NUR 101 (NUR101) ADVANCED CLINICAL CONCEPTS (Detailed HESI Study Guide)/NUR 101 ADVANCED CLINICAL CONCEPTS

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NUR 101 (NUR101) ADVANCED CLINICAL CONCEPTS (Detailed HESI Study Guide)/NUR 101 ADVANCED CLINICAL CONCEPTS ADVANCED CLINICAL CONCEPTS • ARDS is an unexpected, catastrophic pulmonary complication occ... urring in a person with no previous pulmonary problems. The mortality rate is high (50%) • In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to high concentrations of oxygen. • Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them from collapsing each time the client exhales. The amount of pressure can be set with the ventilator and is usually around 5 to 10 cm of water. • Suction only when secretions are present. • Before drawing arterial blood gases from the radial artery, perform the Allen test to assess collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture. • If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death will occur. However, they must be removed from any source of imminent danger, such as a fire. • PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. • A child in severe distress should be on 100% O2. • Early signs of shock are agitation and restlessness resulting from cerebral hypoxia. • If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous return further to the left ventricle. • Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All organs are damaged, and if perfusion problems exist, the damage can be permanent. • All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do not change infusion rates simultaneously. • A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is the first priority? Maintaining an open airway (the allergic reaction damages the lining of the airways causing edema). Also, keep the client warm without constricting clothing; keep legs elevated (not Trendelenburg because the weight of the lower organs restricts breathing). • Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild • Epinephrine: 1:10,000, or 5ml IV for severe • Volume expanding fluids are usually given to clients in shock. However, if the shock is cardiogenic, pulmonary edema may result. • Drugs of choice for shock - Digitalis preparations: Increase the contractility of the heart muscle - Vasoconstrictors (Levophed, Dopamine): Generalized vasonconstriction to provide more available blood to the heart to help maintain cardiac output. • A common volume-expanding substance is plasma and possibly whole blood. • You are caring for a woman who was in severe automobile accident several days ago. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, short of breath, has a weak thready pulse, has cold and clammy skin, and hematuria. - What do you think is wrong with the client, and what would you expect to do about it? - These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her management would be administration of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is poor). • NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are required for each of the following situations? - A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic. - A 36-year old first time pregnant woman who arrests during labor. - A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to catch fire. - A 40-year old businessman who arrests two days after a cervical laminectomy. • WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS) - The American Heart Association recommends that those with known angina pectoris seek emergency medical care if chest pain is NOT relieved by three nitroglycerin tablets 5 minutes apart over a 150minute period. - A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes or longer should seek emergency medical treatment. • It is important for the nurse to stay current with the American Heart Association’s guidelines for Basic Life Support (BLS) by being certified every two years as required. • If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4 cycles, then reassess for breathing and pulse. If two rescuers are performing CPR, a 15:2 ratio is now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min compression rate. When trading off, start with compressions. • Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support (ACLS) guidelines. • When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless hyperkalemia and/or preexisting acidosis is documented. • Infants/prematures may have problems with the following that can predispose to arrest: Beware of the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory acidosis), hypercoagulability (if polycythemia exists). • Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration. • Dextrose 10% is a hypertonic solution and should be administered IV. • Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medication. • Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid into intracellular or extracellular spaces. • Potassium imbalances are potentially life-threatening, must be corrected immediately. A low magnesium often accompanies a low K+, especially with the use of diuretics. • Fluid Volume Deficit: Dehydration - Elevated BUN: The BUN measures the amount of urea nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys. - Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a 1:20 ratio. - Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.” - Urine osmolality and specific gravity increase. • Check the IV tubing container to determine the drip factor because drip factors vary. The most common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per milliliter. • Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent complications such as infiltration, emboli and infection. • A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE. • The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal. • Review the order of blood flow to the heart: - Unoxygenated blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber) and out the aorta. - Review the three structures that control the one-way flow of blood through the heart: 1. Valves Atrioventricular valves  Tricuspid (right side)  Mitral (left side) Semilunar valves  Pulmonary (in pulmonary artery)  Aortic (in aorta) 2. Cordae Tendinae 3. Papillary muscles • Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia. • Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on the client with an arrythmia. • REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess to determine if the leads are attached properly. • Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the involvement of the client. • Wound dehiscence is separation of the wound edges and is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus. • NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process. Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have her gallbladder removed in a same-day surgery using a scope instead of an incision. What nursing needs will dominate each phase of her short hospital stay? - Preparation phase: Education about postoperative care, NPO, assist with meeting family needs. - Operative phase: Assessment, management of the operative suite. - Post-anesthesia phase: Pain management, post-anesthesia precautions. - Post-operative phase: Prevent and assess for complications, pain management, dietary restrictions, activity. • HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.). • STANDARD PRECAUTIONS: - Wash hands, even if gloves have been worn to give care - Wear gloves (latex) for touching blood or body fluids, or any non-intact body surface. - Wear gowns during any procedure that might generate splashes (changing clients with diarrhea). - Use masks and eye protection during activity which might disperse droplets (suctioning). - Do not recap needles, dispose of in puncture-resistant containers. - Use mouth piece for resuscitation efforts. - Refrain from giving care if you have open skin lesions. • Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV). • Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis. • The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and management of complications associated with HIV. • For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed, until 1.0mg is achieved. • Use non-invasive methods for pain management when possible: - Relaxation techniques - Distraction - Imagery - Biofeedback - Interpersonal skills - Physical care: altering positions, touch, hot and cold applications. • Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory depression). • Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed. • Do not take away the coping style used in a crisis state… DENIAL. It is a useful and needed tool at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment – endangering the patient. MEDICAL –SURGICAL NURSING RESPIRATORY SYSTEM • Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature also increases metabolism and the demand for oxygen. • High risk for pneumonia: - Any person, who has altered level of consciousness, has depressed or absent gag reflex and cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized individuals, those with brain injury, drug overdose, or stroke victims). - When feeding, raise the head of the bed and position the client on side – not on back. • Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. • Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of fluid are lost daily by the lungs through evaporation. • Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain. • Pneumonia preventatives: - Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); do not smoke. - Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance of rest and activity. - Comatose and immobile persons: elevate head of bed to feed; turn frequently. • Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is imperative that baseline data are obtained on the client. • Productive cough and comfort can be facilitated by Semi- Fowler’s or high Fowler’s positions, which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion. • Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in adequate to oxygenate the tissues. • Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right- sided heart failure. • Cells of the body depend on oxygen to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers. • Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia (hypoxic drive) not the usual hypercapnia, the stimulus to breathe for healthy persons. Therefore, if too much oxygen is given, the client may stop breathing! • Health Promotion: - Eating consumes energy needed for breathng. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. - Prevent secondary infections – avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke). - Teach client to report any change in characteristics of sputum. - Encourage client to hydrate well and to obtain immunizations needed (flu and pneumonia). • When asked to prioritize nursing actions, use the ABC rule: - Airway first - Then breathing - Then circulation • Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate oxygenation is not occurring. • The key to respiratory status assessment of breath sounds as well as visualization of the client. Breath sounds are better “described,” not named, e.g., sounds should be described as “crackles,” “wheeze,” “hihg-pitched whistling sound,” rather than “rales,” “rhonchi,” etc., which may not mean the same thing to each clinical professional. • Watch for NCLEX-RN questions that deal with oxygen delivery. In adults, O2 must bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. • With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black, and may appear patchy. • Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing. • Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. • A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours). • Fear of choking is very real for laryngectomy clients. They cannot cough as before because the glottis is gone. Teach the “glottal stop” technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube). • TB SKIN TEST: a positive TB skin test is exhibited by an induration 10mm or greater in diameter 48 hours after skin test. Anyone who has received a BCG vaccine will have a positive skin test and must be evaluated using a chest x-ray. • Teaching is very important with the TB client. Drug therapy is usually long term (9 months or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard. • TEACHING POINTS – - Rifampin: Reduces effectiveness of oral contaceptives; should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contacts. - Isoniazid (INH): Increases Dilantin levels. - Ethambutal: Vision check before starting therapy and monthly; may have to take 1 to 2 years longer. - Teach rationale for combination drug therapy to increase compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time. • Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the remaining chest organs to fill the empty space. • If the chest tube remains disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected. • If the chest tube is accidentally removed from the client, the nurse should apply pressure immediately with an occlusive dressing and notify the healthcare provider. • Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact and should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, since expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied the fluctuations cease. Most hospitals DO NOT MILK chest tubes as a means of clearing or preventing clots – it is too easy to remove chest tubes. Mediastinal tubes may have orders to be stripped because of location, compared to larger thoracic cavity tubes. • Various pathophysiological conditions can be related to the nursing diagnosis “Ineffective Breathing Patterns.” 1. Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) 2. Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) 3. Accumulation of fluid in the air sacs (pneumonia) 4. Respiratory muscle fatigue (COPD, pneumonia) RENAL SYSTEM • Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about 1 to 2 liters in a 24-hour period. • Electrolytes are profoundly affected by kidney problems. There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions. • In some cases, persons in ARF may not experience the oliguric phase but may progress directly to diuretic phase during which the urine output may be as much as 10 liters per day. • Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all clients with renal failure – done on the same scale at the same time every day. • Fluid Volume Alterations Fluid • Excess symptoms: - Dyspnea - Tachycardia - Jugular vein distention - Peripheral edema - Pulmonary edema • Fluid deficit symptoms: - Decreased urine output - Reduction in body weight - Decreased body turgor - Dry mucous membranes - Hypotension - Tachycardia • Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea. • Potassium has a critical safe range (3.5 to 5.0 mEg/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modification. Limit high potassium foods (bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium. • Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased dilution). Limit fluid and sodium intake in ARF clients. • During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal, aRF is determined to be resolved. • Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs causing muscle wasting. The glomerular filtration rate (GFR) is most often used as an indicator of level of protein consumption. • DIALYSIS COVERED BY MEDICARE: - All persons in the United States are eligible for Medicare as of their first day of dialysis under special End Stage Renal Disease funding. - Medicare card will indicate ESRD. - Transplantation is covered by Medicare procedure; coverage terminates six months postoperative if dialysis is no longer required. • Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea, creatinine. Ensure high calorie intake so protein is spared for its own work: give hard candy, jelly beans, flavored carbohydrate powders. • As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity since digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse <60 beats per minute (bradycardia). • The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur. • The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics round-the-clock and not skip doses so that a consistent blood level can be maintained for optimal effectiveness. • Location of the pain can help determine location of the stone. - Flank pain usually means the stone is in the kidney or upper ureter. If it radiates in the abdomen or scrotum, the stone is likely to be in the ureter or bladder. - Excruciating, spastic-type pain is called colic. - During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort. • Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid which will dissolve the stone, or ultrasonic sound waves (lithotripsy) can be directed through the needle/catheter to break up the stone which then can be eliminated through the urinary tract. • Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized balloon on the catheter (30 to 45 cc inflate) will cause a continuous feeling of needing to void. The client should not try to avoid around the catheter since this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given. • Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP since the irrigation must be isotonic to prevent fluid and electrolyte imbalance. • Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of blood or frank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood during the healing process as well as small clots. He should rest quietly and continue drinking large amounts of fluid. CARDIOVASCULAR SYSTEM • What is the relationship of the kidneys to the cardiovascular system? - The kidneys filter about a liter of blood per minute - If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems. - When the kidneys produce and excrete 0.5 ml of urine per kg of body weight or average 30 ml/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs. • Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for acute angina? - Digoxin – Not appropriate – Increases the strength and contractility of the heart muscle; the problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help. - Nitroglycerin – Appropriate – Causes dilation of the coronary arteries, allowing more oxygen to get to the heart muscle. - Atropine – Not appropriate – Increases heart rate by blocking vagal stimulation, which suppresses the heart rate. Does not address the lack of O2 to the heart muscle. - Propanolol (Inderal) – Not appropriate – for acute angina attack; however, is appropriate for long-term management of stable angina because it acts as a beta-blocker to control vasoconstriction. • Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart. • Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives. • The number one cause of CVA with hypertensive clients is non-compliance with medication regime. Hypertension is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their antihypertensive medications, the more likely they are to take them – teaching is important. • Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client actually realizes the damage is being done. • A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse obtain in the first few hours? - Vital signs q1 hour - Neurological vital signs - Respiratory status - Urinary output - Peripheral pulses • During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems. • A positive Homen’s sign is considered an early indication of thrombophlebitis. However, it may also indicate muscle inflammation. If a deep vein thrombosis has been confirmed, a Homan’s sign should not be elicited because of the increased risk of embolization. • Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites. • HEPARIN: - Antagonist: Protamine Sulfate - LAB: PTT or APTT determines efficacy - Keep 1.5 to 2.5 times normal control • COUMADIN: - Antagonist: Vitamin K - LAB: PT determines efficacy - Keep 1.5 to 2.5 times normal control • INR: Desirable therapeutic level usually 2 to 3 seconds (reflects how long it takes a blood sample to clot). • A holter monitor offers continuous observation of the client’s heart rate. To make assessment of the rhythm strips, most meaningful, teach the client to keep a record of: - Medication times and doses - Chest pain episodes – type and duration - Valsalva maneuver (straining at stool, sneezing, coughing) - Sexual activity - Exercise • Cardioversion is the delivery of synchornized electrical shock to the myocardium. • Differentiate in synchronous and asynchronous pacemakers: - Synchronous or demand pacemaker fires only when the client’s heart rate falls below a rate set on the generator. - Asynchronous or fixed pacemaker fires at a constant rate. • Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. • DIGITALIS: - Side effects of digitalis are increased when the client is hypokalemic. - Has a negative chronotropic effect, i.e., it shows the heart rate. Hold the digitalis if the pulse rate is <60, >120, or has markedly changed rhythm. - Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include nausea, vomiting, and headache in adults. - If withheld, consult with physician. • Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk of embolization; erosion/perforation of the valve leaflets; or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur depending upon the type of damage inflicted by the lesions, leading to symptoms of left – or right-sided heart failure. • Acute and Subacute Infective Endocarditis - There are 2 types of infective endocarditis: - Acute, which often affects individuals with previously normal hearts and healthy valves, and carries a high mortality rate - Subacute, which typically affects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk for both acute and subacute bacterial endocarditis. When this population develops Subacute Infective Endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are typically affected due to the introduction of common pathogens which colonize on the skin (S. epidermis and Candida) into the venous system. • Pericarditis – presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST segment elevation and T wave inversion are also signs of pericarditis. • With mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In early period, there may be no symptoms; but, as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrillation is common. GASTROINTESTINAL SYSTEM • A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount of regurgitation as well as preventing the encroachment of the stomach tissue upward through the opening in the diaphragm. • Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation. • CLINICAL MANIFESTATIONS OF GI BLEEDING: - Pallor: conjuctival, mucous membranes, nail beds - Dark, tarry stools - Bright red or coffee-ground emesis - Abdominal mass or bruit - Decreased BP, rapid pulse, cool extremities (shock). • The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8 liters per day. Large fluid losses can occur if vomiting and/or diarrhea exists. • Opiate drugs tend to depress gastric motility. However, they should be given with care, and those receiving them should be closely monitored because a distended intestinal wall accompanied by decreased muscle tone may lead to intestinal perforation. • Diverticulosis is the presence of pouches in the wall of the intestine. There is usually do discomfort, and the problem goes unnoticed unless seen on radiological examination (usually prompted by some other condition). • Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the bowel. • A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed with diverticulitis. What are the nutritional needs of this client throughout recovery? - Acute phase – NPO graduating to liquids. - Recovery phase – no fiber or foods that irritate the bowel. - Maintenance phase – high-fiber diet, with bulk-forming laxatives to prevent pooling of foods in the pouches where they can become inflamed. Avoid small, poorly digested foods such as popcorn, nuts, seeds, etc. • Bowel obstructions: - Mechanical: due to disorders outside the bowel (hernia, adhesions), due to disorders within the bowel (tumors, diverticulitis), or due to blockage of the lumen in the intestine (intussusception, gall stone). - Non-mechanical: paralytic ileus, which does not involve any actual physical obstruction, but results from inability of the bowel itself to function. • Blood gas analysis will show alkalotic state if the bowel obstruction is high in the small intestine where gastric acid is secreted. If the obstruction is in the lower bowel where base solutions are secreted, the blood will be acidic. • A client admitted with complaints of constipation, thready stools and rectal bleeding over the past few months is diagnose with a rectal mass. What are the nursing priorities for this client? - NPO - NG tube (possibly an intestinal tube such as a Miller-Abbott) - IV fluids - Surgical preparations of bowel (if obstruction is complete) - Teaching (preoperative, nutrition, etc.) • Diet recommended by the American Cancer Society to prevent bowel cancer: - Eat more cruciferous vegetables (from the cabbage family such as broccoli, cauliflower, Brussels sprouts, cabbage, and kale). - Increase fiber intake. - Maintain average body weight - Eat less animal fat. • AMERICAN CANCER SOCIETY RECOMMENDATIONS for early detection of Colon Cancer: - A digital rectal examination every year after 40. - A stool blood test every year after 50. - A sigmoidoscopy examination every 3 to 5 years after the age of 50, based on the advice of a physician. • Cancer of the colon is the most common cancer in the US when considering men and women together. An early sign is the rectal bleeding. Encourage patients 50 years of age or older, or those with increased risk factors, to be screened yearly with fecal occult blood testing. Routine colonoscopy at 50 is also recommended. • CLINICAL MANIFESTATIONS OF JAUNDICE - Yellow skin, sclera, and/or mucous membranes (bilirubin in skin) - Dark-colored urine (bilirubin in urine) - Chalky or clay-colored stools (absence of bilirubin in stools) • Fetor hepaticus is a distinctive breath odor of chronic liver disease. It is characterized by a fruity or musty odor which results from the damaged liver’s inability to metabolize and detoxify mercaptan which is produced by the bacterial degradation of metionine, a sulfurous amino acid. • For treatment of ascities, paracentesis and peritoneovenous shunts (LaVeen and Denver shunts) may be indicated. • Esophageal varices may rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade – a Blakemore- Sengstaken or Minnesota tube. Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions. • Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level rises. • PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING for clients who are anorexic and/or nauseated: - Remove strong odors immediately; they can be offensive and increase nausea. - Encourage client to sit up for meals; this can decrease the propensity to vomit. - Serve small, frequent meals. • Liver tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration of liver tissue being destroyed by the disease. Since many drugs are metabolized in the liver, drug therapy must be scrutinized carefully. Caution the client that recovery takes many months, and previously taken medications should not be resumed without the healthcare provider’s directions. • Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore, sitting up or leaning forward will reduce the pain. • Following an endoscopic retrogade cholangiopancreatography (ERCP), the client may feel sick. The scope is placed in the gallbladder and the stones are crushed and left to pass on their own. These clients may be prone to pancreatitis. • Non-surgical management of the client with cholecystitis includes: - Low-fat diet - Medications for pain and clotting if required - Decompression of the stomach via NG tube ENDOCRINE SYSTEM • Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Grave’s disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension. - Primary nursing interventions include maintaining an airway and adequate aeration. - Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation. • Post-operative thyroidectomy: be prepared for the possibility of laryngeal edema. Put a tracheostomy set at bedside along with oxygen and a suction machine; Ca++ gluconate easily accessible. • Normal serum calcium is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a decrease in the client’s calcium compared to the preoperative value. • If two or more parathyroid glands have been removed, the chance of tetany increases dramatically: - Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal range) - Check for tingling of toes, fingers, and around the mouth. - Check for Chvostek’s sign (tap over the parotid gland and which for twitching of lip = positive) - Check Trousseau’s sign (carpopedal spasm after inflating BP cuff above systolic pressure = positive). • Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and carbondioxide narcosis). The airway must be kept patent, and ventilator support as indicated. • Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the need to teach clients the importance of precisely following the prescribed regimen. They should be cautioned against suddenly stopping the medications and be informed that it is necessary to taper off taking steroids. • ADDISON”S CRISIS IS A MEDICAL EMERGENCY: Brought on by sudden withdrawal of steroids or a stressful event (trauma, severe infection) - Vascular Collpase: Hypotension and tachycardia occur; administer IV fluids at rapid rate until stabilized. - Hypoglycemia: Administer IV glucose - ADMINISTER PARENTERAL HYDROCORTISONE: Essential for reversing the crisis. - ALDOSTERONE REPLACEMENT: Administer fludrocortisone acetate(Florinef) PO (only available as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit. • Teach clients to take steroids with meals to prevent gastric irritation. They should never skip doses. If they have nausea or vomiting for more than 12 to 24 hours, they should contact the physician. • Why do diabetics have trouble with wound healing? High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing or breaks in the skin, cardiovascular abnormalities, etc. • Glycosylated Hgb (Hgb A1C) - Indicates glucose control over previous 120 days (life of RBC) - Valuable measurement of diabetes control. • The body’s response to illness/stress is to produce glucose. Therefore, any illness results in hyperglycemia. • If in doubt whether the client is hyperglycemic or hypoglycemic, treat for hypoglycemia. • SELF-MONITORING BLOOD GLUCOSE (SMBG) - Provides tight glucose control thereby decreasing the potential for long-term complications - Technique is specific to each meter if meter is used. - Monitor before meals, at bedtime, and any time symptoms occur. - Record results and report to healthcare provider at time of visit. MUSCULOSKELETAL SYSTEM • A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use and which methods would the nurse not use? - Use inspection, palpation, and strength testing. - Do not use range of motion (this activity promotes pain because ROM is limited). • In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for joint deformity; and NSAIDS for the pain. • Synovial tissues line the bone of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease will go into remission. Decreasing the amount of bone and joint destruction will reduce the amount of disability. • What activity recommendations should the nurse provide a client with rheumatoid arthritis? - Do not exercise painful, swollen joints. - Do not exercise any joint to the point of pain. - Perform exercises slowly and smoothly; avoid jerky movements. • NCLEX-RN questions often focus on the fact that avoiding sunlight is key in management of lupus erythematosus – this is what differentiates it from other connective tissue diseases. • Degenerative joint disease (DJD) and osteoarthritis are often described as the same disease, and indeed they both result in hypertrophic changes in the joints. However, they differ in that osteoarthritis is an inflammatory disease and DJD is characterized by non-inflammatory degeneration of the joints. • Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. While TUMS is an excellent source of calcium, it is also high in sodium and hypertensive or edematous individuals should seek another source for supplemental calcium. • The main cause of fractures in the elderly, especially women, is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles’ fracture of forearm. • NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a non-wheeled walker, the client should lift and move the walker forward, then take a step into it. The client should avoid scooting the walker or shuffling forward into it which takes more energy and is less stable than a single movement. • What type of fracture is more difficult to heal, an extra capsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)? - The blood supply enters the femur below the neck of the femur. Therefore, an intra-capsular fracture is much more harder to heal and has a greater likelihood of necrosis since it is cut off from the blood supply. • The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2). Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation. • In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive range of motion exercises, elastic stocking use, elevation of the foot of the bed 25 degrees to increase venous return, and low- dose hepatin therapy. • Clients with fractures, casts, or edema to the extremities need frequent neurovascular assessment distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain and pulses should be assessed. • Assess the “5 Ps” of neurovascular functioning: pain, paresthesia, pulse, pallor and paralysis. • Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often. • A big problem after joint replacement is infection. • Fractures of bone predispose the client to anemia, especially if long bones are involved. Check hemtocrit every 3 to 4 days to monitor erythropoiesis. • Instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket. • Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (may limit milk intake), and venous thrombosis (may be on prophylactic anticoagulants). • The residual limb should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can cause contracture. NEUROSENSORY SYSTEM • Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye exam. • Eye drops are used to cause pupil constriction since movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after administration of pilocarpine and adaptation to dark environments is difficult because of pupillary constriction (desired effect of the drug). • There is an increased incidence of glaucoma in the elderly population. Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postoperative complications associated with constipation, and implement a plan of care directed at prevention, and, if necessary, treatment for constipation. • The lens of the eye is responsible for projecting light, which enters onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred. • When the cataract is removed, the lens is gone, making prevention of falls important. If the lens is replaced with an implant, vision is better than if a contact lens is used (some visual distortion) or if glasses are used (greater visual distortion – everything has a curved shape). • The ear consists of three parts: the external ear, middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the CNS., often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems (conductive) may result from infection, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids. • NCLEX-RN questions often focus on communicating with older adults who are hearing impaired. - Speak in a low-pitched voice, slowly, and distinctly. - Stand in front of the person with the light source behind the client. - Use visual aids if available. NEUROLOGICAL SYSTEM • Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded. • Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care. • Clients with an altered state of consciousness are fed by enteral routes since the likelihood of aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying and the feeding should be held. • Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression. • Any client on bedrest/immobilized must have range of motion exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return is dangerous, i.e., sitting with dependent extremities for long periods. • If temperature elevates, take quick measures to decrease it since fever increases cerebral metabolism and can increase cerebral edema. • Safety measures for immobilized clients: - Prevent skin breakdown with frequent turning. - Maintain adequate nutrition. - Prevent aspiration with slow, small feedings or NG feedings. - Monitor neurological signs to detect the first signs that intracranial pressure may be increasing. - Provide range of motion exercises to prevent deformities. - Prevent respiratory complications – frequent turning and positioning for optimal drainage. • Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not over-sedate, and report any symptoms of restlessness. • The forces of impact influence the type of head injury. They include acceleration injury, which is caused by the head in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists. • Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP. • CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur. • Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level of responsiveness. • Physical assessment should concentrate on respiratory status, especially in clients with injury at C-3 to C-5, as cervical plexus innervates diaphragm. • It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12 to 24 hours. • A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in alkaline media, so keeping urine diluted ad acidic is prophylactic against infection. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder. • Benign tumors continue to grow and take up space in the confined area of the cranium causing neural and vascular compromise for the brain, increased intracranial pressure, and necrosis of brain tissue – even benign tumors must be treated as they may have malignant effects. • Craniotomy post-operative medications: - Corticosteroids to reduce swelling - Agents and osmotic diuretics to reduce secretions (atropine, robinul) - Agents to reduce seizures (phenytoin) - Prophylactic antibiotics • Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of the cases. MS is more common in women. Progression is not “orderly.” • Drug therapy for MS clients: ACTH, cortisone, Cytoxan, and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on prevention of infection. • In clients with Myasthenia Gravis, be alert for changes in respiratory status – the most severe involvement may result in respiratory failure. • Bedrest often relieves symptoms. Bladder and respiratory infections are often a recurring problem. Need for health promotion teaching. • Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic crisis is associated with a negative test. • NCLEX-RN questions often focus on the features of Parkinson’s disease – tremors (a coarse tremor of fingers and thumb on one hand which disappears during sleep and purposeful activity – also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: SAFETY! • An important aspect of Parkinson’s treatment is drug therapy. Since the pathophysiology involves an imbalance between acetylcholines and dopamine, symptoms can be controlled by administering dopamine precursor (Levodopa). • CNS involvement related to cause of CVA: - Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue – often related to hypertension. - Embolytic: caused by a clot, which has broken away from some vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may happen again). • Atrial flutter/fibrillation has a high incidence of thrombus formation following arrythmias due to turbulence of blood flow through all valves/heart chambers. • A woman who had a stroke two days ago has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the client’s recovery period? - The quicker movement is recovered, the better the prognosis is for more or full recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely. • Words that describe losses from CVA: - Apraxia: inability to perform purposeful movements in the absence of motor problems. - Dysarthria: difficulty articulating - Dysphasia: impairment of speech and verbal comprehension - Aphasia: loss of the ability to speak - Agraphia: loss of the ability to write - Alexia: loss of the ability to read - Dysphagia: dysfunctional swallowing • Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers. HEMATOLOGY/ONCOLOGY • Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels drop below 7g/dl. • ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood products. TWO registered nurses should simultaneously check the physician’s prescription, client’s identity, and blood bag label. • A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myeologenous leukemia. What are the expected laboratory findings for this client and what is the expected treatment? - Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high). - Treatment: Prevention of infection; prevention and/or control of bleeding; high protein, high calorie diet; assistance with ADL; drug therapy. • Infection in the immunosuppressed person may not be manifested with an elevated temperature. It is imperative, therefore, that the nurse performs a total and thorough assessment of the client frequently. • Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! Advise client to stay away from persons with known infections such as colds. In the hospital, maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or fruits – only cooked to destroy any bacteria. • Hodgkin’s is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy renders many male clients sterile. May bank sperm prior to treatment, if desired. REPRODUCTIVE SYSTEM • Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to benign uterine tumors. Assess for signs of anemia. • What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall. • Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagina, rectum, and bladder are removed in an attempt to stop metastasis). Chemotherapy is not useful with this type of cancer. • Pap smears should begin within 3 years of having intercourse or no later than age 21, whichever comes first. Should be done annually until age 30 and then may be done every 2 to 3 years if a woman has 3 consecutive normal results. After age 70 may stop if woman has 3 consecutive normal and no abnormal pap smears in last 10 years. Women at high risk should have annual screenings. • Ovarian cancer is the leading cause of death from gynecologic cancers in the US. Growth is insidious, so it is not recognized until it is at an advanced stage. • The major emphasis in nursing management of cancers of the reproductive tract is early detection. • The importance of teaching female clients how to do self- breast examination cannot be overemphasized. Early detection is related to positive outcomes. • The presence or absence of hormone receptors is paramount in selecting clients for adjuvant therapy. • Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at high risk for developing testicular cancer. The most common symptom is the appearance of a small, hard lump about the size of a pea on the front or side of the testicle. Manual testicular examination should be done after a shower by gently palpating the testes and cord to look for a small lump. Swelling may also be a sign of testicular cancer. • STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report cases of child abuse. Chlamydia is the most reported communicable disease in the United States. • Pelvic inflammatory disease (PID) involves one more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics and warm sitz baths. Bedrest in a semi-Fowler’s position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain. • A client comes to the clinic with a chancre on his penis. What is the usualy treatment? - IM dose of penicillin (such as Benzathine penicillin G 2.4 million units). - Obtain sexual history, including the names of his sex partners, so that they can receive treatment. BURNS • Massive volumes of IV fluids are given. It is not uncommon to give over 1,000 cc/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but is not overloaded. • Infection is a life-threatening risk for those with burns. Dressing changes are VERY PAINFUL! Medicate client prior to procedure. • Pre-existing conditions that might influence burn recovery are age, chronic illness, diabetes, cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug and/or alcohol abuse. PEDIATRIC NURSING GROWTH AND DEVELOPMENT: 1. When does birth length double? = by 4 years 2. When does the child sit unsupported? = 8 months 3. When does a child achieve 50% of adult height? = 2 years 4. When does a child throw a ball overhand? = 18 months 5. When does a child speak 2-3 word sentences? = 2 years 6. When does a child use scissors? = 4 years 7. When does a child tie his/her shoes? = 5 years • Be aware that a girl’s growth spurt during adolescence begins [Show More]

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