UWORLD Review PDF

UWORLD REVIEW  TB and all airborne transmission based precautions (chickenpox, measles) Use a surgical mask not an N95 for clients. This helps protect Health care workers and other clients from respiratory secretions, and contain respiratory secretions The HCWs who transport the clients from a negative pressure room to another location need to wear an N95 mask to protect themselves from infection.  Cirrhosis of the liver. These blood tests would be elevated in the lab results: Ammonia, bilirubin, prothrombin time Elevated bilirubin (jaundice) exists due to the decreased inability of the liver to conjugate and excrete bilirubin Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, the PT, aPTT, and INR levels are elevated.  Total knee replacement A recent/current infection is a contraindication to total replacement surgery as a wound infection is more likely to occur in a client with a preexisting infection. Burning on urination should be investigated as it could indicate a UTI Severe knee pain is expected. Stop taking NSAIDS including selective COX2 inhibitors (celecoxib) 7 days prior to surgery to decrease the risk of intra and post op bleeding.  Transfusion reaction Chills, fever, low back pain, flushing, itching) Stop transfusion immediately, maintain IV line with NS, monitor VS, notify HCP and blood bank, recheck tags numbers and client’s blood type, and return bag to blood bank for further testing. Collect blood and urine sample to evaluate hemolysis, and complete necessary facility paperwork to document the reaction.  Chronic kidney disease with a large plural effusion. Findings : Decreased fremitus Diminished lung sounds A pleural effusion is an abnormal collection of fluid (>1520ml) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully. This results in decreased lung volume, Atelectasis, and ineffective gas exchange. Other s/s: dyspnea on exertion, nonproductive cough, diminished breath sounds, dullness to percussion, and decreased tactile fremitus. If the effusion is large, the trachea is deviated to the opposite side. Sounds travel faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in pleural effusion and Pneumothorax.  Cancer Unintentional weight loss of greater than 10 percent of usual weight (in nonobese) clients require evaluation and could indicate underlying cancer. N, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss. CAUTION acronym of cancer Change in bowel or bladder habits A sore throat that does not heal Unusual bleeding or discharge from body orifice Thickening or lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness Orange peel appearance of breast tissue, or retracted nipple  Restrained client Position sideways or semi fowlers, because supine position can cause risk of aspiration Don’t tie the knot a square knot. Do a quick release knot. Tie to bed frame not bed rail Provide care to meet basic needs every 2 hours  Gout To prevent future exacerbations 1) Achieve and maintain a healthy weight 2) Drink plenty of fluids 3) Limit alcohol consumption and carbonated beverages containing high fructose corn syrup. You don’t need to eliminate all foods with protein. Just red meats and seafood intake  Hip fractures external rotation, abduction, muscle spasm, and shortening of the affected extremity.  Raynaud’s phenomenon An episodic vasospastic disorder of the small cutaneous arteries, mainly of the fingers and toes. Occurs most often in young women age 1540. Vasospasm induced color changes of the fingers, toes, ears, and nose. Decreased perfusion initially causes pallor (white) followed by cyanotic (blue purple) and last color change is red. Coldness numbness, followed by throbbing, aching, tingling, swelling (hyperemic phase). Exposure to cold, emotional stress, and caffeine, and tobacco use may bring on symptoms. Don’t use substances with vasoconstrictive properties Perform stress management  Emphysema Barrel chest, decreased activity tolerance, diminished breath sounds, distant heart sounds Wheezing SOB that worsens over time tachypnea, prolonged expiratory phase Hyperresonance on percussion, pursedlip breathing, use of accessory muscles and use of tripod position  Hyperosmolar hyperglycemic state complications: Blood glucose levels are very high (>600) History of type 2 diabetes. Older age Neurological manifestations (blurry vision, lethargy, obtundation (decreased LOC), progression to coma) Gradual onset of hyperglycemic symptoms (as some insulin is produced) Hyperventilation and abdominal pain less common Bicarb greater than 18 mEq/L Normal anion gap Serum osmolality >320 mOsm/kg Negative or small serum ketones  Diabetes insipidus Insufficient production or suppression of ADH Polydipsia (increased thirst); polyuria (increased urine output) and can lead to dehydration resulting in weight loss, hypernatremia, and high serum osmolality (>295 mmol/kg). Dilute and copious urine (220 L/day) with a low specific gravity (500 mf/day. Good oral hygiene can limit symptoms. Other s/s: ataxia, decreased alertness  Metronidazole Metallic taste in the mouth is common It’s an antibiotic  Trisomy 18 A genetic disorder with a short life expectancy (a few weeks after birth). It’s a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. End of life issues should be discussed early after the diagnosis is confirmed. Trisomy 13 (patau syndrome) also results in death No treatment at this time available  Warfarin Anticoagulant. Range: 2.33.5. Warfarin should only be administered after INR has been checked. Can be given if it is less than 3.5 and should be held and HCP contacted if greater than 3.5. Antidote: Vitamin K  Neutrophils Normal: >1500/mm3 Neutropenic precautions: private room, strict Handwashing, avoid exposure to people who are sick, avoid ALL fresh fruits, veggies, and flowers; ensure all equipment used with the client has been disinfected. Infections in immunosuppressed clients are life threatening Avoid IM injections and minimize venipunctures when platelet count is below 50,000 as these can cause prolonged bleeding  Blood lead levels Common source is lead based paint found in houses built before 1978. Screenings are recommended at ages 1, 2, and up to 6, if not previously tested. Lead poisoning particularly affects the neurological system, due to immature development of the brain and nervous system. This is more concerning than the other effects. Can cause neuro impairment, developmental delays, reading difficulties, visualmotor issues; can lead to permanent cognitive impairment, seizures, blindness, or even death. GI bleeding is for iron toxicity not lead poisoning. Lead poisoning is the most threatening to the kidneys and neuro system (developmental delays, cognitive impairment, seizures). Liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome.  Asystole Total absence of ventricular electrical activity (pulseless, apneic, unresponsive) Treatment: CPR, ACLS, epinephrine and/or vasopressin, advanced airway use, and any reversible treatment. Vasopressin is a vasopressor, that increases vasoconstriction and MAP  SIDS Sudden unexplained death of an infant age 20/min WBC >12,000/mm3; 10% immature (band) forms Additional s/s: SBP: 140 mg/dL) Early therapy: aggressive fluid resuscitation and early administration of antibiotics. Can occur as a complication of pneumonia who don’t respond to a/b care. It is caused by the entry of bacteria from the alveoli into the bloodstream. It can progress to septic shock and/or multisystem organ dysfunction syndrome. To limit progression assess oxygenation (pulse oximeter, ABGs); airway (patency); breathing (resp pattern and rate); circulation (vital signs); tissue perfusion (LOC, cap refill, skin temp and color, bowel sounds) and urine output. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the GI to the vital organs. Prolonged cap refill (>34 seconds in an adult) indicates inadequate blood flow to peripheral tissues. Serum glucose >140: gluconeogenesis occurs in response to the physiologic stress of infection. insulin resistance is associated with anaerobic metabolism Kidney Biopsy Bleeding is a major complication following the procedure. Pre procedure: client must give consent and d/c all anticoagulants (heparin, warfarin, rivaroxaban) and antiplatelet agents (aspirin, clopidogrel, NSAIDS) for atleast 1 week Post procedure: monitor v/s at least Q15 mins for the first hour as tachycardia, tachypnea, and hypotension can indicate blood loss. Assess puncture site dressing for bleeding. BUN and creatinine levels would not change much within 3060 mins. These are usually measured once every 24 hours and rarely every 12 hours. Inserting an indwelling urinary catheter is not necessary to perform a kidney biopsy. Place prone during procedure to facilitate access to kidney Place on affected side after procedure to provide pressure and help prevent bleeding. Bed rest for 24 hours Statins Prior to starting therapy with statin drugs, the client’s liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug induced hepatitis and increased liver enzymes. Drug can also cause muscle aches, and rarely severe muscle injury (rhabdomyolysis). Educate client to report the development of muscle pain while on therapy. Assessing muscle strength or dietary intake prior to therapy is not necessary. May slightly increase serum digoxin levels, but is not essential to determine this before therapy is started. Acute urinary retention Treated with rapid, complete bladder decompression instead of intermittent urine drainage. This can lead to Hematuria, hypotension, and diuresis. Maintaining perfusion and adequate blood pressure is the priority concern. Bradycardia is also a complication Pessary is a vaginal support device recommended for pelvic organ prolapse. Chronic Kidney Disease Decreased glomerular filtration rate, resulting in fluid, K, and phosphorus retention. Fluid retention is initially treated with Na restriction and diuretic therapy. Dietary adjustments should also be made to reduce serum K and phos levels. Dairy products (milk, yogurt) and certain fruits (banana, oranges, coconuts, watermelons, and avocados) contain high K. Allowable foods: apples, pears, grapes, pineapple, blackberries, blueberries, plum Lasix(furosemide) Potassium depleting loop diuretic. Hypokalemia can lead to heart palpitations and/or dysrhythmias. Bladder cancer: Tell tale symptom: painless Hematuria. Primary cause is cigarette SMOKING or other tobacco use Occupation cal carcinogen exposure is the second most common factor (printing, ironing, and most aluminum processing, industrial painting, metal work, machining, and mining). Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors) Other risk factors: high fat diet and artificial sweeteners Influenza Has an incubation period of 14 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 57 days after illness stage begins. Transferred through inhaling airborne droplets (sneezing, coughing, speaking) and DIRECT CONTACT Wear a mask if contact with infected person is unavoidable. Those with influenza cannot transmit the virus during the incubation period and illness stage of the infection. Avoid close contact with others during illness stage, esp those with impaired immune system TB Gram positive acid fast bacillus (mycobacterium tb) Transmitted airborne droplets (cough or sneeze in the air, or exhaling breathing, singling talking, laughing) Need standard and airborne transmission precautions and wear a highefficacy particulate or N95 resp. Mask. PTB Not spread with contact of clients blood, urine or soiled clothing, bed linens, or eating utensils 85% pulmonary, but can also be extra pulmonary (meninges, genitourinary, bone and joints, GI) Symptoms: Low grade fever Night sweats Anorexia and weight loss Fatigue Pulmonary TB: cough, purulent or blood tinged sputum, SOB Genitourinary TB: Dysuria Liver involvement jaundice, but also as a side effect to TB drugs (Isoniazid) Spinal tb: back pain Cardinal (major) constitutional (minor) s/s/ Dyspnea and hemoptysis seen in later stages Classic signs of TB can be absent in immunocompromised clients and the elderly. Vancomycin to an MRSA infected client Check the Bun and creatinine before administering the drug (23 times a week) d/t increased risk of nephrotoxicity especially in those that are >60 y/o and have an impaired renal function. Vancomycin is excreted by the kidneys. It is used to treat gram positive (MRS and diarrhea associated with C.Diff). Normal BUN levels: 718 mg/dL Normal creatinine level: 0.61.2 md/dL An increased glucose level is expected in clients with an infection due to physiological stress and gluconeogenesis. Does not need to be reported to the HCP. An elevated WBC count is expected and not needed to be reported. Hemoglobin levels: 13.517 g/dL in men; 1216 in women). Magnesium levels: 1.52.5 mEq/L Antiplatelet therapy (aspirin, clopidogrel, prasugrel, ticagrelor) Initiated to prevent platelet aggregation in those at risk for MI, stroke, or other thrombolytic events. This therapy increases the risk of bleeding. Assess for bruising, tarry stools, and other signs of bleeding. It can cause thrombotic thrombocytopenia purpurea. Baseline liver enzymes assessment is not needed Statins and Isoniazid (for TB) Assess baseline liver enzymes Cystoscopy Pink tinged urine, frequency, and Dysuria are expected for up to 48 hours following a cystoscopy. Need to increase fluid intake (drink 46 glasses of water to help dilute urine) Avoid alcohol and coffee for 2448 hours as this can irritate the bladder Abdominal discomfort and bladder spasms may occur for up to 48 hours following procedure. Frequent complications: retention, hemorrhage, infection. Notify the doctor if there is any bright red blood when urinating, blood clots, inability to urinate, fever >38C and chills/abdo pain unrelieved by analgesia. Tub/sitz bath to relieve discomfort/pain (except with recurrent urinary tract infections) Meningitis Inflammation of the meninges covering the brain and spinal cord. Key s/s: fever, severe headache, N,V and nuchal rigidity. Other s/s: photophobia, decreased LOC, and ICP Diagnosis done through: lumbar puncture which assesses the CSF. As the client is hypotensive and septic, they first need to be given treatment in the following order: 1) initiate fluids 2) blood cultures taken for antibiotics 3) a/bs given stat 4) head CT scan after the client’s BP is normal and treatment with fluids/vasopressors is normal to rule out ICP (altered mental status, seizures, neuro effects) and brain herniation risk. 5) Lumbar puncture West Nile Virus Mosquito borne disease (encephalitis) that occurs mainly during the summer months, especially during humid weather. Use insect repellant and prevention methods (long sleeves, long pants, light colours, avoid outdoor activities at dawn and dusk when mosquitoes are most active). Transmitted through an infected mosquito bite Hep A and typhoid Transmitted fecal, oral and through contaminated food, water Ringworm Superficial fungal(tinea) skin infection that mostly affects scalp or feet (athlete’s foot) Limit contact with infected pets Spread through contact and indirect contact Fungus thrives in warm, moist areas. s/s: itchy, red, raised, scaly patches that may blister or ooze. Sharply defined edges. Red on the outside normal skin on the inside, looking like a ring. Tests: KOH exam, skin biopsy, skin culture, skin observation Keep skin clean, dry. Apply antifungals (miconazole, ketoconazoletc); shampoo regularly, especially after haircuts, do not share personal items, wear sandals and shoes at gyms, lockers, pools, avoid touching pets with bald spots. Allergies/asthma (from mites) or scabies (contagious skin infection by mites) Wash bedding in hot water Ur ine testing Clear catch or midstream urine samples are collected for urinalysis or urine culture and sensitivity testing. Creatinine clearance test: all urine for 24 hours must be collected. The first urine specimen is discarded in a container and kept cool and the time is noted. After 24 hours, the client should void one last time and add the specimen to the container. Blood is also drain to measure the creatinine level. Creatinine clearance is the measure of the glomerular function and is a sensitive indicator of renal disease progression. An in an out catheter (straight catheter) is used for any rest requiring a urine specimen when the client is unable to urinate or unable to follow the specimen collection procedure. A catheter is also used for a cystourethrogram or a residual urine test. The first AM void is preferable for a urinalysis or urine culture and sensitivity as an overnight specimen is more concentrated. Infected endocarditis: Check temperature regularly as persistent elevations could mean the a/b therapy is ineffective or complications have developed. Client should notify HCP if fever persists at home. Client has risk of reoccurrence. They should receive prophylactic a/b before high risk procedures. Vegetations on valves and surfaces can form, and embolization to various organ sites can occur. Slurred speech could indicate that this has occurred, and could lead to a possible stroke. s/s: one sided weakness, slurred speech, paralysis, painful, cold extremities. a/bs for up to 46 weeks. Morphine sulfate N, V are expected s/e of opioid meds when treatment is initiated. But, tolerance develops quickly and persistent Take an antiemetic with the pain med. N, V less likely to occur in a recumbent position, and risk increases by 40% in clients who are up and walking. Taking meds on empty stomach may increase risk of N N, V decreases when the pt lies in a flat position Pain In the right lower quadrant: appendicitis. Pain starts in periumblical region and migrates to the McBurney’s point. Client will attempt to decrease pain by lying still, with right leg flexed and preventing intra abdominal pressure (avoid coughing, sneezing, deep inhalation) In the left lower quadrant: diverticulitis (often in the sigmoid colon). Other s/s include palpable tender abdominal mass, and systemic symptoms of infection (fever, increased C reactive protein, and Leukocytosis with a left shift) C reactive protein: a by product of inflammation; a globulin that is found in the blood in some cases of acute inflammation. It’s a protein made by the liver and released within a few hours of tissue injury, start of infection/cause of inflammation. Pain in the right upper quadrant referred to the right scapula: acute cholecystitis. Also experience indigestion, N, V, restlessness, and diaphoresis Small Bowel Follow Through (SBFT) Examines the anatomy and function of the small intestine using Xray images taken in succession. Barium is ingested and xray images are taken every 1560 minutes to visualize the barium as it passes through the small intestine. This can help identify decreased motility, increased motility, fistulas, and obstructions. Clients should follow these instructions: fast 8 hours prior to the exam. Polyethylene glycol is prescribed as bowel prep for a colonoscopy NOT an SBFT. the test usually takes 60120 mins, but it can take longer if obstruction or decreased mot. Occurs drink plenty of fluids after the exam to help remove barium. Chalky stools may be present for 2472 hours after the exam. If brown stools don’t return after 72 hours or abdo pain or fullness is present, contact HCP Black tarry stools are not expected, it can indicate a GI bleed. Report stat to HCP Endoscope is not used for this test Celiac disease a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food. This damage makes it hard for the body to absorb nutrients, especially fat, calcium, iron, and folate. Gluten is a form of protein found in some grains and should be eliminated from diet. This reduces the risk for nutritional deficiencies, and intestinal cancer (lymphoma). s/s: abdo bloating, pain, gas, diarrhea, pale stools, weight loss; skin rash, iron deficiency anemia; muscle cramps, joint and bone pain. Growth problems and failure to thrive. Seizures, tingling sensation (caused by nerve damage and low calcium); sores in mouth; missed menstrual periods gluten foods: wheat, rye, barley, oats. Processed foods (chocolate, candy, hot dogs) may contain hidden sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Rice, corn, and potatoes are allowed. Salem Sump Tube Checking for residual volume is not appropriate as the sump is attached to continuous suction for decompression and is not being used to administer enteral feeding. The air vent (blue pigtail) must remain open as it provides continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). If the gastric content refluxes, 1020 ml of air can be infected into the vent. And the vent is kept above the level of the client’s stomach to prevent reflux. Place in semifowler’s position to keep the tube from lying against the stomach wall to help prevent reflux. Provide mouth care every 4 hours to help maintain moisture of oral mucosa and promote client comfort. Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds Inspect the drainage system for patency (tube kinks, blockage) Hiatal hernia Occur d/t a weakened diaphragm and increased intraabdominal pressure. The interventions are similar to those for GERD and focus on decreasing intraabdominal pressure. Diet mod: avoid high fat foods, and those that decrease lower esophageal sphincter pressure (chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals; decrease fluid intake during meals to prevent distention. Avoid meals close to bedtime and nocturnal eating. Lifestyle changes: smoking cessation, weight loss Avoid lighting/straining Elevate the HOB to 30 degrees: this can be done at home using pillows or 46 in blocks under the bed. Wearing a girdle or tight clothes increases pressure and should be avoided. Colostomy care: Ensure sufficient fluid intake (at least 3,000 ml/day unless contraindicated) to prevent dehydration. Identify times to increase fluid requirements (hot weather, increased perspiration, diarrhea) Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, Brussels sprouts) Empty pouch when it becomes 1/3 full to prevent leaks due to increasing pouch weight PPIs (pr oton...) Are associated with decreased bone density (calcium malabsorption) which increases the possibility of fractures of the spine, hip and wrist. It causes acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper GI tract. This leads to increased risk of pneumonias. It can also increase the risk of Cdiff associated diarrhea. Unclear cause. Receiving a/bs for a UTI will further increase risk of C diff infection. Take medication prior to meals. PPIs don’t affect BP Increase calcium and vitamin D intake to prevent osteoporosis. Phenytoin Anticonvulsant Toxicity: gait disturbances (ataxia) Bisphosphonate (Alendronate, risedronate) Bisphosphonates are a class of drugs that prevent the loss of bone mass, used to treat osteoporosis and similar diseases Drink extra water and stay upright for 30 mins after taking the drug to prevent esophagitis. Jaw necrosis is a toxicity s/s Lithium (mood stabilizing drug) and Albuterol (bronchodilator, short acting betaagonist) Toxicity: tremors Dialysis Peritonitis is the most common complication of dialysis. Chills may indicate elevated temp (sign of infection) and rebound tenderness a sign of peritonitis (inflammation of the peritoneal cavity, with cloudy effluent). Abdo pain also present. Assess peritoneal fluid for C&S. Clients receiving peritoneal dialysis often have diabetes, and glucose (dextrose) is the osmotic agent in dialysate. Monitor glucose levels closely. Regular insulin can be added to the dialysate before the solution is instilled or it can be administered subQ to control glucose levels. Ulcerative colitis Chronic disease , inflammation of the large intestine Results in urgent, frequent bloody diarrhea; abdo pain, anorexia; and anemia. The gFOBT (guaiac fecal occult blood test) Correct sequence of test: Obtain supplies, wash hands, don nonsterile gloves Open the slide’s flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the side Wait 35 mins Open the back of the slide and apply 2 drops of developing solution to the boxes on the side Wait 3060 seconds Document the results in the EMR This test is used to assess the microscopic blood in the stool and as a screening tool for colorectal cancer. Assess recent consumption of red meat or Vit C in the last 3 days, or using certain meds (aspirin, anticoagulants, iron, ibuprofen, and corticosteroids) as they can interfere with the results. If the test paper turns blue, the test is positive and the stool contains blood. Exacerbations tested for HF BNP: B –type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles d/t increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany with HF. Elevation of BNP >100 pg/mL helps to distinguish cardiac from resp causes of dyspnea. MAP Average pressure within the arterial system felt by the vital organs. A MAP > 60 is necessary to adequately perfuse and sustain the organs. When it falls below this number, the organs can be underperfused and become ischemic. Normal MAP: 60105 mm Hg. Formula: SBP + (DBP X2) / 3 Systemic Lupus An autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. Mild (skin, muscles, joints) Severe (affecting kidneys, heart, lung, blood vessels, CNS) Lupus nephritis: increased creatinine, BUN, and abnormal urinalysis (protein RBCs, cellular casts). A positive ANA (antinuclear antibody titer, >1:40); elevated ESR; anemia, mild leukopenia (220/120. Need to lower the BP gradually, and the SBP should not fall below 170. Torsades de pointes Ventricular tachycardia, due to increased magnesium Occurs with haloperidol, methadone (analgesic) , ziprasidone( antipsychotic), erythromycin (antibiotic to treat gram positive infections, similar in effects to PCN) Spironolactone (Aldactone) K sparing diuretic BNP Hormone released by the heart muscle in response to mechanical stress (stretching). BNP levels are usually elevated (>100 pg/ml) in clients with HF, and the prescription of Lasix is expected. Atrial Fib Total disorganization of atrial electrical activity resulting in the loss of effective atrial activity resulting in the loss of effective atrial contraction. Atrial rate can be 350600/min. P waves are not visible. They are replaced by fibrillatory waves. Ventricular rate varies, but the rhythm is typically irregular. Results in: decreased CO, d/t loss of atrial kick and/or a rapid ventricular response. Clots may form in the atria, putting the client at an increased risk of stroke. Treatment: rate control, and anticoagulation. Atrial Flutter Recurring, regular, sawtoothedshaped flutter waves. Rate: 200350 Complete Heart Block The presence of more P waves than QRS complexes. The PR interval is variable. There is no communication between the atria and ventricles. Each is firing independently at each other. MVP (mitral valve prolapse) may have palpitations, dizziness, and lightheadedness. Chest pain can occur, but its etiology is unknown in this client population. Chest pain does not typically respond to anticoagulant treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Interventions: Adopt healthy eating habits and avoid caffeine as it stimulates and may exacerbate the symptoms Check OTC meds or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms. Reduce stress, and avoid alcohol use. Begin an exercise program, preferably aerobic exercise, to achieve optimal health. A/bs is indicated for clients who have prosthetic valve replacement, repaired valves, or a history of infectious endocarditis, as MVPs may place the client at an increased risk for infective endocarditis. Prophylactic a/b before dental procedures are not indicated. No need for a medical alert bracelet, as MVPs are usually a benign condition. beta blocker any of various drugs used in treating hypertension or arrhythmia; decreases force and rate of heart contractions by blocking betaadrenergic receptors of the autonomic nervous system Coronary Arteriogram (angiogram) Invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. Client should have an IV line started for sedating meds. The femoral or radial artery will be accessed during the procedure. General anesthesia is not given. Instruct the clients: Do not eat or drink anything 612 hours prior to the procedure (depending on the particular health care provider performing the procedure) Client may feel warm or flushed while the contrast dye is being injected Homeostasis must be obtained in the artery that was cannulated for the procedure. Mostly the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure homeostasis. If the procedure is just a diagnostic study, the client will often go home the same day. Hospitalization for 13 days may be required if angioplasty or stent replacement is performed. Automatic dysreflexia (hyperreflexia) Massive, uncompensated cardiovascular reaction by the SNS in spinal injury at T6 or higher. Due to an injury, the PNS cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum d/t bladder irritation, bowel impaction. S/s: severe HTN (up to 300 mm Hg systolic) , throbbing headache, diaphoresis above the injury level, Bradycardia (3040/min) , piloerection (goose bumps), nausea and flushing. This is an emergency situation requiting immediate intervention to prevent hypertensive stroke and seizures. Management: Raise HOB and then treat the cause. Catheter the pt if needed, and assess for kinks in existing catheters Perform digital rectal exam. Remove constrictive clothing to decrease skin stimulation. Contact HCP Alpha adrenergic blocker, or an arteriolar vasodilator (Nifedipine) may be prescribed. Elevate HOV to 45 degrees or High fowlers to decrease HTN. The Sim’s position is supine and sidelying and not the right position. Myasthenia gravis Autoimmune disease muscle weakness and ptosis. Weakness increases with activity, and ptosis is present at the end of the day. These are expected findings. Respiratory failure is possible, so monitor closely. Transverse myelitis (spinal cord inflammation) Usually results from a recent viral infection. classic symptoms include paralysis, urinary retention, and bowel incontinence. Some recover, others have permanent disability. Normal muscle strength: 5 on a 05 scale. Weakened muscle strength (2+ means only able to move laterally, not able to lift up against gravity.. this is expected. PSVT (paroxysmal supraventricular tachycardia HR: 150220/min Prolonged episodes can = hypotension, palpitations, dyspnea, angina Treatment: Vagal maneuvers (valsalva, coughing, carotid massage) Adenosine is the DOC, administered rapidly via IVP over 12 seconds and followed by 20 ml saline bolus d/t it’s short halflife. An increased dose can be given twice if the previous admin. Is ineffective. (Adenosine is an antiarrhythmic and a nucleoside. It works to treat irregular heartbeat by slowing the electrical conduction in the heart, slowing heart rate, or normalizing heart rhythm. It helps during a stress test of the heart by improving blood flow to the heart.) Betablockers, CCBs, and amiodarone, can be considered as alternatives. If drug therapy is useless, synchronized cardioversion may be used. Defibrillation Used only in clients with V fill and pulseless V tach. External pacing and atropine(anticholinergic used to increase HR) Used in symptomatic bradycardia (100.4/38) or hypothermia (90/min RR: >20/min or alkalosis (paCO2 12,000 or 10% immature neutrophils –bands) CVP: normal : 26 mmHg indicates circulating volume. It is decreased not increased, in septic shock d/t massive vasodilation and misdistribution of blood flow. MAP: normal: 70100 mmHg, and is not associated with SIRS. Carbon Monoxide Poisoning pulse oximeter reading is normal because it cannot differentiate hemoglobin saturation with CO versus O2. Nonspecific s/s: headache, dizzy, fatigue, N, dyspnea) Serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are 2 3% in nonsmokers and slightly higher in smokers. Requires immediate admin of 100% O2 to correct hypoxemia and eliminate CO from blood. Methylphenidate (Ritalin, Concerta) CNS stimulant used to treat ADHD and narcolepsy. It contributes to hyperactivity and lack of impulse control by affecting neurotransmitters (dopamine, norepinephrine) Common side effect: loss of appetite, resulting in weight loss. Parents and caregivers should weigh child with ADHD at least weekly d/t the risk of temporary interruption of growth and development. Compare weight/height measures from one well child checkup to the next. Increased BP and tachycardia can also be a side effect. Monitor before and after starting treatments. Statins Significant s/e: muscle aches (myopathy)/weakness. Call HCP who will then obtain a blood sample to assess the CK levels. If the CK is significantly elevated (>or=10Xnormal) the drug will be d/c. Benzodiazepines Antianxiety drugs. May cause sedation, which can interfere with daytime activities. Giving dose at bedtime will help the client sleep. Never stop abruptly. It should be tapered gradually to prevent rebound anxiety and a withdrawal reaction (anxiety, confusion, etc). Monoanine oxidase inhibitors (Tranylcypromine, phenelzine) Used for depressive disorders. Eliminate cheese, prcessed meats, and other tyramine containing items. Could cause photosensitivity. Aspirin toxicity Tinnitus Hemophilia Bleeding disorder d/t deficiency in coagulation proteins. Clients with classic hemophilia or hemophilia A lack factor VIII. Those with Hemo. B (Christmas disease) lack factor IX. Most frequent sites of bleeding are the joints, especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur. Methotrexate Used in treating rheumatoid arthritis and psoriasis Folate antimetabolite, Antineoplastic, immunosuppressant drug used to treat various malignancies as a nonbiologic diseasemodifying antirheumatic drug (DMARD) Can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Increased susceptibility to infection. Obtain vaccines, avoid crowds, and persons with known infections. Herpes zoster (live vaccine) is contraindicated. Inactivated vaccines (influenza and pneumococcal) are allowed Avoid alcohol as it is hepatotoxic. GI irritation Eyes do not need to be checked every 6 months for this drug. it does need to be checked for the DMARD antimalarial drug hydroxychloroquine (plaquenil) as it can cause retinal damage. Can cause congenital anomalies and fetal death. Client should not become pregnant while taking this drug or for 3 months after it is d/c. It is teratogenic. Photosensitivity Tetracyclines, thiazide diuretics, sulfonamides Nephrotoxicity Aminoglycosides, vancomycin, and NSAIDS 12 month old infant Equal head and chest circumference. Triple birth weight Sits from a standing position without help Prefers parents and exhibits fear when separated Should have about 6 teeth Should attempt to place small objects into a narrow opening but is unsuccessful INH (Isoniazid) Used for TB It interferes with the action of Vitamin B6 resulting in peripheral neuropathy (ataxia and paresthesia) Those most prone to these are older adults, malnourished people, diabetic clients, pregnancy or breastfeeding clients, alcoholics, children, those with liver/renal disease, and HIV+ individuals. Give VitB6 at 2550 mg/day for those at high risk. Neurological s/e can also occur. Spironolactone (Aldactone) Potassium sparing diuretic that counteracts K loss by other diuretics (thiazides) Helps treat HTN, ascites (d/t liver disease) Questran May be given to excrete bile salts in the feces to reduce pruritus (during cirrhosis). Powder form, must be mixed in foods (applesauce) or juice (apple juice) and should be given one hour after all other meds. Malignant Hyperthermia hereditary condition in which certain anesthetics (e.g., halothane,) (andanectine, succinylcholine a muscle relaxant) cause high body temperatures and muscle rigidity do proper screening and a thorough pre-op nursing assessment/health history to minimize client risk. Moderate to Severe Asthma tachycardia>120/min tachypnea>30/min saturation3 years old pull pinna of ear upward and back to straighten the external ear canal. 5 years. This is done when there has been no response to behavioral approaches and/or when shortterm improvement of enuresis is desired for attending sleepovers/overnight camp. Trial run usually done at least 6 weeks before camp to see if the drug is appropriate and effective. There is a high risk of prolapse however, once the drug is d/c. Medications used to treat this: Desmopressin, reduces the urine production during sleep. Tricyclic antidepressants (imipramine, Amitriptyline, desipramine) which help improve the functional bladder capacity. Intussusception Is an intestinal obstruction that occurs when a segment of a bowel folds (telescopes) into another segment. It causes increased pressure, causing ischemia, and leakage of blood and mucous into the lumen. Stool mixed with mucus (red currant jelly). Initially, infants may only have general symptoms (irritability, diarrhea, lethargy). Subsequently (sudden, abdominal pain(cramping), drawing the knees up to the chest, and inconsolable crying, are seen. After an episode, the infant may vomit and then appear otherwise norma. Assessment may show sausage shaped abdominal mass. Oily, bulky, foulsmelling stools Excess fat in stool (steatorrhea) from malabsorption. Characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. Dark red, black sticky stools Upper GI bleed, gastritis (in infants and toddlers) Hirschsprung disease (congenital aganglionic megacolon) Thin, ribbon like stools. Bowel obstruction is d/t failure of the internal spincter to relax. Beta blockers (“lols”) Used for CHRONIC heart failure In acute decompensated HF (ADHF) these drugs can further deteriorate the client’s condition. (marginally low BP, crackles in lungs, low O2 sat, jugular vein distention, peripheral edema). Statins Contraindicated in severe liver or muscle injury. Anaphylactic Shock Call for helpfirst action Maintain airway, breathingadminister high flow O2 via nonrebreather bask Epinephrine, intramuscularDOC. Dilates and constricts. If no response, repeat Q515mins Elevate legs Volume resuscitation with IV fluids Bronchodilator (Albuterol) to dilate small airways and reverse constriction Antihistamine (diphenhydramine) to modify hypersensitivity reaction and relieve pruritus Corticosteroids (Solumedrolmethylprednisolone) to decrease airway inflammation and swelling d/t allergic reaction. Creatinine level: 0.61.3 mg/dL Ace inhibitors: hyperkalemia and hypotension are contraindications for this drug. these drugs are excreted renally and can worsen renal function, so evaluation of the kidney function is essential for clients taking these meds. (same for Aminoglycosidesgentamicin) and digoxin Normal fetal heart tones: 110160/min Normal pulse rate in a 5 year old: 70120/min average is 100 Albuterol(Ventolin) is a bronchodilator betaadrenergic, and the expected s/e are: tremors, tachycardia, palpitations DONNING Hand hygiene Gown Mask/respirator Goggles/face shield Gloves Hypokalemia: muscle cramps in legs, weakness, paralysis Epiglottitis Haemophilus influenza type B vaccine reduces the incidence due. It’s an inflammation by bacteria of the tissues surrounding the epiglottis. Edema can develop and obstruct the airway, occluding the trachea. Classic symptoms: high grade fever with toxic appearance, severe sore throat, and the 4 D’s: dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling, and distressed respiratory effort. Place pt. in tripod position. It helps open the airflow. Sit rather than lie down. ICP in a child Wide, bulging fontanelle Prominent scalp veins Increased head circumference Sunset eyes (6th cranial nerve palsy (paralysis of upward gaze) as a result of ICP, hydrocephalus. It’s an acute, delayed sign and requires timely priority diagnosis and treatment. This sign is more likely to be noted after the fontanelles have closed (posterior by 6 and anterior by 18 months) and the pressure increases. Metclopramide Antiemetic and/or prokinetic agent that promotes GI motility and gastric emptying. Commonly used to treat N, V and gastroparesis. It can cause tardive dyskinesia (TD) a condition characterized by unusual uncontrollable movements of the arms, legs, head, and face, or entire body. (twisting/protruding tongue movements, lip smacking, torticollis, and pianoplaying finger movements) TD is irreversible in many cases, and the risk for developing this kid of TD is greater with advanced age, long term therapy, and high drug doses. Diarrhea is not a serious s/e. Burping does not occur as TD does not affect HR. Chest drainage >100 ml/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. Patient can become hemodynamically unstable. Snellen Letter chart Tests visual acuity in those ages 6 and older Position 10 ft (3 m) from chart and ask to read letters. Standard testing for visual acuity is 20 ft (6m) but it’s easier to maintain child’s attention with 10 and provides more accurate results. If child wears glasses, they remain in place. Child must identify 4 of 6 letters in each line before moving to the next. Refer to an ophthalmologist if child is unable to identify 4 correct letters on the 10/15 line (equivalent to 20/30 vision) with either eye. Following a bright colored object or a human face Method to check acuity and fixation in infants. If this is not present by 34 months, referral is made for a formal ophthalmic exam. Fat embolism Life threatening and occurs in fractures, especially those of the long bone and pelvis. Globules of fat leave the bone and travel through the bloodstream to the lungs, skin, and brain where they can occlude the small vessels. Altered mental status will result from blocked blood vessels in the brain. Embolism to the lung would result in respiratory distress. Hallmark sign of fat emboli=presence of petechiae (pin sized red/purple spots) that result from smallvessel clotting and appear across the chest, in the axillae and in the soft palate. Respiratory distress, mental status changes, and petechiae are the classic manifestations. Asthma NSAIDS(ibuprofenmotrin; and aspirin)and Beta blockers have the potential to cause problems for clients with asthma. 1020% of asthmatics are sensitive to these meds and can experience severe bronchospasms after ingestion. This is prevalent in clients with nasal polyposis Guaifenesin(mucinex) an expectorant used to facilitate mobilization of mucus and should not have the potential to exacerbate asthma or cause an attack. Loratadine (Claritin) an antihistamine Vit D: helps maintain bone density Addisonian crisis Addison’s diseases is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenal insufficiency is a potentially lifethreatening complication. N, V, abdo pain, hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, confusion. Priority emergency management: shock treatment, fluid resuscitation (0.9 saline and 5% dextrose) and administration of high dose hydrocortisone replacement IV push Pleural Effusion Abnormal collection of fluid (>1520 ml) in the pleural space between the parietal and visceral pleurae that prevents lungs from expanding fully Causes decreased lung volume, Atelectasis, and ineffective gas exchange Clients commonly have dyspnea on exertion, and nonproductive cough, diminished breath sounds, dullness to percussion, and decreased tactile fremitus. If the effusion is large, the trachea (mediastinum ) is deviated to the opposite side Dullness with pleural effusions and pneumonia Hyperresonance with Pneumothorax (percussion shows hyperresonnance) Wheezing shows obstructive process (asthma, COPD) not in pleural effusion Kawasaki Disease a disease of unknown cause, occurring primarily in young children and giving rise to a rash, glandular swelling, and sometimes damage to the heart. Treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG (immunoglobulin) therapy will remain in the body for up to 11 months and may interfere with the desired immune response. To live vaccines. Therefore, live vaccines (varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child’s ability to produce the appropriate amount of antibodies to provide lifelong immunity. Haemopholus influenza type b (Hib) and PCV (pneumococcal conjugate) Not a live vaccine, and final dose (4th) is recommended between ages 1215 months, accordring to the CDC. Hep B Not a live vaccine, the 3rd (final) dose should be given between ages 618 months. Order of Head to Toe Assessment for Infants Auscultate first, as the infant is quiet. This allows the nurse to clearly hear the heart and lung sounds, and efficiently count the heart rates and respirations. Palpation and percussion is next, and are performed together in a head to toe i=direction, when the infant is still calm. This helps the nurse to assess while the abdo muscles are still relaxed. Traumatic procedures are performed towards the end (eyes, ears, mouth while crying). Reflexes (grasping, babinski) are performed last, and the last step is doing the Moro reflex, as the infant is moving around and awake at this point. The expected response to a sudden dropping or jarring motion is a reflexive startle and crying. Ausculate heart and lungs, palpate fontanels, Percuss abdomen, inspect eyes, elicit moro reflex Allopurinol To prevent gout attacks (pain and inflammation in joints caused by uric acid deposits) It inhibits uric acid production and improves solubility Gout is a build up of uric acid deposits in the joints that cause pain and inflammation. This med helps to prevent uric acid deposits in the joints and the formation of uric acid kidney stones Take with a full glass of water, and educate client about goof fluid intake as it will help prevent the formation of renal stones and promote diuresis (increase drug and uric acid excretion). This is the priority nursing action. Biosynthesis of uric acid occurs in the liver, and anti gout meds are excreted via the kidneys, so need to assess liver and renal fxn tests. Blood counts need to be monitored as well, as some anti gout meds can cause blood dyscrasias (abnormal state of the fluid). Any rash, even if mild, should be reported ASAP to the HCP, and stop taking the med immediately, schedule an appointment, and notify the HCP. Even more serious hypersensitivity reactions can follow this: stevensjohnson syndrome and toxic epidermal necrolysis ( life threatening issue that causes the epidermis to separate from the dermis). This drug takes several months to become effective, and is used to treating gout attacks. It’s not effective in treating acute attacks. Clients will need to continue to take anti inflammatories (NSAIDs and colchicines) for acute attacks. Metoprolol, bisoprolol, carvedilol (beta blockers) Used for chronic heart failure ACE inhibitors (prils) and angiotensin II receptor blockers (ARBS) (sartans) Create a risk for hyperkalemia. Ace inhibitors decrease the excretion of aldosterone, increasing K. Cirrhosis and Lactulose Lactulose helps excrete ammonia in cirrhosis with hepatic encephalopathy. Achieve 23 soft stools/day. Vancomycin Should be infused over at least 60 mins (100 mins if infusing > or = 1 gram). Isosorbide and hydralazine are used in African Americans with HF It reduces preload and after load, decreasing cardiac workload Gestational hypertension > or=140/90 that occurs after 20 weeks gestation without proteinuria Preeclampsia occurs when proteinuria or signs of end organ dysfunction occurs. Pregnancy Fetal tachy: >160 beats/min for >10 mins. The most sensitive indicators of fetus health is fetus movement and fetal HR 4 movements/Hour or 10 movements in 2 hours is a reassuring finding Braxtonhicks contractions are felt mid pregnancy onward. These painless, occasional physiological contractions are normal. They are a concern if they become regular and persistent. Metabolic syndrome Factors that increase the risk of CVDs and diabetes mellitus Criteria for metabolic syndrome include the presence of 3 or more of these following conditions: 1) abnormal obesity with increased waist circumference (> or = 40 inches in men, and > or = 35 in women) 2)hyperglycemia > or = 110 3) low HDL ( or = 130/85 Lithium Mood stabilizer used to treat bipolar affective disorders. Therapeutic index: 0.61.2. levels >1.5 are considered toxic. Tocicity: Dehydration Decreased renal function (elderly) Diet low in Na Drug drug interactions (NSAIDS and thiazide diuretics) Lithium is cleared renally, even mild changes in kidney function can cause serious lithium toxicity. Drugs that decrease renal blood flow (NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief. Blood should be drawn frequently to monitor for therapeutic levels and toxicity. FIRE ALARM RACE Rescue clients from immediate danger and move to safety Alarm and activate the agency’s fire response Confine the fire by closing the doors to all rooms and fire doors to the entrance of the unit Extinguish the fire if possible with the fire extinguisher Liver biopsy Position on right side afterwards for a minimum of 24 hours to splint the incision site. Client stays on bed rest for 1214 hours. Lie supine with right arm over head with client holding breath before needle is inserted between the 6 and 7 or 8 and 9 ribs. Sickle Cell crisis (vasoocclusive crisis) Elevated bilirubin levels d/t the breakdown of hemoglobin and excess hemolysis. When this is 23X the normal level, jaundice results. Elevated reticulocyte count Hemoglobin or = 60/min. Hypokalemia can increase the risk of toxicity. Incidence reports Adverse events are injuries caused by medical management rather than a client’s underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems. Potentially harmful drugs to avoid or administer with caution in the elderly d/t high incidence of drug toxicity, cognitive dysfunction and falls: Antipsychotics Anticholinergics Antihistamines Antihypertensives Benzodiazepines Diuretics Opioids Sliding insulin scales  Amitriptyline is an antidepressant used to treat depression and neuropathic pain. It’s anticholinergic properties can cause dry mouth, constipation, blurred vision, and dysrhythmias  Chlorpheniramine is a sedating histamine H1 antagonist used to treat allergy symptoms. It can increase CNS effects (drowsiness, dizziness)  Lorazepam (Ativan) is a benzodiazepine (tranquillizer, hypnotic, muscle relaxant) with a long half life (1017hours) s/e: drowsiness, dizziness, ataxia, and confusion.  Benzos: antipsychotics (valium, clonazepam) Infants and hypoglycemia Infants of diabetic mothers are at risk of hypoglycemia and hypocalcemmia. Hypoglycemia is considered a blood glucose level

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