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Comprehensive Nclex Notes - Easy To Read
Comprehensive Nclex Notes - Easy To Read
Comprehensive Nclex Notes - Easy To Read
Furosemide is potassium wasting dangerous for ppl with heart failure d/t
dysrhythmias
o Need potassium supplements
Potassium tak with plenty of water (at least 4 oz), sit upright for a bit after
ingestion to prevent pill from lodging in esophagus and eroding over time or
pill induced esophagitis
Methylphenidate admin in divided doses 2-3 times daily, 30-45min before
meals
o It is a stimulant so it may interfere with sleep so do not give later
than 6pm
o Monitor closely initially for tics
Adalimbumab (TNF inhibitor) = immunosuppressant
o Increases risk of new infection, including reactivation of previous
infection (e.g. latent TB, hep B)
Lithium carbonate = mood stabilizer for schizophrenia and bipolar
o Narrow therapeutic index (0.6-1.2 mEq/L), levels > 1.5 are
toxic
o Acute toxicity = GI sx (n/v, diarrhea)
o Chronic toxicity = neuro manifestations (ataxia, confusion, agitation,
neuromusc excitability) and as diabetes insidpius (polyuria, polydipsia)
Heparin
o Risk is herparin induced thrombocytopenia (HIT)
o Normal platelet range = 150 000 400 000 u/L
o aPTT 46-70 sec when on heparin therapy (1.5-2.5x normal range)
ACE inhibitors (e.g. Lisinopril)
o Teratogenic, esp in first 13 weeks gestation
o Produce non-productive cough
Nitroglycerin
o Vasodilation, can lower BP, make sure BP > 80 mmhg systolic
Phenytoin
o Gingival hyperplasia or hypertrophy is a side effect
Warfarin
o Desired result is a therapeutic range rather than a normal value when
not on drug
o Therapeutic range is 1.5-2.5 x control (INR of 2-3) but up to 3-4 x (INR
2.5-3.5) the control in high risk situations (ie. Artificial heart valve)
o Antidote = vit K
Gs Ginseng, garlic, green tea, gingko biloba, grapefruit
Cranberry juice
Watch out for leafy green vegetables (rich in vit k)
Atropine = anticholinergic
o Anticholinergic dries things out (eyes, mouth) use it for death rattle
to dry secretions in mouth
Metoclopramide = for GERD and antiemetic
Management
synthetic thyroid hormone: levothyroxine sodium (give on empty
stomach one hour before meal, drink a lot of water, can cause
dysrhythmias)
protect client from cold
Hyperthyroidism
o Overactive thyroid
o Thyrotoxic crisis (thyroid storm) precipitated by factors like stress,
infection, pregnancy
o Graves disease: leads to exophthalmos (bulging eyes), heat
intolerance, anxiety.
Accounts for most cases of hyperthy
o Causes: too much iodine, thyroiditis, overdosage of thyoid hormone
o Findings: difficulty concentrating, fatigue, wt loss, heat intolerance,
tachycardia, insomnia,
o Drugs: sodium 131 (radioactive iodine), methimazole, propanolol
o Care of post-thyroidectomy: assess for excessive swallowing or pooling
of blood behind neck, report changes in voice or findings of
hypocalcemia (b/c it is close to parathyroid, which regulates
calcium), avoid fowlers position (due to strain on incision) but 30
degree fowler to prevent blockage of airway
Hypoparathyroidism
o parathyroid produces too little parathyroid hormone; results in
hypocalcemia
o Findings : irritability, personality changes, muscular weakness,
numbness of fingers, carpopedal spasms, laryngospam, seizure, hair
loss, dry, abdominal cramp
o positive Chvostek's sign (facial muscle twitching when cheek is
stroked)
o positive Trousseau's sign (carpal spasm as inflated BP cuff is released)
o Drug: calcium replacement, vitamin D
o Decrease phosphorus intake (fish, eggs, cheese, and cereals)
Hyperparathyroidism
o
o
o
o
o
o
o Striae (purple marks)
o Management: slowly decrease corticosteroid medication
o Monitor for hypokalemia and hypernatremia
Diabetes Mellitus (DM)
o a chronic condition in which the pancreas produces too little insulin, or
cells stop responding to insulin; results in hyperglycemia
o Findings:
Hyperglycemia, fatigue, weight loss (diabetes type 1), blurred
vision, slow wound healing
3 polys of diabetes mellitus
Polydipsia (increased thirst)
Polyuria (increased urine production)
Polyphagia ( increased hunger)
o type 1 DM
hypertensive medications, including angiotensin-converting
enzyme (ACE) inhibitors or angiotensin II receptor blockers
(ARBs)
cholesterol-lowering drugs (the statins)
o oral hypoglycemic medications - sulfonylureas, meglitinides,
biguanides, thiazolidinediones and alpha-glucosidase inhibitors
for type 2 diabetes
same with metformin only given to type 2 diabetes
Hypoglycemia (insulin shock)
o Blood sugar below 50 mg/dl
Due to too much insulin, too little food and excessive physical activity
Findings: diaphoresis, cold, clammy skin, anxiety, tremor, slurred
speech, weakness, nausea, mental confusion, headache
o Management
Give 15 -20 grams of carbohydrates, 4 ounces of juice
If unconscious 1 mg glucagon IM
Diabetic ketoacidosis in type 1 diabetes
o Severe Insulin deficiency
o Sudden onset
o Finding: blood sugar level greater 300 mg/dl
Elevated ketone levels sweating or odour , sweet odor to
breath
Metabolic acidosis pH less than 7.35, dry skin, kussmauls
respirations
Thirst, polyuria, drowsiness, anorexia, shock/coma
o Management
Correct fluid (IV fluid), electrolyte depletion (especially K),
correct metabolic acidosis (regular) insulin IV
Hyperosmolar hyperglycemic state in type 2 diabetes
o Gradual onset, more in old ppl
o Findings
Severe hyperglycemia > 600 mg/dl
pH > 7.4
negative ketones
profound dehydration
altered LOC
o precipitated by physical stress like infection
o for non-diabetics d/t tube feedings without supplemental water or too
rapid rate of infusion for parenteral nutrition
diabetic triopathy
o retinopathy impairs retinal circulation, causes hemorrhage
o nephropathy decline in kidney fx
o neuropathy - deteriorates nervous system, nonhealing foot ulcers
macorvascular complications
o CAD, peripheral vascular disease,
medication interactions with insulin and oral hypoglycemic medications
o medications that can increase blood glucose levels: glucocorticoids,
thiazide diuretics, thyroid agents, oral contraceptives, estrogen
o medications that can further decrease blood glucose levels: aspirin,
alcohol, oral anticoagulants, beta blockers, tricyclic antidepressants,
tetracycline, monoamine oxidase inhibitors
exercise decrease blood sugar but increases insulin sensitivity
Illness can increase the need for insulin and raise blood sugar
Glycated hemoglobin (HbA1c) predicator of diabetes management for past 2
to 3 months Normal value less than 6% and diabetics should keep it
below 7%
Target blood glucose for diabetics -- 90 to 130 mg/dl (before meal) and
less than 180 mg/dl (after 1 or 2hr meal)
o
o
MI
o
o
o
o
o
Findings:
Pectus excavatum , arachnodactyly, dilation of aorta, more
aware of heartbeat
If nail tip is pressed, the root will flush and then pale
(Quinckes sign)
High pitched diastolic murmur
Pulsus bisferiens double beat pulse
Widened pulse pressure
Chest pain unrelieved by sublingual nitroglycerin
Same mgmt. (DO ABLE) and surgery
Same assessment (CARDIAC LEVELS, anticoags)
Can be sudden/gradual, total event can take b/w 3-6h
Equal b/w men and women
Findings
Classic: persistent, crushing substernal chest pain
Pain radiates from LEFT arm jaw, neck, shoulders with
feeling of impending doom
Pain doesnt resolve with rest
Some pts report no pain or think its mild indigestion
(mostly in older adults or ppl with diabetes)
Silent MI heart failure, change in mental status,
unexplained abdo pain, dyspnea, fatigue
Some older women = only fatigue, n/v, SOB, flu like
symptoms
Sudden death
May get HTN within first hour
Others can get hypotension with signs of shock
ST elevation on ECG
Diagnosis
CK-MB isoenzyme rise 4-6 degrees after acute MI (goes back to
normal 3-4 days)
Troponin rises quickly, elevated for 2 weeks
Immediate administration (M.O.N.A) morphine, oxygen,
nitrates, aspirin
Goal is resolution of symptoms as quickly as possible think
time is muscle
Emergency coronary angiogram with revascularization
Cardiac catheterization stent insertion
Thrombolytic agents such as tPa (tissue plasminogen
activator) to dissolve the thrombus in the coronary
artery and reperfuse the myocardium
Induce hypothermia after return of spontaneous circulation
Pharmacologic agents
Antiplatelets and or anticoagulants (aspirin, heparin) to
prevent recurrent thrombosis
Heart failure
o Inability to pump fluid overload
o Left sided
Systolic heart failure, LV ejection fraction < 40% (cant contract
properly)
Diastolic heart failure, LV ejection fraction > 50% (normal) so
its also called heart failure with normal ejection fraction; cant
relax properly
o Heart muscle dmg = cardiomyopathy
o
-
Hypertension
Category
Systolic BP
Optimal
< 120
and
< 80
Normal
< 130
and
< 85
High-Normal
130-139
or
85-89
Hypertension - stage 1
140-159
or
90-99
Hypertension - stage 2
160-179
or
100-109
Hypertension - stage 3
180 or higher
or
110 or higher
Diastolic BP
DVT
-
Accurate I+O
B-thalassemia
- Inherited blood disorder characterized by deficiencies in rate of
production of specific globin chains in Hb
- Auto recessive, Mediterranean people
- Findings
Severe anemia, pallor
Microcytic RBCs
Impaired growth
Splenomegaly
- Diagnostic Hb and Hct, Hb electrophoresis
- Mgmt.
Iron chelating agent to counteract hemosiderosis
Splenectomy
Chronic transfusion therapy
Bone marrow transplantation
Bleeding disorders
Idiopathy thrombocytopenic purpura
- Acquired hemorrhagic disease
- Unknown etiology but occurs one to two weeks after febrile viral
illness
- Patho: autoimmune disorder, platelets killed and fewer made, can
be acute/chronic
- findings
excessive bruising, petechiae, internal bleeding
- mgmt.
pharmacologic corticosteroids, IV immunoglobins,
immunosuppression
immunoabsorption apheresis (to filter abx from
bloodstream)
splenectomy for chronic disease
- nursing interventions
monitor for bleeding
do not use aspirin use Tylenol for pain
dont do contact sports
Von Willebrands disease
- Clotting protein (von willebrand factor) deficient or defective
- Findings: easy bruising, nosebleeds, menstrual periods, blood in
stool, urine
- Mgmt
Doesnt require tx if findings mild
Avoid blood-thinning eds, like aspirin and some NSAIDs,
clopidogrl, warfarin, heparin, antidepressants
replace missing clotting factors or administer antidiuretic
desmopressin acetate (DDAVP) after surgery, tooth
extraction or accident
Aplastic anemia
- Body stops producing enough new blood cells
Neurological
-
Parkinson disease
- due to decrease in dopamine levels
- mental function is still intact
- Findings:
Resting tremors, bradykinesia/akinesia, fatigue, drooling
T- tremors, R- rigidity, A- akinesia/bradykinesia, P- postural
instability (TRAP)
- Meds:
Anticholinergics minimize extrapyramidal effects
Dopamine hydrochloridergics and agonist
MAO inhibitors
Huntington disease
Dementia
-
Epidural bleeds
Cerebral arterial vessel and loss of transient
unconsciousness
Subdural bleeds
Veins involved take months to be evident
o Pharmacologic
Antihypertensive agents, systemic
steroids, osmotic diuretics,
antifibrinolytic, anticonvulsant
ICP treatment
- Elevate the head of the bed 15-30
- Monitor respiratory status
- Maintain body temperature
- Limit fluid to 1200 ml/day
- Avoid straining activities
Changes in ICP
Altered LOC, headache, abnormal respirations, rise in
blood pressure, slowing pulse, elevated temperature,
vomiting, pupil changes, changes in motor function
Observe for herniation syndrome
Irregular breathing/pulse, loss of brainstem reflexes
(blinking, gagging), respiratory arrest, cardiac
Meningitis
- Acute or chronic inflammation of the meninges
Bacterial, viral, or fungal
Findings: severe headache, sudden high fever/chills, changes
in LOC, petechial rash
Positive kernigs sign = 90 flexion of hip/knee extension of
knee causes pain
Positive Brudziski sign flexion of neck causes flexion of hip
and knee
Nursing
Provide care for ICP, seizure,
Parameningeal infections
- Localized collection of exudate in the brain or in the spinal cord
- Findings: headache, fever, stiff neck, decrease in LOC
Encephalitis
- Inflammation of the parenchyma of the brain or spinal cord
Findings: sudden fever, severe headache, changes in LOC, flu
like symptoms
Botulism
- Acute flaccid paralysis due to bacteria in food
Findings: blurred vision, diplopia, lethargy, vomiting and
dysphagia (weakness of difficulty speaking)
Multiple sclerosis
- Demyelination of white matter throughout brain and spinal cord
Partial Seizures
Focal motor, client remains conscious
Simple partial
o Motor finding, autonomic findings, no loss of
conscious
Complex partial
o Psychomotor seizure, impairment of
consciousness
Generalized seizures both hemispheres
Absence petit mal
Less than 10 sec loss of consciousness and blank
starring
Myoclonic
Clonic
Violent bilateral muscle movements
o Hyperventilation, face contortion, salivation,
tachycardia
Tonic
Loses consciousness and muscle contract bilaterally
Opisthotonos position, jaws clenched, pupils dilated
and unresponsive
Less than a minute
Tonic clonic (grand mal) most common type
Movements bilaterally
Last 2 to 3 mins
Incontinent bowel/bladder unresponsive for 5 mins
Disorientation / confusion
Atonic sudden loss of postural muscle tone with collapse
Status epilepticus
Rapid sequence of seizures without interruption
Medical emergency
Postictal state
Due to stop of maintenance anticonvulsant
Severe organ and muscle hypoxia
Pharmacologic
o Benzodiazepines (active seizures),
anticonvulsants, barbiturates, succinimides
Contusion bruising on the surface of the brain
Intracerebral- bleeding directly in the brain tissue; secondary to invasive
skull trauma
Epidural damaged artery b/w skull and dura mater risk of death
- Loss consciousness lucid LOC drop quickly in 24 hrs
Subdural damaged veins b/w subdural space secondary to closed head
injury
- Acute 24 to 74 rapid neurologic deterioration
- Subacute 72 to 2 week will slower progression
- Chronic gradual clot formation minimal deterioration
Cardiac Disease
-
Antianginal agents
- Nitrates (i.e. nitroglycerin)
Relaxes vascular smooth muscles through vasodilation
Tx: angina given 3 dose w/ 15mins
S/E: severe hypotension, dizziness, edema, flushing
Contraindications: Sildenafil (viagara), hypovolemia,
hypotension, heart failure, increased ICP
Nursing: alcohol intoxication can occur, avoid tolerance by
having nitrate free period
- Isosorbide
Vasodilation by relaxing arterial muscle
Tx: prevent acute attack and angina pectoris
Maintance therapy for angina, CAD
- Beta-adrenergic blocking agent beta blocker
Ex: Atenolol, metoprolol, propranolol
Slower heart rate, decreased vasoconstriction heart failure,
hypertension, migraine headache prophylaxis
S/E: bradycardia, bronchospasm, hypotension
Most common: fatigue, dizziness, constipation,
depression, impotence, disorientation, weakness,
nausea
Dont give to cardiogenic shock, AV block, bronchial asthma,
thioridazine
May hide symptoms of hypoglycemia or cause asthma
symptoms
Taken at bedtime
- Calcium channel blocker
Amlodipine, diltiazem, verapamil
Use: hypertension, angina, arrhythmias
S/E: hypotension bradycardia, AV block, heart failure
Monitor BUN, creatinine, liver enzyme
Avoid Grapefruit and older clients
Change position slowly can cause dizziness
Anticoagulants (i.e. warfarin)
- Prevents the formation of clots
- S/E: hemorrhage, purple toe syndrome, bruising
pH
HCO3
PaCO2
(< 7.35)
(> 26)
(> 45)
respirator
y alkalosis
(> 7.45)
(< 22)
(< 35)
metabolic
acidosis
(< 7.35)
(< 22)
(< 35)
metabolic
alkalosis
(> 7.45)
(> 26)
(> 45)
respirator
y acidosis
Rhinitis
-
Sinusitis
-
S/S: frontal headache, fever, tooth pain, malaise, tenderness in sinus area
Fluid intake, hot shower, nasal irrigation (saline)
Pharyngitis
-
Inflammation of tonsils
S/S: sore throat, fever, difficulty swallowing, foul smelling breath
(halitosis), ear infection
Post-op
- Position prone and head to side
- Hemorrhage or airway obstruction
- Semi-liquid diet 48 to 72 hr postoperative
Peritonsillar abscess
-
Asthma
Bronchodilators
-
Endotracheal tube auscultate the lung sounds for the placement of tube
Respiratory failure
Allen test
-
When doing ABG to ensure patency of ulnar artery through allen test
Bronchoscopy
-
Post-op
- After the procedure : No smoking, gargle with salt water and low
grade fever
- Notify HCP if chest, cough or frank blood sputum, shortness of
breath
Genitourinary
BPH
-
Endometriosis
-
Findings
- Dysuria (painful urination), frequency, urgency, nocturia,
suprapubic pain
- If kidney involved, then hematuria
Mgmt
- Uncomplicated infections
Co-trimoxazole (1st line)
Quinolones
Nitrofurantoin
- Complicated: IV, oral antimicrobials
Complications
- Pyelonephritis
- Sepsis
Nursing
- Assess hx of UTI, voiding and hygiene habits, hx of vaginal issues
- Manage pain
- Prevention: to females, void after intercourse and wear cotton
underpants
- Nutrition: increase water intake, avoid carbonated and caffeinated
fluids
Mgmt
- Pharm: diuretics to prevent calcium stones and control
hypercalciuria
Allopurinol (prevent calc stones)
Opioids, abx
Complications
Mgmt.
- Discontinue all nephrotoxic drugs
Ex. Aminoglycosides, ACE inhibitors, NSIADs
- post renal causes are obstructing from kidney due to: tumors,
neurogenic bladder, prostatic hypertrophy.
- Tx Life threatening issues:
IV fluids
Control potassium: calcium, glucose, sodium polystyrene
sulfonate (controls hyperkalemia)
Restore calcium levels (low calcium levels)
- Hemodialysis
Complications
- Infection, arrhythmias due to hyperkalemia, electrolyte imbalance,
multiple organ system failure, GI bleed due to ammonia
Nursing intervention
- Monitor 24hr urine, neurologic function
- Regulate protein intake offer high carbohydrate options
- Restrict foods in high potassium, phosphorus and sodium
3. Findings
System
Respiratory
Cardiovascular
Neuromuscular
Metabolicendocrine
Acid-base
Gastrointestina
l
Blood
Skeletal
Skin
Psychosocial
Mgmt
Nursing intervention
-
Chlamydia
-
Gonorrhea
-
Syphilis
-
Findings
- Clustered painful vesicles or ulcers on / around genitals or rectum
- Mild lymphadenopathy
- Reactivation can be due to stress, infection, pregnancy,
sunburn
Prognosis: chronic, life long viral infection
- Recurrent genital sores
- Pregnant woman with active genital lesions may need c
section b/c can be fatal to newborn and fetus
Nursing
- Avoid tight clothing
Genital warts
-
Hep B
-
HIV
-
Family planning
-
First trimester
-
Fertilization to 12 weeks
- Able to know the sex of the child
Findings of pregnancy
- Presumptive/possible subjective/objective findings
Nausea/vomiting, skin, basal body temperature
- Probable signs observed
Second trimester
-
Third trimester
-
Impending signs
Nausea, irritability, severe discomfort
3. Third stage (5 to 30 mins)
Placental stage birth of baby and delivery of placenta
Placental separation
o Uterus becomes globular in shape, rises in
abdomen, sudden gush of blood
4. Fourth stage (1 to 2 hrs after birth)
Recovery
Delivery of placenta to uterus no longer tends to relax
Prevent hemorrhage due uterine atony, cervical or vaginal
lacerations
Massage fundus if boggy
Ice to perineum area
Give oxytocic (stimulates uterine contraction), try
breastfeeding, void within 1 hr
Mechanisms of labour
1. Engagement, descent, flexion
2. Internal rotation
3. Extension
4. External rotation
5. Expulsion
Normal active labour progresses for primipara is (1.2cm) and multipara
(1.5cm)
Safest time to give analgesics when woman is dilated b/w 4 to 7 cm
Normal Postpartum
-
birth to 6 weeks
1. fundus (above umbilics on day 1) moves downward (firm grapefruit
decrease to nonpalpable in 10 days), lochia (minimal clots),
perineal healing
2. estrogen and progesterone decrease
3. oxytocin and prolactin (milk production) increase
Maternal Postpartum assessment BUBBLE-HE
1. B Breast
Nipples, tissue, temperature, colour
2. U- Uterus
Location mildline or deviated
Tone firm or boggy
3. B- bladder
Last time emptied
4. B bowel
Last bowel movement
Flatus and hunger
5. L lochia
Colour, amount, presence of clots free flow of lochia
Rubra (red) 1 to 3 days
Serosa (pink to brown) 3 to 7 days
6.
7.
8.
9.
Newborn assessment
-
Hearing test
-
Abdomen assessment
-
Musculoskeletal
-
Cranial nerves
On Old Olympus Towering Tops A Fin And GermanViewed Some Hops
(S=sensory, M=motor, B=both): Some Say Marry Money But MyBrother Says Big Business Makes
Money
Motor nerve function
Psychosocial intergrity
-
Aphasia
-
Global aphasia most severe cannot read, write, and understand speech
Broca aphasia (non-fluent) limited mainly to short utterances of less than
four words and limited writing but able to understand speech/read
Wernickes aphasia (fluent) inability to understand then meaning of
spoken words, reading and writing able to speak but speech is not
consistent
Ask yes and no questions
Clients Post-CVA
-
Anxiety disorders
-
Depressive disorder
-
Neurodevelopmental disorders
-
Personality disorders
-
Lifelong condition that makes it hard to think clearly, to the difference b/w
real or not real to have normal emotional responses and to act normally in
social situations
1. Leads to delusions, hallucinations, disorganized speech, flat affect
Early symptoms irritable, tense feeling, trouble concentrating, trouble
sleeping
Later symptoms involve thinking, emotions/behaviour. Isolation,
problems paying attention. Delusions. Loose associations
Antipsychotic
1. Typical and atypical
2. Give antiparkinsoism agent to counteract the extrapyramidal side
effects (tardive dyskinesia)
Build trust, be honest, dependable
Though the clients statements are not typical of logical communication, the second
and third remark contain elements of the preceding sentence (moon, walk).
Neologisms refers to making up words that have personal meaning to the client.
Flight of ideas defines nearly continuous flow of speech, jumping from one
unconnected topic to another. Word salad refers to stringing together real words
into nonsense sentences that have no meaning for the listener.
Fluid needs
1. 6 to 8 wet diapers per day for baby
2. Infant need 2.2 gm/kg/day protein
3. Breast milk for 1st 6 months of life and milk around 1 year
Pre-pregnancy add 400 ug/day folic acid
Pregnancy add per day 300 calories, 15 mg iron, 30 g protein, 400 g
calcium, 400 folic acid for 1st trimester
Lactation add 500 calories and 2 quarts extra fluid per day
3500 kcal = 1 lb
Carbohydrates
1.
2.
3.
4.
5.
Lipids
1. Lack of it leads to problems with skin, blood and arteries
2. Functions:
Most concentrated source of energy ( 9 kcal/gram)
Insulation, cell membrane ,
Carries fat soluble vit A, D, E and K
Total fat intake shouldnt exceed 30% of daily calories and
saturated fat not exceeding 10% of total daily caloric intake
Proteins
1. Amino acids
2. 8 essential amino acids not produced by body
3. Function:
Secondary energy source = 4 kcal/gram
Only source of nitrogen
0.8 g per kg of body weight per day
Vitamins
1. Body cant synthesize vitamins
2. Types:
Water soluble
Vit c, b complex ( thiamin, riboflavin, niacin,
pantothenic acid, biotin, B6, folate, B12)
Cant be stored- daily intake required
Excess is eliminated daily little risk of toxicity
Fat soluble
A, D,E, K
Stored in liver and adipose tissue
Minerals
1. Inorganic substances essential as catalyst in biochemical reactions
2. Regulation of acid-base balance and heart muscle respond
3. Major minerals
Calcium, magnesium, sodium, potassium, phosphorus, sulfur,
chlorine
4. Trace minerals
Iron, copper, iodine, manganese, cobalt, zin
Water
1. 60 to 70% of total body weight and (70 to 75% of total body weight
of children)
Aldosterone
-
Diabetic diet
-
Gluten free
-
Low cholesterol
-
High fiber
-
Low residue
-
Gastric tube
-
Orthostatic hypotension
-
Thrombus/emboli formation
-
Mechanical aids
-
Catheterization
-
Ileostomy
-
Semi-formed stool
Effect potassium and sodium levels
Digestive enzyme in stool irritate skin
Dont give laxatives
Lavage can be done to clear food blockage
Colostomy
-
Theories of pain
-
St John wort
-
Pediatrics
- Cardio
-
Pediatric respiratory
-
Late decelerations occurs after the onset of a uterine contraction and continue
beyond its end
-
If LMP in January, February, or March then birth will occur the current year
Abnormalities in newborn
-
Oxytocin Is used to induce labour however it can reduce placental blood flow
leading to irregular non reassuring FHR this leads to need for emergency
caesarean birth
-
IV fluid bolus
Consider terbutaline
Circumcision:
-
After 24 hours yellow exudate occurs and dark red dont remove this
normal healing process
1. Redness, swelling, odor and discharge indicate infection
2. If bleeding greater than a quarter also a worry
S/S: Hypotension and tachycardia, dizziness, pallor, cold and clammy skin
Tx: reposition to right or left side
1. If supine place a wedge under the client hip
Prolapse umbilical cord lies below the presenting part of the fetus
-
McRobert maneuver used to straighten the sacrum used for shoulder dystocia
Green amniotic fluid indicates the presence of meconium
-
Boggy uterus should massage the fundus to prevent blood loss after child birth
-
Placenta previa placenta is implanted over or very near the cervix risk for
hemorrhage
-
Knee chest position during episode of hypoxia and cyanosis in infants with
tetralogy of fallot (TOF)
Hypovolemic shock (hemorrhage) due to ectopic pregnancy
-
Bishop score rate the inducibility of cervix score less than 8 indicate labor
induction will be successful (vaginal birth)
-
Breast tissue the becomes red, warm, has orange peel (peau dorange)
and pitting appearance
Tx: excerise, water intake, vegetables and fruits and bulk forming fibre
(psyllium)
1. Avoid laxatives as it can lead to preterm labour and dehydration
2. Avoid coffee during pregnancy
Breastfeeding
-
On demand
8 to 12 times a day
15 to 20 mins per breast
Cleft palate risk for aspiration and inadequate nutrition due difficulties with eating
-
Upright position
Point down and away from cleft
Special bottles and nipples
Burped often
Feed slowly over 20 to 30 mins
Feed every 3 to 4 hours
Prevent by:
1. Firm surface
2. Avoid soft objects
3. Avoid bumper crib pads
4. Avoid overheating
5. Use pacifier
6. Breastfeeding
7. Use sleeping sack or a thin tucked blanket
Infant assessment
-
Starts at 6 months
Peaks at 10 to 18 months
Reaction is normal resolves by age 3
1. More stress (then pain, injury)
3 stage
1. Protest refuse attention from other and crises
2. Despair withdraw and quiet
3. Detachment happy and building relationships
Provide calm environment build trust and connection with family
1. Favorite toy, daily schedule, calming presence, phone calls, play
activities
Due to preterm birth, breatfeeding issues, GI, cleft palate, SES factors
Less than 80% of ideal weight so observing the child feeding is
important
Toddler (12 months to 3 years) - show behaviour of negativism and ritualism they
seek autonomy
-
6 months Be DR HIP
Hematological/Oncological
Lymphedema accumulation of lymph fluid in soft tissue due to lymph node
removal or radiation treatment
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Client arm may feel heavy, painful and motor function can be impaired
increases the risk of infection and injury to limb
Tx:
1. Decongestive therapy (massage to mobilize fluid)
2. Compression bandaging to increase distal pressure
3. Elevation of arm level with heart
4. Isometric exercise
Therapeutic range is 1.5 to 2.0 (46 to 70 sec) times the control value - it
remain there until the infusion stops
So infiltration can lead to drop in PTT levels to control value
Low platelets increase the risk for clot formation due to HIT NOT
bleeding
Reverse heparin through Protamine
Platelets count less than 40,000 is life threatening autoimmune
stop heparin due HIT
1. Changes with LOC are emergency situation (indicates increase
bleeding and ICP)
Warfarin check PT/INR therapeutic range is 1.5 to 2.0x the control value
Brachytherapy ( internal radiation) implant of radioactive at the site of tumor
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S/S: localized, persistent back pain, motor weakness and sensory changes
(numbness, paresthesia), bowel or bladder dysfunction
A slack, relaxed jaw and open mouth due to loss of facial muscle tone
Difficulty maintaining body posture or positions
Eyelids half-open
Cheyne stokes or uneven respirations with periods of apnea
Urine output decrease and become darkened (concentrated) due to
dehydration
Brain natriuretic peptide (BNP) increase is associated with heart failure leading to
dyspnea (shortness breathing)
Polycythemia vera (PV) bone marrow produces an abnormally high number of
RBCs
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CRP- C-reactive protein used to detect acute or chronic inflammation in the body
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Used in RA
Chew sugar free gum and lemon juice or hard candy, ice, fruit juices
1. Increases saliva and thin thick mucus
2. Avoid anything causes dryness and thickness mucus
Infectious Disease
S/S: flushing, erythema, and pruritus (face, neck, chest), muscle pain,
spasms, dyspnea, hypotension
It is a infusion reaction not allergic
Tx: by reducing the infusion rate of vancomycin to minimum 60 mins
Anaphylaxis
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Droplet protection
In immunosuppressed patient
1. Taking corticosteroids (Latent TB), chemotherapy/radiation, AIDS,
prolonged high dose of antibiotic (since it reduces normal flora),
dentures, uncontrolled diabetes
Treat with oral hygiene, proper nutrition and antifungal medication
(nystatin) swish/swallow it
Mild (skin, muscle and joints) severe (kidneys, heart, lung, blood vessels,
CNS)
Butterfly shape across the bridge of the nose and cheeks
Monitor increased
1. Creatinine
2. BUN
3. Urinalysis
To assess for lupus nephritis (kidney damage) serious
complication
4. They may also have increase erythrocyte sedimentation,
antinuclear antibody, anemia, mild leukopenia, thrombocytopenia
Tx: Hydroxychoroquine
1. Reduces fatigue and treat skin and arthritics
2. Treats inactive and mild disease take months to see therapeutic
effect
3. Adverse effect:
Retinal toxicity and visual disturbance require examination
eye every 6 months
4. Should be taken with food
Severe SLE treated through corticosteroid to prevent organ damage
Vaccines
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Reye syndrome
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Develop as result of child have a recent viral infection (i.e. chicken pox,
flu)
S/S: fever, lethargy, acute encephalopathy and altered hepatic function
1. Elevated ammonia
Risk increase due to aspirin and salicylate especially in client with
Kawasaki
Most contagious 1 to 2 days not contagious after all lesion are crusted
over
Immunization side effects: discomfort, redness, few vesicles
1. Cover with small bandage to reduce risk of transmission
Febrile seizures
Community acquired
Infection of lower urinary tract
S/S: hyperemia, tissue hemorrhage, pus formation
1. Burning, dysuria, frequency and urgency, hematuria and suprapubic
discomfort
Kawasaki disease tx with aspirin and IVIG to prevent coronary artery aneurysm
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BP < 90 mmHg
Change in mental status
Hyperglycemia > 140 mg
WBC > 12,000, <4000
Respiration >20
Absent bowel sounds, cap refill > 5 sec
Assess oxygenation, airway , breathing, circulation, tissue perfusion and
urine output
Tx: through IV fluids and antibiotics
Development of cold and clammy skin will indicate progressive septic
shock requires immediate intervention
Aortic dissection moving, ripping back pain, tearing, worst ever, due to
uncontrolled hypertension
LPN limited to lung, bowel sounds and neurovascular checks cant perform initial
assessment
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UAP assist with ROM exercise after taught by RN, remind about Incentive
spirometer, remind pt to use overhead trapeze, notify RN of client reports/states,
report observations, remind client to change position
START simple triage and rapid transport look at airway, breathing and
circulation
Priority goes to client that going to survive
Bacterial meningitis high fever, LOC, nuchal rigidity and meningeal sign (positive
kernigs and brudzinski sign)
Orthopaedics