ATI Live Review

MISC. Surgery Pre-op, includes prophy antibiotics within 60 mins of incision Post-op, anticoagulants, pain meds Highest risk for infection or thrombus emboli Laparoscopic, post-op abdominal pain/distention referring to the shoulder is normal Rheumatoid arthritis T reated with methotrexate, check pregnancy in women (-) Adverse effects: low WBC, low PLT, weight loss due to stomatitis, pancytopenia Vitamin replacement of folic acid is needed Urine specific gravity/osmolarity: focus on concentration, urine low = no call to hcp, diluted ROLES LPN : cannot EAT or start/initiate IVs, can do drips, no IV push , given stable patient, data collection, REINFORCE teaching UAP : ADLS, VS, weight, I/O, safety, cannot do anything sterile RN : given unstable patient, assess, teach, plan Epiglottitis: caused by H Influenza B POA trumps advance directives 8oz Ice is 120mL Newborn meds: eyes and thighs, 25 gauge (5/8 th in) Okay to massage the area after the injection Vitamin K- in the thigh Diabetes Mellitus: blood sugar <70, hyper >250 Goal: A1c <5.7%, 6.5% A1c to diagnose, if diagnosed the goal is <7% Type II: can be managed with oral DM Insulin Pump needed for short and rapid-acting Rapid-acting: “Rapid LAG” Lispro, Aspart, Glulisine. Given 5-10 min before a meal or while eating Short-acting: Long-acting: glargine, Levemir. Peaks in 6-8hrs, given before bedtime Mix: regular and NPH IV ONLY regular DKA – if BP is low, fluids first , then insulin , blood sugar should only be lowered 50-75mg/dL/ hr via an insulin pump . Keep anion gap <12 Criteria for oral meds to insulin: pregnancy, non-compliance, or adherence Thyroid Hyper thyroidism: graves, weight loss, heat intolerance (sweating), tachycardia Methimazole /Propylthiouracil: monitor WBC Hypo thyroidism: Hashimoto’s, constipation, brittle hair/nails, depression, weight gain Levothyroxine: taken early AM, take on an empty stomach, dosage changes over time based on age/weight HEMATOLOGY Blood products Packed RBCs: severe or hemolytic anemia, hemoglobinopathy, erythroblastosis fetalis Monitor Hgb, normal F: 12-16g/dL, M 14-18g/dL Second nurse needed to verify Stay with patient first 15-30mins Platelets Active bleeding, thrombocytopenia, aplastic anemia, bone marrow suppression Monitor platelets, normal 150,000-400,000mm 3 Albumin Expand vascular volume, hypovolemia, hypoalbuminemia, burns, severe nephrosis, newborn hemolytic disease Monitor albumin 3.5-5g/dL FFP (fresh frozen plasma) Hemorrhage, burns, shock, thrombocytopenic purpura, bleeding from warfarin Prothrombin time, normal 11-12.5 seconds Reactions: Hemolytic chills, fever, lower back pain, tachycardia, tachypnea, hypotension occurs during 50mL of infusion STOP infusion, maintain NS IV A feeling of “impending doom” DO NOT discontinue IV, only tubing Send tubing to the lab, collect a urine sample to test for RBCs and bilirubin Anaphylactic Anxiety, wheezing, urticaria shock, cardiac arrest STOP infusion, maintain NS IV CPR IM epi Febrile Increase of 1 o C over 101.4F MEDICATIONS Albuterol lower airways, Nebulizer Epi croup Medication monitoring Digoxin: potassium, interacts with medications, initial sign of toxicity GI symptoms/nausea, Apical HR 60 adult, 70 children, 90 baby Acetaminophen: temperature, max adult dose is 4g Glipizide: blood glucose, causes hypoglycemia, given 30 min before meals Morphine: respiratory rate, blood pressure Prednisone: delayed wound healing, blood glucose. Treatment for Addison’s (ADD the steroids), and Cushing’s (d/t too much) Warfarin: INR, normal 2-3 Zolpidem: sleep patterns, take before bedtime Olanzapine: mood Levofloxacin: culture and sensitivity, stocked up for inhalation anthrax outbreaks (along with Doxy/Cipro) ACE inhibitors, remember “ACE” A-angioedema C- cough E- elevated K+ Beta-blockers: pulse and BP, not for asthmatics and bronchospasms Calcium channel blockers: “A Very Neat Drug”, do not give with history of CHF A- amlodipine V- verapamil N- nifedipine D- diltiazem Adenosine: short half-life, makes your heart stop briefly Dutasteride: used in conjunction with tamsulosin for BPH Warfarin: takes 3-5 days to work, INR 2-3 Phenytoin: can cause hyperplasia Metronidazole: for trichomoniasis, avoid alcohol/cologne/perfumes, metallic taste in the mouth Cyclobenzaprine: for muscle spasms, don’t take with opioids Trazadone: anti-depressants, off-label use for insomnia, can cause priapism (painful persistent erection), can cause falls or sedation Hydrocodone with acetaminophen (short-hand APAP): Vicodin, for pain control Montelukast: 2hr before exercising, prevent bronchospasms Dilaudid : caution dosing Tramadol: not for patients with history of seizures Methylergonovine: BP, a major potent vasoconstrictor. Not good for pre-eclampsia/eclampsia Nitroglycerin Reduced preload, decreased afterload Hypotension, headache, reflex tachy , tolerance Heparin vs. Warfarin Heparin: IV/SQ, immediate onset Monitor aPTT (1.5-2) and platelets (watch for HIT, heparin-induced thrombocytopenia, life-long) Antidote protamine sulfate Warfarin: oral, 3-5 days onset Monitor INR Antidote vitamin K Anticoagulant Interferes with the clotting process Rivaro xa ban, Api xa ban, heparin, warfarin Supplements may increase bleeding risk (“No Gs ”, garlic, ginger, ginkgo) Antiplatelet Interferes with platelet aggregation ASA, clopidogrel Ecchymosis and tarry stools may indicate prolonged bleeding Thrombolytic Dissolves clots (tPA, STEMI) Alteplase, reteplase Must be given within 4-6 hours of symptoms Nephrotoxic medications Vanco, Genta, IV contrast, amphotericin b, sulfamethoxazole, trimethoprim, NSAIDs Medication Diets MAOI’s no tyramine, aged cheese, fava beans. Soy sauce, salami, sauerkraut, draft beer Levodopa/Carbidopa: low protein, taken on an empty stomach Doxycycline: no calcium with admin Lithium: consistent salt intake and water Warfarin: consistent intake of vitamin K-rich foods Cardiovascular medications CCB contraindications: no HF Nitroglycerin: monitor blood pressure AFib: amiodarone, Cardizem/diltiazem if RVR, digoxin, and patients will need anticoagulant MENTAL HEALTH Lithium carbonate Takes 1-2 weeks to work AVOID dehydration, thirst is normal and common , 2-3L fluid /water a day with salty snacks to hold onto fluid, NOT SALT SUBSTITUTES Monitor: TSH, Na, Cr, and Lithium levels drawn 12 hours after the last dose right before next dose (0.4-1.5mEq/L) Complications: drowsiness/weight gain, toxicity, F/E imbalances, goiter/hypothyroidism Toxicity Early 1-1.5: GI distress, confusion, tremors Late 1.5-2: ataxia, blurred vision, hypotension Severe 2.5-3: oliguria, seizures, coma AVOID: NSAIDs, ACEs, diuretics Nursing actions: administer with food, increase fluid intake 2-3L/day Typical vs atypical antipsychotics Typical: haloperidol, chlorpromazine, thiothixene, fluphenazine Sedation, EPS, anticholinergic effects, tardive dyskinesia Agranulocytosis Neuroleptic malignant syndrome : tachycardia, fever , muscle stiffness , Seizures Atypical ( pines, dones , pip): risperidone, clozapine (watch neutrophil count for neutropenia), aripiprazole Low risk of EPS and TD Risk of weight gain, diabetes, dyslipidemia, Agranulocytosis, seizures, and ortho hypotension Anxiety and depression Tricy cl ic antidepressants: nort r iptyline and amitriptyline Highly anticholinergic Could be fatal in an overdose SSRI’s and SNRI’s: citalopram, escitalopram, fluoxetine, duloxetine, venlafaxine 4-6wks for efficacy, increased weight with some medications Bupropion: NO patient with hx of seizures Buspirone: non-benzo for anxiety RESPIRATORY MEDS Budesonide: rinse mouth afterward Sulfamethoxazole: wear SPF Isoniazid: foods rich in B6 Albuterol: monitor HR, may increase Montelukast: 2 hours before exercise Pseudoephedrine: may increase BP SAFETY S eizures p66 Pre-seizure : IV access, blankets/pillows/patients to the floor During-seizure : lorazepam and diazepam, 5 mins+ call rapid Canes Hold on the strongest side of the body, advance cane 6-10in Cane weaker stronger Lead with unaffected leg going upstairs Crutches 15-30 o , “tripod position” 6in to side, 6in ahead, weight supported in hand grips Lead with unaffected leg going upstairs “up with good, down with bad” Height of crutches to height of patient DEFAULT STRATEGIES Approaching questions Always s tay with the client , yell for help Use what you know Always p revent harm to the client , safety is a priority Safe and effective delegation Look for the most complete answer Adverse effects, always choose the WORST answer Communication must include task plus a follow up “Scheduled” medications will have priority when answering priority or first questions Not everything in the EMR is protected, ex: demographics, face sheets, insurance Fire evacuation First: whoever is closest to fire Second: most mobile or ambulatory Horizontal over vertical evacuation MED SURG FOCUS Treatment for hypercalcemia, loop diuretic furosemide Loop diuretic gets rid of everything Electrolytes imbalance/interventions p. 81 Maintain UOP at least 0.5mL/kg/ hr Interventions for respiratory tests , pg. 85 Sputum: provide oral care Bronchoscopy: assesses gag reflex QuantiFERON Gold: assigned to a private room Thoracentesis: place chest tube in room Chest tubes Pneumothorax p. 90-91 Hemothorax: normal max drainage 70mL/ hr Chambers Drainage: where blood/fluid drains into, far right side Water seal: should tidal upon inspiration/expiration, intermittent bubbling NO continuous (signs of air leak) Suction: wet system controlled by water; dry system set dial. CONTINUOUS BUBBLING OK Dislodgement: From the patient 3 sided OCCLUSIVE Vaseline gauze From the suction device place the end in sterile water Mechanical vent Assist with vent ilation Assess breath sounds Maintain ET tube position Suction as needed Manage client, not alarms PEEP: increases pressure in the chest, used for ARDS, can drop blood pressure Dumping syndrome: food goes too fast through the colon and bowel, use gravity to slow down, lay down 15-20 mins Bariatric surgery Gastric bypass (risk for pernicious anemia) and Gastric band High-risk patient Activity to decrease risk for VTE Diet: first 5-7 days clear liquids, low glycemic foods with full liquid Dumping syndrome: only with gastric bypass Postoperative stoma care p. 107 Mild soap on the skin Change appliance 3-5 days Stoma should protrude 1-3cm Empty ½ to a third full Renal diet Restrict Na+, K+, phosphorus Protein 0.8-1.0g/kg/day Renal vitamin Restrict fluids IV FLUIDS Isotonic: no fluid across the cell membrane , used for shocks 0.9% NS: Lactated ringers: contain lactate to prevent acidosis Hypotonic :“ C ells become a hippo”, fluid moves into the cell 0.45% NS 0.33% NS Not given for ICP or edema Hypertonic: “high number,” fluid out of the cell TPN D 5 NS D 5 LR Mannitol: refrigerated, shake until crystals are gone, give with a filter ACID-BASE IMBALANCE p. 84 “ROME”, respiratory opposite, metabolic equal pH, HCO 3 , CO 2 Compensation Partial: all three abnormal Uncompensated: pH + 1 other abnormal Full: pH normal, other 2 values abnorma l MUSCULOSKELETAL DISORDERS Osteoarthritis and rheumatoid arthritis, p. 109-111 Ice/heat/rest, 20 min max Acetaminophen NSAID Steroid Joint replacement Medications: Osteoarthritis glucosamine, rheumatoid DMARDs Fracture complications, p. 112 Fat emboli: confusion, tachypnea, tachycardia, petechiae Pelvic/ femur/ hip fractures d/t supporting fatty areas of the body DO NOT WALK, immobilize fractures NO heparin or thrombolytics Compartment syndrome: 6P’s pain, pressure, pallor, paresthesia, paralysis, pulseless Early sign: Pain not relieved by an opioid, paresthesia Keep limb at the level of heart Treat with fasciotomy Skeletal traction, p. 113 Bucks’ traction: pillow under calf , not knee ENDOCRINE Diabetes insidious: desmopressin SIADH: tolvaptan Addison’s disease: hydrocortisone Thyroid storm: propranolol Hypothyroid: levothyroxine DI vs SIADH , p. 116 Diabetes insipidus: “dry inside”, polyuria, low urine concentration, hemoconcentration, fall precautions Treat with desmopressin for central DI SIADH: “soaked inside” small cell lung cancer, oliguria/high urine concentration, fluid retention, hemodilution, and hyponatremia (seizure precautions) Treat with fluid restriction Addison’s vs Cushing’s Cushing’s disease: excessive steroid, hirsutism, hyperglycemia, weight gain, hypocalcemia, hypokalemia, diet considerations corticosteroids break down bone, increase the need for calcium, low carbs to reduce sugars, avoid crowds (long-term steroid use causes leukopenia), use salt substitutes, no contact sports (risk for fracture) Addison’s disease: fluid volume deficit, hypoglycemia, weight loss, hyperkalemia, hyponatremia, diet considerations Ad iet low in potassium and high in salt (no salt substitute), treat ed with hydrocortisone ONLY 2 fluids, D 5 NS and NS, NO DEXTROSE ALONE CARDIOVASCULAR Myocardial infarction Pain: chest pain or discomfort, in the jaw/neck/arms/back/abdomen, occurs without cause and is relieved by opioids Associated symptoms: N/V, diaphoresis, SOB, dizziness, fatigue, fear/anxiety MONA, morphine, nitro, oxy, asa STEMI: ST elevation MI, immediate PCI within 90 mins Heart failure, p.131-132 ECHO to diagnose HF, systolic HF EF <40%, diastolic HF EF normal S3 in pregnant women is normal Systolic HF Left: “lungs”, dyspnea, frothy sputum, crackles, cough Right: “rest of body”, JVD, weight gain, edema Management Daily weight Medications: ACI, diuretics, low dose BB, AVOID NSAIDs and CCB Diet and exercise (report 2-3lbs overnight, 3-5lbs/week) Arterial vs Venous insufficiency Arterial: claudication, delayed cap refill, hair loss on legs/extremities, cyanotic extremities Arterial ulcers end and in-between the toes, deep and even edges with little granulation Venous: painless ulcers (ankle area, uneven edges with granulation tissue), lower leg edema, hyperpigmentation (think of spider veins rupturing causing pooling of veins) NEUROSENSORY DIAGNOSTICS, pg 148-149 Lumbar puncture: for severe headaches EEG: avoid caffeine 8hrs before the test CT: first for stroke and CVA, “dry CT” CTA: cerebral angio graphy requires contrast MRI: NO PACEMAKER, OK for pregnant women ICP, INCREASED INTRACRANIAL PRESSURE Contributing factors: Manifestations: Interventions: HOB 30-45 degrees, low stimuli environment, patent airway, mannitol (given with filter) BURNS, pg. 165 Electrical: treat as if SCI is present Chemical: rinse with water before touching the skin Thermal: airway, breathing, circulation, risk for inhalation (reddened mucus membranes, singed nasal hairs, throat pain), fluid resuscitation Parkland formula: 4mL x kg x %, ½ first 8, ½ next 16 Carbon monoxide: dangerous due to odorless and tasteless properties, FIRST get out of the environment, do not go by pulse ox, and give O2 high flow 15-30mins MENTAL HEALTH PHARM Haloperidol: high risk of EPS Clozapine: monitor neutrophil count Phenelzine: No Tyramine (MAOI) Methylphenidate: used for ADHD, causes weight loss Paroxetine: SSRI causing weight gain Bupropion: do not give with a seizure disorder Olanzapine: hyperglycemia St. John’s Wort: do not give SSRI Clonidine: alcohol/opioid withdrawal, ADHD Amphetamines: limit caffeine intake Trazadone: used for insomnia Lithium: monitor Cr , can be nephrotoxic ANXIETY, pg. 176-177 Minimize situations that increase anxiety Encourage problem-solving Therapeutic communication Panic attack for Interventions: Use firm and simple statements, minimize stimuli, stay with the client, and rarely last more than 30 minutes Defense mechanisms: mature vs immature Sublimation: exchanging something inappropriate for something appropriate SCHIZOPHRENIA, pg. 178 Negative vs. Positive Positive: altered thought/delusions, altered speech/echolalia, altered perception/hallucinations Negative: flat affect (apathy), anhedonia, algoia , lack of motivation (avolition) ADHD Manifestations: inattentive, hyperactive, impulsivity Treatment: Stimulants: methylphenidate, amphetamine Non-stimulants: atomoxetine, and guanfacine, take a couple of weeks to have an effect AUTISM SPECTRUM DISORDER Introduce new activities slowly Decrease environmental stimuli Promote positive reinforcement Alterations: Social skills: preference to be alone Language: Behaviors: unusual movement, self injury Cognition: short attention Health : SUICIDE, pg. 180 Ideation, previous attempt hx , family hx , impulsive CM: use of drugs/alcohol, giving things away, statements such as, “I won’t be another much longer” Management: assess for plan and ability to initiate plan, initiate preventive measures, implement 1:1 supervision PERSONALITY DISORDERS pg. 181 Cluster A: Paranoid: distrust toward others Schizoid: emotional detachment Schizotypal: extreme anxiety in social situations Cluster B Antisocial: disregard for the rights of others Borderline: instability of affect, self-mutilation Histrionic: attention seeking Narcissistic: arrogance, lack of empathy Cluster C Avoidant: social inhibition, feel ing inadequate Dependent: excessive clinging, submissive Obsessive-compulsive: perfectionism and control ALCOHOL WITHDRAWAL pg. 182 Symptom + Intervention: Hypertension clonidine Diaphoresis fluid replacement Wernicke-Korsakoff infused IV thiamine Delerium tremens lorazepam Hallucinations decrease stimuli NEUROCOGNITIVE DISORDERS Dementia pg. 183 Do not confront, use distraction Reminiscence and routine Provide limited options Cue, not quiz Caregiver referrals Cover large mirrors Use symbols and pictures Use calendars and clocks Watch for wandering ANOREXIA/BULIMIA Priority: assess physical health and safety Focus on participation in treatment rather than weight Prevent purging, stay with the client following meals MATERNAL NEWBORN OB, pg. 189 Non-stress test: done in 3 rd semester, looking for FHR concerning fetal activity Chorionic villus sampling: can be done at 10wks, looks for chromosomal abnormalities Fetal scalp blood sampling: like and ABG Maternal serum alpha-fetoprotein detects neural tube defects between 16-18wks Test/intervention Ultrasound: may need a full bladder, transvaginal better Non-stress: FHR increases with fetal movement, REACTIVE GOOD, 15bpm x 15 secs Contraction stress test: negative test has no late decelerations, NEGATIVE GOOD, “always good to be early, not late” Biophysical profile: five variables are assessed, fetal breathing movements, gross body movements, fetal tone, reactive FHR, amniotic fluid volume Amniocentesis: give RhoGAM after test to Rh- patient Terms GTPAL: Gravidity (# of pregnancies), Term (38wks or more), Preterm (before 22wks), Abortions/miscarriages (counted after 21wks), Living Children Prenatal care Assess: anticipatory guidance, maternal VS/weight, fundal height, FHR, fetal activity, urine (glucose/protein) Specific assessments: 14-15wks amniocentesis, 16-18wks screen for NTD, 24-28wks screen for diabetes, 35wks test for strep B Quickening: first fluttering a woman feels with pregnant Nutrition/vaccinations/exercise during pregnancy Nutrition 300-400 kcal/day Iron intake 30mg of iron/day Folate intake 600mcg/day Prenatal vitamins Limit caffeine intake of 200mg/day Vaccines to AVOID During pregnancy: live vaccine, HPV, Polio, MMR, LAIV (live attenuated influenza vax), BCG (tuberculosis), Zoster During lactation: yellow fever, smallpox, monkeypox Preeclampsia, pg. 197-198 Magnesium sulfate is given IV, stop if patient has adverse effects HELP Manifestations Mild: elevated BP, proteinuria Severe: CNS irritability, liver involvement, oliguria Eclampsia: seizures, coma Complications of pregnancy Placenta previa: implantation of the placenta in the lower uterus Risk: multiple gestation, previous placenta previa, previous c-section Causes: smoking and cocaine use Manifestations: sudden onset of painless uterine bleeding in the last half of pregnancy Dx: transvaginal US ACTIVE LABOR Epidural anesthesia: give fluid bolus before the procedure STAGES OF LABOR First stage: longest Latent: 0-3cm Active: 4-7cm Transition: 8-10cm Second stage: pushing stage, support mom, assess FHR Third stage: delivery of placenta within 20-25 mins (if assistance needed increased risk of hemorrhage) Fourth stage: recovery and bonding, hemorrhage, 2 pads in one hour TOO much, normal is 1 pad/2hrs FHR MONITORING, pg. 204-205 Early deceleration: FHR and contractions mirror each other, which may indicate head compression Variable deceleration: Prolapse: can see the cord, relieve the pressure with 2 fingers on the cord, do not push back in Cord compression: internal compression, repositioning patient knee to chest or Trendelenburg Late deceleration: reposition the client and apply oxygen via face mask, turn off oxytocin “VEAL”, “CHOP” “MINE” NEWBORN, pg. 214 APGAR: normal 7-10 Suction mouth first, then nose Cold stress: cyanotic, cool clammy extremities, risk for hypoglycemia Initial care, pg. 215 ABC’s: temp, pulse, respirations Thermoregulation: major heat loss through the head Umbilical cord: “AVA” artery, vein, artery APGAR Safety: band infant and mother, abduction still occurs (have a newborn on the opposite side of the door, female is the typical perpetrator) NURSING CARE OF CHILDREN Pain management, pg. 241-242 Identifying pain: behaviors, pain scales, is it painful for adults? Analgesics: PCA age 7+, topical anesthetic cream Non-analgesics: comfort, environment, distraction Response to terminal illness pg. 243-244 Infant/toddler: mirror emotions of parents Pre-school: may believe thought caused the illness School-age: uncooperative with treatment due to fear Teen: stressed by appearance changes CLUB FOOT VS HIP DYSPLASIA Club foot: passive exercise, inversion (internal rotation), cast Hip dysplasia: Ortolani (takes legs and moves like a bicycle, if + you will hear a click), Pavlik (diaper under harness, no lotions or creams under harness, do not adjust straps), cast CLEFT LIP, pg. 252 Provide special feeding devices Feed in an upright sitting position Feed slowly over a 20 to 30 min period Introduce solids at 6mo Burp frequently AVOID prone position AFTER surgery, position upright in a special seat and/or elbow restraints CONGENITAL GI DISORDERS Pyloric stenosis: projectile vomiting Hirschsprung’s: no peristalsis in the large bowel, bilious vomit, classic sign failure to pass meconium, will need colectomy, the major complication is enterocolitis, fecal incontinence and obstruction (abdominal rigidity and fever) Intussusception: bloody stool, telescopes into itself, may resolve on its own Cleft palate: aspiration risk ACUTE GI DISORDERS The younger the child, the more serious the condition Infants and young children dehydrate quickly Monitor weight GOLD STANDARD Loss of 0.5kg body weight is equal to 500mL EPIGLOTTITIS NO throat cultures, sore throat in a tripod position with drooling, priority patient d/t potential of throat closing APPENDICITIS Expected findings: focal tenderness, right hip pain with ambulation, low-grade fever, dehydration, pain increases upon coughing Antibiotics , fluids, maintain NPO, pain assessment Interventions for rupture: open would you irrigate as prescribed, maintain NG to LIS, encourage the expression of feelings TONSILLECTOMY, pg. 259-260 Signs of hemorrhage: frequent swallowing, clearing throat, hematemesis Higher risk at first 2 days and 1 week due to scabs falling off Diet: crushed ice ok, no rough edges or hot soups/spice Pain: NO codeine COMMUNICABLE DISEASES, pg. 268-269 “ adulTDAP ” “ chilDTAP ” CYSTIC FIBROSIS Multi-system disorder, prevent respiratory complications Pancrelipase the desired effect is steady weight/height gain, fatty diarrhea stools decreased Diet: high fat, high calorie, and high Na, (ex: milkshake with whipped cream) Deficiency of fat-soluble vitamins CELIAC Monitor GI symptoms No “BROW”, barley-rye-oats-wheat