Simple Nclex...pdf

‫المذكرة هدفها‪...‬‬ ‫تذاكرها امتي ‪...‬؟‬ ‫المضمون ‪...‬؟‬ ‫‪١٨‬‬ ‫‪١٨‬‬ ‫(ربنا يوفقنا جميعا وال تنسونا من صالح دعائكم(‬ ‫‪2‬‬ v PDF Index: v Strategy Insight for INCLEX exam. v Delegation v Ethics and Electrolyte v Acid -Base v Infection control …………Still v Respiratory v Phar...

‫المذكرة هدفها‪...‬‬ ‫تذاكرها امتي ‪...‬؟‬ ‫المضمون ‪...‬؟‬ ‫‪١٨‬‬ ‫‪١٨‬‬ ‫(ربنا يوفقنا جميعا وال تنسونا من صالح دعائكم(‬ ‫‪2‬‬ v PDF Index: v Strategy Insight for INCLEX exam. v Delegation v Ethics and Electrolyte v Acid -Base v Infection control …………Still v Respiratory v Pharmacology v Renal v Maternity v Mental health v Pediatrics v Endocrine v Lab value v Musculoskeletal v Integumentary v Neurological 3 v Strategy Insight 1-The first thing you should know The NCLEX is Just a Safety Exam, if You are a safe nurse, you will Pass on the NCLEX. 2- Second thing the Study Plan: • Study Calendar, Focus on Your time and take it Seriously. • Study on the Morning and the Evening. (Only 60 Questions per day and write down the list of Topics that you got Wrong then review the rational on the Evening» • Always use one notebook. Don’t Use many resources. • Focus on Your Key numbers at least 1,200 questions. NCLEX Mindset: • On the exam expect to get all the NCLEX questions. • Expect the first 10 to 15 Questions to be very hard. • Do not Expect to Know everting. • Do not change the First answer, if you are not 10000% sure that you’re correct. • Where Your Focus goes, Your energy Flows. (Focus on Preparing not in Passing) • Put in Your mind you already Passed. ‫• الكالم ال جاي اقرئه ممكن متفهموش ف األول بس اقرئه بتركيز هتتعلم ازاي تحل‬ ‫السؤال في نكلكس ممكن دلوقت يكون بنسبالك فلبيني الكن اما تحل اسأاله في نكلكس‬ ‫هتفتكر الكالم ده‬ 4 v SATA Questions. • Means select all that apply.  First Rule Ask yourself about safety Principles. • Simply Ask: • what kills this patient first…? What harms first? • then you must Look at the Key words like  (New, Sudden, abrupt, rapid) If you See those keywords this never a good thing you need to assess, intervention or educate the client immediately here.  Second rule: • If in doubt, go without which mean: ➢ If you don’t know, just don’t select it. Always ask yourself if it’s necessary in terms of Safety or not. v NCLEX test taking strategies: • Avoid Using absolutes on the NCLEX like « always, Never, must, cure» it's always typically to be wrong in the answer. • The NCLEX does not like absolutes. • The NCLEX will not suddenly Cure or heal your client. • Don’t read into the Question. o use only what they give you in the question. o Don’t add extra meaning. • Always Least invasive First to most invasive procedure is always last. • Assessment comes first and interventions or even treatment comes second. 5 • Always assess the Patient First before assessing machines or even equipment. • The Answer that delays the Care or even treatment is Usually wrong. • if two answer choices are exact opposite, so one is probably the answer. • if two options are very similar or saying the same thing so both are noncorrect. • If one part of the answer option is wrong, so the whole answer option is wrong. vTherapeutic communication: • Assess the Clients feelings by ask open- ended Questions. • We provide information. Don't tell the Client after medication everything will be ok. v Priority actions vs best actions:  The priority means: o What you Will do right now to save the client from dying. Ask about What Kills your client right now?  The best action: o Asking For you to only do one thing and nothing else. Just think How Can I fix this problem in one only. 6 v Lecture two v Prioritization and delegation v For Prioritization, Remember, unstable client comes first on the answer. • Unstable clients mean. o This is acute patient there is change happened. • Stable Clients o Have no Changes and are long term. Client. With Long term Conditions. as Chronically Conditions. v Six Words for NCLEX Priority Clients That Indicate instability) unstable client: • New, Sudden, Worsening, rapid, return to the Floor after any Procedure, Post operative after Surgery. • New such as patient new diagnosis: • Even his Vital signs are Stable. It Consider Unstable because It's new. *Always Remember. The NCLEX will not cure Your Client. v Maslow's Hierarchy of needs.  He identifies the level of human needs, The main Point here is that he addresses physical needs, before psychosocial needs.  In case of a group, how to Prioritize of Chronically ill Clients IF you get Four clients and all are critical. o You must Start Prioritizing the order of most important organs in the body to the least important. it's not always about the ABCs here. Your priority organ here First, Brain. Second, lungs. Third, Heart. 7  in Case of a single Client, not a group. o This Is Where ABCs Work. • How about to Prevent injury just some tips here for attention: o Low glucose levels, less than 70, the brain will die. o Any Creatine level over 1.3 dead kidney. o Infection any Temp that is high, especially for those who have weak immunity, Chemo, immunosuppressants, neutropenic precaution’s any slight increase in temperature will kill him even 100.7. o NCLEX Toxic Lab level: o Digoxin, Lithium, Phenytoin. v (4) Pain: • Think when will Pain Kill? When will pain harm the Client detrimentally? o You must prioritize the Pain based on the area involved. ▪ IF there is two Client just ask yourself: ▪ Who Will be harmed First? What the Worst thing that Can happen? ▪ You must think, what client losses of life or loss Limb First? v (5) What the ABCs really mean:  (A)- for airway:  Stridor: means Any threat Swelling, even noisy, Squeaky breathing you must think no Airway after any threat Surgery especially Thyroidectomy or even Parathyroid. v Hypoxia:  Means low oxygen. 8  What about hypoxia? o What's the First Sign of Low oxygen. o Is it a Low Pulse (NO) o Is it a low Cap refill. (No)  On NCLEX the first Indicator: o Clinical Manifestation of Low oxygen is Change in mental Status Level consciousness, agitation, Confused.  (B)-For Breathing Normal is 𝐩𝐚𝐜𝐨𝟐 = 35-45: • High Carbon dioxide, 45 or more means hypercapnic respiratory failure. • CO2 above 45 means hypercapnic respiratory failure.so, much CO2 that carbon dioxide it turns into carbon diacid that turns the body to an acidic state and shuts off the breathing.  (C) Circulation: o We're talking about heart and blood vessels. So, Vital Signs are important. o So, What Kills First? o Think Pulses: • No Pulses has no Perfusion especially in the extremities. o Blood pressure: o What BP Will Kill on the NCLEX? o Low BP→ Shock means Low oxygen to the body. o High BP →over 180 systolic Stroke its brain bleeding.  One other thing in Circulation: Bleeding→Internal bleeding in the abdomen this Indicates bleeding in the Abdominal area after any surgery any type of trauma or even acute condition. 9  Labs For bleeding: • Platelets Under 150,000 is thrombocytopenia the blood Cannot Clot (is very risky if any under 150 clients bleed out and die)  What about giving blood thiners like heparin even Warfarin? • PTT Levels and INR must be assessed. • If it's too high, Think Clients bleed out and die. v Part two Delegation " RN, LPN, LVN" v RN Never Delegate What U EAT:  U→unstable Client: • Ex→New admission, Sudden, Worsening, Return to the Floor Fresh Post operative.  E→Evaluation: • Ex→Interpreting blood Valve. Trending Vital Signs Trend’s Pain levels  A →Assessment: • Do not delegate initial, First, Primary assessment. • You can delegate secondary Follow up assessment.  T→Teaching: • Only RN Can do initial, First, Primary teaching. • They Can do Secondary teaching. Follow up teaching.  Legally speaking Whenever you are delegate: • Always Follow up and reassess tasks that you delegate. • Legally this is negligence, negligence is not good outcome. 10  Nurse aid: • Hang a bag of IV Fluids on a client it's outside of scope of his Practice. The nurse aid Cleary didn't have the credentials to do that. • This will be a Violation of delegation.  Newly admitted→ Unstable Cannot delegate.  Discharge→ You can delegate If he is stable.  Trending Vital signs, evaluation of lab Values Cannot.  Initial assessment→cannot delegate.  Interpretation of EKG→Cannot delegate any evaluation or even interpretation. v What We Can delegate to LBN, LVN? • Do Secondary things. Follow up or reassessment. • Three days after Surgery with no new changes. • Delegate administration of S.C insulin to a diabatic Client, even IM injection. • We Can delegate "Maintaining an IV for Stable client Nothing new, nothing Change • We Can delegate monitoring IV fluid.  What We Cannot delegate to LBN, LVN?? • No IV Push medication. • Ne Starting or initiating blood transfusion. • No Center line drugs. • We Cannot delegate titrating on iv drip mean change the iv drip it's Unstable. v Delegation to UAPS: • UAP→unlicensed assistive Personnel. 11 v For UAPS WE Cannot do three things:  Teach -Assess -Do Medication v What Can UAP legally do on the Nclex:  Activities of daily living.  V→vital signs  A→ambulation VAPER  P→position changes  E→Eating Feeding  R-recording is input and output. o During hospital Stay UAP Never delegate anything to the Family members. o Can a family member walk grandma to the bathroom? No o Family member Wants to help with feeding after Client surgery or Stroke pt. No v IF there something illegal going on, what will you do?  Example: o Nurse taking opioid (Pain medication) to home what should you do? ▪ First report this to supervisor  If there is something illegal going on and will harm the Client, what will you do? o intervene Immediately 12 v« Lecture 3 » v ETHICS and Legal terms. v «HIPAA Violation» ‫انتهاك‬ v Which Violates HIPAA? o Always think about Safety.  Remember: Team members directly involved with care NO over sharing on the personal information. v NOT Violate HiPAA as :  Discussing with other nurse “that you’re giving a report to her in Semiprivate room as long as reasonable measure by closing curtain.  What about tell a visitor to wear a mask because the client on isolation  What about 15 years minor doesn’t need her parents know about ask for a prescription of Birth control? Since the client a minor less then 18 means the parents have the right to view her medical.  What about discussing a client Personal information in the nurse station?  Calling a client Full legal First and last name in the waiting room? v Violate HIPAA means as:  Over Sharing:  What about telling the hospital transporter very specific details about Labs, diagnose?  Chemo nurse from another unit who asked about client information stat that "this client my husband co-worker.  Sharing username and password to supervision even direct. 13  What about if a family needs Copy of report? we must ask the Client first v NCLEX Legal words:  1-abandonment ‫تخلى عن المريض‬  You left the client to die essentially.  defined as Leaving of a Client by anyone Who assume to care.  Example: o You're taking care of this Client, and you didn't give Someone a report or transfer care to another nurse you just left the unit. o leaving the unit on a family emergency without transferring Care or giving a report to another nurse abandonment  2-Negligence: ‫إهمال‬ • N For Not Caring. • Failure to provide adequate Care. ▪ Example: ▪ The nurse did not use a sterile technique prior to inserting a folly Catheter negligence. ▪ What if a nurse identifies the absence of Peripheral Pulses in the extremity or basically a Casted extremely in the morning and the nurse reports to the HCP early in the afternoon. ▪ What about with holding the diagnosis of Cancer From a Client because the son thinks the Parent Cannot handle the Cancer diagnosis this is negligence because the Client has the right to Know if thy dying or if they have Cancer. 14  Malpractice (fetal errors): • Bad Practice by a licensed professional • This results in provable damage to the client. ‫اي ضرر يمكن بالفعل‬ ‫اثباته‬ ▪ Example: ▪ RN Failed to Check the dose on a medication Vial which harmed the Client. v physical and verbal abuse:  1-Assault. ‫تهديد‬ ✓ Threat of harm. ✓ Not actual Physical harm, Just the threat.  2-Battery: ✓ You physically did Something to the client without their consent contact that Cause harm.  3-False Imprisonment: ‫تعمل للمريض حاجه مش عازوها‬ ▪ Think You're in prison with False imprison. You are Keeping Someone against their will. ‫شيء ضد رغبته‬ ▪ Using physical restraints, seclusion,‫ اعزاله‬or even Chemical restrains like a sedating drug. This For Stable Clients. Not included Client who are Unstable on Psychiatric unit. or even those on a suicide hold.  4-Defamation of Character: ‫تعليقات سخيفة‬ ▪ This includes making rude Comments, insulting remarks that harm a client's reputation and this is included written and spoken. 15  5-Defamation of Character: ▪ It Could also Pertain to Coworkers. Written even spoke.  5-Libel: ▪ This is Written defamation of Character.  6-Slander: - ‫تسجيل كالم مش كويس‬ ▪ is Spoken, defamation of Spoke. ▪ Example: - The Nurse says I will restrain you to the bed to Keep you from getting out of bed «Assault » and Verbal threat. - What about Performing a procedure Without the Client, Consent « Battery»? - What about Chemically restrains a client who is competent and able to make their own decisions or to do that to prevent than from leaving the health care: - « Batter "and« False Imprisonment» - Force a client to take a medication that the client refuses in this case if the Client stable and not altered or non-Combative. This is: <Battery> - What about reading a letter your Coworker wrote about a nurse having an alleged relationship with a client on the unit: - < Libel> v Ethical key terms  Autonomy:‫يقدر ياخد قراره‬ • Think always in control with autonomy. 16 • This means the Client is given the right to make their own medical decision.  Advocacy: ‫يدافع عن المريض‬ • That means you're an advocate to Protect Clients health right, and even safety.  Beneficence: Think benefit with beneficence. We're benefiting The Client here.  Fidelity: ‫انك مخلص وبتدي كل حاجه ف معادها وانك بتعمل متابعه‬ • Staying Faithful, to follow through with your word. • If you say you’re ggoing to give a drug for pain medication, then following with that.  Justice: • Think You just treating People Fairly and equally.  Non maleficence: • To avoid causing harm <<No harm is Causing here>>  Veracity:  in Veracity is Very honest means tell the truth. v Examples: • Client Who reports the pain is 8 out of 10 and the nurse States he will return with Pain meds and Follow through the act: • (Fidelity) • Respecting the Client's right to refuse the treatment. • (Autonomy) but also your job educates them not Force. 17 • How about providing Care equally Regardless of race, gender, religion, even. Culture • (Justice) • How about Calling a family of a client to tell them that their loved one is critically ill and you're Caring For their needs. • (Beneficence) • How about reporting critical Changes in Client Critical Condition to advocate for Further treatment? • (advocacy) • What about double checking a drug dosage with another nurse to avoid a medication error. • (Non-maleficence) • How about questioning a provides order, who order too much of an antibiotic by accident and now this overdose can kiill the Clients Kidney? o This is both advocacies, advocating For Safety. o Non maleficence. • You are a nurse, and you accidentally Commit a medication error by luck, there no adverse effects, but still, you need to report the error. • « Veracity» • How about ensuring that time resources are distributed equally to Clients. You Just being Fair. Justice 18 v In Formed Consent:  Informed is Just getting information. Consent is deciding to do Something a voluntary decision.  Terms of safety: 1. Informed Consent is Just required before any invasive procedure and even any Surgery. 2. Informed Consent Confirm clients, voluntary decision to both the benefits as well as the risks. 3. For non-English Speakers they Cannot Consent without medical translator “It should be medical translator» not a family member. v Medical interpreter:  Consent must be given by a Competent adult. Competent in NCLEX include A health Care Surrogate, or (Power of attorney) or (Proxy) and parents or garden of a family if less than 18 years.  Can consent alone. • Less than 18, pregnant, if Marry, Substance abusees, or STI Members of military  Examples • Can a pregnant 16-Year-old Clint Who’s 36 Weeks with Painful Vaginal bleeding be Providing Consent by themselves Yes or no? Yes, this is a Competent adult. • How about a 14-Year-old Who’s Prescribed antipsychiatry medications without the parent Consent? Cannot give consent there must be assigned consent from a guardian before a minor is treated. As Long as it’s not emergency. 19 • Can a nurse Fluent in Spanish, translate for a native Spanish Speaker to obtain Consent? • No only medical interpreters who Know medical terminology.  Remember: ✓ Stay away from educating about the Procedure. Surgery he is the one will explain the Procedure. ✓ Nurses job only to Witness not to obtain.  Examples: ✓ Client is having a gall bladder removed and wants to talk about diet after the surrey. This nurses roles because we are not talking specific about the Surges. ✓ IF the Client wants to know about the surgery risks in this case this surgeon and providers roles. PHC v Nurses Role For informed consent: 1. Witness the consent. Not to obtain 2. Document both the date and the time the signature was obtained. 3. Assess and verify that the Client is Competent and Voluntarily sign.  Example: • What if a client who had a history of dementia but is alert and oriented times four, who gives Consent in this situation? ...... • What if a client States, I've changed my mind, I don't want to have Surgery. How Should the nurse respond in this case? I will notify your provider or your surgeon about your decision do not educate her. 20 • What about if the Client has a question about exercise after Surgery after a procedure? Nurses can educate about Post of Care • How about a Client going for a Partial hysterectomy and want to Know if they Can Still have children with one ovary left. Nurses can't provide Specifics. • How about a Client who's anxious about an upcoming Surgery wants to cancel it due to all the risks? Does the nurse educate him? No v Advanced Directives: ➢ Are legal documents that outlines desired medical Care if a client becomes unable to verbalize their wishes. ➢ is a living Will. The signed document that outlines wishes and desired medical care if the Client unable to Communicate. v There are four types: ➢ A full Code is Full resuscitative measures, mean we will do everything to save this Clint life. ➢ A Chemical Code is medications only So no Shocking No CPR, no respiratory help. ➢ ADNI means do not intubate. ➢ DNR means do not resuscitate at all ≪No CPR No resuscitate action≫. 21  Example: • Can a Client with DNR get oxygen Via nasal cannula For a Comfort measure? if it's clearly Stated comfort measures only, Not resuscitative measures. So yes. • Client Came to ER unconscious or has a brain bleed and unable to speak and we can’t find advanced directives. What do you do? Full treating Full life Saving. v Durable Power of Attorney (POA):  Means assigns another Person, called a health Care Proxy or surrogate, to make decisions for the Client if unable to do. ➢ Health Care Proxy, or Surrogate: This Parson will make decisions for the Client, not spouse, not family even the girl friend or Fiancée. ➢ if the sister of the Client is POA and not the wife, then the sister can make the final decision. This Proxy (POA) Can be changed any time. v Refusal of Care and AMA. - The Client has the right to refuse treatment. - Competent adult Can refuse treatment even if the partner does not agree, even Child, Spouse, Mother Mandatory. v AMA: ➢ Leaving against medical advice but, does any Client have the right to leave the hospital for any reason or at one time? ➢ The answer depends on several factors: ➢ Was the Client properly educated as Why they Should Stay in the hospital? Yes 22 ➢ Are they Competent to make their own decision? Yes ➢ Any they mentally stable? If yes So, Cannot Leave because they are on a suicide hold v But in case they are able to make their own decision and Fully conscious and awareness? 1. So, my rule to educate him about the risks of leaving the hospital. 2. Notify the Provider. 3. Remove any IV Catheters and tubes. 4. Sign AMA Consent. 5. Follow principles do not inform the security. vMandatory Reporting. ➢ Assess First, then intervention. ➢ If abuse is Suspected You must Legally report. 1. Protect the Client from that immediate harm. 2. Separately interview the Client. 3. Collect and Prepare evidence. 4. Create a Safety Plan and Provide information like shelters of even houses.  Some examples:  charge nurse delegates beginning CPR: • R.N • Licensed Practical Nurse (LPN). • Certified nurse assistant. • Orderly ≪ Non 11 license hospital assistants ≫ 23 • physical Therapy assistant. v Client ≪ Diabetes type 2 → Metformin ≫Done Cot with Contrast: • Avoid taking Metformin for u 8hr after the procedure o Prevent lactic acidosis. v Case manger's recommendation for disease management what You Know about disease management? • Recommended for Client with lifelong disease Chronic include DM, COPD • Promat Communication, education 24 v Lecture four vAcid, Base imbalances.  What is acid and base imbalances?  Balance between Acid and base of the body kind of like a tug of war the body Loves to keep these in balance. v Measured in blood via PH: Under 7.35 Above 7.45 The body goes Into Acidosis The body goes Into Alkalosis Too Low Two High v The Key Players that keep us in balance: 1. Hco3 → o Bicarbonate Known as bicarb this is our Base that helps to put the body in Alkalosis. Too much Hco3 get body in Alkalosis. 2. Co2 → o Carbon dioxide is our Acid helps to put the body in Acidosis.  Memory Tricks o Too much Co2  get the body in Acidosis. o High Carbon dioxide is high Carbon de acid. 3.H2→Hydrogen ions acidic‫شكل من أشكال الحمضيات‬ o H2 = Hydrogen ions are form of acid. o found in: - The stomach acids and urine. 25  Memory Tricks: - Hydrogen ions is high acid - Too much hydrogen ions equals an Acidotic  So, what makes the body Acidosis? o "H2 " hydrogen ions get High acid. o 𝐂𝐨𝟐 Carbon dioxide Just think Carbon diacid.  What makes the body Alkalosis? - Hco3 Bicarb base  The main organs that Control Acid and base are. - The lungs and the Kidneys.  First the Lungs Control Carbon dioxide 𝐜𝐨𝟐 (Respirators): - we breath in oxygen and breathe out co2 v Hypoventilation: o less breath out co2 means Less co2 out So more co2 retained in the body which makes the body more Acidic that’s mean more Carbon dioxide is more Carbon diacid and occurs for that patient. o Example: o Intoxicated, overdosed, Head injury. v Hyperventilation: o So more co2 out from the body which makes the body more alkalosis. Hyperventilation From an anxiety attack and panic attack. v Second Kidney. (Metabolic). ✓ Hydrogen ions ≪Acid≫ 26 ✓ Bicarbonate Hco3 “Base"  Metabolic alkalosis ✓ Vomiting ✓ NGt Suction  Metabolic acidosis ✓ Diarrhea ✓ Renal failure ✓ DKA ≪ Diabetic keto acidosis≫.  Respiratory Acidosis (Hypoventilation)  Every Condition that's breathing too slow is acidosis for respiratory Acidosis.  Low and slow respiratory rate. ✓ Sleep apnea. ✓ Head trauma. ✓ Post Operative. ✓ Drugs * CNS depressants. NELX TIP o Opioid overdose. o Alcohol in toxication. o Benzodiazepines (Diazepam) o Pneumonia and COPD or Asthma attack  Respiratory alkalosis (Hyperventilation)  Every Condition that's breathing too fast is Alkalosis For respiratory alkalosis. 27 - Fast respiratory rate - Hyperventilation=increase respiratory rate  Example: o Panic attack  Sign and Symptom for Respiratory alkalosis: o Low Paco2. o Low Hco3  Compensation:  Kidney excrete less H2 Base ‫ عشان نحافظ‬reabsorb less Hco3  which client to be in respiratory acidosis? 1. Morphine overdose. 2. CODD. 3. Asthma attack 4. Alcohol. 5. Apnea. v How can I solve the question for PH:  PH: 7.35 TO 7.45  PCO2: 35 TO 45  HCO3: 22 TO 26 v Notes:  Always Look to PH First.  Match PH with Partner.  compensated or uncompensated v how can I know compensated or non?  if PH Normal →Fully Compensated.  PH not normal→uncompensated. 28  partially compensated: ‫اسال نفسك‬ ‫طب‬uncompensated ‫مش طبيعي معني كده انه‬PH ‫ ف حاله ان لقينا ان‬ ‫ عشان نعرف هنشوف الطرف التالت هل هو بيحاول‬partial compensated or not ‫هل هو‬ .‫ زي ما هتشوف ف االمثله‬compensated or not ‫يساعد وال ال يعني يحاول يعمل‬  How does the nurse expect the client to show compensation for the following ABG values? alkalosis ‫ ميكنش ف الطبيعي ويميل الي‬paco2 ‫الزم‬compensation ‫عشان يكون في‬ o PH = 7.20 o Co2=37 o HCO3= 15 - Decreased respiratory rate X - increased respiratory rate ✓ - increased renal retention X - Most Important Objective data when determining if a client is Hypoxia? - Abnormal blood gases “ABG” - Best Diagnostic test to Evaluate patient oxygenation ventilation After a Traumatic brain injury? - Arterial blood gases ABG  Allen’s test: o Done to determine potency the history of the ulnar artery. - client makes a fist the Rt occlude the radial artery. - The palm is opened to reveal a pale palm from the lack blood flow. - Releasing the pressure on the ulcer artery. First the palm should regain its color in about 15 seconds or less. 29  AFTER: o Hold Firm Pressure.  Essential action after ABGs is down: o Apply pressure to puncture Site.  Priority Intervention following ABG Procedure: Examples: - PH= 7.25 Acidosis → uncompensated - Paco2 =55 ACIDOSIS - HCO3=25 Normal  Respiratory Acidosis uncompensated - PH 7,57 ... Alkalosis....uncompensated - Paco2. 25 ...... Alkalosis - Hco3. 22......Normal  Respiratory alkalosis uncompensated - PH 7,21.... Acidosis.... uncompensated - Paco2.... 39....Normal - Hco3.... 19.......Acidosis  Metabolic acidic uncompensated - PH. 7,32.... Acidosis - Pco2...55...... Acidosis - Hco3......42..... Alkalosis  Respiratory acidosis partially compensated. ‫ يعني بيحاول يساعده‬Balance‫ عشان بيحاول يعمل‬Alkalosis ‫ بقى‬Hco3 ‫الن‬ 30 - PH 7,55.... Alkalosis - Paco2...49...... Acidosis - Hco3...35...... Alkalosis  Metabolic alkalosis partially compensated. balance‫ عشان يحاول يعمل‬acid ‫ بقي‬Paco2 ‫الن‬ - PH 7, 37....Normal - Paco2...52...... Acidosis - Hco3...32....Alkalosis Hco3 ‫ وال اقرب‬paco2 ‫اقرب لمين هل اقرب ل‬PH ‫ نشوف ال‬Base ,Acid ‫عشان نعرف هي‬ Acid‫ اى‬7,35 ‫ معنا كده هي اقرب‬7,37 ‫الن فيه هنا المثال‬  Respiratory acidosis with fully compensated. - PH ...7,43......Normal ……. alkalosis ‫اقرب لي‬ - Paco2...43.... normal - HCO3....... Alkalosis……. METABOLIC  Metabolic alkalosis fully compensated. 31 vElectrolytes  Potassium 𝐊 + )3.5- 5(  Function of 𝐊 +:  Priority: o pumps the heart and Muscles.  Hypokalemia: o Below 3.5  Manifestants: 1. Heart→ o low and Slow Pumps o Flat T wave o ST depression Wave. 2. Neuromuscular: Low and Slow 1. Shallow Respiration Most deadly 2. Decreased DTR 3. Muscle Clamping, Flaccid, paralysis, paralyzed. 3-Gi= Low and Slow o Constipation o Hypo active bowel sounds o Paralytic illuis, (Paralyzed intestine Priority Risk for SBO small bowel obstruction 32  Causes of Hypokalemia:  Fluid Loss means electrolyte Loss.  Diarrhea  Diuretics  Diet Low Potassium  ↑High aldosterone  DKA  Hyperkalemia: o over 5.0  Manifestations: 1) Heart o High Pumps o Peaked T wave, St Elevate o Sever Ventricular Fibrillation o Cardiac arrest o Hypo tension Brady Cardia 2-Neuro muscular→ High 1) Increased DTR 2) Paralysis, Paresthesia (numbness) (Tingling) 3) Muscle Weakness (General Feeling of heaviness) 3-Gi=High Pump Diarrhea, Hyperactive bowel Sounds 33  Causes Hyperkalemia o Renal Failure and Low aldosterone vSodium Na 135-145  Function of Sodium: - S-Swells the body With Fluid.  Maintains - Blood Pressure - Blond Volume - PH balance. v Hyponatremia: - Below 135  Manifestations:  Brain: - Low slow Inside the Bain - Headache, cerebral edema - Mental States Changed - Seizures Coma.  Muscular: - Low and slow. - Fatigue, Muscle Clamps - Respiratory Low and slow 34 - Respiratory arrest  Causes of Hyponatremia: - Sweating - Excess water intake. (running in the extreme heat) - SIDH ↑ increase excess ADH↑ - vomiting | Darrah - Diuretics, Diuresis - Low aldosterone - Diet low in Salt. v Hypernatremia: - Over-145  Manifestations: - Body Big - Edema (Very swollen body). - Flushed Red Rosey skin. - increased muscle Tone. - Swollen dry Tongue. - Nausea vomiting  Causes of Hypernatremia: - Low ADH (antidiuretic hormones) (Di: Diabetes insipidus) - Rapid respirations - Watery diarrhea makes the body dry so high sodium. - Loss of Thirst he cannot explain Thirst, Immobility Pat. 35 vChlorride (CL 97-167)  Function Maintains - Blood Pressure. - Blood Volume. - PH bedance. v Hyperchloremia - Over 107  Manifestations: - - swollen and dry tongue. Nausea, vomiting. - Alkalosis → vomiting  Hypochloremia: - Below 97  Manifestations: - Fatigue Muscle cramps - Fever only different vMagnesium (Mg 1.3/2.1)  Function: - Mellow The muscle.  Hypomagnesaemia: - Below 1.3  Manifestations:  Heart o Low Mellow Excited o Torsade's de Points ECG Leading to V. Fib (Ventricular Fibrillation) 36 o DTR Low Mellow Excited o Hyperreflexia increased DTR  Causes Of Hypomagnesaemia: o Crohn’s disease o celiac disease. o Crohn’s disease and celiac disease are separate conditions that both affect the gastrointestinal (GI) tract. They can cause similar symptoms, making it difficult to tell them apart without diagnostic testing. In some cases, a person can develop both Crohn's and celiac. v Hypermagnesemia - Over 2.1  Manifestations: 1. Heart → High Mellow - Heart Block - Hypertension, Brady Cardio, low blood pressure and low heart rate. 2. DTR: High Mellow - Hyporeflexia (decreased DTR) 3. lungs, Gi= High mellow - depressed respirations 4- Hypoactive Bowel Sounds. v Causes of Hypermagnesemia: - Renal Feline. - Alcoholism 37 - Malnourishment v Calcium (CA 9 - 10.5)  Function. 1. KEEPS the 3 B. Strong Bon, Blood Clotting, Beats (heart)Contacts The Muscle.  Hypocalcemia: o Below 9.0  Manifestations: 1) T-trousseaus Sign o Twerking arm When RP Cuffing o Tetany muscle spasms all over 2) (c) Chvostek’s Sigh o Cheek Smile When stroking Face. 3) Diarrhea 4) Weak Bones, Blood Clotting Beats  Causes of Hypocalcemia o Hypoparathyroidism: o Low PTH lead to Low Calcium o Renal Failure: o chronic kidney disease CDK. o low Ca due to retention of phosphate Causes Hyperphosphatemia. v Hypercalcemia  Over 10.5 38  Manifestations: - kidney Stones, moans groans) Renal Calculi) - Constipation - Bone pain - Sever Muscle Weakness Lethargy - Calcium Control by PTA v Causes - Hyperparathyroidism - High PTH lead to high Calcium. - Cancer - PTH→ Parathyroid hormone. v Phosphate (3- 4.5)  Function o Inverse relationship with calcium - Ca High= Phosphate Low - Ca Low = Phosphate High  Hyperphosphatemia o over 4,5  Manifestations: - Think low calcium. - Trousseaus SIGN, tetany - Chvostek's - weak (Bones, blood, Beasts).  Cause of Hyperphosphatemia - Renal failure chronic kidney disease. 39  Hypophosphatemia o Below 3,0  Manifestations: - Think High Calcium signs. - Kidney Stones (Means, groans) it’s Called Renal Calculi - Constipation, Bone Pain, Sever Musca Weather lethargy.  Causes of Hypophosphatemia:  Hyperparathyroidism → Lead to High PTH = high on Calcium - Genetic and Cancer. v Hemostats:  The body being in Harmony and all systems are Within Normal limits.  Therapeutic range: o The range at which a Therapeutic Regimen is Working it's Best. vWrite 10 Times Before, After Study  Foods rich in Electrolytes. - Potassium: (K 3.5- 5)  Any fruit+ Green, Leafy" Veggies (Spinach Salt Substitutes) - Sodium (Na 135-145)  Table salt, cheese, spices, canned, processed food - Magnesium (1.3 -2.1)  spinach, almonds, yogurt, green vegetables. - Calcium 9- 10,5  Milk, Chee’s, green Veggies. - Phosphate 3-4.5  Dairy, Meats, beans 40 - Chloride (97-107)  with Salify Foods, in salt substitutes. v Droplets Electrolyte’s?  V• Vomiting Fluid  P• = Fluid  P• Diarrhea = Fluid  S• Sweating =fluid. v Hemoconcentration:  Dehydration (High, dry, Lab, Values) o Hemodilution  Low liquidly overhydration  Client has DM type one which lab tests included? o Creatinine o Hemoglobin A1C o Fasting blood glucose. o Total Cholesterol. 41 Pediatrics 42 v Pediatrics v What is the best way to teach all those Child? v 1-From Zero to two years old basically infant and Toddler or toddler hood - They learn by example by teaching in the moment, The present moment, not in the past, not in the Future. Just while you are doing something.  example  We are doing a foley Catheter insertion for an 18-month-old what do you do for teaching: - simply, teach him while you are doing the procedure. Never tell the toddler, I will do an IV, or putting this big tube inside you. v 2-Preschoolers basically from 3 to 6 years: - Has Preoperational thinking. - There are Very Imaginative has magical thinking and cannot understand cause and effect. - Teach him the day of, or even a few hours before.  Example:  we are doing Catheter to a Four-year-old child: - Teach the child what we are going to do, use Pictures, Stuffed animals, or tell him I will do this procedure and show him by Pictures. - The Points here to show them what you are going to do a few hours before. v Seven to 11 Years old: - They Love to Follow the rules and are very rigid in their thinking. - They are skilled learning includes skills like Insulin injections. 43 - you must teach days before; they have Concrete operational thinking and when you are teaching him something there is only one way of doing something because they Can’t switch injection location which means if You Show them How to do something that one time, they are going do it that same exact way every single time.  Tip:  They have very limited abstract, thoughts. So, you must teach days before.  They don’t know How to manage their own care.  Example  Which child Can the nurse teach bandage skills to? - it will be anyone seven years old or more, they have that Concrete operational thinking, and there's only one way of doing it. - So, if You Show them How to do something that one time, they are going do it that same exact way every single time. like child with diabetes.  The best place to give an insulin injection: - is right near the umbilicus, right near the belly button. - You Fold the Fat, clean with alcohol, inject that little area, in Fuse the insulin.  From 12 - to 15 years old. (Adolescent Clients) (Teenager) - They Can switch location injection and They understand Thought process. - Adult Learners known as Formal operational thinking. They Know how to manage their own care. - Teach them How to reports Findings and other more complex things. 44  Example:  We will teach bandage placement for an infected wound: - If the little infected wound gets more infected, we will teach them to report other signs of infection Red, worm wounds or even Purulent drainage, or any Spike in Fever. - We win teach him to report the provider because the can understand.  Which Child Can manage their own Care? - is 14 years old child with diabetes (right) - 6 Years old with diabetes (wrong) because they have Preoperational Thinking.  How about teaching an eight-year-old how to give Sub Injection? - They know how to do the skill but only one skill in that one certain way. They Know How to do that one thing very well. - But They don’t know How to manage their own care.  Teenagers (12 - to 15 years) have risk taking behavior: - Noncompliance will mediations and treatments. - Aren't Perfect at managing their own care. v Toilet trainings: - Begins during toddler age.18 month to 24 months. - Anything before 18 month the body can’t be able to control the bowels. - T→ Toddler From 18 month to 24 month. - T→ Toilet train ready when they tell you ‘’I need to Poop') - T →Two years or more They should have full bowel as well as bladder Control.  Note: Bladder Control Comes after Bowell Control. 45  The Following Factors to show readiness if the child is ready to do the toilet training: - So How do we determine readiness?  Can the child Perform simple tasks?  Can they walk and sit on the toilet?  Can they remain on the toilet or basically in one place for Five to eight minutes?  Are they able to pull clothes up and down?  What happens If the child makes a potty mistake? - Big thing avoids Punishing the child. Never Punish For making mistake simply, clean it.  Example:  What major task characterizes toddler hood?  Toddler Training is Toilet Training. v Play Types:  Remember  For little children, Play is an integral Part of the brain.  is a primary role for child.  During hospital Stay Play serves as a big Factor to relieve stress and anxiety.  The Top nursing considerations for Safety,  Airway, you must see if the toy is a choking hazard. So, any child under 4 years old no small toys Huge Choking Fisk  No metal toys near oxygen use any spark Can Cause a Fire 46  infection We need to prevent it, use hard toys for any Client who is Immunosuppressed, or Chemo treatment and We have to put them in their own room For Solitary Play.  Realistic expectations. v Actual Play Types: v From Zero to Six Months: - The best Toy for them is anything Softer or large that Play music. - Loves Solitary Play, they play by themselves. - Always Choose a Toy that Stimulates Both motor, Sensory think about touching, Fasting, Feeling, or moving arms. v From 6- to 9-month-old. - Love Cover and uncover toy, like Peekaboo, jack inbox, you are hiding eyes behind your hands and then you are uncovering and covering.  The worst thing to do for this age group from 6- to 9-month-old.  is giving a child something that they can strangle themselves with. like Music mobiles. v Nine to 12 months.  They are learning, Sensory motor.  Always choose any toy that talks back to the child, Talking Toy, Talking books.  This age is a Purpose Ful Play like, Hard Plastic blocks, like. building something, Sorting, stacking, making a construction all those is a purpose Ful Play. 47 v one to 3 years old.: - Toddler age - Best Toy, Wagons, Strollers, Stacking hard blocks. - The best toys Push-Pull toy, Like Wagons toy. - Parallel Play and Play between one and 3 They are start Playing near other children and after that integrating their play. v Growth Motor Skills from one to 3 years old.: - They are Learning, Running, Jumping, but they often have no Finger dexterity. - We can’t give them scissors to use. and can’t use color Pencils or even coloring stuff. v Growth Motor Skills Preschoolers 3-to six years: - They Love Pretend Play and even dress up Doll, Puppets tea Parties, imitating adults. - Learning Fine motor skills, Can Use scissors, using Tricycles. - More Integrated type of Play, learning imaginative Play associative Play.  Associative Play: - More Collaborative type of Play, especially with arts ds and crafts. v Growth Motor Skills by Four or Five Years old: - Love Fake Play with doll or dress up.  Example  what each group the nurse suspect when children are observed borrowing blocks From one another without interaction with one another? - This is one by one Play They are playing Separately but its Parallel Play they are playing near each other, so this is one to 3 years. 48  What about a long-Term hospitalized Four-year old? Which Toy is most appropriate? - Dolls - Puppets  - Stacking hard blocks (wrong) From 9-12 month. - Jack in a box (wrong) from 6-9 month. - dress up and Tea Parties  v School aged children: v From six to 12 Years: - They Love Creating, Competition, Collecting like baseball Cards. - also learning Creativity like logos, Painting or drawing  What Can you do to encourage creativity? - Encourage arts and Crafts, create by themselves. - Do not give him Something that already done. - always give them a blank Piece of Paper. - Collecting Something like Pokémon. - Competition like Monopoly. v 12 to 18 months adolescents: - These are Teenagers that are rebels Without a Cause. - The big thing that they are Learning Peer group socialization, basically, how social media is taking hold. - Example: - Meeting with Friends, Texting Friends, Taking with Friends. - always encourage these clients to meet With Friends and to do Peer group socialization. 49  Tip:  A Teenager (12 - to 15 years) who is in some type of traction device or after Sugary and the Client is an ugly hospital gown and her teenager's Friends Will Come to Visit him What is nursing Intervention You can do for making the teenager Feel Comfortable? - let him use his Favorite Shirt, get dressed Put Some Makeup  Big Safety Risk:  Who Cannot have friends visit: - client on Chemo, Immune Compromised. That’s No Fresh Flower, Fresh Fruits. - Client immediate after surgery - Contagious. v Developmental Milestones:  Always use two simple principles when answering developmental milestone questions. - When in doubt, use rule number one. Simply Call it normal. - always use the simplest task or simply Call it normal. v Start With Two- to Three-month-old: - Start kicking their legs and start raising their head in prone position. - Have Less head lag. - Sucking Their toes because she is learning sensory motor. - She always to smile specially When See Family Faces v Four- to Five-month-old:  No More head Lag We must report the provider increase of found head lag. 50  Should be No more head lag around Four.  If they have head Lag in Month five, they cannot control their head we have to report.  Fine Motor skills in the age Four- to Five-months:  They learning to grab objective Voluntarily.  They can grab a rattler and have diminished motor reflex Basically that Start reflex.  at this age other Flexes are diminishing. v From Six to 9 months: - The birth weight doubles by month six. - They can roll from their back to Their Front and even sit up unsupported. and Push Themselves up. - They can also hold baby bottle at around seven months. - They Can transfer objects from one hand to other.  Speech in the age Six to 9 months: - They start babbling a few words like mom, dada. - They can respond to their own none name and babble a few Words like Momo, Doda. If They can’t they have Speech delays - Separation anxiety begins at six months. v 10 to 12 months old: - They are using their 10 Fingers. - They can use Pincer grasp to Pick up small Food or other things. - Can Fully grasp a rattle or grab a dull by the arm. - Transfer objects from one hand to other hands more smoothly. - Birth weight Triples. - They Can sit down from Standing Position. 51 - Around 12 months learning How to take their first few steps While holding a hand.  Speech in the age 10 to 12 months old:  They are learning Vocalization.  So, that’s Why taking toys, and talking books are the best because They Start to barn How to Vocalize and speak.  Like Tickle Me Elmo is Best.  Fine Motor skills in the age 10 to 12 months old: - They are learning that one and two. - So, using a pincer grasp, they are basically using two Fingers for one. and two for 12 months. - They are Learning How to build blocks, basically two block towers, but unsuccessfully. - They are attempting to turn Pages a book, messy like swipe the whole Pages in the book.  Language: - its developing even Further, they must 5 Words in their Vocabulary at 12 months.  Example  when Would You report to the primary care provider or what needs Further investigation? - How about nine month who is not babbling or say mum? Yes, have to report. - Six month Who rolls over in both direction (that’s Normal)  Four month What Should be most concerned about it? - Head lag No More 52  When do you expect the little child to walk while holding a hand: - They take their First two steps or Few at 12 months. v 18 Month: - The big thing here is growth motor skills. - They Can walk up and down stairs while holding a hand. - Learning How to throw a ball, as well as Jumping in Place with both feet. - Learning How to turn Pages more smoothly in a book. - They Can build a Tower using Four blocks and scribble With Crayons. - No Finger dexterity, They Can be able to sit down. - Cannot use scissors or coloring Pencils.  Speech: - They have 10 words or more in their Vocabulary. - Know How to Follow Commands.  Example:  If you told him don’t touch that, he will Follow. - They Can use 10 Fingers by hold spoon or a cup. v Two Years: - They are learning How to walk on their own with two legs. - They can walk up and down stairs independently, but only one step at a time. - They are also Noting two names, First Name Last Name - They can for two- or three-word sentences. - They Should have learned toilet training, also Can draw Vertical lines. 53 v Three years: - They are Learning How to Jump Forward and How to use a tricycle. 3 wheels.  Fine motor skills: - They can draw circles and even spoon feed trans themselves (also Can draw Shapes) - They are Learning How to use scissors as well as holding Crayons win their Fingers, or even their fist. - They are Learning a lot of dexterity with their Fingers and Can even ZIP up and zip down zippers.  Speech:  Can Put together three-to-four-word sentences and they love. asking why? They Can't Follow Complex Instructions. v Age Four: - They are learning how to skip on one foot an even catch a ball ground half the time.  Fine motor skills: - Can draw Four Sides to a shape, like a Square or even a rectangle.  Example:  What is the highest Level of developmental milestone? - If a Child Can use their hands to open the door by turning the knob by age two it shows a lot of motor skills. 54 v Pediatric Physical assessment:  Assessing a Child: - Always interact with the Parent First. - Always encourage the Patent to be involved. like have the child on Parent Lap‫ يجلس علي رجله‬and use simple Communication  Tip: - Keep equipment out of the sight of Child because we don’t want Child scare with unneeded anxiety. - Keep least invasive Frist to most invasive last.  Example:  if we have a little kid on their mother's lap, then where do we start assessment? - Always Start by observing the child. We Can Count respiratory rate by looking at the child, not even touching him. - Then we can move closer a Just touch For a Pulse. - Then Finally, when needed, we can pull out that big scary blood Pressure Cuff. - The worst you can do. Put the Blood Pressure first.  Preparing to Perform a physical assessment on a 22 month what order Should the nurse Complete the assessment? - interact with the Parent First - Use a toy to Play with the child and build that comfort. - Start with Least invasive first, like taking the child’s weight or looking at (Rr) and then go more inventive listen to heart sounds With a stereoscope and Very last When You Pull out the equipment like a BP, Thermometer. 55 v Physical assessments: - Remember Growth is the biggest thing for Safety.  So: - Doubled birth weight by six months and tripled birth weight by 12 months. You must report if you didn’t Find that... v Nutrition:  From Zero to 12 months: - Solid Foods begin between Four to six months We are introducing one Food at a time and any one new Food Per Week.  The Worst you can do from (Four to six months): o That offer a big buffet or a big Casserole.  Use breast milk and iron Fortified Formula.  The Worst you can do from (Four to six months): o The worst Thing to use Cow milk. v Head assessment: - For Fontanels, is bulging at rest it's Indicate then Something wrong. Maybe infection or increased ICP - The only Time that Fontanels is bulging during crying or Coughing.  What does Sunken fontanel mean? - Means Dehydration or even Fluid Volume defect. v Respiratory distress:  There are a few certain for a little bay to respiratory distress:  Nasal Flaring, accessory muscle we and even abdominal breathing, with a nonproductive Cough. 56  What is the First thing You will do in case of respiratory distress? - Assess the respiratory Pattern, and Frequency and even the quality of the cry.  quality of Cry: - Any high Pitch cry is not good, this a big indication ' of deadly increased; ICP, or even brain damage. v Reflexes: v Babinski. o when stroking the bottom of the foot or the Sole of the foot, The big toe bonds backwards. and other toes Fan out. v From zero to four months:  We see rooting reflex or sucking reflex by stroking the side of the cheek on any infant. v Tonic neck reflex:  Where they turn their head to the side with one arm stretched out.  Example:  We get a 9-month baby which reflex would you expect? o Babinski reflex.  How will the nurse assess the rooting reflex? o Rooting reflex is the sucking reflex by stroking the side of the cheek. v GI assessment:  The key term is scary is bloody mucus in anew born diaper this is completely normal for only newborn.  We always continuous monitor the color, amount and consistency. 57  What color of stool the nurse to expect on the third day of life? yellow brownish. v Safety teaching:  Choking hazards, we must avoid food that can cause a choking hazard under the age of four.  Like:  Any little hot dog slices any baby carrots or even small apples, grapes or anything can get stuck we want to avoid any small item.  Example:  What about Marshmallow Ns? o We have to avoid.  What about nuts and seeds? o We have to avoid.  How about popcorn? o It's small we must avoid.  How about box of raisins? o It's small we have to avoid. v Burns:  We always apply sunscreen at least 15 minutes or more before going outside and make sure to reapply every two hours or three while out of the sun. v Drowning safety:  We never leave the child alone near a body of water even a bathtub. v Crib ‫ سرير‬safety:  Infants are always to be placed on their back or basically supine position. 58  Never on their stomach or basically prone position. In case you put them in prone position leads to SIDS that sudden infant death syndrome.  How about going to bed with baby bottle is it safe? o This is not safe because formulas have sugar in it so too much sugar can lead to dental cavities or tooth decay all that sugar will corrode the teeth.  What age do we remove these musical mobiles from the crib? o Whenever the little kid can start standing up its happened around six month. v Ear assessment: o Less than 3 we pull down on the ear and over 3 years we pull up and back.  Example:  Where do you position the pinna visualize the eardrum of a four years old? o Pull up and back.  Which direction do you put the pinna in an infant ear exam? o In infant that’s mean less than 3 years pull it down. v School age children:  Any school age children or even adolescent child we can do physical assessment just like an adult. Explain the results of the exam to the child but always respect privacy.  Example:  You are caring 11 years old client wit abdominal pain what best actions during a physical assessment should you perform? 59  1-we are going to complete a head-to-toe assessment the same as an adult.  2-explaine the results of the exam to both parents and child.  3-ask the child to describe the primary symptoms that’s subjective assessment.  4-respect the request to examine the child without the guardian present. v Cardiac defects:  Congenital heart disease also known as heart defect or cardiac defects: o These are abnormal or heart defect develop before birth.  Normal heart function: o Happens in two parts. Deoxygenated blood gets vacuumed back to the heart Via the veins through right vena cava into right side of the heart. o The veins vacuum deoxygenated blood back to the right side of the heart and then the right side of the heart pushes it into the lungs to get filled with Oxygen. o Once the oxygen gets on the blood, hen it's pushed over to the left side of the heart which pushed it out to the body this is where we get cardiac output means Oxygenated blood out to the body.  But in the heart defect: o The heart structure is changed so we get decreased cardiac output or basically decreased blood being pumped out to the body. So, anytime hear the word decreased cardiac output thing less oxygen rich blood out to the body. 60  It's simple concept:  If the heart defect starts with a letter(T), the client can traumatically die. Let me show you by example for traumatically die Like: o Tricuspid a Tersia, TOF (tetralogy of Fallot), TGA (transposition of great vessels). All these diseases start of letter T.  If the heart defect doesn’t start with a letter(T) it doesn’t require immediate intervention so it's traumatic problem. o For traumatically problem Like: o ASD (arterial septal defect,). OA (overriding aorta). All these diseases do not start of letter T.  Sign and symptoms that make these clients the worst or basically very traumatic and most critical:  1-Oxygen problems: o Traumatic cardiac defects are hypoxic problems. The heart is pushing blood away from the lung that makes the babies blue which cyanosis. Also have poor feeding as well as weight gain and even clubbing fingers. o Clubbing fingers: o Is huge for low oxygen as well as dyspnea and tachypnea or basically difficult of breathing and fast respiratory rate.  2- Hemoglobin: o We have to report any HG level over 22 is very deadly the priority intervention gives IV fluids.  Hemoglobin high: o high risk for blood clots leading to a stroke. 61  Why high hemoglobin cause clots? o Hemoglobin helps to carry oxygen around the body, so the clients have low oxygen the body will increase red blood cells due to this hypoxia and the body starts pumping out all new red blood cells to compensate for low oxygen but instead of perfusion the body ,the extra red blood cells start clumping and getting crowded inside the blood vessels leading to blood clots .that’s why always start clients on IV we infuse a lot of fluids into the blood stream to dilute the blood .  Tip: o Any traumatic cardiac defect that starting with T, infuse hydration basically Oral or IV.  Anything that doesn’t start with T simply not an oxygen problem it's cognitive heart failure: o ASD, VSD, PDA, AVSD. You must think the body is filling up with fluid. v Heart failure: o Weight gain. o Pale, cool extremities from all that water as wee as puffiness especially around the eyes known as periorbital edema. o Reduction in the number of wet diapers.  When is heart failure deadly: o Grunting during feeding because all that fluid pressure building up in the body and possibly overflowing into the lungs making feeding harder. So, might show signs of dyspnea, shortness of breathing or even difficult of breathing with tachypnea as well as tachycardia.  Tip: o All these conditions less deadly because hypoxia is not the primary problem anything doesn’t start with T is not an Oxygen problem. 62 o Every congenital heart defect will have a MURMUR, especially PDA (patent ductus arteriosus) this has a vey loud distinct machine-like murmur. v TOF (tetralogy of Fallot): o We have four defects in one it's a troubling heart defect.  Four defects in TOF: o P……. Pulmonary stenosis o R……Right ventricular hypertrophy or hypertrophy o O……Overriding aorta. o V……. Ventricular septal defect.  Deadly sign and symptoms for TOF:  1-Tet spells: o Oxygen problem it's a traumatic problem. o Also called hyper cyanotic spells.  Intervention: o For infant Put the knees to the chest. o For older children squatting position and give 100% oxygen also pain medication, IV fluids then document.  To prevent TET spells: o Do not interrupt sleep always provide a calm, quiet environment upon waking up. The worst thing you can do Sacre the little baby rushing into the room it will go into oxygen problem and starting too fast. o Offer a pacifier during crying because we want to slow down the breathing. o Small frequent feeding o Swaddle or hold the infant during procedure. 63  Example  So, what is going look like? o Oxygen being low. Client will present with cyanosis a blue baby. blue skin. o O2 FROM 65% to 85%. o Clubbing round fingers. o Increase hemoglobin level over 22 know as polycythemia.  Polycythemia: o Too many blood cells and we have a big risk for clots. o Huge risk for stroke and we must report.  Number one intervention: o Dilute the blood with IV fluids. v Treatment for cardiac defects:  Treatment: o Take these little babies to the cardiac Cath lab for cardiac catheterization where a small little tube is tethered right through an artery, near the groin in the femoral or even in the neck. And it goes through the blood vessels and into the heart where surgery takes place. o So, we must go any cardiac Cath lab you have to assess for any allergy to Iodine. Keep them NPO to six hours in children and even shorter in infants.  Big safety precautions and should report: o Sever diaper rash so, what harms the client? o Infection, diaper indications. From the Cath. 64  After the procedure, what kills the client? o Loss of life and loss of limb then.  Priority assessment from anyone going to a Cath lab, o if you hear the word Cath lab you must understand loss of limb because once you go to Cath lab infuse contrast iodine which kill the kidney, so always check creatine levels. o And, we have a huge tube inserted during Cath lab so, you must check pulses on the affected leg.so, always assess pulses distal