COMPS-2.pdf

COMPS >{Yellow-question / Green-answer}1.2 or “2.8” do not allow them to have the procedure, question the order, requires follow-up, and intervene Central line care ○ Change dressing every 7 days unless dirty ○ Sterile procedure ○ Do not get wet...

COMPS >{Yellow-question / Green-answer}1.2 or “2.8” do not allow them to have the procedure, question the order, requires follow-up, and intervene Central line care ○ Change dressing every 7 days unless dirty ○ Sterile procedure ○ Do not get wet or submerge underwater ○ Nurse is caring for a triple lumen central venous catheter = flush NS w/ a 10 mL syringe after each use Chest tube assessment 5  ○ Coarctation of the aorta - COA ○ Narrowing of the descending aorta ○ Can cause murmurs ○ Treatment is a balloon plasty 6  ○ Their lower body may have poor perfusion (assess femoral pulses) CVA ○ Usually caused by atherosclerosis, smoking, HTN, a-fib, HLD, DM ○ Shows one sided weakness, slurred speech, arm drift ○ High risk for aspiration due to dysphagia Digoxin ○ Digoxin toxicity (>2) s/s - confusion, loss of appetite, nausea/vomiting/diarrhea, visual disturbance, yellow/green halos Assess VITAL SIGNS (not obtain prescription for digoxin level) Place them on a cardiac monitor Report to PCP Monitor for hypomagnesemia and hypokalemia Eat foods that are high in potassium if they have low vitamin K Do not administer if heart rate is below 60 ○ Do not administer if the heart rate is below 90 in children ○ Patient teaching: take apical pulse for 1 full minute ○ Do not take with thiazide or loop diuretics: increase risk for hypokalemia ○ No ACE inhibitors ”-prils” or ARBS “-sartan” ○ No verapamil ○ It would require further teaching if the pt taking digoxin says I need to avoid food high in vitamin K including avocado, potatoes, and bananas DVT ○ Redness, swelling, warmth, and pain in legs ○ Do not press ○ At risk to develop a pulmonary embolism ○ Heparin therapy, Lovenox/Enoxaparin ○ The nurse should instruct the client to elevate the affected extremity in bed or chair. DO NOT PUT PILLOW UNDER THE KNEES ○ SCD’s ○ Assess pulses distal to the affected area ○ Apply warm, moist compresses to the affected area Hypovolemic shock ←blood loss / hemorrhaging ○ Bolus fluids, be careful as they can cause pulmonary edema ←crackles ○ PT who has developed hypovolemic shock and has a HR of 160 BPM and is receiving O2 @ 2L via nasal cannula, which of the following actions would be priority for the nurse to perform? Administer prescribed IV (if pt is not on O2 already, give O2 FIRST) Infective endocarditis ○ Inflammation of the endocardium ○ Can be caused by Strep infections, rheumatic fever ○ S/S: murmurs, clots, fever, low cardiac output/oxygen, heart failure JVD ○ Right sided heart failure 7  ○ Hypervolemia Left sided heart failure- think lungs ○ Pulmonary edema symptoms ○ No JVD Nitroglycerin ○ Vasodilates vessels to ensure blood flow ○ Take 1, after five minutes call 911/help if pain continues and take another; can take up to 3 ○ May cause headaches ← normal side effect ○ THE PRESCRIPTION IS GOOD FOR 5 MONTHS ○ (No alcohol, no eating/drinking until sub-lingual tablet dissolves, keep NTG in its original container). ○ Which statement if made by the pt taking NITROGLYCERIN for chronic angina requires further teaching? I will call my PCP to request a new prescription 3 months after opening the bottle PVC’s ○ Premature ventricular contractions, 3 or more is V-tach ○ Causes: Hypokalemia, hypoxemia 1. Check peripheral pulses 2. Check K+ V-fib ○ Ventricular quivering ○ Medication - amiodarone or defibrillation or CPR ○ Assess pulses, call code, CPR, defib is priority 8  V-tach ○ Medication is amiodarone and can cardiovert ○ Pulseless must resuscitate ○ “Tombstones” VTE (venous thromboembolism) ○ Ensure adequate hydration (mobility and compression devices are not options) Pacemaker care ○ Report before having an MRI ○ Do not put cellphones in chest pocket: keep phone in the OPPOSITE pocket ○ Notify airport security before traveling, they will get patted down ○ You can use a microwave ○ The pt w/ a newly implanted pacemaker can’t lift their arm above their head for 4-6 weeks. During this time, they should not lift anything >10lbs. ○ FOLLOW UP = If Dr orders a MRI ○ The nurse is teaching a client who is scheduled to have a permanent pacemaker implanted. Which of the following statements should the nurse include in the teaching? “You will need to use cellular phones on the opposite side of where the pacemaker is placed.” Pericarditis ○ Emergency ○ Inflammation of the pericardial sac ○ Can be heard on a stethoscope as a friction rub Stroke ○ CVA or TIA ○ High risk for aspiration and falls ○ May need to be put on clot busters ○ It would require further teaching if a stroke pt says 9  they should NOT tilt their head forward to swallow if they are experiencing dysphagia Superior vena cava syndrome ○ Partial or complete obstruction of superior vena cava ○ Swelling of arms and face SVT ○ Supra ventricular tachycardia Right sided heart failure ○ Shows systemic edema Would it require f/u if a pt scheduled for cardiac cath has a creatinine of 2.8? Yes, the procedure will require iodine and pt needs functioning kidneys The pt with atherosclerosis should avoid eggs. Cardiogenic shock (failure of the heart to pump adequately) ○ = digoxin & dobutamine ○ DO NOT GIVE FLUIDS Aortic valve = place the stethoscope on the 2nd intercostal space, right sternal border 10  ELECTROLYTES: Hypernatremia (>145) ○ Causes confusion, fever, flushed skin, restlessness, edema/fluid retention, decreased urine output ○ Sign of dehydration ○ Restrict sodium intake ○ Give isotonic (LR/ 0.9% NS) or hypotonic (>0.9% sodium chloride) fluids Hyponatremia ○ Seizure precautions ○ Sign of fluid overload, SiADH ○ S/S: Stupor, abdominal changes, confusion, lethargy, decreased DTR, shallow respirations, muscle spasms Hypocalcemia: ○ Initiate seizure precautions ○ Trousseau sign Caused by hypocalcemia Arm begins to flex/contract when a blood pressure cuff is placed on the arm and inflated Hyperkalemia: ○ Insulin! It pushes the potassium back into the cells EMERGENCY MANAGEMENT: 11  Chemical poisoning ○ Obtain history and physical exam Disaster triage ○ Green - minor injuries ○ Yellow - injuries - serious injuries but not life-threatening ○ Red - life-threatening injuries ○ Black - too many resources to help Mass Casualty —> The nurse working in the ED has been made aware of the following client situations. Which client information requires reporting by the nurse to an outside public health agency? ○ A 27 year old who was admitted with a confirmed sexually transmitted infection (STI) The nurse working on a medical-surgical unit is caring for the following assigned clients when the facilities emergency response plan is activated. Which client should the nurse recommend for discharge? ○ The client with pneumonia, a history of asthma, and a new prescription to switch from IV to oral antibiotic 10 inch gushing laceration to the head ED: ○ 1st thing= apply pressure to stop bleeding 12  ○ 2nd: start IVs (2 large bore needles) to start fluids next Triage for mass casualty: 80% burn = no priority (give morphine and move on) Urgent care triage: 46 year old diaphoretic with epigastric pain ED reports to health department: suspected gonorrhea ENDOCRINE/GU: Acute adrenal insufficiency (Addison’s disease) ○ High amount of ACTH in the adrenal glands and insufficient cortisol ○ S/S: Bronzed skin Lethargy, fatigue, and muscle weakness GI disturbances (weight loss) Menstrual changes Low BP/temperature cold intolerance Hypoglycemia, hyponatremia Hyperkalemia, hypercalcemia Elevated BUN ○ Interventions: Monitor VS (Hypotension), daily weights (loss), I/Os, glucose, K, Na, and Ca levels ○ Patient teaching: Need lifelong glucocorticoid replacement and possibly lifelong mineralocorticoid replacement Corticosteroid replacement will need to be increased during times of stress. Avoid individuals with an infection Avoid strenuous exercise and stressful situations Avoid over-the-counter medications Diet should be high in protein and carbohydrates; clients taking glucocorticoids should be prescribed calcium and vitamin D supplements to maintain normal levels and to protect against corticosteroid-induced osteoporosis; some clients taking mineralocorticoids may be prescribed a diet high in sodium. Wear a MedicAlert bracelet Report signs and symptoms of complications, such as under replacement and overreplacement of corticosteroid hormones. Addisonian crisis ○ Life-threatening disorder ○ Caused by stress, trauma, infection, or surgery ○ Hyponatremia, hyperkalemia, hypoglycemia and hypovolemic shock ○ S/S: weakness, fatigue, dehydration, severe headache, severe hypotension ○ Treatment: IV glucocorticoids and dextrose with water ○ Monitor vital signs, I&O’s, daily weights, LOC, and heart rhythm ○ Bed rest and quiet environment 13  Calcium oxalate ○ Most common form of kidney stone ○ Foods to stay away from: Calcium: Dairy, beans and legumes, fish with bones (sardines, salmon), dried fruits, nuts, chocolate (cocoa) Oxalate: Dark leafy veggies, cabbage, tomato, beets, nuts, instant coffee, tea, Worcestershire ○ Urolithiasis: refers to the formation of urinary calculi, these form in the ureters ○ Nephrolithiasis: kidney calculi ○ Caused by: Family hx Diet high in calcium, vitamin D, protein, oxalate, purine, or alkali Obstruction and urinary stasis Dehydration Use of diuretic UTIs and prolonged urinary catheterization Immobilization Hypercalcemia & hyperparathyroidism Elevated uric acid level AV fistula ○ Do not take bp on the affected arm ○ Used for dialysis ○ Vein and artery joined together ○ Should be able to palpate a thrill and auscultate a bruit Desmopressin ○ Raises blood pressure, synthetic ADH, used for DI ○ THERAPEUTIC EFFECT→Urine output from 2,500mL to 1,200mL Diabetes insipidus ○ Insufficient ADH (kidneys fail to absorb water) ○ A deficiency of antidiuretic hormone (ADH or vasopressin) due to a disorder of the posterior pituitary gland that results in the inability of the kidneys to conserve water appropriately. DI is caused by head trauma, tumor, surgery, radiation, CNS infections, malignant tumors, or failure of the renal tubules. ○ Causes hypokalemia and hyperglycemia ○ S/S: Polyuria, increased urinary output Polydipsia, may crave ice water in excessive amounts Diluted urine (300 ○ Hydrate, and administer insulin, ○ Check ABGs pH: poop bag ○ Empty when ⅓-½ full to prevent leakage/skin irritation: EMPTY 30 min AFTER EATING ○ Change Q3-7days ○ Hydrate! Fluid deficit is common due to liquid stools. Increase fluid intake to at least 1920mL/day If no stool passes in 6-12hr - call MD Ileal Conduit → bladder bag Lipodystrophy 31  ○ Abnormal fat proportions in the body ○ Lost in one area and gained in another IBS-C = QUESTION THE ORDER for loperamide (this med treats diarrhea, not constipation) Ulcerative colitis ○ Chronic abdominal pain ○ Inflammation and ulcer formation on the inner lining of the colon ○ Triggers involve stress, viral/bacterial illness, dairy intake, or NSAID use ○ S/S: urgent/frequent bowel movements, anemia, weight loss, rectal bleeding, Bright red blood in diarrhea, ○ Complications - pouch formation in colon, colon cancer rupture, or peritonitis ○ Meds - immunosuppressants, ABx, steroids, or aminosalicylates Peptic ulcer disease ○ Ulcers that form in the GI tract, most commonly caused by H. Pylori infection or NSAID use ○ Abdominal pain that worsens with eating ○ Duodenal ulcer pain is relieved with eating ○ Can cause GI bleeding or perforation ○ Medications - antacids, pepto-bismol, proton pump inhibitors (protonix) ○ May need surgery (gastric resection) ○ Draw type and cross for admin of PRBCs: @risk for hemorrhage ○ Sigmoid colon resection: ○ possible hypovolemic shock (HR increases from 88 to 120) Teach pts to get a colonoscopy at age 50, the every 10 years. Would it require f/u by the RN if a pt develops difficulty swallowing after ERCP? YES HEPATIC: Hepatic encephalopathy ○ Call the provider when urine output of 450mL in 24hrs / (it should at least be 720mL in 24 hours. ○ Expected: ammonia levels high, increased ICP, HA ○ Ammonia build up ○ Follow up teaching, protein decreases ammonia levels? NO, it can INCREASE levels ○ (A). administer lactulose to decrease ammonia in body to reduce confusion and abnormal stools → diarrhea is OD ○ (A). Naproxen requires FOLLOW UP Hyperbilirubinemia ○ Jaundice ○ From excessive red blood cell breakdown 32  Liver cirrhosis ○ Caused by alcohol intake ○ Results in jaundice, impaired liver function, can result in ascites (distended abdomen) ○ High protein, low sodium diet ○ Monitor blood sugar and for bleeding ○ Medications - beta blockers, vitamin K, diuretics ○ Early stages = increase protein ○ Late stages = decrease protein Portal hypertension ○ Esophageal varices ○ Increased pressure in the portal system because of liver dysfunction INFECTIOUS DISEASES: Chronic streptococcal infection ○ Swollen tonsils, exudate, pain when swallowing ○ Salt water gargles, anti-inflammatories ○ ABx treatment (must finish full course) ○ At risk for glomerulonephritis (THIS PT WOULD HAVE HTN, EDEMA, AND FACIAL SWELLING “PERIORBITAL EDEMA” Disseminated herpes zoster ○ Generalized lesion eruption around the body Gingival hyperplasia ○ Abnormal growth of the gum Haemophilus influenzae ○ Droplet precaution ○ S/S:severe headache, stiff neck, seizures, drowsiness, loss of consciousness ○ Give ABx HIV ○ Retrovirus that attacks the immune system ○ CD4 and t-helper cells are targeted ○ At high risk for infection ○ Must be on antiretroviral therapy for life ○ Can lead to AIDS if not treated VRE ○ Vancomycin resistant enterococci ○ Contact precautions MRSA ○ Contact precautions Tuberculosis ○ Airborne precautions ○ Wear N95 ○ Have client wear a surgical mask when being transported to prevent transmission 33  Pertussis ○ Whooping cough in children ○ Can be prevented with vaccine administration at 2 months of age Toxoplasmosis ○ Parasitic infection ○ Medications: pyrimethamine Shingles ○ Droplet precaution with negative airflow room ○ People who have had chickenpox are at risk for shingles ○ Encourage varicella vaccine First dose at 12 months of age Second dose at 4 years old Lab Values: Galen lab values ○ Warfarin - INR (0.9-1.2) normal range ( 2-3x times values) 1. Therapeutic range (1.8 - 3.6) PT (11-12.5) normal range (1.5-2.5x times values) 1. Therapeutic range (16.5-31.25) If a PT (11-12.5) is taking Warfarin w/ a PT of 22, would this be within therapeutic range? YES ○ Heparin - aPTT (30-40) normal range (1.5-2.5x times values) 1. Therapeutic range (45-100) PTT (20-30) 1. Therapeutic range (30-75) ○ Pts can receive heparin and then warfarin at same time. Pts on warfarin drip cannot go home, so they take warfarin ○ HDL: H = happy; good cholesterol: Males >45, Females >55 ○ LDL: L = losers; bad cholesterol: