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Copy of ATI Remediation
Transcript of Copy of ATI Remediation
April 18, 2012
Silviya P. Serrano
Management of Care
Is also called CVA, brain attack or stroke.
It occurs when blood flow to the brain is stopped suddenly (ischemia) and oxygen can’t reach that area.
It can be caused by fatty plaque that broke away from a blood vessel
A thrombus in a an artery that blocked the flow of blood (Thrombotic stroke).
A thorn artery that causes bleeding to occur (cerebral hemorrhage or hemorrhagic stroke).
Hypertension the single most important modifiable risk factor.
Priority issue: oxygenation and perfusion.
S/S: headache, dizziness, visual disturbances, slurred speech, difficulty swallowing.
Nursing Diagnosis: Ineffective cerebral tissue perfusion related to interruption of blood flow as evidence by restlessness, altered mental status, and intracranial pressure.
Maintain adequate oxygenation
Assess for a decline in neurologic deficit
Immediately following ischemic stroke, use drugs to lower BP
Monitor fluid and electrolytes
Keep hydrated 1500-2000ml/day
Avoid solutions with glucose and water because it can increase cerebral edema and and ICP.
More likely to occur in hemorrhagic strokes
Keep HOB elevated, maintain head and neck alignment, and avoid hip flexion.
Treated with anticoagulants ( Coumadin) and platelet inhibitors (Plavix, aspirin)
Coordinating Client Care
Change of Shift report:
Who will you see first? You want to choose…
A, B, C
Systemic before local (“life before limb”)
Acute before chronic .
Actual problems before potential future problems.
Trends versus momentary findings.
Medical emergency and complications versus expected findings.
Apply critical knowledge to procedural standards to determine priority action.
Prioritizing Care in
the Emergency Department
Parent of a minor, legal guardian, court-specified representative, spouse or closet available relative that has durable power of attorney can grant consent.
Consent for Minor
Minors how are independent from their patents (married) can consent for themselves.
To witness the clients signature and to ensure that the informed consent has been appropriately obtained.
Legal Rights and Responsibilities
How to manage a safe environment?
Make sure restrained ordered for shortest duration necessary and if only less restrictive measured have been proved insufficient.
Replace restrains frequently every 15-30 mins to allow for circulation and assess for the need of food, fluids, comfort, and safety.
At least every 2 hours perform neurosensory checks (circulation, sensation, mobility), monitor vitals, and perform ROM of extremities.
Safety & Infection Control
Home Safety for Toddlers (1-3yrs):
Small objects should be kept out of reach (coins, grapes, candy, toys, balloons)
Keep sharp objects away, cabinets and boxes locked, and electric outlets covered.
Safety gates across stairs
Crib mattresses at lowest position.
Appropriate use of crutches:
Support body weight at the hand grips.
Elbows flexed at 30 degrees.
Position crutches on the unaffected side when sitting or rising from a chair.
Good leg goes first when walking upstairs then bring crutches up to the same step; bad leg goes first coming down the stairs. The crutches move with the bad leg going down the stairs.
Handling Hazardous and Infectious Materials
It’s an infectious disease by a bacteria called Bacillus Anthracis.
Ciprofloxacin (Cipro) is the drug of choice.
It commonly involves the skin, GI tract, or lungs.
Cutaneous anthrax is most common. It’s caused by spores that can be found in infected animals.
Inhalational involves spores reaching the lungs through the respiratory tract. This commonly occurs when workers breathe in the spores.
If anthrax is used as a bioterrorism act, people need to be isolated if any symptoms or visible powder is seen.
Symptoms include: Begins with fever, malaise, headache, cough, shortness of breath, and chest pain. Fever and shock may occur later.
Safe Use of Equipment
What are some safe ways to use oxygen therapy in respiratory management?
Make sure oxygen is delivered at the lowest liter flow.
Humidifier if over 4L.
Promote turning, coughing, deep breathing, use of incentive spirometry, and suctioning.
Auscultate the lungs for adventitious sounds such as crackles and wheezes.
Watch for oxygen toxicity….
Substernal pain, nasal stuffiness, N/V, fatigue, headache, and hypoventilation.
For patients with COPD watch for oxygen-induced hypoventilation which is caused by high levels of oxygen.
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Appropriate Cleansing Agents:
Chlorahexidine, povidone-iodine, or parachlorometaxylenol (PCMX).
Applies to all body fluids (except sweat), non-intact skin, and mucous membranes.
Gloves a worn if touching body fluids, skin, and mucous membranes is expected.
Masks, gown, and/or eye protection is required if there is a potential for splashing.
Hand hygiene can be done by handwashing or using an alcohol-based product.
Before and after care
At least 15 seconds
List of Restraints/Safety Devices
Never be used a punishment.
Never interfere with treatment.
Be used when all other interventions have failed.
The nurse should…..
Obtain an order within 1 hour of application of restraints.
Have the provider rewrite and assess the need for elongating the application of restraints every 24 hours.
Assess the patient every 15-30 minutes, provide neurosensory checks, offer food, . water, ROM exercises, and monitor vital signs
Health Promotion & Maintenance
Food choices for toddlers…..
Provide finger foods to increase autonomy.
24-30oz of milk per day
Juices 4-6 oz per day
Avoid chocking hazard foods. These usually are anything that has a skin (nuts, grapes, hot dogs, peanut butter, raw carrots, popcorn).
Avoid snacks high in sugar
Cut food into bite size pieces
Provide a regular mealtime and nutritious snacks.
Correct Use of Condoms
Some facts about condoms…..
It can be used with spermicidal gel cream to increase effectiveness.
There is a high rate of noncompliance.
It does not provide a 100% guarantee that pregnancy will not occur.
Only water-soluble lubricants should be used be used to avoid breakage.
Withdrawal from Sedatives
Start within 4-12 hrs, peak after 24-48hrs
Symptoms: abdominal cramping, vomiting, tremors, restlessness, increased heart rate, blood pressure, respiratory rate, temperature, and tonic-clonic seizures.
Treatment: Benzodiazepine (Librium, Diazepam, Ativan) – maintain vital signs, decreases risk for seizure, and decreased symptoms.
Symptoms: anxiety, insomnia, hypertension, diaphoresis, and sometimes seizure acitivity.
Treatment: Diazepam or Chlordiazepoxide.
keep side rails up, quite environment, prevent falls, watch for signs and symptoms of bleeding because liver might be compromised.
Pentobarbital (Nembutal), Secobarbital (Seconal).
Abdominal cramping, vomiting, tremors, restlessness, inability to sleep, increased BP, HR, Temp, and RR.
Treatment: Tegretol (decreases seizures), clonidine (decreases seizures, BP, HR, and diaphoresis), and Propranolol (decreases BP, HR, and diaphoresis).
Post-Traumatic Stress Disorder
What is PTSD?
A person witnesses or experiences an actual event that threatens severe injury or death to themselves or others.
The onset of symptoms are delayed for 3 months or may not even occur until years later.
What should the nurse do?....
Provide safety and comfort.
Remain with the client.
Provide safe environment for other clients.
Use therapeutic communication.
Provide a structured environment.
Use relaxation techniques.
Use modeling to help demonstrate appropriate behavior in a stressful situation.
Use Systemic desensitization (exposing client to increasing levels of anxiety provoking stimuli).
Use cognitive reframing (replace negative self-talk)
Provide group and family therapy.
Provide medications such as:
Antidepressants :Zoloft, Diazepam, Prozac, Celexa
Serotonin norepinephrine reuptake inhibitor : Effexor
Bipolar Disorder: Manic Phase
What is this?
Bipolar Disorder is a mood disorder in which the person experiences episodes of depression and mania.
Occurs usually in late adolescents/early adulthood.
What can be a nursing diagnosis?...
Risk for injury related to elevated mood as evidence by irritability, impulsivity, attention-seeking behavior.
Focus on safety
Assess for suicidal thoughts
Monitor sleep, fluid intake, and nutrition (patient should have at least 4-6 hrs of sleep).
Provide rest periods.
Can give medications
Mood stabilizers: lithium carbonate, klonopin, Tegretol, neurontin.
Bezodiazepines: Lorazepam (Ativan) for short-term in cases where patient is sleep deprived.
Schizophrenia: Expected Findings and Signs & Symptoms
Schizophrenia is a group of psychotic disorders that affect thinking, behavior, emotions, and ability to perceive reality.
Diagnosis can’t be made until after age 7 to rule out ADHD.
There are positive and negative symptoms…
Positive: hallucinations, delusions, alterations in speech, bizarre behavior.
Negative: affect (usually blunt or flat facial expression), Alogia (only mumbles or responds to questions vaguely), Avolition (lack of motivation in activities), Anhendonia (lack of pleasure or joy), Anergia (lack of energy).
There are also Cognitive and depressive symptoms
Cognitive: disordered thinking, inability to make decisions, poor problem-solving ability, memory deficits.
Depressive: hopelessness, suicidal ideation.
Schizophrenia: Expected findings
Expect the client to have one of the different types…
Paranoid: suspicion toward others.
Disorganized: withdrawal from others; inappropriate behavior.
Catatonic: abnormal motor movements.
2 stages: withdrawn stage (appears comatose, waxy flexibility) & Excited stage ( constant movement, incoherent speech).
Residual: two or residual symptoms such as anhendonia, alogia, odd behaviors, impaired role function.
Undifferentiated: has symptoms of schizophrenia but doesn’t meet criteria of any type. Both positive and negative symptoms can be present.
Anxiety Disorder: Priority Intervention
What is the priority intervention?...
To keep the patient safe and reduce stimuli
Talk in a clam manner
Use therapeutic communication
Remove client away from anxiety provoking stimuli
Monitor for and protect from self harm
Help client develop realistic goals for the future.
Basic Care and Comfort
Post-operative care following disorders & cancers of male reproductive system
These include: testicular cancer, benign prostatic hypertrophy, prostate cancer.
So what are some post-op care?....
Testicular caner: manage pain with analgesics and ice packs, observe for signs and symptoms of infection, instruct client to avoid heavy lifting, importance of performing testicular self-examinations, help re-establish positive body image.
What is an ileostomy?....
It is a surgical opening into the ileum to drain stool.
It is performed when the entire colon must be removed due to a disease, Crohn’s Disease.
How do we care for it?...
Monitor for leakage because skin integrity is important.
Assess appearance of stoma. It should be pink and moist.
Apply skin barriers such as stoma adhesive paste.
Empty bag when it is ¼ to ½ full.
Teach client the signs and symptoms of dehydration, including thirst, dry tenting skin, abdominal cramps, rapid heart rate, confusion and low blood pressure.
If the ostomy involves the small intestine , the client should avoid high-fiber food for first 2 months (want to avoid blockages!), chew food well, and drink fluids.
By 12 yrs of age, the child should be eating adult portions.
Avoid fast food and
Follow “my pyramid”
School-aged Child (6-12yrs): Nutritional Status
Crohn’s Disease: Food Options
Whether it’s from allergies, genetic predisposition, infection, immune disorder or lymphatic obstruction; the inflammation spreads slowly. Lymph node become enlarged and the block flow to the submucosa. Because of this, edema, fissures, and mucosal ulcerations “skipping lesions” develop. Fibrosis thickens the bowel wall, diseased bowel segments become scattered with healthy ones, and the diseased parts of the bowel become thicker, narrow, and shorter. (Lippincott, 2007).
Nursing care & food options?...
Eat foods high in protein, calories and low in fiber.
Avoid caffeine and take multivitamins that have iron.
Assist the client in identifying trigger foods.
Inform if fever, severe abdominal pain, vomiting (bowel obstruction or perforation) to seek emergency care.
Treatment of venous thrombosis and thrombus formation.
Prevent recurrent myocardial infarction or transient ischemic attacks.
Side effects?... Hemorrhage, hepatitis, and toxicity/overdose.
Monitor vitals, signs and symptoms of bleeding (increased HR, decreased BP, petechiae, tarry stools),
Obtain baseline PT (therapeutic 18-24 sec) and INR (2-3), administer vitamin K (mephyton) if overdose in small doses in a dilutes solution (0.5-1mg IV or 2.5mg PO), monitor liver enzymes.
Avoid using aspirin, heparin, acetaminophen, glucocorticods, and sulfonamides because it increases warfarin effects = risk for bleeding.
Avoid Tegretol, Dilantin, oral contraceptives , and excessive vitamin k = risk for decreasing anticoagulation effects.
Maintain constant intake of vitamin K but do not exceed (dark green leafy veggies)
Pharmacological and Parenteral Therapies
Assessing for Nephrotoxicity
Some antibiotics that can affect protein synthesis and thus prevent/slows growth of micro-organisms are:
Tetracyclines (Sumycin, Viramycin)
Aminoglycosides (Gentamicin, Amikin)
Complication of aminoglycosides.
Due to high doses.
Results in proteinuria, casts in urine, dilute urine, elevated BUN, and creatinine levels.
Lithium is used to control episodes of acute mania, helps prevent the return of mania/depression, and decreases the incidence of suicide.
Can also be used for alcoholism, bulimia, and schizophrenia.
Medication Interactions include…
NSAIDS [ibuprofen, celebrex]…..increases renal absorption of lithium = toxicity.
Anticholinergics [antihistamines, tricyclic antidepressants]….can cause urinary retention and polyuria = abdominal discomfort.
Diuretics = excretion of sodium = toxicity.
Drink 2,000ml – 3,000ml of water per day day.
What should be monitored??
Plasma lithium levels. Lithium blood levels obtained 12hr after last dose in the morning.
Initial treatments levels should be 0.8-1.4mEq/L
Maintenance level 0.4 – 1.0 mEq/L
Plasma levels > 1.5 = toxicity
Monitor Sodium. Make sure client is consuming adequate amount. Lack of can cause dysrhythmias.
Obtain baseline T3, T4, and TSH because long term can lead to Hypothyroidism (administer Synthroid)
Early signs of toxicity [less than 1.5 mEq/L] : Diarrhea, N/V, thirst, polyuria, muscle weakness and slurred speech.
Advanced signs [1.5-2.0] : GI distress, N/V, diarrhea, confusion, poor coordination and coarse tremors.
Discontinue medication. Administer new dose based on serum lithium levels.
Severe toxicity [2.0-2.5] : extreme polyuria and dilute, tinnitus, blurred vision, ataxia, seizures, hypotension that can lead to coma and death from respiratory complications.
Perform gastric lavage or can administer urea, mannitol, or aminophylline to increase rate of excretion
***greater than 2.5 need hemodialysis.
Drug Interactions: Lithium Carbonate
What is this medication used for?
Early onset of labor [20-37 weeks]
Tocolytic therapy that relaxes the smooth muscle of the uterus =inhibits uterine activity.
Pregnancy induced hypertension.
s/s of pulmonary edema, chest pain, SOB, respiratory distress, wheezing, crackles, and/or blood-tinged sputum.
Monitor for magnesium toxicity
Loss of deep tendon reflexes, urinary output <30ml, respirations <12, pulmonary edema/chest pain.
So what’s the antidote??...... Calcium Gluconate
Teach the client to report blurred vision, headache, N/V, or difficulty breathing.
Rheumatoid Arthritis: Risk Factors for Infection
It develops in 4 stages
Synovitis: developed from congestion and edema of the synovial membrane and joint capsule. Lymphocytes, macrophages, and neutrophils gather and continue an inflammatory process. These cells then produce enzymes that breakdown bone and cartilage.
Pannus: This is a thick layer of granulated tissue. It destroys joint capsule and bone.
Fibrous ankylosis: Which is a fibrous invasion of granulated tissue and scar formation. This fills into joint spaces = misalignment, visual deformities, atrophy.
Lastly, fibrous tissue calcifies = bony ankylosis and total immobility.
Arthrocenthesis, NSAIDS, corticosteroids (prednisone).
-Acute/chronic pain related to fluid accumulation and joint distention as evidence by patient reporting of pain, finger deformities, and guarding.
Erythrocyte sediment rate elevated (20-40mm/hr mild, 40-70 moderate, 70-150 severe inflammation).
C-reactive protein elevated and WBC.
RF antibody [1:40 – 1:60]
Morning stiffness apply heat (hot shower), pain in hands (use heated paraffin), edema (cold therapy), encourage physical activity, provide safe environment, conserve energy.
Clients with severe renal disease, hypoaldosteronism.
Concurrent use of potassium-sparing diuretics (spironolactone) or ACE inhibitors such as Lisinopril because they increase risk for hyperkalemia.
Used to control blood pressure, HTN, heart failure, decrease risk of myocardial infarction, and diabetic/nondiabetic nephropathy.
Captopril, Vasotec, Monopril, Lisinopril.
Blocks the production of angiotensin II, which causes vasodilation, excretion of sodium and water, and retention of potassium.
Improves BP, cardiac output, urine output, and increases renal perfusion.
Larger doses [2-10mcg/kg/min] stimulate dopaminergic and beta1-adrenergic receptors, producing cardiac stimulation and renal vasodilation.
These medications prevent the inflammation and dilation of intracranial blood vessels = relieving migraine pain.
An opioid agonist
Used for moderate to severe pain.
How does it work??
It binds to opiate receptors in the central nervous system = depression of CNS, and alteration of perception of painful stimuli.
Side effects: confusion, sedation, dizziness, constipation, hypotension.
Discontinue any MAOIs prior
Avoid any alcohol, antidepressants, antihistamines, and sedatives because this can increase risk of CNS depression.
What to monitor and assess?
BP, pulse, and respirations
Administer laxatives if constipation occurs.
Administer Narcan if respiratory depression
Administer IV slowly [do not exceed 2mg over 3-5mins] because can cause respiratory depression, hypotension, and circulatory collapse.
Pudendal block consists of: Lidocaine or Marcaine.
Administered transvaginally into the space in from of the Pudendal nerve.
Provides local anesthesia to the perineum, vulva, and rectal areas.
It’s administered in the 2nd stage of labor 10-20 mins before delivery.
Compromise of maternal bearing down reflex.
Instruct client about method
Coach when to bear down
Assess perineal and vulvar area postpartum for hematomas.
Reduction of Risk Potential
Actions & Interventions?
X-ray required to check for placement.
Assess site q8h, use 10 ml to flush
For intermittent medication….. Flush before, between, and after with 10ml 0.9% sodium chloride.
Obtaining samples?.....withdraw 10ml of blood, take second syringe and withdrawal 10ml of blood for sample, take third syringe and flush with 10ml 0.9% sodium chloride.
Use transparent dressing.
Monitor for phlebitis (erythema, pain/burning, warmth, edema, slowing infusion rate).
Treatment? Discontinue IV, apply warm compress.
Monitor for occlusion
Flush line at least every 12 hrs with 10ml 0.9 sodium chloride (why? Just as effective as heparinized flush solutions)
Administer Urokinsae (Abbokinase) to lyse obstructions.
Monitor for Thrombosis/Emboli
Flush, don’t force (may dislodge), use large barrel syringe (10cc) to avoid excess pressure.
Infiltration: fluid leaking into surrounding subq tissue
Remove, apply cool compresses.
Put in trendelenburg, left side and give oxygen if client is SOB.
Leave lines clamped when not in use to avoid this.
Osteoporosis: Preventing Injury
What is Osteoporosis?
Metabolic bone disorder that results in low bone density. Osteoporosis occurs when the rate of bone resorption (osteoclast cells) exceed rate of bone formation (osteoblast cells).
Osteopenia [bone mineral density lower than normal] is the precursor.
Risk factors?.... Age over 60, female, postmenopausal estrogen deficiency, family history, history of low calcium, history of high alcohol, long term corticosteroids uses.
S/s?..... Reduced weight, back pain after lifting or bending, restriction in movement, history of fractures, kyphosis.
Chronic pain, acute pain related to fracture, or Impaired physical mobility.
- Remodeling cycle is interrupted and new bone formation falls behind resorption.
Sterile Specimen Collection
A sterile urine specimen can be obtained either by inserting a straight catheter into the urinary bladder and removing urine or by obtaining a specimen from the port of an indwelling catheter using sterile technique.
Empty and clamp drainage tubing for 30 minutes before collection.
Cleanse catheter sampling port with alcohol, Povidone-iodine, or other disinfectant swab.
Insert needle into catheter sampling port and withdraw the amount of urine required.
Transfer urine from the syringe into the specimen container.
Pain Management Priority Finding
Safety for the mother and fetus
Assess for orthostatic hypotension
IV vasopressor (Ephedrine), position laterally, increase IV fluids, and initiate oxygen.
Assess for maternal hypotension
Usually result of epidural block. So….. Administer bolus of IV (at least 500ml Lactated Ringers)
Assess for respiratory depression of newborn from opioid analgesics such as Demerol.
Have Narcan available.
Serum calcium less than 9.0mg/dL
End-stage kidney disease
Inadequate intake of calcium
Signs & Symptoms
Paresthesia of fingers and lips
Hyperactive deep tendon reflexes
Positive Chvostek’s sign (tapping on facial nerve = facial twitching).
Positive Trousseau’s sign (hand/finger spasms with blood pressure cuff inflation).
Decreased HR and hypotension
*implement seizure precautions.
Food high in calcium??
Yogurt, milk, cheese, almonds, green leafy vegetables (turnip)
- Administer oral or IV supplements.
- implement seizure precautions.
Head Injury: Assessing Neurological Status
1hr “golden window” to treat head injuries
Respiratory status is priority! Because brain function diminished within 3 minutes of not having oxygen.
Motor function – squeeze hands
Level of consciousness – provides earliest indication of neurological deterioration.
Cushing's triad (increasing systolic blood pressure with a widening pulse pressure, bradycardia, bradypnea)- produced from increased ICP. Late sign.
It’s commonly caused by E.Coli
If left untreated, it can lead to urosepsis which can cause septic shock and death.
Frequent use of feminine hygiene sprays, tampons, and spermicidal jell
Wet bathing suits
Mentoring Client Response to Moderate(Conscious) Sedation
This sedation produces relaxation. Minor procedures can be performed (dental, endoscopy, bone marrow aspiration, lumbar puncture, suturing, burn debridement)
The client CAN respond to verbal stimuli, retain gag reflex, is easily aroused, and independently maintains own patient airway.
May special attention to…
Cardiac respiratory status
Amnioinfusion is a procedure in which normal saline or lactated Ringers solution is placed into the uterus.
Oligohydramnois: not enough amniotic fluid
Fetal cord compression
Assist with amniotomy if membranes aren’t ruptured yet.
Warm fluid using warmer prior to infusion.
Promote comfort and dryness because it will continuously leak.
Monitor for urine distention. This can cause FHR changes, and intensify or initiate uterine contractions.
Monitor FHR (120-160bpm).
Don’t remove radiation marks.
Don’t apply powders, lotions, or perfumes to irradiated skin.
Wear soft clothing over irradiated skin.
Gently wash the skin with mild soap and water. Dry using matting motions.
Don’t expose area to sun or heat.
Excessive nausea and vomiting (high human chorionic gonadotropin levels) that is prolonged past 12 weeks of gestation and results in 5% weight loss from pregnancy weight, electrolyte imbalance, acetonuria, and ketosis.
There is a risk for intrauterine growth restriction or preterm birth.
Maternal age younger than 20
Vitamin B deficiency
High stress level
Nursing diagnosis: Imbalanced nutrition: less than body requirements related to frequency of nausea and excessive vomiting; fluid volume deficit related to excessive fluid loss.
Risk Factors for Glomerular Disease
Usually follows an infection. Most common, streptococcal, viral, and pneumococcal.
Occurs 10-21 days post infection.
- Acute poststreptococal glomerulonephritis results from the entrapment and collection of antigen-antibody complexes in the glomerular capillary membrane after an infection. The antigens which can be either endogenous or exogenous, stimulate the formation of antibodies. The circulating antigen-antibody complexes become lodged in the glomerular capillaries and thus glomerular injury occur because they release an immunologic substance that lyses cells and increases membrane permeability. An activated complement attacks neutrophils and monocytes. Membrane damage leads to platelet aggregation and degranulation. This releases substances that increase glomerular permeability. Now, protein and RBC’s can pass into urine. Glomerular bleeding causes acidic urine which turns hemoglobin to methemoglobin and results in brown tissue without clots. The inflammatory process decreases GFR = fluid retention, decreased urinary output, extracellular fluid volume expansion, and hypertension.
Pulmonary Embolism: Effectiveness in Treatment
What is PE?
It is a solid, gaseous, or liquid substance that enters the venous circulation and forms a blockage in the pulmonary vasculature.
Most common is an emboli from DVT.
It’s a medical emergency because there is hypoxia to tissues and impaired blood flow.
- Thrombus formation results directly from vascular wall damage, venostasis, or hypercoagulability of the blood. Trauma, changes in peripheral blood flow or muscle spasms can cause the thrombus (now called embolus) to break free, float to the right side of the heart and enter the lung through the pulmonary artery. The occlusion prevents the alveoli from producing enough surfactant to maintain alveolar integrity. This results in alveoli collapse and atelectasis develops.
Information Provided by
But I did want to mention...
I knew this information all along
Anxiety related to current memory of traumatic event as evidence by patient stating she was assaulted and showing intense fear.
What's the issue?.....safety and constantly reliving the events.
What is happening?
The client continually re-experiences the event through either recollection, dreams, images, flashbacks, illusions, or hallucinations.
The client also becomes increasing arousable, has sleep disturbances, and difficulty concentrating. The client will avoid people or any stimuli that causes the re-experiences of the event.
What are the types?
Duration of symptoms lasts more then a month but less than 3 months.
Duration more than 3 months.
What is the priority issue for patient in manic phase?
Physical illness such as delirium, substance abuse, anxiety disorder, attention deficit hyperactivity disorder (ADHD).
What is the Manic Phase?...
It’s a phase of elevated mood (expansive or irritable).
s/s: decreased sleep, agitation, increase in talking, flight of ideas, poor judgment, demanding and manipulative behavior, and possibility of delusions and hallucinations.
Patient must have at least 4 symptoms of mania and depression for at least two weeks, then they might have bipolar disorder. (Aloi, 2011).
BPH: adjust rate of CBI if bright-red urine appears, observe for and unkink catheter so that bladder spasms don’t occur. Turn off CBI and irrigate with 50ml irrigation solution.
Instruct client not to urinate around the catheter.
Monitor vital signs and urinary output.
Administer stool softeners (Colace, dulcolax), antispasmodics (Phenobarbital), antibiotics, and analgesics.
Once CBI and catheter removed, instruct the client that 150-200ml every 3-4 hours of urine output is expected.
Avoid heavy lifting, drink 12 or more 8oz of water, avoid bladder stimulants like coffee, if urine becomes bloody must stop activity, rest and increase fluid intake.
Prostate Cancer: watch for infection, provide catheter care, administer bladder antispasmodics .
If has a suprapubic prostatectomy, a suprapubic catheter as also placed.
Instruct client to avoid heavy lifting, and to avoid tub baths for at least 2 -3 weeks.
What is Crohn’s Disease?...
This disease is one of three different diseases that all fall under Inflammatory Bowel Disease (IBD). IBD is characterized by diarrhea, crampy abdominal pain, and exacerbations/remission.
Ulcerative Colitis: edema and inflammation, affects entire colon.
Diverticulitis: inflammation of a hernia (diverticula) in the intestinal wall.
It’s an inflammation and ulceration of the GI tract, usually at the distal ileum.
All bowel layers are involved, and the lesions skip.
Most prevalent in ages 20-40.
Weight loss, diarrhea, pain (right lower quadrant).
Alteration in nutrition: Less than body requirements related to anorexia, diarrhea, and decreased absorption of the intestines.
Corticoseroids to reduce inflammation and pain. [Prednisone, Budesonide] – monitor BP, electrolytes and glucose, take with food, avoid crowds (for clients taking immunosuppressants such as methotrexate).
Antidiarrhreals to decrease risk of fluid volume deficit and electrolyte imbalance. [Imodium, Lomotil]
Watch for sx of toxic megacolon (hypotension, abdominal distension, decrease in bowel sounds).
Replace fluids and electrolytes, rest bowel insert NGT, start antibiotics like amipicillin, and IV steroids.
Observe for respiratory depression in older adults.
What is Rheumatoid Arthritis?
It’s a chronic autoimmune disease. It’s a progressive inflammatory disease that attacks joints bilaterally and symmetrically. It normally affects several joints.
It can be caused by: abnormal immune activation, development of immunoglobulin M against body’s own IgG, infection, and lifestyle.
s/s: fatigue, weight loss, low-grade fever, warmth at the joints, morning stiffness, pain at rest and with movement.
Female, age 20-50, genetics, Epstein-Barr virus, stress.
Essential for nerve impulse conduction, muscle stimulation, and regulation acid/base balance.
Used to treat hypokalemia, clients that have vomiting, diarrhea, abuse laxatives, intestinal drainage, and GI fistulas.
The Do’s & Don’t of Potassium supplements….
Do mix powdered formula in at least 4oz of liquid.
Do take tablet of potassium or potassium chloride with a glass of water to avoid GI problems and oral ulcerations.
NEVER administer IV infusion of potassium rapidly = fatal hyperkalemia.
Do use IV infusion pump to control rate.
Don't give faster then 10mEq/L
Do monitor for hyperkalemia (bradycardia, hypotension, and ECG changes)
Do monitor cardiac
Do monitor I&O
Do assess IV site for irritation, infiltration.
If extravasation occurs, affected area should be infiltrated liberally with 10–15 mL of 0.9% NaCl containing 5–10 mg of phentolamine.
Monitor blood pressure, heart rate, pulse pressure, ECG, cardiac and urine output.
If HTN occurs, rate should be decreased.
Tachyarrhythmias and Pheochromocytoma.
Headache, arrhythmias, hypotension, angina, ECG change, palpitations, vasoconstriction.
Don’t use with MAOI’s [Phenelzine (Nardil), Isocarboxazid (Marplan)] or ergot alkaloids (ergotamine, doxapram) because it can result in severe HTN
MAOI'sneed low tyramine diet. (no cheese, soy sause, pepperoni).
Administer Reglan if GI discomfort.
Stop medication if Egotism occur (muscle pain, paresthesias in fingers, and toes; cold, pale extremities).
Don’t take with Imitrex because can cause a spastic reaction of blood vessels.
Serotonin receptor agonist: Sumatriptan (Imitrex)
Can cause chest pressure.
Don’t administer to client that has or is at risk for coronary artery disease because it can cause vasospasms and angina.
Don’t take with MAOIs because it can lead to MAOI toxicity. Do not give Imitrex within 2 weeks of stopping MAOIs.
Beta-Blockers: Propranolol (Inderal)
Inform client to report extreme tiredness, fatigue, depression, and asthma exacerbations. Also bradycardia and hypotension.
Monitor HR and BP, take apical pulse prior.
Monitor ECG because Calan and Cardizem can cause a cardiosuppressive effect.
This medication can mask the hypoglycemic effects of insulin and prevent breakdown of fat.
Anticonvulsants: Divalproex (Depakote)
Monitor liver enzymes =liver toxicity.
Don’t use with benzodiazepines because it can cause CNS depression.
What is this?
It’s an infusion tube located in or near the heart.
What’s it used for?
Giving medications, fluids, nutrients, or blood products.
Nontunneled percutaneous central catheter
Can use up to 3 months, tip in the distal third of the superior vena cava, and administer blood, chemotherapeutic agents, antibiotics, and total parenteral nutrition.
Peripherally inserted central catheter
Can use up to 12 months, advanced until tip reach lower one-third of superior vena cava, and can administer…[same as above].
Tunneled percutaneous central catheter
For long term use, lies in a subcutaneous tunnel. No dressing is needed because entrance to the skin and vein are separate and tissue granulates into cuff, providing a barrier.
Port is surgically implanted into chest wall pocket. Tip of catheter is in the superior vena cava. Used long term, commonly for chemotherapy.
Nursing Care and Injury Prevention?
Ensure client eats adequate amount of calcium and vitamin D, esp. before 35.
Exposes areas of skin to sun 5-30mins twice a week.
Encourage weight bearing exercises to prevent injury.
Instruct client to avoid cold whether
Estrogen (Premarin): Enforce monthly breast self-examination and risk for DVT.
Calcium-carbonate: Give with food and 6oz water, may cause GI upset, monitor kidney stones.
Vitamin D supplements: Increase absorption of calcium. Watch for toxicity: nausea, constipation, and kidney stones.
Bisphosphonates (Fosamax): Inhibits bone resorption. Take with 8oz water early in the morning before eating and remain upright for 30mins. Risk for esophagitis (indigestion, chest pain, difficulty swallowing).
Urinate every 3-4 hours
Ciprofloxacin, Macrobid. Sulfonamides (Bactrim) – make sure not allergic to sulfa.
Take with food, take the prescribed amount.
Phenazopyridine (bladder analgesic): to relieve bladder discomfort.
Continue urology services to manage UTI
Drink cranberry juice
Urinate before and after intercourse.
Abdominal or low back pain, nausea, urinary frequency/urgency, spasms, hematuria, fever
nocturia, cloudy/smelling urine.
Urinalysis, urine culture & sensitivity, WBC above 10,000/mm3
Airway obstruction: Insert airway and suction
Respiratory depression: Apply oxygen and Narcan
Cardiac arrhythmias: Hook up to ECG, provide fluids, and antidysrhythmics.
Hypotension: Provide fluids and vasopressors
Anaphylaxis: Administer epinephrine.
NPO 4 hours before
Establish IV access
Assess LOC and vitals during a procedure.
Have fully equipped crash cart available, oxygen, suctions, ECG monitor.
Have Narcan or Romazicon available to reverse moderate sedation.
LOC as on admission
VS stable for 30-90 mins
Able to cough and deep breathe, tolerate oral fluids, void
Absence of N/V, SOB, or dizziness.
Monitor I&O, skin turgor, weight
Give IV lactated ringers for hydration
Give Vitamin B6 (pyridoxine) injections
Can give Reglan for N/V. TPN may be needed if vomiting returns.
Use corticosteroids to treat refractory Hyperemesis Gravidarum.
Increased pulse rate
Poor skin turgor
Most important test?.... Urinalysis for ketones and acetones (breakdown of protein and fat)
Sodium, potassium, and chloride can be reduced.
Thyroid test can indicate hyperthyroidism
Hematocrit is elevated because of inability to retain fluids.
Restrict food high in potassium during periods of oliguria.
Provide small frequent meals
Monitor for skin breakdown
Restrict fluids during periods of edema and HTN
Monitor and prevent infection
Give diuretics and antihypertensive
Monitor for hypokalemia.
If potassium-sparing diuretics are not used, eat foods high in potassium.
Decreased glomerular filtration rate, anorexia, pallor, distended neck vein, periorbital edema, HTN
Elevated BUN and creatinine
Proteinuria, smoky or tea-colored urine, elevated specific gravity
Recent upper respiratory infection, history of cancer, blood or lymphatic system disorders, heart infections, use of NSAIDs.
Administer oxygen, initiate IV access, monitor LOC, control anxiety, high fowlers.
Administer levonox, heparin, and warfarin
Monitor PT and INR for warfarin
aPTT for heparin
Embolectomy (removal of embolus)
Long-term immobility, oral contraceptives, pregnancy, tobacco use, elevated platelet count, obesity, HF, surgery, advanced age.
Anxiety, impending doom, pain on inspiration, air hunger, tachycardia, hypotension, diaphoresis, decreased O2 stat, petechiae.
Low PaCO2, D-dimer elevated (in response to clot and fibrin)
Nursing diagnosis: Impaired gas exchange related to decreased pulmonary perfusion as evidence by dyspnea, feeling of impending doom, and decreased 02 stat.
Monitor BP after first dose for at least 2 hours to detect hypotension.
Captopril should be taken at least 1 hour before meals. All other ACE inhibitors can be taken with or without food.
Prohibited in clients with renal stenosis, history of angioedema, and use cautiously in clients with renal impairment = neutropenia.
NSAIDS can decrease the antihypertensive effect.
Potassium supplements and potassium-sparing diuretics increase the risk of hyperkalemia.
First-dose orthostatic hypotension if taking diuretic. Stop for 2-3 days prior to start of ACE inhibitor.
Dry cough: medication should be discontinued. This is related to the inhibition of Kinase II which results in bradykinin.
Hyperkalemia: Avoid use of salt substitutes containing potassium.
Angioedema: swelling of tongue and pharynx. Treatment??? Subq injection of Epinephrine.
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Atypical Antipsychotics [+ & -]: Resperidone (Risperdal), Clozapine (Clozaril), Olanzapine (Zyprexa).
Conventional Antipsychotics [+]: Haloperidol (Haldol), Loxapine (Loxitane), Chlorpromazine (Thorazine)
To minimize anticholinergic effects: chew sugarless gum, eat foods high in fiber, and drinl 2-3L of fluid/day.
- Inform symptoms of postural hypotension (lightheadedness, dizziness). If this occurs sit or lie down.
Antidepressants: Paroxetine (Paxil)
-Monitor for suicidal ideation and avoid abrupt cessation.
Anxiolytics/Benzodiazepines [+, -, anxiety]: Lorazepam (Ativan), Clonazepam (Klonopin).
-Blood tests needed to monitor for agranulocytosis.
Nursing Diagnosis: Disturbed sensory perception, risk for injury, anxiety.
Provide structured environment.
Use therapeutic communication to lower anxiety.
Encourage participation in group work.
Ask directly about hallucinations.
Focus conversations on reality-based subjects.
Use symptom management techniques (music, attending activities, walking).
Global Assessment of Functioning (GAF) scale to help determine ability to perform ADLs and function independently.
Patient-related risk factors: age over 60, underlying renal insufficiency, glomerular filtration rate less than 60, volume depletion, diabetes, heart failure, and sepsis.
Treatment: removal of toxin, dialysis if necessary, management of hypertension (ACE inhibitors), restrict sodium intake, adequate hydration, phosphate restriction in chronic renal failure.