NCLEX Study Guide PDF

Must Know PT - Prothrombin Time Blood test that assesses how FAST blood clots Dependent on vitamin K (made by the liver) to make clots High levels caused by: vitamin K deficiency, cancer, liver disease INR Lab used for patients who are taking warfarin INR level determines amount of w...

Must Know PT - Prothrombin Time Blood test that assesses how FAST blood clots Dependent on vitamin K (made by the liver) to make clots High levels caused by: vitamin K deficiency, cancer, liver disease INR Lab used for patients who are taking warfarin INR level determines amount of warfarin given *Warfarin* Measures the speed of clotting using extrinsic pathway PTT - Partial Thromboplastin Time Lab used to assess if blood-thinning therapy (heparin) is working Intracellular - fluid inside of a cell Extracellular - fluid outside of cells Includes: interstitial fluid, connective tissue, bone, blood Intravascular - fluid inside a blood vessel Isotonic No osmotic pressure; cells stay same size 0.9% NS, Lactated Ringers, D5W Hypotonic Water enters the cells. *Assess for edema* 0.45% NS, 0.33% NS Hypertonic Water is removed from cells 3% and 5% NS, D5W with ½ NS, D10W, D5LR Colloid Fluid moves from interstitial to intravascular compartment. *Given to patients in severe hypovolemia* Albumin, Dextran Beta 1 and Beta 2 Beta 1 - found in heart Beta 2 - found in lungs Remember: 1 heart, 2 lungs Electrolyte Level Relationships  Must Know Acid Base Balance From the butt (diarrhea) - Metabolic Acidosis From the mouth (vomitus) - Metabolic Alkalosis ALKALOSIS: K is LOW Acidosis: K is HIGH Hyperventilation increases chance of respiratory alkalosis due to increase of carbon dioxide in the blood Alkalosis: too much bicarb or loss of acid from the blood Antidotes Heparin → Protamine Sulfate Warfarin (Coumadin) → Vitamin K Potassium → Insulin, Kayexalate Magnesium sulfate → Calcium Gluconate Tylenol (Acetaminophen) → Mucomyst (acetylcysteine) Opiates → Narcan Narcotics → Narcan Digoxin → Digiband Insulin → Glucose Cholinergic crisis → Atropine and oximes Iron → Deferoxamine Beta Blockers → Glucagon TPA → Aminocaproic acid Benzodiazepines → Romazicon Important Info NPO anytime there is a GI issue Pt needs 2-3L of fluid/day Give meds 1 hour before meal or 2 hours after meal Give antacids 1 hour before meds or 4 hours after meds Neuro pt → keep head of bed 30-45 degrees After surgery monitor: first 24 hours → bleeding. 48 hours → infection If pt is admitted for a fluid problem → check daily weights In patients with severe vomiting and diarrhea, monitor for electrolyte imbalances Anaphylaxis → give ordered epinephrine ALWAYS obtain cultures before starting antibiotics If pt has dysphagia → risk for aspiration pneumonia When in doubt Electrolytes: choose potassium (K+) Choose an answer that has you stay with your patient Remove any answer choices that are absolutes (all/none) Pick the least invasive option first (if it is not an emergency) Emergency → choose STAT words. Choose the first thing you would do in order to save or avoid causing harm to the pt Never withhold treatment from a patient Empower your patient Tell Tale Signs Older patient with acute onset confusion → UTI Restlessness, agitation, decreased level of consciousness → EARLY SIGN of deterioration  Hallmark Signs Addison’s - bronze skin IBS - GI pain, diarrhea, constipation Anaphylaxis- tachycardia & wheezing ICP (elevated) - Cushing’s Triad (HTN, bradycardia, bradypnea) Angina - sharp chest pain Intussusception - sausage-shaped mass on R Appendicitis - rebound tenderness side Asthma - expiratory wheezing Kawasaki Syndrome - strawberry tongue Bulimia - chipmunk cheeks Leprosy - lion face BPH - polyuria at night Liver cirrhosis - spider veins Cataract - blurred vision Lupus - butterfly rash Cushing’s - moonface/buffalo hump Lyme Disease - Bull’s eye rash Cystic fibrosis - salty skin Measles - Koplick’s spots Cystitis - burning urination Meningitis - Brudzinski and Kernig’s sign Diabetes Mellitus - polyuria, polyphagia, Myasthenia Gravis - descending weakness polydipsia Myocardial infarction - chest pain, radiated to DKA - Kussmaul’s breathing left arm and neck DVT - Homan’s sign Pancreatitis - Cullen’s sign Emphysema - barrel chest Parkinson’s - tremor Epiglottitis-Dysphagia, dysphonia, drooling Pernicious anemia - beefy red tongue Glaucoma - halo vision; painful Pneumonia - rust colored sputum Guillain Barre - ascending weakness Sepsis- tachycardia, hypotension, SOB Hyperglycemia - acetone breath Shock - tachycardia, tachypnea, hypotension Hyperthyroidism - bulging eyes TEF - cyanosis, choking, coughing, continuous drooling Hypocalcemia - Chvostek & Trousseau sign Ulcerative colitis - frequent bloody diarrhea  Patient Positioning Epidural puncture → side lying During lumbar puncture → lateral recumbent fetal position After lumbar puncture → supine (to prevent headache and leaking of CSF) Pulmonary embolism → turn to left side and lower HOB Shortness of breath → high fowlers Lung biopsy → lay on side of the bed or with arms raised up on pillows over bedside table Chest tube insertion → arm raised above head NG tube placement → high fowlers Tube feeding with decreased LOC → put on right side (promotes emptying of stomach) with HOB elevated (prevent aspiration) Prevent dumping syndrome → eat in low-fowlers, lie down after meals for 30 min Hiatal hernia → Fowler or semi-Fowler (reduce regurgitation) After thyroidectomy → low semi-fowlers After myringotomy → lay on affected ear (allows drainage) After cataract surgery → lay on unaffected side During continuous bladder irrigation → keep leg straight During internal radiation → on bedrest while implant in place Pt with heat stroke → lie flat with legs elevated After total hip replacement → sleep on unaffected side, don’t elevate HOB more than 45 degrees, maintain hip abduction by separating thighs with pillow Buck’s Traction → elevate foot of bed for counter traction Above and below knee amputation → elevate for first 24 hours, position prone daily for hip extension Back pain → William’s position Myocardial infarction → semi-fowlers Autonomic dysreflexia/hyperreflexia → elevate HOB Head injury → elevate HOB 30 degrees (decrease intracranial pressure)  Patient Positioning After supratentorial surgery (incision behind hairline) → elevate HOB 30-45 degrees After infratentorial surgery (incision at nape of neck) → lay flat and lateral on either side Peritoneal dialysis when outflow is inadequate → turn pt side to side then check for kinks in tubing Administering an enema → lay on left side with knees flexed (Sim’s) After appendectomy → right side with legs flexed During paracentesis → High fowler’s (HOB 45-90 degrees) During thoracentesis → sit at edge of bed, lean forward, and rest arms on table Spina bifida → prone (so sac doesn’t rupture) Infant with cleft lip → side, supine, or upright in infant seat to prevent ripping of suture line. Infant with ONLY cleft palate → side or abdomen Woman in labor with unreassuring FHR → turn on left side Prolapsed cord → knee to chest or Trendelenburg  Diagnostic Signs/Tests Allen’s Test Assesses arterial blood supply in hand. Positive test means the pt does NOT have adequate blood supply to the hand How to do: block both radial and ulnar arteries until skin becomes pale, then release ulnar. If hand becomes pink, ulnar arteries work, and a ABG/radial stick can be done Cullen’s Sign Internal hemorrhage causing ecchymosis around umbilical region; seen in pancreatitis Turner’s sign Internal hemorrhage seen as grayish blue on your flanks; pancreatitis Murphy’s Sign Pain with palpation of gallbladder area; cholecystitis McBurney’s Point- RLQ pain indicative of appendicitis LLQ Pain- diverticulitis; make sure pt has no seeds, nuts, peas RLQ Pain- appendicitis; assess for peritonitis Guthrie Test Neonatal heel prick that tests for PKU (phenylketonuria) Babinski Sign- assessment for nervous system issues done by stimulating bottom of foot Negative: toes curl Normal in adults and children older than 2 years, abnormal in children 2 years and under Positive: toes fan Abnormal in adults and children older than 2 years, normal in children 2 years and under Beck’s Triad Indicative of cardiac tamponade - hypotension, JVD, muffled heart sounds Halo Sign Positive - appears as concentric rings (bloody circle surrounded by yellow border) Fluid from head injury contains cerebrospinal fluid (CSF); fluid also contains glucose Endoscopic Retrograde Cholangio Pancreatography (ERCP) Procedure to examine diseases of the pancreas, liver, galballder, and bile ducts Preop - NPO. Postop- assess gag reflex and s/sx of perforation Additional Notes If at home: Call 911 if chest pain is not relieved by nitroglycerine; keep med in original container and away from light Definitive diagnosis for abdominal aortic aneurysm → CT scan  General Nursing #1 Priority- ABC’s 1. Airway 2. Breathing 3. Circulation Maslow’s Hierarchy ABC’s Safety Comfort (Pain) Psychological Social Spiritual When in distress, DO NOT ASSESS! Fire Safety RACE - rescue patients at risk, activate alarm, contain fire by closing doors and windows, extinguish fire if able Prevention Types Primary Preventing disease or injury Ex: educating on first aid Secondary Treating patients who are injured Ex: emergency department, triage Tertiary Follow-up care Nursing Process: 1. Assessing - gather information 2. Diagnosing - name the problem 3. Outcome/Planning - develop plan of care 4. Implementing - perform nursing interventions 5. Evaluating - did interventions work? Order of Assessment *In kids, go from least to most invasive Pulse Strength 0 absent, 1+ weak, 2+ normal, 3+ bounding Arterial Blood Gases Before drawing an ABG, perform the Allen’s Test to check for sufficient blood flow ABG needs to be in a heparinized tube (blocks clotting cascade) Put on ice immediately after drawing  General Nursing Burns #1 priority: Maintain a patent airway Rule of 9s 9= head 18= arms 36= torso 36= legs 1= perineum Parkland Formula Calculation for the total fluid requirement 24 hours after a burn 4ml x Total Burn Surface Area x body weight (kg) = Total fluid pt will receive in 24 hrs 50% given in the first 8 hours 50% given in the next 16 hours 1st Degree- red and painful 2nd Degree- blisters and edema 3rd Degree- no pain due to nerve damage Burn Types NI: airway patency (intubation may be necessary), give O2, assess vital signs, give IV fluids, assess for paralytic ileus, pain management, assess for s/sx of infection Glasgow Coma Scale  General Nursing Cranial Nerves Cultural Jewish: no meat and milk together Greek: puts protective charms on baby’s neck to avoid eny from others Blood O- universal donor AB + is the universal recipient Patients who are Rh negative should NOT receive Rh positive blood Blood Transfusions Stay with pt for first 15 minutes Multiple blood transfusions = risk for hyperkalemia Transfusion reactions s/sx: fever, SOB, hypotension, fever, dizziness If reaction occurs: STOP transfusion, start IV line with NS, call MD and blood bank, monitor pt for s/sx Compartment Syndrome Emergency situation caused by increased pressure and restricted blood flow to an extremity, which results in pain and paresthesia Requires immediate action, as damage is irreversible after 4-6 hours 5 P’s: pain, paresthesia, paralysis, pallor, pulselessness NI: notify MD, fasciotomy to relieve pressure, loosen cast Sucking stab wound Dress wound and tape it on 3 sides so air can escape Do NOT use occlusive dressing Next steps: get chest tube tray, labs, and start an IV Chest Tube If it is accidently removed, use occlusive dressing taped on 3 sides (allows air to escape and prevents tension pneumothorax) If it becomes disconnected, do NOT clamp Place the end of the tube in a container of sterile saline (or water if saline not available) Fluctuations = good (fluid moves up with each inspiration and down with expiration) mean the chest tube is working No fluctuations → check for kinked tubing, occlusions, or ask patient to change position Continuous bubbling when the chest tube is connected to suction → air leak Safety in the patient’s room Ensure all the wheels are locked and bed is in lowest position Having all 4 side rails up is a form of restraint (even in patients who are considered a fall risk)  General Nursing Pressure Ulcer Stages Don and Doff Order Precautions Contact Gloves, gown *water and soap for c. diff Mrs. Wee M - multidrug resistant organism R - respiratory infection S - skin infections (herpes simplex, impetigo, scabies) W - wound infections E - enteric infection (c. diff) E - eye infection Droplet Gloves, gown, face mask, eye shield Spiderman S - Sepsis, streptococcal pharyngitis, scarlet fever P - Pneumonia, pertussis, parovirus B19 I - Influenza D - Diphtheria E - Epiglottitis R - Rubella M - Meningitis, meningeal pneumonia, mumps An - Adenovirus Airborne Standard Precautions + gloves, N95 mask MTV M - Measles T - Tuberculosis V - Varicella Zoster  Medical Surgical Respiratory Early sign of cerebral hypoxia → restlessness and irritability Respiratory status Key is visualization and assessment of breath sounds If lungs sound clear and patient is blue, they are not receiving enough oxygen Asthma Difficulty of breathing due to the narrowing, swelling, and production of mucus in the airway S/sx: SOB, wheezing, coughing, hypoxemia, respiratory acidosis NI: Administer bronchodilators and steroids, maintain hydration, deliver oxygen or nebulizer as prescribed Avoid morphine → histamine releasing opioid can lead to exacerbation Avoid NSAID’s and aspirin - can worsen asthma symptoms COPD - characterized by bronchospasm and dyspnea Bronchitis Inflamed bronchioles, increased mucus Blue bloaters, barrel chest Emphysema Destruction of alveoli Pink puffers Encourage pursed-lip breathing (promotes CO2 Bronchitis Emphysema elimination), high-fowlers and leaning forward Normal SpO2 for COPD: 88-92%. Do NOT raise SpO2 level higher than 92% because a low SpO2 is what stimulates pt to breathe NI: offer mechanically soft foods (to save pt energy), teach pt to inject at least 3L of fluid/day (thins mucus) Empyema Pus in the pleural cavity; associated w/ pneumonia or after thoracic surgery NI: elevate HOB, abx, chest tube or thoracentesis (drainage) Acute Respiratory Distress Syndrome (ARDS) Fluid fills the alveoli in the lungs and inhibits oxygen exchange; causes severe hypoxemia First sign- increased respirations. Followed by dyspnea, retractions, cyanosis Hypoxemia is NOT responsive to O2 therapy because the fluid in the alveoli blocks the diffusion of oxygen NI: mechanical ventilation with PEEP Pulmonary Embolism (PE) Thrombus gets lodged into pulmonary artery, blocking blood flow. Other cause is fat embolism from long bone fracture First sign - chest pain. Then dyspnea, tachypnea, blood tinged sputum Body compensates by hyperventilating → respiratory alkalosis NI: elevate HOB, give O2, thrombolytic therapy, pain control, encourage ambulation (prevent venous stasis)  Respiratory Pneumonia Infection resulting in decreased gas exchange in the affected lung lobes Alveoli become blocked with purulent fluid → impairs ventilation V/Q Mismatch Alveoli continue to receive perfusion from the pulmonary Ventilation (airflow) or artery resulting in deoxygenated blood perfusion (blood flow) in Ventilation to perfusion (V/Q) mismatch or pulmonary shunt the lungs is impaired May result in hypoxia and respiratory distress Blood flow in the lungs is partially influenced by gravity, S/sx: SOB, fatigue, meaning blood flows in higher volumes to dependent parts headache, confusion, of the lung dizziness, cyanosis Unilateral pneumonia should be positioned with the unaffected (good) lung down to improve perfusion and oxygenation *Ex: pt with a left lobar pneumonia: position in the right lateral position Unaffected (good) lung down (right lung) to increase blood flow to the lung most capable of oxygenating blood Crackles heard on auscultation suggest pneumonia At risk: people 65 or older and infants under 2 years old (immune system still developing) Pneumococcal vaccine recommended for pts 65 years and older S/sx: pleuritic pain, wheezing, fever, sputum, change in LOC NI: Droplet precautions, O2 as needed, encourage deep breathing and coughing, increase fluid intake (thin mucus), abx, monitor LOC Pleural Effusion Fluid buildup between the lungs and chest; prevents lung expansion S/sx: pleuritic pain, dyspnea, dry cough, orthopnea NI: high Fowler’s, monitor breath sounds, encourage deep breathing and coughing, prep for thoracentesis Pleurisy Stabbing chest pain that usually increases on inspiration or with cough Caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity) The pleura space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration When inflamed, they rub together and cause pleuritic pain Fremitus Palpable vibration felt on the chest wall Expected finding in pneumonia Sound travels faster in solids (consolidation) than in aerated lung → increased fremitus in pneumonia Tuberculosis PPD test: skin assessed 48-72 hours post administration Positive if induration is: >15 mm in healthy pt or >10 mm in immunocompromised pts or >5 mm in high risk pts (HIV, recent contact with TB pt) Positive and no symptoms → chest x-ray Positive and symptomatic → sputum culture Anyone who has received a bacillus Calmette-Guerin (BCG) vaccine will have a positive test and needs chest x-ray Airborne precautions, pt must wear mask if leaving room Public health risk; if pt does not comply with treatment, they need supervision Teaching is very important! Drug therapy is typically 6 months or longer Med: Rifapentine (Prifin) - may cause orange colored body secretions, take w/ meals  Respiratory Pneumothorax Lung collapse due to air in pleural space (space b/w lungs and chest wall) Open pneumothorax -air circulates freely into pleural space Closed - air in pleural space does not increase Tension pneumothorax - air cannot leave pleural space; compresses lungs and shifts the mediastinum S/sx: sharp chest pain, SOB, cyanosis, tachycardia, tachypnea, hypotension NI: 3 way dressing, oxygen, chest tube, surgery (if needed) Nasopharyngeal airway Tube-like device used to maintain upper airway patency Used in alert or semiconscious patients; less likely to cause gaging NEVER insert them in a pt who may have had a head trauma (which might occur during a seizure) bc if they have a skull fracture, it may be malpositioned into structures and tissues in the brain CT must be done first to rule out fracture Size- measure tip of nose to the earlobe; select diameter smaller than naris  Cardiovascular Blood Flow Tricuspid → Pulmonic → Mitral → Aortic Toilet Paper My Ass Listening to Heart Sounds APE To Man Aortic valve, pulmonary valve, Erb’s point, tricuspid valve, mitral valve Acute Coronary Syndromes Unstable Angina Minor occlusion → pain Typically relieved by meds PCI (percutaneous coronary intervention) may be diagnostic NSTEMI Partial occlusion leads to ischemia and damages heart muscle Labs: elevated biomarkers Requires PCI or thrombolytic STEMI Full occlusion → infarction or death of heart muscle Labs: elevated biomarkers ST elevation on EKG PCI needed Angina Chest pain caused by reduced blood flow to heart NI for active angina: have pt rest, take vitals, ECG, give no more than 3 nitroglycerin (vasodilator) tablets 5 minutes apart, get help if no pain relief after med administration Prinzmental’s Angina (aka variant, angina inversa) Chest pain that occurs at rest, usually at night or early morning Triggered by emotional stress, cold weather, smoking, medications that narrow blood vessels NI: Nitrates, calcium channel blockers Myocardial Infarction Blockage of blood flow to heart; ECG shows ST Meds for MI elevation M Morphine S/sx: severe chest pain/pressure, dyspnea, diaphoresis O Oxygen Women s/sx: neck, shoulder or jaw pain, fatigue, SOB, N Nitroglycerine n/v, heartburn A Aspirin Meds to give: MONA Morphine, oxygen, nitrates, aspirin Tests: Myoglobin, CK, and Troponin Heart Failure Heart is unable to pump enough blood to meet the body’s oxygen demands Blood backs up into body (right sided HF) or into lungs (left sided HF) NI: O2 if needed, diuretics, monitor vital signs and I&O’s, listen to heart and lung sounds, assess for hypoxia and edema, daily weights, fluid and sodium restriction Right-sided HF/ Cor Pulmonale Caused by left ventricular failure Normal Heart Failure S/sx: peripheral edema, JVD, weight gain, hepatomegaly Left Sided HF S/sx: pulmonary edema, dyspnea, orthopnea crackles, cough  Cardiovascular Cardiac Tamponade Fluid buildup in the pericardium → creates pressure → heart unable to pump effectively Medical emergency → cardiac arrest and circulatory shock Beck’s Triad - hypotension, JVD, muffled heart sounds Pericardiocentesis needed to remove pericardial fluid Pericarditis Inflammation of outer layer of the heart Indicator: presence of a friction rub. S/sx: pleuritic chest pain ECG finding: ST elevation and T-wave inversion NI: pain control, NSAID’s, corticosteroids, monitor for s/sx of tamponade Myocarditis Inflammation of the myocardium; typically caused by viral infection S/sx: fever, fatigue, chest pain, SOB NI: O2 as needed, bed rest, diuretics, ACEi, sodium restriction (if heart failure develops) Endocarditis Inflammation of inner lining of heart Causes: Infection (TB or Staph), autoimmune conditions (lupus) S/sx: SOB, fever, palpitations, night sweats, chest pain NI: IV abx, promote oral hygiene, assess for signs of emboli, surgery if needed Peripheral Arterial Disease (PAD) Chronic atherosclerotic disease caused by buildup of plaque within the arteries Commonly affects lower extremities → tissue necrosis (gangrene) Management: lower extremities below heart, moderate exercise to promote circulation, daily skin care, maintain mild warmth (socks, blankets), stop smoking, avoid stress and tight clothing, take prescription meds (vasodilators, antiplatelets) to increase blood flow Coronary Artery Disease (CAD) Plaque buildup causes coronary arteries to narrow → limits blood flow to heart S/sx: angina, fatigue, SOB, heart attack NI: control BP, low fat and low salt diet, quit smoking, exercise, encourage healthy lifestyle Scleroderma Causes abnormal blood flow in response to cold → Raynaud phenomenon Fat Embolism Usually occurs after fractures of long bones At risk: femur fracture S/sx: SOB, confusion, tachycardia, lethargy Diagnostic/labs: “snow storm” on chest x-ray, increased ESR (detects inflammation in the body), hypocalcemia, respiratory alkalosis NI: Oxygen, IV fluids, bed rest, assess respiratory status Deep Vein Thrombosis (DVT) Thrombus forms in vein; typically legs Risk → Virchow’s Triad Virchow's Triad S/sx: warm skin, calf pain, edema S Stasis of venous circulation NI: bed rest (prevent clot dislodgment), elevate H Hypercoagulability extremity, compression stockings, administer E Endothelial damage anticoagulants and/or thrombolytics, measure circumference of affected area  Cardiovascular Additional Notes: Improve perfusion → EleVate Veins, dAngle Arteries Assess BP in both arms of patients who have new diagnosed hypertension If pt has mechanical valves → need anticoagulation therapy for life to prevent thromboembolism If your patient has fluid retention, think heart issue first BNP (lab) is made by the heart and is released when the heart is under stress, trying to meet the demands of the body BNP >100 pg/mL = heart failure  Neurology Decorticate positioning Arms bent, legs straight, stiff Key Words Damage to cortex Aphasia- inability to speak Dysphasia- difficulty speaking Decerebrate positioning Arms and legs straight Dysarthira- slurred speech Severe damage to cerebellum or brain stem Apraxia- inability to perform movements or tasks Seizures Tonic- stiff then loss of consciousness Clonic- body spasms Myoclonic - quick muscle jerk Atonic - sudden lack of muscle strength Postictal phase - occurs after a seizure and ends when pt is back to baseline Status epilepticus Seizure lasting more than 5 min or having multiple seizures without regaining full consciousness Convulsive vs nonconvulsive Convulsive - most dangerous; tonic-clonic seizures Seizure Nursing Interventions (NI): help pt lay down, place on side (to maintain airway), loosen tight clothes, give O2, record seizure duration Strokes Risk factors: hypertension, atherosclerosis, history of strokes, diabetes, smoking S/sx: motor loss (hemiparesis or hemiplegia), communication loss (dysphasia, dysarthria, apraxia, aphasia), vision changes, decreased mental acuity Start rehabilitation as soon as patient is stable NI: control BP, neuro assessment, position pt to decrease edema, bed rest, stool softeners Ischemic Stroke; TIA Hemorrhagic Stroke Blockage of blood flow to brain due to clot Brain bleed due to ruptured blood vessels NI: give TPA within 3-4 hours of symptoms Anticoagulation therapy is contraindicated Aneurysm Bulge in a blood vessel that can lead to rupture → hemorrhagic stroke S/sx: vision changes, headache, nuchal rigidity, dizziness NI: promote calm environment, bed rest Parkinson’s Disease Central nervous system disorder that affects motor ability due to low dopamine levels S/sx: tremors, pill rolling movement, rigidity, stooped posture, bradykinesia, difficulties with gait NI: promote pt safety, schedule activities later in the day (conserves pt energy to perform self-care activities), calm environment, soft diet, physical therapy  Neurology Increased ICP Cushing's Triad Pressure builds in the skull; blocking brain circulation Sign = Cushing's Triad, change in LOC or pupil size, headache, Bradycardia blurry vision, vomiting Hypertension NI: elevate HOB 30 degrees, keep body midline, promote calm environment, give stool softeners, tell pt to avoid Wide pulse Valsalva maneuver pressure Meningitis Inflammation of the membranes surrounding the brain and spinal cord Caused by viral, bacterial, or fungal infections Early warning signs: photophobia, drowsiness, confusion S/sx: nuchal rigidity (stiff neck), Brudzinski’s (when pt neck is flexed → flexion of knees & hips) and Kernig’s sign (pt unable to straighten leg when hip is flexed), fever, headache, muscle pain Diagnostic test: Cerebrospinal fluid test If positive, CSF will have high protein and low glucose NI: give abx, Droplet/contact precautions, neuro assessment, vital signs, keep environment dark and calm, seizure precautions Guillain Barre Immune system attacks it’s own nerves, causing ascending paralysis S/sx: paresthesia (numbness and tingling), difficulty breathing, pain, vision changes NI: Assess respiratory status, mechanical ventilation may be needed Multiple Sclerosis Chronic disease that affects the brain and spinal cord; more common in women Immune system attacks myelin sheath → breakdown of communication between neurons Bladder and bowel dysfunction occurs in most cases S/sx: numbness, vision problems, slurred speech, fatigue NI: promote tolerable exercises, implement rest breaks, create voiding schedule, high fiber diet and fluid intake Myasthenia Gravis Muscle weakness and fatigue of voluntary muscles; d/t issues concerning ACh Improves with rest and worsens with physical activity S/sx: diplopia (double vision), ptosis (eyelid drooping), weakness, breathing issues NI: assess respiratory status, have trach kit at bedside, administer cholinergic meds, cluster care (to conserve pt energy), encourage deep breathing and coughing Myasthenia Crisis Medical emergency due to worsening muscle weakness, causing respiratory failure Caused by undermedication, stress, or infection S/sx: worsening MG symptoms Diagnostic: positive Tensilon test Cholinergic Crisis Occurs when there is excessive acetylcholine (ACh) in the neuromuscular junction Typically caused by too much anticholinesterase medication (given in myasthenia gravis) S/sx: cramps, diaphoresis, diarrhea NI: give antidote = atropine sulfate  Neurology Amyotrophic Lateral Sclerosis (ALS) Progressive muscular disease caused by the degeneration of nerve cells Affects voluntary muscle movements, such as walking, breathing, and talking NI: assess respiratory status, encourage PT/OT/SP Autonomic Dysreflexia Medical emergency seen in spinal cord injuries - T6 or higher S/sx: severe hypertension, bradycardia, sweating, anxiety, headache Nursing: elevate HOB to 90 degrees, remove tight clothing, administer antihypertensive medications Basilar Skull Fracture Fracture of one of the bones at the base of the skull S/sx: Bruise behind ear (battle sign), periorbital hematoma (raccoon eyes), halo sign, hearing loss NI: assess ABC, neuro exam, GCS, CT scan Wernicke’s Encephalopathy Neuro disorder characterized by low thiamine (Vitamin B1) D/t alcohol abuse, eating disorders, or chemo C S/sx: confusion, ataxia, abnormal eye movements Spinal Cord Injuries If injury is between: T1 - L4 - Paraplegia T C1 - C8 = Quadriplegia C2 - C3 = Typically fatal C4 and above = require ventilator NI: assess respiratory status, neuro checks, immobilize pt on backboard, keep body midline L S  Immunology Immunoglobulins IgA- viral protection IgE- allergy and parasite infestation IgG- second antibody protection IgM- primary antibody protection Allergies Basophils release histamine during an allergic response In pts with latex allergies → assess for allergies to bananas, kiwis, apricots, avocados, grape Sepsis Medical emergency in which the body’s response to an infection gets out of control, which can cause tissue damage and organ failure S/sx: Hypotension, tachycardia, SOB, fever, confusion Anaphylaxis Severe allergic reaction that requires immediate intervention S/sx: nausea/vomiting, SOB, rash, anxiety HIV Spread by contact through blood, semen, vaginal secretions, breast milk No cure but can be controlled. Pt is on standard precautions Priority: prevent infection Lab testing: positive ELISA, Western blot test, PCR If not treated, it can lead to AIDS AIDS Virus caused by HIV S/sx: low WBC, low CD4, low platelets, weight loss, fever, night sweats, weakness, infections Pt must maintain strict adherence to antiretroviral therapy Official diagnosis: CD4+ falls below 200 cells/mcl Incubation is variable, but typically occurs within 10 years after infection Systemic Lupus Erythematosus (SLE) Autoimmune disease that causes extensive inflammation and tissue damage S/sx: butterfly rash, joint pain, fever, fatigue, weight loss, nephritis Triggers: sunlight, stress, drugs, pregnancy NI: teach patient to avoid sunlight exposure, provide steroids, advise patient to wash skin with mild soap  Oncology & Hematology Radiation Monitor pt for infection due to leukopenia Metastasis Common sites: liver, brain, bone, lung, lymph Breast Cancer Modifiable risk factors: alcohol consumption, smoking, sedentary lifestyle, poor diet high in fat Non-modifiable risk factors: BRCA1 & BRCA2 mutations, having a 1st degree relative with breast cancer, history of uterine cancer, menarche before 12 years old, menopause after 55 years old Exam: check for lumps or hard knots in the shower, under arms and around entire breast area. Examine any changes in the shape of the breast and nipple by looking in the mirror. Perform exam monthly, preferably post menstrual bleeding. If postmenopausal, exam should be done the same date every month. Mammography is helpful in early detection Treatment depends on stage of disease: mastectomy, chemotherapy, radiation, hormonal therapy Post Mastectomy Elevate arm to avoid lymphedema, avoid heavy activity and lifting, do not wear constrictive clothing or get BP reading from affected arm Testicular Cancer Small, hard lump on the front or side of testicle At risk: men whose testes have not dropped into the scrotum or whose testes dropped after age 6 All men 14 years and older should do self exams monthly in the shower Multiple Myeloma Cancer of plasma cells (WBC’s that produce antibodies) Myeloma cells prevent the normal production of antibodies → infection Radioactive Iodine ***FLUSH with at least 3-4 liters/day for 2 days and flush the toilet twice Limit contact with others to 30 minutes/day No pregnant nurses, visitors, and no kids Immunosuppression Most oncologic meds cause immunosuppression → prevention of infection is vital Place pt in private room. Pt should NOT eat raw fruits or vegetables Tumor Lysis Syndrome Tumor cells release their contents into the bloodstream Causes hyperkalemia requires insulin to IV solution to decrease potassium level. *Check blood glucose Thrombocytopenia Place on bleeding precautions Give soft bristled toothbrush Decrease IM meds and do not insert anything (enema or suppositories) Iron Deficiency Anemia Give iron PO with vitamin C or on an empty stomach Iron given IM- Inferon via Ztrack Pernicious Anemia Needs to take Vitamin B12 for LIFE- due to lack of intrinsic factor in the gastric mucosa S/sx: tachycardia, pallor, beefy red tongue Shilling Test- determines how well one absorbs Vit. B12 *If a patient has low hematocrit and/or hemoglobin, assess for signs of bleeding (i.e. dark stools)  Nephrology Acute Kidney Injury Kidney’s unable to filter waste from the blood; potentially reversible S/sx: High level of creatinine and/or reduction in urine output, fluid retention (edema, HTN), changes in LOC, uremia NI: Monitor I&O, daily weight, BP, hyperkalemia, limit sodium and fluid intake, dialysis may be needed Chronic Renal Failure Irreversible damage which causes uremia Dialysis needed to remove waste from blood Pt at risk for hyperkalemia and fluid overload NI: Restrict protein in CRF patients, monitor for fluid overload (JVD), daily weights, monitor I&O Glomerular Filtration Rate (GFR) Ranges >90 = normal 60-89 = mild CKD; Stage 2 30-59 = moderate CKD; Stage 3 15-29 = severe CKD; Stage 4 300, ketones in urine, fruity breath, confusion, Kussmaul’s respirations, increased thirst and urination 1st thing to do → start IV infusion of normal saline Severe dehydration occurs and must be rehydrated before insulin is administered *Expect potassium to drop rapidly, so be ready with potassium replacement Dropping glucose down too fast can cause increased intracranial pressure d/t water being pulled into the CSF Type II DM Resistance or lack of insulin Hyperglycemic Hyperosmolar Non-ketonic Syndrome (HHNS) Glucose >600 Severe dehydration, low potassium due to diuresis, no ketones or acidosis S/sx: altered LOC, increased thirst and urination, lethargy, coma HbA1C Test that averages blood glucose levels over the past 90-120 days 4-6 = blood sugar level around 70-110 7 is ideal for a diabetic Drawing up insulin: Nicole Richie RN Air into NPH, then air into Regular, draw up Regular insulin then NPH Insulin Dawn Phenomenon Early morning hyperglycemia in pts with diabetes Somogyi Effect Occurs when pt takes insulin before bed, has hypoglycemia around 2-3am, and wakes up with hyperglycemia. The insulin lowers the blood sugar too much, causing a rebound effect  Endocrine Additional Notes Fluids are the most important intervention in DKA and HHNS Do NOT give oral hypoglycemic meds to unconscious patients d/t risk of aspiration Additional insulin may be needed for patients on steroids (i.e. prednisone). Steroids increase glucose levels. Diabetic neuropathy Earliest sign is microalbuminuria Diabetes Insipidus: disorder of salt and water metabolism Excessive thirst and urination, dehydration, weakness Decreased ADH NI: monitor electrolytes, I&O’s, give fluids, monitor urine specific gravity and serum osmolality SIADH: water retention and dilutional hyponatremia Body retains water which can lead to water intoxication and hyponatremia Increased ADH Nursing interventions: daily weights (monitor for fluid overload), give diuretics, assess deep tendon reflexes, assess for neurological changes if sodium