassium: 3.5 5.1 (major intracellular cation) (higher than magnesium &
phosphorus)
Serum protein: 6-8 g/dL (think of 6-8 protein bars = enough for just over or under a
weeks supply)
The following medications have normals values of 10-20.
Dilantin
Theophylline
Acetaminophen
Phenytoin
Chloramphenicol
Hope this helps some of you who are visual learners! Blood transfusions should not exceed 4
hours.
2. with infections the prodromal stage is the onset of the first symptoms and the Most contagious.
3. With Chronic Renal Failure diet is high in Carbohydrates.
4. with Cholecystitis pain starts in RUQ and radiates to right shoulder and scapula.
5.The 3 signs of pregnancy induced hypertension(PIH) 1. Edema above waiste. Proteinuria. BP
increase of 3ommhg systolic and 15 mmhg diastolic above the basline BP..
ok hope these are helpful!!
Special Considerations
Infants
Greatest risk for fluid and electrolyte imbalance
Hypothermia and infections
Approach them in non-threatening manner
Toddler
Increased separation anxiety
Briefly prepare them for procedures due to short attention span
Describe sensation that they may feel during procedure
Preschooler
Fear of physical harm
Believe that illnesses is a form of punishment
Explanations must be brief, honest and in natural terms
Use demonstrations and play in providing health teaching
Can use adult seatbelt if 40lbs or 40 inches tall, also if he could look at the window in sitting position
School Age
Realistic understanding of death = 9 -10
Needs more detailed teachings
Allow them to make some choices
Adolescence
Developed abstract thinking and ability to problem solve
Logic and reasoning
Full and honest explanation
Primary concern are with the present time
Focus on appearance
Elderly
Nutrition is a primary concern
Muscle atrophy
Dec body water, BMR
Dec renal, CV, GIT function
Dec taste, smell, visual acuity (cataract, arcuc senilis = fatty deposits around pupil_)
With multiple medications due to chronic diseases
More legalese
Nurse practice act: Authority is given to state boards of nursing to define the practice of nursing
within broad parameters that are specified by the legislature, mandate the requisite preparation
for the practice of nursing & discipline members of the profession who deviate from the rules
governing the practice of nursing.
Malpractice refers to a professional's wrongful conduct while performing his/her professional
duties or failure to meet standards of care for the profession, which results in harm (physical,
emotional or financial) to an individual entrusted to the professional's care. Example: Not giving
medications properly
(Liability has to be proven)
Negligence is failure to provide care that a reasonable person would ordinarily provide in a similar
situation.
Assault: Threat to touch another in an offensive manner without having that person's permission.
Battery: Actual touching of a person without that person's consent.
Libel is something that was said
Slander is something that is written
Another diagnosis
Cretenism
Patho: Congenital condition due to thyroid hormone deficiency due to defective physical
development or mental retardation. Appears at 3-6 months of age in bottle-fed babies. Delayed in
breast-fed infants.
Symptoms: Large puffy eyes, thick protruding tongue, dry skin, lack of coordination
If left untreated, permanently dwarfed, could be extremely mentally retarded, sterile
Disequilibrium Syndrome:
(complication of hemodialysis)
s/s:
nausea
vomiting
headache
hypertension
restlessness and agitation
confusion
seizures
notify Doc
reduce environmental stimuli
dialyze pt for a shorter period at reduced blood flow rates to
prevent occurrence
Treatment of Cholecystitis
* Morphine is not given for pain because it can cause spasms of the sphincter of Oddi.
* Clients with colostomies will have formed stool because the water is absorbed in the colon, whereas,
ileostomy clients have liquid stools because the water has not been absorbed in this area.
Hematological Disorders
* The hematologic system consists of blood, blood cells, and blood forming organs. Because circulation
of blood provides oxygen and nutrients to all body systems, a functioning hematological system is
essential to health and well being. A disorder in the system might result from a lack of function, a
reduction in production or an increase in the destruction of blood cells.
Sikle Cell Anemia
* The vaso-occlusive crisis is the primary crisis type that causes the client to have pain.
Iron Deficiency Anemia
* Intramuscular iron (Imferon) is given through the IM Z track method.
Polycythemia Vera
* This disorder is characterized by thicker than normal blood. There is an increase in the clients
hemoglobin to levels of 18 g/dL, RBC of 6 million/mm or hematocrit at 55% or greater and increased
platelets)
Transfusion Therapy
* If a client is receiving blood components, assess the chart for a physician order, identify the patient
by armband numbers, blood bag label, attached tag, requisition slip, and blood expiration date. Each
identification should be checked by two registered nurses with documented signatures of the
assessment by both.
Neurological Disorders
* Remember the mnemonic APQRST to trigger recall of all import points to access whenever the client
has an acute onset symptom
o A any associated symptoms with chief compliant
o P what provokes (makes worse) or palliates (makes better) symptoms
o Q- quality of pain
o R region and radiation
o S- severity of pain on a scale of 1 to 10
o T- timing: when it stops and starts, whether it is intermittent or constant its duration
* Recall that the words Kernigs and knee both begin with K while Brudzinkis and brain both begin
with B. This will aid in recalling how to conduct each test.
Neoplastic Disorders
*
*
o
o
o
o
o
* To increase blood flow to the Arteries- legs down- act like the long lines from the A are
the legs pointing down
peritoneum. You should also watch for signs of increasing intracranial pressure, such as irritability,
bulging fontanels, and high-pitched cry in an infant. In a toddler watch lack of appetite and headache.
Careful on a bed position question! Bed-position after shunt placement is flat, so fluid doesnt
reduce too rapidly. If you see s/s of increasing icp, then raise the hob to 15-30 degrees.
What could cause bronchopulmonary dysplasia? Dysplasia means abnormality or alteration.
Mechanical ventilation can cause it. Premature newborns with immature lungs are ventilated and
over time it damages the lungs. Other causes could be infection, pneumonia, or other conditions that
cause inflammation or scarring.
It is essential to maintain nasal patency with children < 1 yr. because they are obligatory nasal
breathers.
Watch out for questions suggesting a child drinks more than 3-4 cups of milk each day. (Milks good,
right?) Too much milk reduces intake of other essential nutrients, especially iron. Watch for anemia
with milk-aholics. And dont let that mother put anything but water in that kids bottle during
naps/over-night. Juice or milk will rott that kids teeth right out of his head.
What traction is used in a school-age kid with a femur or tibial fracture with extensive skin damage?
Ninety, ninety. Huh? I never heard of it either. The name refers to the angles of the joints. A pin is
placed in the distal part of the broken bone, and the lower extremity is in a boot cast. The rest is the
normal pulleys and ropes youre used to visualizing with balanced suspension. While were talking
about traction, a kids hinder should clear the bed when in Bryants traction (also used for femurs
and congenial hip for young kids).
If you can remove the white patches from the mouth of a baby it is just formula. If you cant, its
candidiasis.
Just know the MMR and Varicella immunizations come later (15 months).
Undescended testis or cryptorchidism is a known risk factor for testicular cancer later in life. Start
teaching boys testicular self exam around 12, because most cases occur during adolescence.
Not pediatrics but have to throw it in A guy loses his house in a fire. Priority is using community
resources to find shelter, before assisting with feelings about the tremendous loss. (Maslow).
No aspirin with kids b/c it is associated with Reyes Syndrome, and also no nsaids such as ibuprofen.
Give Tylenol.
CSF in meningitis will have high protein, and low glucose.
It is always the correct answer to report suspected cases of child abuse.
No nasotracheal suctioning with head injury or skull fracture.
Feed upright to avoid otitis media.
Position prone w hob elevated with gerd. In almost every other case, though, you better lay that kid
on his back (Back To Sleep - SIDS).
Pull pinna down and back for kids < 3 yrs. when instilling eardrops.
Kids with RSV; no contact lenses or pregnant nurses in rooms where ribavirin is being
administered by hoot, tent, etc.
Positioning with pneumonia lay on the affected side to splint and reduce pain. But if you are
trying to reduce congestion the sick lung goes up. (Ever had a stuffy nose, and you lay with the stuff
side up and it clears?)
A positive ppd confirms infection, not just exposure. A sputum test will confirm active disease.
Coughing w/o other s/s is suggestive of asthma. Speaking of asthma, watch out if your wheezer
stops wheezing. It could mean he is worsening.
You better pick do vitals before administering that dig. (apical pulse for one full minute).
Tet spells treated with morphine.
Group-a strep precedes rheumatic fever. Chorea is part of this sickness (grimacing, sudden body
movements, etc.) and it embarrasses kids. They have joint pain. Watch for elevated
antistreptolysin O to be elevated. Penicillin!
Dont pick cough over tachycardia for signs of chf in an infant.
Random Tips:
No milk (as well as fresh fruit or veggies) on neutropenic precautions.
Tylenol poisoning liver failure possible for about 4 days. Close observation required during this
time-frame, as well as tx with Mucomyst.
Radioactive iodine The key word here is flush. Flush substance out of body w/3-4 liters/day for 2
days, and flush the toilet twice after using for 2 days. Limit contact w/patient to 30 minutes/day. No
pregnant visitors/nurses, and no kids.
The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis).
Common sites for metastasis include the liver, brain, lung, bone, and lymph.
Orthostasis is verified by a drop in pressure with increasing heart rate.
Bence Jones protein in the urine confirms multiple myeloma.
Dont fall for reestablishing a normal bowel pattern as a priority with small bowel obstruction.
Because the patient cant take in oral fluids maintaining fluid balance comes first.
Pernicious anemia s/s include pallor, tachycardia, and sore red tongue.
With flecainide (Tambocor), an antiarrythmic, limit fluids and sodium intake, because sodium
increases water retention which could lead to heart failure.
Basophils release histamine during an allergic response.
Adenosine is the treatment of choice for paroxysmal atrial tachycardia.
Iatragenic means it was caused by treatment, procedure, or medication.
Other than initially to test tolerance, G-tube and J-tube feedings are usually given as continuous
feedings.
Four side-rails up can be considered a form of restraint. Even in LTC facility when a client is a fall
risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked.
Your cancer patient is getting radiation. What should you be most concerned about? Skin irritation?
No. Infection kills cancer patients most because of the leukopenia caused by radiation.
A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the
adverse effect could be irreversible.
Digitalis increases ventricular irritability, and could convert a rhythm to v-fib following
cardioversion.
If your normally lucid patient starts seeing bugs you better check his respiratory status first. The
first sign of hypoxia is restlessness, followed by agitation, and things go downhill from there all the
way to delirium, hallucinations, and coma. So check the o2 stat, and get abgs if possible.
The biggest concern with cold stress and the newborn is respiratory distress.
Look carefully when you have no idea. In a word like rhabdomyosarcoma you can easily ascertain it
has something to do with muscle (myo) cancer (sarcoma). The same thing goes for drug names. For
example, if it ends in ide its probably a diuretic, as in Furosemide, and Amyloride.
Lasix can cause a patient to lose his appetite (anorexia) due to reduced potassium.
If your laboring moms water breaks and she is any minus station you better know there is a risk of
prolapsed cord.
In a five-year old breathe once for every 5 compressions doing cpr.
After g-tube placement the stomach contents are drained by gravity for 24 hours before it can be
used for feedings.
Cephalhematoma (caput succinidanium) resolves on its own in a few days. This is the type of
edema that crosses the suture lines.
During the acute stage of Hep-A gown and gloves are required. In the convalescent stage it is no
longer contagious.
Low magnesium and high creatinine signal renal failure.
Pain is usually the highest priority with RA
If a TB patient is unable/unwilling to comply with tx they may need supervision (direct observation).
TB is a public health risk.
Level of consciousness is the most important assessment parameter with status epilepticus.
Crackles suggest pneumonia, which is likely to be accompanied by hypoxia, which would manifest
itself as mental confusion, etc.
Cant cough=ineffective airway clearance
Absence of menstruation leads to osteoporosis in the anorexic.
Toddlers need to express autonomy (independence)
A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding,
Remember the phrase step up when picturing a person going up stairs with crutches. The good leg
goes up first, followed by the crutches and the bad leg. The opposite happens going down. The
crutches go first, followed by the good leg.
While treating DKA, bringing the glucose down too far and too fast can result in increased
intracranial pressure d/t water being pulled into the CSF.
Polyuria is common with the hypercalcemia caused by hyperparathyroidism.
Remember the action of vasopressin because it sounds like press in, or vasoconstrict.
Water intoxication will be evidenced by drowsiness and altered mental status in a patient with TUR
syndrome, or as an adverse reaction to desmopressin (for diabetes insipidus).
Burning sensation in the mouth, and brassy taste are adverse reactions to Lugol solution (for
hyperthyroid). Report it to the doc.
Give synthroid on an empty stomach
Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased
glucose).
Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure
Patients with GERD should lay on their left side with the HOB elevated 30 degrees.
Unusual positional tip - Low-fowlers recommended during meals to prevent dumping syndrome.
Limit fluids while eating.
In emphysema the stimulus to breathe is low PO2, not increased PCO2 like the rest of us, so dont
slam them with oxygen. Encourage pursed-lip breathing which promotes CO2 elimination,
encourage up to 3000mL/day fluids, high-fowlers and leaning forward.
Theophylline causes GI upset, give with food
TB drugs are liver toxic. (Does your patient have hepB?) An adverse reaction is peripheral
neuropathy.
Thats the end of her tips everyone! Happy Studying! I wish everyone taking it soon the very best of luck!
Scenario- If RN is working for a Poison Control Center and parents say that their child has drunk drain
cleaner (alkaline), the RN would suggest parents to have child drink orange juice (acidic) to neutralize
the substance
Clients with GERD need to avoid eating 2 hours before going to sleep and
an upright posture should be maintained for 2 hours after eating to allow
for stomach emptying
Hospitalized patients, especially those on antibiotic therapy are at high
risk for getting C. difficile
Remember pain is whatever the client says it is
Autonomy- individuals must be free to make independent decisions about
participation in research without coercion from others
While assessing the vitals in a child, the RN should know the apical HR is
preferred until the radial pulse can be accurately assessed at 2 years of
age
A newborn is expected to lose 5-10% of birth wt in 1st few days postpartum d/t changes in elimination and feeding
Blood sugars...
premature neonate= 20-60mg/dl
neonate= 30-60mg/dl
infant= 40-90mg/dl
Here's my facts for the day
a.INTEGUMENTARY SYSTEM
1.autograph: after the surgery the site is immobilized for 3-7 days
2.burns on the face and head: elevate the head of the bed
3.burns on the extremities: elevate the extremities above the level of the heart
4.Skin graft: elevate and immobilize the graft site
B.REPRODUCTIVE
1.Mastectomy-semi fowler's 30* with the affected arm elevated on a pillow,turn only on the unaffected
side and back
C.ENDOCRINE SYSTEM
1.Hypophysectomy-elevate head of the bed
2.Thyroidectomy-semi fowler's- sandbags/pillows support head and neck
D.GASTROINTESTINAL
1.HEMORRHOIDECTOMY-lateral side lying
2.GERD-reverse trendelenberg
3.LIVER BIOPSY-during procedure:supine right side right arm extended on the left shoulder
after procedure:right lateral(side lying)place small pillow or folded towel under the punctured site
4.NG TUBEa)insertion-high fowler's
b)irrigation/feeding-semi fowler's head of bed 30*
5.Rectal enemas-left sim's position
E. RESPIRATORY
1.COPD-sitting position,leaning forward with clients arms over several pillows
CAN YOU PLEASE HELP ME ANSWER THE TWO QUESTIONS I HAVE IN RED
FONTS BELOW? THANK YOU.
ACID/BASE BALANCE
pH- 7.35-7.45
PCO2- 35-45 mmHg
PO2- 80-100 mmHg
HCO3 22-27 mEq/L
ACIDOSIS
-decrease pH
-Potassium increases
AKALOSIS
-increase pH
-Potassium decreases
ROME
respiratory oppossite metabolic equals
----------------------------------------------------------------------RESPIRATORY ACIDOSIS
Causes of Respiratory Acidosis (mostly airways/lungs related)
-Asthma: spasms causing the brochioles to constrict
-Atelectasis: excess mucus collection
-Brain trauma: excessive pressure on the respirtory center
-Bronchiectasis: bronchi become dilated as a result of inflammation
-COPD
-Emphysema: loss of elasticity of alveolar sacs, restricting airflow
-Hypoventilation: Carbon dioxide is retained
-Pulmonary Edema: accumulation of fluid in acute CHF
-Medications
Assessment for Respiratory Acidosis
-headache
-restlessness
-drowiness/confusion
-visual disturbances
-diaphoresis
-cyanosis as the hypoxia become acute
-hyperkalemia
-rapid, irregular pulse
-dysrhythmias leading to VFib.
Interventions for Respiratory Acidosis
-monitor signs of respiratory distress
-administer oxygen as prescribed
-semi-fowler
-encourage and assist the client to turn, cough, and breathe deeply
-hydration to thin secretions unless contraindicated
-suction airway if necessary
-monitor for potassium (because it is high in acidosis already)
-administer meds (antibiotics) and NOT meds that would place the client in more respiratory
depression
----------------------------------------------------------------------RESPIRATORY ALKALOSIS
Causes of Respiratory Alkalosis
-Fever (increases metabolism)
-Hyperventilation
-Hypoxia
-Hysteria
-Overventilation by mechanical ventilators
-Pain
-Aspirin
1. When getting down to two answers, choose the assessment answer (assess,
collect, auscultate, monitor, palpate) over the intervention except in an
emergency or distress situation. If one answer has an absolute, discard it.
Give priority to answers that deal directly to the patients body, not the
machines/equipments.
2. Key words are very important. Avoid answers with absolutes for example:
always, never, must, etc.
3. with lower amputations patient is placed in prone position.
4. small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be
delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes.
9. If the patient is not a child an answer with family option can be ruled
out easily.
10. In an emergency, patients with greater chance to live are treated first
.
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton)
impulse conduction.
82. myasthenia gravis= decrease in receptor sites for acetylcholine. Since
smallest concentration of ACTH receptors are in cranial nerves, expect fatigue
and weakness in eye, mastication, pharyngeal muscles.
83. Tensilon test given if muscle is tense in myasthenia gravis.
84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory
system.
85. parkinsons = RAT: rigidity, akinesia (loss of muscle mvt), tremors.
Treat with levodopa.
86. TIA (transient ischemic attack) mini stroke with no dead brain tissue
87. CVA (cerebrovascular accident) is with dead brain tissue.
88. Hodgkins disease= cancer of lymph is very curable in early stage.
89. Rule of NINES for burns
Head and Neck= 9%
Each upper ext= 9%
Each lower ext= 18%
Front trunk= 18%
Back trunk= 18%
Genitalia= 1% ?
90. Birth weight doubles by 6 month and triple by 1 year of age.
91. if HR is <100 do not give dig to children.
92. first sign of cystic fibrosis may be meconium ileus at birth. Baby is
inconsolable, do not eat, not passing meconium.
93. heart defects. Remember for cyanotic -3Ts( Tof, Truncys arteriosus,
Transposition of the great vessels). Prevent blood from going to heart. If
problem does not fix or cannot be corrected surgically, CHF will occur
following by death.
94. with R side cardiac cath=look for valve problems
95. with L side in adults look for coronary complications.
96. rheumatic fever can lead to cardiac valves malfunctions.
97. cerebral palsy = poor muscle control due to birth injuries and/or
decrease oxygen to brain tissues.
98. ICP (intracranial pressure) should be <2. measure head circonference.
99. dilantin level (10-20). Can cause gingival hyperplasia
100. for Meningitis check for Kernigs/ Brudzinskis signs.
101. Wilms tumor is usually encapsulated above the kidneys causing flank
pain.
102. hemophilia is x-linked. Mother passes disease to son.
103. when phenylalanine increases, brain problems occur.
104. Bucks traction= knee immobility
105. Russell traction= femur or lower leg
106. Dunlap traction= skeletal or skin
107. Bryants traction= children <3y, <35 lbs with femur fx.
108. place apparatus first then place the weight when putting traction
109. placenta should be in upper part of uterus
110. eclampsia is seizure.
111. a patient with a vertical c-section surgery will more likely have
another c-section.
112. perform amniocentesis before 20 weeks gestation to check for cardiac
and pulmonary abnormalities.
113. Rh- mothers receive rhogam to protect next baby.
114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.
115. caput succedaneum= diffuse edema of the fetal scalp that crosses the
suture lines. Swelling reabsorbs within 1 to 3 days.
116. pathological jaundice= occurs before 24hrs and last7 days.
Physiological jaundice occurs after 24 hours.
117. placenta previa = there is no pain, there is bleeding. Placenta
abruption = pain, but no bleeding.
118. bethamethasone (celestone)=surfactant. Med for lung expansion.
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hi. for those who passed the nclex rn exam? how did u make it? i mean how u review in
preparing for test? also what materials did u use before u take the test? how many months
GOOD LUCK!!!! Biggest help for me was AllNurses.com and their many resources in Sticky
Threads!!!!
Here's my tip: Look through Sticky Threads here and you'll find a wealth of valuable information,
facts, tips, and memory joggers. There are lots of great educational resources here.
Second fact/tip: Give yourself breaks when studying so your mind can rest and be fresh to learn and
retain more info.
Third: Take care of yourself, eat well, get plenty of rest and exercise, destress. This is only a test and
you took lots of tests in nursing school.
I wanted to stop by and give you few "ideas" that may help you for your incoming
test! I hope I don't get in trouble for this. I am not discussing test questions, I am
just relaying few facts regarding the general consensus out there on the NCLEX.
3. Spend time (if you can) learning some rare diseases such as Kawasaki
disease, Fifth disease,... Know the major signs and symptoms and how you
treat them.
Good luck to all of you and if I did it, you can also do it!
Value
Normal Range
BUN
10 25 or 5 - 25
Kaplan
Creatinine
Creatinine Clearance
85 135
Albumin, serum
3.5 5.0
Potassium
3.5 5.0
Specific Gravity
1.010 1.030
Sodium, serum
135 145
Calcium
9 - 11
Magnesium
1.3 2.1
Chloride
95 105
Phosphate
3.0 4.5
Serum Osmolarity
285 - 295
Glycosylated Hemoglobin
4 6%
3 month review of
Glucose
pH
7.35 7.45
Acid
Alkaline
HCO3
22 26
Acid
Alkaline
PCO2
35 45
Acid
Alkaline
PO2
80 100
O2 saturation
96 - 100
Metabolic Alkalosis
pH , PCO2 , HCO3
Metabolic Acidosis
pH , PCO2 , HCO3
Respiratory Alkalosis
pH , PCO2 , HCO3
Respiratory Acidosis
pH , PCO2 , HCO3
Phosphate
3.0 4.5
CVP
3 11 or 2 8
HGB, hemoglobin
12 15
HCT, hemocrit
36 45
Platelets
150,000 450,000
Neutrophils
2500 8000
Lymphocytes
1000 4000
RBC
3.2 5.2
WBC
5000 10,000
ESR
0 20
PTT
PT/INR
10 14 seconds
Bilirubin
0.1 1.0
ALT/AST
8 - 20
Digoxin
0.5 2
Dilantin
10 20
Toxic > 30
Theophylline
10 - 20
Toxic > 20
Lithium
0.5 1.2
Tylenol
Hey guys. I just passed the NCLEX and I can give you few ideas
about preparing for NCLEX
1. Be familiar with the NCLEX test.
2. Know your NCLEX weak areas and focus on them
3. Maintain a consistent study habit. Study at least 2-3 hours a
day EVERY DAY!
4. Focus on nursing interventions. Most NCLEX questions are
about what you can do for the patient
control contents
7. Know the major drugs classes and at least 3-5 drugs in each
class. Focus on patient teaching
8. Include Saunders in your study books. Saunders book is best
thinking
10.
11.
This thread is a very good idea. I learnt so much from it. But the
"random facts" should help you to be familiar with the content.
Don't just focus on memorizing them. Make sure that you know how
you can "apply" those facts to any given scenario regarding patient
care. NCLEX is about critical thinking...
Good luck to all of you!
Can anyone add to this and/or correct me if I am wrong??
Seems like these are pretty important to know, everyone seems to get a good amount of
questions on this..
INFECTION CONTROL
Airborne Precautions:
Varicella
TB
Rubeola
pt must wear mask when transporting
what else?!?
Droplet Precautions:
Mennigittis
Pneumonia
Pertussis
Rubella
Mumps
private room unless other pt has same organism
maintain 3 feet distance unless giving care
anything else??
Contact Precautions:
RSV
Synctial virus
C Diff
MRSA
Ecoli
Scabies
Impetigo
Room needs to be private unless same organism
gloves/gown when in contact with secretions
anything else??
Standard Precautions:
CF
Bronchitis
Hantavirus
Tonsillitis
Cutaneous Anthrax
Hey Kristina,
This is good, thanks for posting it.
For airborne, make sure the patient is in a room that has negative air pressure with at least 6-12 exchanges an
hour, and N95 mask for TB.
Also remember MTV Cd for airborne: Measles (Rubeola), TB, Varicella (Shingles), Chickenpox,
Disseminated varicella zoster.
Here are 2 links I have been using regarding infection control. Hope you find them useful.
http://allnurses.com/forums/f197/qui...-314902-4.html
http://allnurses.com/forums/f197/isolation-precautions-316743.html
hypertension
provide for physical and emotional rest
provide for special safety needs
health teaching (client and family)
dysrhythmias
provide for emotional and safety needs
prevent thromboemboli
prepare for cardioversion with atrial fibrillation if indiated
provide for physical and emotional needs with pacemaker insertion
cardiac arrest
prevent irreversible cerebral anoxic damage
establish effective circulatio
n, respiration
angina pectoris
provide relief from pain
provide emotional support
health teaching
myocardial infarction
reduce pain, discomfort
maintain adequate circulation, stabilize heart rhythm
decrease oxygen demand/promote oxygenation, reduce cardiac workload
maintain fluid electrolyte, nutritional status
facilitate fecal elimination
provide emotional support
promote sexual functioning
health teaching
cardiac valvular defects
reduce cardiac workload
promote physical comfort and psychological support
prevent complications
prepare for surgery
cardiac catheterization & percutaneous transluminal coronary angioplasty
precatheterization:
provide for safety, comfort
health teaching
postcatheterization:
prevent complications
provide emotional support
health teaching
cardiac surgery
cardiopulmonary bypass
preoperative:
provide emotional and spiritual support
health teaching
postoperative:
prevent complications
health teaching
respiratory alkalosis
increase carbon dioxide level
prevent injury
health teaching
metabolic alkalosis
obtain, maintin acid-base blance
prevent physical injury
health teaching
pneumonia
promote adequate ventilation
control infection
provide rest and comfort
prevent potential complications
health teaching
severe acute respiratory syndrome (SARS)
infection control
supportive care
atelectasis
relieve hypoxia
prevent complications
health teaching
pulmonary embolism
monitor for signs of respiratory distress
health teaching
histoplasmosis
relieve symptoms of the disease
health teaching
tuberculosis
reduce spread of disease
promote nutrition
promote increased self-esteem
health teaching
emphysema
promote optimal ventilation
promote comfort
observe for indications of malignant hyperthermia
postoperative experience
promote a safe, quiet, nonstressful environment
promote lung expansion and gss exchange
prevent aspiration and atelectasis
promote and maintain cardiovascular function
promote psychological equilibrium
maintain proper function of tubes and appatatus
general postoperative nursing care
promote lung expansion
provide relief of pain
promote adequate nutrition and fluid and electrolyte balance
assist client with elimination
facilitate wound and prevent infection
promote comfort and rest
encourage early movement and ambulation to prevent complications of immobilization
general nutritional deficiencies
prevent complications of specific deficiency
health teaching
celiac disease
altered nutrition, less than body requirements
diarrhea
fluid volume deficit related to loss through excessive diarrhea
knowledge deficit
hepatitis
prevent spread of infection to others
promote comfort
pancreatitis
control pain
rest injured pancreas
prevent fluid and electrolyte imbalance
prevent respirtory and metabolic complications
provide adequate nutrition
prevent complications
health teaching
cirrhosis
provide for special safety needs
relieve discomfort caused by complications
improve fluid and electrolyte balance
nephrectomy
preoperative ptimize physical and psychological functioning
postoperative
promote comfort and prevent complications
renal calculi (urolithiasis)
reduce pain and prevent complications
health teaching
lithotripsy
enourage ambulation and promote diuresis through forcing fluids
benign prostatic hyperplasia
relieve urinary retention
health teaching
prostatectomy
promote optimal bladder function and comfort
assist in rehabilitation
urinary diversion
prevent complications and promote comfort
health teaching
laryngectomy
preoperative care: provide emotional support and optimal physical preparation
health teaching
postoperative care
maintain patent airway and prevent aspiration
promote optimal physical and psychological function
health teaching
aphasia
assist with communication
Menieres disease
provide safety and comfort during attacks
minimize occurrence of attacks
health teaching
otosclerosis & stapedectomy
preoperative health teaching
postoperative
promote physical and psychological equilibrium
health teaching
deafnessmaximize hearing ability and provide emotional support.health teaching
glaucoma
reduce intraocular pressure
provide emotional support
health teaching
cataract & cataract removal
preoperative
prepare for surgery
postoperative
reduce stress on the sutures and prevent hemorrhage
promote psychological well-being
health teaching
retinal detachment
preoperative:
reduce anxiety and prevent further detachment
health teaching
postoperative
reduce intraocular stress and prevent hemorrhage
support coping mechanisms
health teaching
blindness
Radiationtherapy
External radiation:
prevent tissue breakdown
decrease side effects of therapy
health teaching
internal radiation : sealed
assist with cervical radium implantation
health teaching
internal radiation: unsealed
reduce radiation exposure of others
Immunotherapy
decrease discomfort associated with side effects of therapy
health teaching
Palliative care
make client as comfortable as possible
assist client to maintain self-esteem and identity
assist client with psychological adjustment
Types of cancer:
Lung cancer
Make client aware of diagnosis and treatment options
Prevent complications related to surgery
Assist client to cope with alternative therapies
colon and rectal cancer
assist through treatment protocol
surgery reoperative
preparefor surgery
promote comfort
postoperative :
facilitate healing
prevent complications
facilitate rehabilitation
health teaching
breast cancer
assist client through treatment protocol
prepare client for surgery
reduce anxiety and depression
prevent postoperative complications
support coping mechanisms
health teaching
uterine cancer
prostate cancer
assist client through treatment protocol
prepare client for surgery
assist with acceptance diagnosis and treatment
prevent complication during postoperative period
bladder cancer
laryngeal cancer
additional typers of cancer,etc.
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Nursing Specialty: Postpartum/Nursery
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Registered User
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Nursing Specialty: LTC, case mgmt, agency
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-lam; antianxiety
-mide ;diuretic
-mycin ;antibiotic
-nium; neuromuscular blocking
-olol; beta blocker
-oxacin ;antibiotic
-pam ;antianxiety
-pril ;ACE inhibitor
-sone ;steroids
-statin ;cholesterol
-vir; antiviral
-zide; diuretic
. When getting down to two answers, choose the assessment answer (assess,
collect, auscultate, monitor, palpate) over the intervention except in an
emergency or distress situation. If one answer has an absolute, discard it.
Give priority to answers that deal directly to the patients body, not the
machines/equipments.
2. Key words are very important. Avoid answers with absolutes for example:
always, never, must, etc.
3. with lower amputations patient is placed in prone position.
4. small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be
delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes.
9. If the patient is not a child an answer with family option can be ruled
out easily.
10. In an emergency, patients with greater chance to live are treated first
.
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton)
are always secondary to something else (another disease process).
12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
13. in pH regulation the 2 organs of concern are lungs/kidneys.
14. edema is in the interstitial space not in the cardiovascular space.
15. weight is the best indicator of dehydration
16. wherever there is sugar (glucose) water follows.
17. aspirin can cause Reyes syndrome (encephalopathy) when given to
children
18. when aspirin is given once a day it acts as an antiplatelet.
19. use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (
rheumatoid arthritis)
20. guided imagery is great for chronic pain.
21. when patient is in distress, medication administration is rarely a good
choice.
22. with pneumonia, fever and chills are usually present. For the elderly
confusion is often present.
23. Always check for allergies before administering antibiotics (especially
PCN). Make sure culture and sensitivity has been done before adm. First dose
of antibiotic.
24. Cor pulmonale (s/s fluid overload) is Right sided heart failure caused
by pulmonary disease, occurs with bronchitis or emphysema.
25. COPD is chronic, pneumonia is acute. Emphysema and bronchitis are
both COPD.
26. in COPD patients the baroreceptors that detect the CO2 level are
destroyed. Therefore, O2 level must be low because high O2 concentration
blows the patients stimulus for breathing.
27. exacerbation: acute, distress.
28. epi always given in TB syringe.
29. prednisone toxicity: cushings syndrome= buffalo hump, moon face, high
glucose, hypertension.
30. 4 options for cancer management: chemo, radiation, surgery, allow to
die with dignity.
31. no live vaccines, no fresh fruits, no flowers should be used for
neutropenic patients.
32. chest tubes are placed in the pleural space.
33. angina (low oxygen to heart tissues) = no dead heart tissues. MI=
dead heart tissue present.
34. mevacor (anticholesterol med) must be given with evening meal if it is
QD (per day).
35. Nitroglycerine is administered up to 3 times (every 5 minutes). If
chest pain does not stop go to hospital. Do not give when BP is < 90/60.
36. Preload affects amount of blood that goes to the R ventricle.
Afterload is the resistance the blood has to overcome when leaving the
heart.
37. Calcium channel blocker affects the afterload.
38. for a CABG operation when the great saphenous vein is taken it is