All Hesi Hints - [DOC Document] (2024)

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ADVANCED CLINICAL CONCEPTS

ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. The mortality rate is high (50%)

In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very responsive to high concentrations of oxygen.

Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them from collapsing each time the client exhales. The amount of pressure can be set with the ventilator and is usually around 5 to 10 cm of water.

Suction only when secretions are present.

Before drawing arterial blood gases from the radial artery, perform the Allen test to assess collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture.

If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death will occur. However, they must be removed from any source of imminent danger, such as a fire.

PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure.

A child in severe distress should be on 100% O2.

Early signs of shock are agitation and restlessness resulting from cerebral hypoxia.

If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous return further to the left ventricle.

Severe shock leads to widespread cellular injury and impairs the integrity of the capillary membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All organs are damaged, and if perfusion problems exist, the damage can be permanent.

All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do not change infusion rates simultaneously.

A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is the first priority? Maintaining an open airway (the allergic reaction damages the lining of the airways causing edema). Also, keep the client warm without constricting clothing; keep legs elevated (not Trendelenburg because the weight of the lower organs restricts breathing).

Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild

Epinephrine: 1:10,000, or 5ml IV for severe

Volume expanding fluids are usually given to clients in shock. However, if the shock is cardiogenic, pulmonary edema may result.

Drugs of choice for shock- Digitalis preparations: Increase the contractility of the heart

muscle- Vasoconstrictors (Levophed, Dopamine): Generalized

vasonconstriction to provide more available blood to the heart to help maintain cardiac output.

A common volume-expanding substance is plasma and possibly whole blood.

You are caring for a woman who was in severe automobile accident several days ago. She has several fractures and internal injuries. The exploratory laparotomy was successful in controlling the bleeding. However, today you find that this client is bleeding from her incision, short of breath, has a weak thready pulse, has cold and clammy skin, and hematuria.

- What do you think is wrong with the client, and what would you expect to do about it?

- These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the formation of thrombin (Coumadin does not do this). However, the client described is already past the coagulation phase and into the hemorrhagic phase. Her management would be administration of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is poor).

NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are required for each of the following situations?

- A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic.

- A 36-year old first time pregnant woman who arrests during labor.

- A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to catch fire.

- A 40-year old businessman who arrests two days after a cervical laminectomy.

WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)- The American Heart Association recommends that those

with known angina pectoris seek emergency medical care if chest pain is NOT relieved by three nitroglycerin tablets 5 minutes apart over a 150minute period.

- A person with previously unrecognized coronary disease experiencing chest pain persisting for 2 minutes or longer should seek emergency medical treatment.

It is important for the nurse to stay current with the American Heart Association’s guidelines for Basic Life Support (BLS) by being certified every two years as required.

If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4 cycles, then reassess for breathing and pulse. If two rescuers are

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performing CPR, a 15:2 ratio is now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min compression rate. When trading off, start with compressions.

Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support (ACLS) guidelines.

When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless hyperkalemia and/or preexisting acidosis is documented.

Infants/prematures may have problems with the following that can predispose to arrest: Beware of the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory acidosis), hypercoagulability (if polycythemia exists).

Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration.

Dextrose 10% is a hypertonic solution and should be administered IV.

Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV flush lines with intermittent IV medication.

Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift fluid into intracellular or extracellular spaces.

Potassium imbalances are potentially life-threatening, must be corrected immediately. A low magnesium often accompanies a low K+, especially with the use of diuretics.

Fluid Volume Deficit: Dehydration- Elevated BUN: The BUN measures the amount of urea

nitrogen in the blood. Urea is formed in the liver as the end product of protein metabolism. The BUN is directly related to the metabolic function of the liver and the excretory function of the kidneys.

- Creatinine, as with BUN, is excreted entirely by the kidneys and is therefore directly proportional to renal excretory function. However, unlike BUN, the creatinine level is affected very little by dehydration, malnutrition, or hepatic function. The daily production of creatinine depends on muscle mass, which fluctuates very little. Therefore, it is a better test of renal function than is the BUN. Creatinine is generally used in conjunction with the BUN test and they normally are in a 1:20 ratio.

- Serum osmolality measures the concentration of particles in a solution. It refers to the fact that the same amount of solute is present, but the amount of solvent (fluid) is decreased. Therefore, the blood can be considered “more concentrated.”

- Urine osmolality and specific gravity increase.

Check the IV tubing container to determine the drip factor because drip factors vary. The most common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per milliliter.

Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent complications such as infiltration, emboli and infection.

A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE.

The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal.

Review the order of blood flow to the heart:- Unoxygenated blood flows from the superior and inferior

vena cava into the right atrium, then to the right ventricle. It flows out of the heart through the pulmonary artery, to the lungs for oxygenation. The pulmonary vein delivers oxygenated blood back to the left atrium, then to the left ventricle (largest, strongest chamber) and out the aorta.

- Review the three structures that control the one-way flow of blood through the heart:

1. Valves Atrioventricular valves Tricuspid (right side) Mitral (left side)

Semilunar valves Pulmonary (in pulmonary artery) Aortic (in aorta)2. Cordae Tendinae3. Papillary muscles

Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat. This action represents a resting and regrouping stage so that the next heartbeat can occur. If defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia.

Observe the client for tolerance of the current rhythm. This information is the most important data the nurse can collect on the client with an arrythmia.

REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess to determine if the leads are attached properly.

Marking the operative site is required for procedures involving right/left distinctions, multiple structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the involvement of the client.

Wound dehiscence is separation of the wound edges and is more likely to occur with vertical incisions. It usually occurs after the early postoperative period, when the client’s own granulation tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus.

NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process. Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have

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her gallbladder removed in a same-day surgery using a scope instead of an incision. What nursing needs will dominate each phase of her short hospital stay?

- Preparation phase: Education about postoperative care, NPO, assist with meeting family needs.

- Operative phase: Assessment, management of the operative suite.

- Post-anesthesia phase: Pain management, post-anesthesia precautions.

- Post-operative phase: Prevent and assess for complications, pain management, dietary restrictions, activity.

HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.).

STANDARD PRECAUTIONS:- Wash hands, even if gloves have been worn to give care- Wear gloves (latex) for touching blood or body fluids, or any

non-intact body surface.- Wear gowns during any procedure that might generate

splashes (changing clients with diarrhea).- Use masks and eye protection during activity which might

disperse droplets (suctioning).- Do not recap needles, dispose of in puncture-resistant

containers.- Use mouth piece for resuscitation efforts.- Refrain from giving care if you have open skin lesions.

Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV).

Pediatric HIV is often evidenced by lymphoid interstitial pneumonitis.

The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and management of complications associated with HIV.

For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3 minutes as needed, until 1.0mg is achieved.

Use non-invasive methods for pain management when possible:

- Relaxation techniques- Distraction- Imagery- Biofeedback- Interpersonal skills- Physical care: altering positions, touch, hot and cold

applications.

Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory depression).

Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional narcotics cannot be given until the Narcan effects have passed.

Do not take away the coping style used in a crisis state…DENIAL. It is a useful and needed tool at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment – endangering the patient.

MEDICAL –SURGICAL NURSING

RESPIRATORY SYSTEM

Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature also increases metabolism and the demand for oxygen.

High risk for pneumonia:- Any person, who has altered level of consciousness, has

depressed or absent gag reflex and cough reflexes, is susceptible to aspirating oropharyngeal secretions. (Alcoholics, anesthesized individuals, those with brain injury, drug overdose, or stroke victims).

- When feeding, raise the head of the bed and position the client on side – not on back.

Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue.

Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of fluid are lost daily by the lungs through evaporation.

Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough oxygen to the brain.

Pneumonia preventatives:- Elderly: flu shots; pneumonia immunizations; avoiding

sources of infection and indoor pollutants (dust, smoke, and aerosols); do not smoke.

- Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance of rest and activity.

- Comatose and immobile persons: elevate head of bed to feed; turn frequently.

Compensation occurs over time in clients with chronic lung disease, and arterial blood gases (ABGs) are altered. It is imperative that baseline data are obtained on the client.

Productive cough and comfort can be facilitated by Semi-Fowler’s or high Fowler’s positions, which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a priority in these clients because it elevates the diaphragm and inhibits lung expansion.

Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in adequate to oxygenate the tissues.

Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure.

Cells of the body depend on oxygen to carry out their functions. Inadequate arterial oxygenation is manifested by

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cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers.

Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia (hypoxic drive) not the usual hypercapnia, the stimulus to breathe for healthy persons. Therefore, if too much oxygen is given, the client may stop breathing!

Health Promotion:- Eating consumes energy needed for breathng. Offer

mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed.

- Prevent secondary infections – avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke).

- Teach client to report any change in characteristics of sputum.- Encourage client to hydrate well and to obtain immunizations

needed (flu and pneumonia).

When asked to prioritize nursing actions, use the ABC rule: - Airway first- Then breathing- Then circulation

Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate oxygenation is not occurring.

The key to respiratory status assessment of breath sounds as well as visualization of the client. Breath sounds are better “described,” not named, e.g., sounds should be described as “crackles,” “wheeze,” “hihg-pitched whistling sound,” rather than “rales,” “rhonchi,” etc., which may not mean the same thing to each clinical professional.

Watch for NCLEX-RN questions that deal with oxygen delivery. In adults, O2 must bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification.

With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black, and may appear patchy.

Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing.

Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty.

A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hours).

Fear of choking is very real for laryngectomy clients. They cannot cough as before because the glottis is gone. Teach the “glottal stop” technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube).

TB SKIN TEST: a positive TB skin test is exhibited by an induration 10mm or greater in diameter 48 hours after skin test. Anyone who has received a BCG vaccine will have a positive skin test and must be evaluated using a chest x-ray.

Teaching is very important with the TB client. Drug therapy is usually long term (9 months or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard.

TEACHING POINTS – - Rifampin: Reduces effectiveness of oral contaceptives;

should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contacts.

- Isoniazid (INH): Increases Dilantin levels.- Ethambutal: Vision check before starting therapy and

monthly; may have to take 1 to 2 years longer.- Teach rationale for combination drug therapy to increase

compliance. Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time.

Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the remaining chest organs to fill the empty space.

If the chest tube remains disconnected, do not clamp! Immediately place the end of the tube in a container of sterile saline or water until a new drainage system can be connected.

If the chest tube is accidentally removed from the client, the nurse should apply pressure immediately with an occlusive dressing and notify the healthcare provider.

Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact and should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, since expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied the fluctuations cease. Most hospitals DO NOT MILK chest tubes as a means of clearing or preventing clots – it is too easy to remove chest tubes. Mediastinal tubes may have orders to be stripped because of location, compared to larger thoracic cavity tubes.

Various pathophysiological conditions can be related to the nursing diagnosis “Ineffective Breathing Patterns.”

1. Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis)

2. Obstruction of the air passages (carcinoma, asthma, chronic bronchitis)

3. Accumulation of fluid in the air sacs (pneumonia)4. Respiratory muscle fatigue (COPD, pneumonia)

RENAL SYSTEM

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Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about 1 to 2 liters in a 24-hour period.

Electrolytes are profoundly affected by kidney problems. There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are the primary extracellular ions. Potassium and phosphate are the primary intracellular ions.

In some cases, persons in ARF may not experience the oliguric phase but may progress directly to diuretic phase during which the urine output may be as much as 10 liters per day.

Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all clients with renal failure – done on the same scale at the same time every day.

Fluid Volume Alterations Fluid Excess symptoms:- Dyspnea- Tachycardia- Jugular vein distention- Peripheral edema- Pulmonary edema Fluid deficit symptoms:- Decreased urine output- Reduction in body weight- Decreased body turgor- Dry mucous membranes- Hypotension- Tachycardia

Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea.

Potassium has a critical safe range (3.5 to 5.0 mEg/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modification. Limit high potassium foods (bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium.

Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased dilution). Limit fluid and sodium intake in ARF clients.

During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal, aRF is determined to be resolved.

Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs causing muscle wasting. The glomerular filtration rate (GFR) is most often used as an indicator of level of protein consumption.

DIALYSIS COVERED BY MEDICARE:- All persons in the United States are eligible for Medicare as of

their first day of dialysis under special End Stage Renal Disease funding.

- Medicare card will indicate ESRD.- Transplantation is covered by Medicare procedure;

coverage terminates six months postoperative if dialysis is no longer required.

Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea, creatinine. Ensure high calorie intake so protein is spared for its own work: give hard candy, jelly beans, flavored carbohydrate powders.

As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity since digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse <60 beats per minute (bradycardia).

The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur.

The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics round-the-clock and not skip doses so that a consistent blood level can be maintained for optimal effectiveness.

Location of the pain can help determine location of the stone.

- Flank pain usually means the stone is in the kidney or upper ureter. If it radiates in the abdomen or scrotum, the stone is likely to be in the ureter or bladder.

- Excruciating, spastic-type pain is called colic.- During kidney stone attacks, it is preferable to administer

pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort.

Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid which will dissolve the stone, or ultrasonic sound waves (lithotripsy) can be directed through the needle/catheter to break up the stone which then can be eliminated through the urinary tract.

Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized balloon on the catheter (30 to 45 cc inflate) will cause a continuous feeling of needing to void. The client should not try to avoid around the catheter since this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given.

Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP since the irrigation must be isotonic to prevent fluid and electrolyte imbalance.

Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of blood or frank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood during the healing process as well as small clots. He should rest quietly and continue drinking large amounts of fluid.

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CARDIOVASCULAR SYSTEM

What is the relationship of the kidneys to the cardiovascular system?

- The kidneys filter about a liter of blood per minute- If cardiac output is decreased, the amount of blood going

through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems.

- When the kidneys produce and excrete 0.5 ml of urine per kg of body weight or average 30 ml/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs.

Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for acute angina?

- Digoxin – Not appropriate – Increases the strength and contractility of the heart muscle; the problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help.

- Nitroglycerin – Appropriate – Causes dilation of the coronary arteries, allowing more oxygen to get to the heart muscle.

- Atropine – Not appropriate – Increases heart rate by blocking vagal stimulation, which suppresses the heart rate. Does not address the lack of O2 to the heart muscle.

- Propanolol (Inderal) – Not appropriate – for acute angina attack; however, is appropriate for long-term management of stable angina because it acts as a beta-blocker to control vasoconstriction.

Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart.

Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives.

The number one cause of CVA with hypertensive clients is non-compliance with medication regime. Hypertension is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their antihypertensive medications, the more likely they are to take them – teaching is important.

Decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client actually realizes the damage is being done.

A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse obtain in the first few hours?

- Vital signs q1 hour- Neurological vital signs- Respiratory status- Urinary output- Peripheral pulses

During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney damage can result. Monitor

daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems.

A positive Homen’s sign is considered an early indication of thrombophlebitis. However, it may also indicate muscle inflammation. If a deep vein thrombosis has been confirmed, a Homan’s sign should not be elicited because of the increased risk of embolization.

Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites.

HEPARIN:- Antagonist: Protamine Sulfate- LAB: PTT or APTT determines efficacy- Keep 1.5 to 2.5 times normal control

COUMADIN:- Antagonist: Vitamin K- LAB: PT determines efficacy- Keep 1.5 to 2.5 times normal control

INR: Desirable therapeutic level usually 2 to 3 seconds (reflects how long it takes a blood sample to clot).

A holter monitor offers continuous observation of the client’s heart rate. To make assessment of the rhythm strips, most meaningful, teach the client to keep a record of:

- Medication times and doses- Chest pain episodes – type and duration- Valsalva maneuver (straining at stool, sneezing, coughing)- Sexual activity- Exercise

Cardioversion is the delivery of synchornized electrical shock to the myocardium.

Differentiate in synchronous and asynchronous pacemakers:- Synchronous or demand pacemaker fires only when the

client’s heart rate falls below a rate set on the generator.- Asynchronous or fixed pacemaker fires at a constant rate.

Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload.

DIGITALIS:- Side effects of digitalis are increased when the client is

hypokalemic.- Has a negative chronotropic effect, i.e., it shows the heart

rate. Hold the digitalis if the pulse rate is <60, >120, or has markedly changed rhythm.

- Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include nausea, vomiting, and headache in adults.

- If withheld, consult with physician.

Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk of embolization; erosion/perforation of the valve leaflets; or abscesses within adjacent myocardial

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tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur depending upon the type of damage inflicted by the lesions, leading to symptoms of left – or right-sided heart failure.

Acute and Subacute Infective Endocarditis - There are 2 types of infective endocarditis:

- Acute , which often affects individuals with previously normal hearts and healthy valves, and carries a high mortality rate

- Subacute , which typically affects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk for both acute and subacute bacterial endocarditis. When this population develops Subacute Infective Endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are typically affected due to the introduction of common pathogens which colonize on the skin (S. epidermis and Candida) into the venous system.

Pericarditis – presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST segment elevation and T wave inversion are also signs of pericarditis.

With mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In early period, there may be no symptoms; but, as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.

GASTROINTESTINAL SYSTEM

A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount of regurgitation as well as preventing the encroachment of the stomach tissue upward through the opening in the diaphragm.

Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation.

CLINICAL MANIFESTATIONS OF GI BLEEDING:- Pallor: conjuctival, mucous membranes, nail beds- Dark, tarry stools- Bright red or coffee-ground emesis- Abdominal mass or bruit- Decreased BP, rapid pulse, cool extremities (shock).

The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8 liters per day. Large fluid losses can occur if vomiting and/or diarrhea exists.

Opiate drugs tend to depress gastric motility. However, they should be given with care, and those receiving them should be closely monitored because a distended intestinal wall accompanied by decreased muscle tone may lead to intestinal perforation.

Diverticulosis is the presence of pouches in the wall of the intestine. There is usually do discomfort, and the problem goes unnoticed unless seen on radiological examination (usually prompted by some other condition).

Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the bowel.

A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed with diverticulitis. What are the nutritional needs of this client throughout recovery?

- Acute phase – NPO graduating to liquids.- Recovery phase – no fiber or foods that irritate the bowel.- Maintenance phase – high-fiber diet, with bulk-forming

laxatives to prevent pooling of foods in the pouches where they can become inflamed. Avoid small, poorly digested foods such as popcorn, nuts, seeds, etc.

Bowel obstructions:- Mechanical: due to disorders outside the bowel (hernia,

adhesions), due to disorders within the bowel (tumors, diverticulitis), or due to blockage of the lumen in the intestine (intussusception, gall stone).

- Non-mechanical: paralytic ileus, which does not involve any actual physical obstruction, but results from inability of the bowel itself to function.

Blood gas analysis will show alkalotic state if the bowel obstruction is high in the small intestine where gastric acid is secreted. If the obstruction is in the lower bowel where base solutions are secreted, the blood will be acidic.

A client admitted with complaints of constipation, thready stools and rectal bleeding over the past few months is diagnose with a rectal mass. What are the nursing priorities for this client?

- NPO- NG tube (possibly an intestinal tube such as a Miller-Abbott)- IV fluids- Surgical preparations of bowel (if obstruction is complete)- Teaching (preoperative, nutrition, etc.)

Diet recommended by the American Cancer Society to prevent bowel cancer:

- Eat more cruciferous vegetables (from the cabbage family such as broccoli, cauliflower, Brussels sprouts, cabbage, and kale).

- Increase fiber intake.- Maintain average body weight- Eat less animal fat.

AMERICAN CANCER SOCIETY RECOMMENDATIONS for early detection of Colon Cancer:

- A digital rectal examination every year after 40.- A stool blood test every year after 50.- A sigmoidoscopy examination every 3 to 5 years after the

age of 50, based on the advice of a physician.

Cancer of the colon is the most common cancer in the US when considering men and women together. An early sign is the rectal bleeding. Encourage patients 50 years of age or older, or those with increased risk factors, to be screened yearly with fecal occult blood testing. Routine colonoscopy at 50 is also recommended.

CLINICAL MANIFESTATIONS OF JAUNDICE- Yellow skin, sclera, and/or mucous membranes (bilirubin in

skin)- Dark-colored urine (bilirubin in urine)- Chalky or clay-colored stools (absence of bilirubin in stools)

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Fetor hepaticus is a distinctive breath odor of chronic liver disease. It is characterized by a fruity or musty odor which results from the damaged liver’s inability to metabolize and detoxify mercaptan which is produced by the bacterial degradation of metionine, a sulfurous amino acid.

For treatment of ascities, paracentesis and peritoneovenous shunts (LaVeen and Denver shunts) may be indicated.

Esophageal varices may rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade – a Blakemore-Sengstaken or Minnesota tube. Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions.

Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level rises.

PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING for clients who are anorexic and/or nauseated:

- Remove strong odors immediately; they can be offensive and increase nausea.

- Encourage client to sit up for meals; this can decrease the propensity to vomit.

- Serve small, frequent meals.

Liver tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration of liver tissue being destroyed by the disease. Since many drugs are metabolized in the liver, drug therapy must be scrutinized carefully. Caution the client that recovery takes many months, and previously taken medications should not be resumed without the healthcare provider’s directions.

Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore, sitting up or leaning forward will reduce the pain.

Following an endoscopic retrogade cholangiopancreatography (ERCP), the client may feel sick. The scope is placed in the gallbladder and the stones are crushed and left to pass on their own. These clients may be prone to pancreatitis.

Non-surgical management of the client with cholecystitis includes:

- Low-fat diet- Medications for pain and clotting if required- Decompression of the stomach via NG tube

ENDOCRINE SYSTEM

Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to Grave’s disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension.

- Primary nursing interventions include maintaining an airway and adequate aeration.

- Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation.

Post-operative thyroidectomy: be prepared for the possibility of laryngeal edema. Put a tracheostomy set at bedside along with oxygen and a suction machine; Ca++ gluconate easily accessible.

Normal serum calcium is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a decrease in the client’s calcium compared to the preoperative value.

If two or more parathyroid glands have been removed, the chance of tetany increases dramatically:

- Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal range)

- Check for tingling of toes, fingers, and around the mouth.- Check for Chvostek’s sign (tap over the parotid gland and

which for twitching of lip = positive)- Check Trousseau’s sign (carpopedal spasm after inflating

BP cuff above systolic pressure = positive).

Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and carbondioxide narcosis). The airway must be kept patent, and ventilator support as indicated.

Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the need to teach clients the importance of precisely following the prescribed regimen. They should be cautioned against suddenly stopping the medications and be informed that it is necessary to taper off taking steroids.

ADDISON”S CRISIS IS A MEDICAL EMERGENCY: Brought on by sudden withdrawal of steroids or a stressful event (trauma, severe infection)

- Vascular Collpase: Hypotension and tachycardia occur; administer IV fluids at rapid rate until stabilized.

- Hypoglycemia: Administer IV glucose- ADMINISTER PARENTERAL HYDROCORTISONE:

Essential for reversing the crisis.- ALDOSTERONE REPLACEMENT: Administer

fludrocortisone acetate(Florinef) PO (only available as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit.

Teach clients to take steroids with meals to prevent gastric irritation. They should never skip doses. If they have nausea or vomiting for more than 12 to 24 hours, they should contact the physician.

Why do diabetics have trouble with wound healing? High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing or breaks in the skin, cardiovascular abnormalities, etc.

Glycosylated Hgb (Hgb A1C)- Indicates glucose control over previous 120 days (life of

RBC)- Valuable measurement of diabetes control.

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The body’s response to illness/stress is to produce glucose. Therefore, any illness results in hyperglycemia.

If in doubt whether the client is hyperglycemic or hypoglycemic, treat for hypoglycemia.

SELF-MONITORING BLOOD GLUCOSE (SMBG)- Provides tight glucose control thereby decreasing the potential

for long-term complications- Technique is specific to each meter if meter is used.- Monitor before meals, at bedtime, and any time symptoms

occur.- Record results and report to healthcare provider at time of

visit.

MUSCULOSKELETAL SYSTEM

A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use and which methods would the nurse not use?

- Use inspection, palpation, and strength testing.- Do not use range of motion (this activity promotes pain

because ROM is limited).

In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for joint deformity; and NSAIDS for the pain.

Synovial tissues line the bone of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease will go into remission. Decreasing the amount of bone and joint destruction will reduce the amount of disability.

What activity recommendations should the nurse provide a client with rheumatoid arthritis?

- Do not exercise painful, swollen joints.- Do not exercise any joint to the point of pain.- Perform exercises slowly and smoothly; avoid jerky

movements.

NCLEX-RN questions often focus on the fact that avoiding sunlight is key in management of lupus erythematosus – this is what differentiates it from other connective tissue diseases.

Degenerative joint disease (DJD) and osteoarthritis are often described as the same disease, and indeed they both result in hypertrophic changes in the joints. However, they differ in that osteoarthritis is an inflammatory disease and DJD is characterized by non-inflammatory degeneration of the joints.

Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. While TUMS is an excellent source of calcium, it is also high in sodium and hypertensive or edematous individuals should seek another source for supplemental calcium.

The main cause of fractures in the elderly, especially women, is osteoporosis. The main fracture sites seem to be hip, vertebral bodies, and Colles’ fracture of forearm.

NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a non-wheeled walker, the client should lift and move the walker forward, then take a step into it. The client should avoid scooting the walker or shuffling forward into it which takes more energy and is less stable than a single movement.

What type of fracture is more difficult to heal, an extra capsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)?

- The blood supply enters the femur below the neck of the femur. Therefore, an intra-capsular fracture is much more harder to heal and has a greater likelihood of necrosis since it is cut off from the blood supply.

The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2). Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation.

In clients with hip fractures, thromboembolism is the most common complication. Prevention includes passive range of motion exercises, elastic stocking use, elevation of the foot of the bed 25 degrees to increase venous return, and low-dose hepatin therapy.

Clients with fractures, casts, or edema to the extremities need frequent neurovascular assessment distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain and pulses should be assessed.

Assess the “5 Ps” of neurovascular functioning: pain, paresthesia, pulse, pallor and paralysis.

Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device usually accompanies the client to the postoperative floor. Check drainage often.

A big problem after joint replacement is infection.

Fractures of bone predispose the client to anemia, especially if long bones are involved. Check hemtocrit every 3 to 4 days to monitor erythropoiesis.

Instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting. This upward motion can pop the prosthesis out of the socket.

Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (may limit milk intake), and venous thrombosis (may be on prophylactic anticoagulants).

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The residual limb should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can cause contracture.

NEUROSENSORY SYSTEM

Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye exam.

Eye drops are used to cause pupil constriction since movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after administration of pilocarpine and adaptation to dark environments is difficult because of pupillary constriction (desired effect of the drug).

There is an increased incidence of glaucoma in the elderly population. Older clients are prone to problems associated with constipation. Therefore, the nurse should assess these clients for constipation and postoperative complications associated with constipation, and implement a plan of care directed at prevention, and, if necessary, treatment for constipation.

The lens of the eye is responsible for projecting light, which enters onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred.

When the cataract is removed, the lens is gone, making prevention of falls important. If the lens is replaced with an implant, vision is better than if a contact lens is used (some visual distortion) or if glasses are used (greater visual distortion – everything has a curved shape).

The ear consists of three parts: the external ear, middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the CNS., often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems (conductive) may result from infection, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids.

NCLEX-RN questions often focus on communicating with older adults who are hearing impaired.

- Speak in a low-pitched voice, slowly, and distinctly.- Stand in front of the person with the light source behind the

client.- Use visual aids if available.

NEUROLOGICAL SYSTEM

Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such as lethargic, stuporous, or obtunded.

Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired persons require total care.

Clients with an altered state of consciousness are fed by enteral routes since the likelihood of aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying and the feeding should be held.

Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression.

Any client on bedrest/immobilized must have range of motion exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return is dangerous, i.e., sitting with dependent extremities for long periods.

If temperature elevates, take quick measures to decrease it since fever increases cerebral metabolism and can increase cerebral edema.

Safety measures for immobilized clients:- Prevent skin breakdown with frequent turning.- Maintain adequate nutrition.- Prevent aspiration with slow, small feedings or NG feedings.- Monitor neurological signs to detect the first signs that

intracranial pressure may be increasing.- Provide range of motion exercises to prevent deformities.- Prevent respiratory complications – frequent turning and

positioning for optimal drainage. Restlessness may indicate a return to consciousness but

can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not over-sedate, and report any symptoms of restlessness.

The forces of impact influence the type of head injury. They include acceleration injury, which is caused by the head in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists.

Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP.

CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur.

Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level of responsiveness.

Physical assessment should concentrate on respiratory status, especially in clients with injury at C-3 to C-5, as cervical plexus innervates diaphragm.

It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12 to 24 hours.

A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in alkaline media, so keeping urine diluted ad acidic is prophylactic against infection. Also, keeping the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder.

Benign tumors continue to grow and take up space in the confined area of the cranium causing neural and vascular compromise for the brain, increased intracranial pressure, and necrosis of brain tissue – even benign tumors must be treated as they may have malignant effects.

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Craniotomy post-operative medications:- Corticosteroids to reduce swelling- Agents and osmotic diuretics to reduce secretions (atropine,

robinul)- Agents to reduce seizures (phenytoin)- Prophylactic antibiotics

Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of the cases. MS is more common in women. Progression is not “orderly.”

Drug therapy for MS clients: ACTH, cortisone, Cytoxan, and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on prevention of infection.

In clients with Myasthenia Gravis, be alert for changes in respiratory status – the most severe involvement may result in respiratory failure.

Bedrest often relieves symptoms. Bladder and respiratory infections are often a recurring problem. Need for health promotion teaching.

Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic crisis is associated with a negative test.

NCLEX-RN questions often focus on the features of Parkinson’s disease – tremors (a coarse tremor of fingers and thumb on one hand which disappears during sleep and purposeful activity – also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: SAFETY!

An important aspect of Parkinson’s treatment is drug therapy. Since the pathophysiology involves an imbalance between acetylcholines and dopamine, symptoms can be controlled by administering dopamine precursor (Levodopa).

CNS involvement related to cause of CVA:- Hemorrhagic: caused by a slow or fast hemorrhage into the

brain tissue – often related to hypertension.- Embolytic: caused by a clot, which has broken away from

some vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (may happen again).

Atrial flutter/fibrillation has a high incidence of thrombus formation following arrythmias due to turbulence of blood flow through all valves/heart chambers.

A woman who had a stroke two days ago has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the client’s recovery period?

- The quicker movement is recovered, the better the prognosis is for more or full recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely.

Words that describe losses from CVA:- Apraxia: inability to perform purposeful movements in the

absence of motor problems.- Dysarthria: difficulty articulating

- Dysphasia: impairment of speech and verbal comprehension- Aphasia: loss of the ability to speak- Agraphia: loss of the ability to write- Alexia: loss of the ability to read- Dysphagia: dysfunctional swallowing

Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers.

HEMATOLOGY/ONCOLOGY Physical symptoms occur as a compensatory mechanism

when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels drop below 7g/dl.

ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood products. TWO registered nurses should simultaneously check the physician’s prescription, client’s identity, and blood bag label.

A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myeologenous leukemia. What are the expected laboratory findings for this client and what is the expected treatment?

- Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high).

- Treatment: Prevention of infection; prevention and/or control of bleeding; high protein, high calorie diet; assistance with ADL; drug therapy.

Infection in the immunosuppressed person may not be manifested with an elevated temperature. It is imperative, therefore, that the nurse performs a total and thorough assessment of the client frequently.

Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! Advise client to stay away from persons with known infections such as colds. In the hospital, maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or fruits – only cooked to destroy any bacteria.

Hodgkin’s is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy renders many male clients sterile. May bank sperm prior to treatment, if desired.

REPRODUCTIVE SYSTEM Menorrhagia (profuse or prolonged menstrual bleeding) is

the most important factor relating to benign uterine tumors. Assess for signs of anemia.

What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vagin*l wall.

Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagin*, rectum, and bladder are

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removed in an attempt to stop metastasis). Chemotherapy is not useful with this type of cancer.

Pap smears should begin within 3 years of having intercourse or no later than age 21, whichever comes first. Should be done annually until age 30 and then may be done every 2 to 3 years if a woman has 3 consecutive normal results. After age 70 may stop if woman has 3 consecutive normal and no abnormal pap smears in last 10 years. Women at high risk should have annual screenings.

Ovarian cancer is the leading cause of death from gynecologic cancers in the US. Growth is insidious, so it is not recognized until it is at an advanced stage.

The major emphasis in nursing management of cancers of the reproductive tract is early detection.

The importance of teaching female clients how to do self-breast examination cannot be overemphasized. Early detection is related to positive outcomes.

The presence or absence of hormone receptors is paramount in selecting clients for adjuvant therapy.

Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at high risk for developing testicular cancer. The most common symptom is the appearance of a small, hard lump about the size of a pea on the front or side of the testicl*. Manual testicular examination should be done after a shower by gently palpating the testes and cord to look for a small lump. Swelling may also be a sign of testicular cancer.

STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report cases of child abuse. Chlamydia is the most reported communicable disease in the United States.

Pelvic inflammatory disease (PID) involves one more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics and warm sitz baths. Bedrest in a semi-Fowler’s position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain.

A client comes to the clinic with a chancre on his penis. What is the usualy treatment?

- IM dose of penicillin (such as Benzathine penicillin G 2.4 million units).

- Obtain sexual history, including the names of his sex partners, so that they can receive treatment.

BURNS Massive volumes of IV fluids are given. It is not uncommon to

give over 1,000 cc/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but is not overloaded.

Infection is a life-threatening risk for those with burns. Dressing changes are VERY PAINFUL! Medicate client prior to procedure.

Pre-existing conditions that might influence burn recovery are age, chronic illness, diabetes, cardiac problems, etc.),

physical disabilities, disease, medications used routinely, and drug and/or alcohol abuse.

PEDIATRIC NURSING

GROWTH AND DEVELOPMENT:

1. When does birth length double? = by 4 years

2. When does the child sit unsupported? = 8 months

3. When does a child achieve 50% of adult height? = 2 years

4. When does a child throw a ball overhand? = 18 months

5. When does a child speak 2-3 word sentences? = 2 years

6. When does a child use scissors? = 4 years

7. When does a child tie his/her shoes? = 5 years

Be aware that a girl’s growth spurt during adolescence begins earlier than boys (as early as 10 years old).

Temper tantrums are common in the toddler, i.e., considered “normal,” or average behavior.

Be aware that adolescence is a time when the child forms his/her identity and that rebellion against family values is common for this age group.

Normal growth and development knowledge is used to evaluate interventions and therapy. For example, “What behavior would indicate that thyroid hormone therapy for a 4-month-old is effective?” You must know what milestones are accomplished by a 4-month-old. One correct answer would be “has steady head control” which is an expected milestone for a 4-month-old and indicates that replacement therapy is adequate for growth.

Use facts and principles related to growth and development in planning teaching interventions. For example: “What task could a 5-year-old diabetic boy be expected to accomplish by himself?” One correct answer would be to pick the injection sites. This is possible for a preschooler to do and gives the child some sense of control.

School-age children are in Erikson’s stage of industry, meaning they like to do and accomplish things. Peers are also becoming important for this age child.

Age groups concepts of bodily injury:- Infants: After 6 months, their cognitive development allows

them to remember pain.- Toddlers: Fear intrusive procedures.- Preschoolers: Fear body mutilation.- School Age: Fear loss of control of their body.- Adolescent: Major concern is change in body image.

CHILD HEALTH PROMOTION

Subcutaneous injection, rather than intradermal, invalidates the Mantoux test.

The common cold is not a contraindication for immunization.

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Following immunization, what teaching should the nurse provide to the parents?

- Irritability, fever (<102F), redness and soreness at injection site for 2 to 3 days are normal side effects of DPT and IPV administration.

- Call health care provider if seizures, high fever, or high-pitched crying occur.

- A warm washcloth on the thing injection site and “bicycling” the legs with each diaper change will decrease soreness.

- Acetaminophen (Tylenol) is administered orally 4 to 6 hours (10 to 15 mg/Kg).

Children with German measles pose a serious threat to their unborn siblings. The nurse should counsel all expectant mothers, especially those with young children, to be aware of the serious consequences of exposure to German measles during pregnancy.

Common childhood problems are encountered by nurses caring for children in the community or hospital settings. The child’s age directly influences the severity and management of these problems.

Teach proper cooking and storage to preserve potency, i.e., cook vegetables in small amount of liquid. Store milk in opaque container.

Add potassium to IV fluids ONLY with adequate urine output.

Urinary output for infants and children should be 1 to 2 ml/kg/hr.

Use of syrup of ipecac is no longer recommended by the American Academy of Pediatrics. Teach parents that it is NOT recommended to induce vomiting in any way as it may cause more damage.

RESPIRATORY DISORDERS

Child needs 150% of the usual calorie intake for normal growth and development.

Do not examine the throat of a child with epiglottis due to the risk of completely obstructing the airway, i.e., do not put a tongue blade or any object in the throat.

In planning and providing nursing care, a patent airway is always a priority of care, regardless of age!

Respiratory disorders are the primary reason most children and their families seek medical care. Therefore, these disorders are frequently tested on the NCLEX-RN. Knowing the normal parameters for respiratory rates and the key signs of respiratory distress in children is essential!

The nurse should be sure a PT and PTT have been determined prior to a tonsillectomy. More importantly, the nurse should ask if there has been a history of bleeding, prolonged/excessive, or if there is a history of any bleeding disorders in the family.

When calculating a pediatric dosage, the nurse must often change the child’s weight from pounds to kilograms.

HINT: weight expressed in kilograms should always be a smaller number than weight expressed in pounds.

CARDIOVASCULAR DISORDERS

Polycythemia is common in children with cyanotic defects.

The heart rate of a child will increase with crying or fever.

Infants may require tube feeding to conserve energy.

Basic difference between cyanotic and acyanotic defects:- Acyanotic: Has abnormal circulation, however, all blood

entering the systemic ciruclation is oxygenated.- Cyanotic: Has abnormal circulation with unoxygenated blood

entering systemic circulation.

Congestive heart failure is more often associated with acyanotic defects.

CHF is a common complication of congenital heart disease. It reflects the increased workload of the heart resulting from shunts or obstructions. The two objectives in treating CHF are to reduce the workload of the heart and increase cardiac output.

When frequent weighings are required, weigh client on the same scale at same time of day so that accurate comparisons can be made.

NEUROMUSCULAR DISORDERS

The nursing goal in caring for children with Down syndrome is to help the child reach his/her OPTIMAL level of functioning.

Feed infant or child with cerebral palsy using nursing interventions aimed at preventing aspiration. Position child upright and support the lower jaw.

The signs of ICP are the opposite of those of shock.- Shock: Increased pulse, Decreased blood pressure.- Increased ICP: Decreased pulse, Increased blood pressure.

Baseline data on the child’s USUAL behavior and level of development is essential so changes associated with increased ICP can be detected EARLY.

Do not pump shunt unless specifically prescribed. The shunt is made up of delicate valves, and pumping changes pressures within the ventricles.

Medication noncompliance is the most common cause of increased seizure activity.

Do NOT use tongue blade, padded or not, during a seizure. It can cause traumatic damage to mouth/oral cavity.

Monitor hydration status and IV therapy carefully. With meningitis, there may be inappropriate ADH secretions causing fluid retention (cerebral edema) and dilutional hyponatremia.

Headache upon awakening is the most presenting symptom of brain tumors.

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Most postoperative clients with infratentorial tumors are prescribed to lie flat and turn to either side. A large tumor may require that the child NOT be turned to the operative side.

Suctioning, coughing, straining, and/or causes increased ICP.

RENAL DISORDERS

Decreased urinary output is FIRST sign of renal failure.

Surgical correction for hypospadias is usually done before preschool years due to achieving sexual identity, castration anxiety and toilet training.

GASTROINTESTINAL DISORDERS

Typical parent/family reaction to a child with an obvious malformation such as cleft lip/palate are quilt, disappointment, grief, sense of loss, and anger.

Children with cleft lip/palate and those with pyloric stenosis both have a nursing diagnosis “alteration in nutrition; less than body requirements.”

- Cleft lip/palate is related to decreased ability to suck.- Pyloric stenosis is related to frequent vomiting.

Nutritional needs and fluid and electrolyte balance are key problems for children with GI disorders. The younger the child, the more vulnerable they are to fluid and electrolyte imbalances and greater is the need for caloric intake required for growth.

Take axillary temperature on children with congenital megacolon.

HEMATOLOGICAL DISORDERS

Remember the Hgb norms:- Newborn: 14 to 24 g/dl- Infant: 10 to 15 g/dl- Child: 11 to 16 g/dl

Teach family about administration of oral iron:- Give on empty stomach (as tolerated for better absorption)- Give with citrus juices (vitamin C) for increased absorption- Use dropper or straw to avoid discoloring teeth- Stools will become tarry- Iron can be fatal in severe overdose; keep away from children.

Do not give with dairy products.

Inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge of genetic transmission patterns. Remember:

- Autosomal recessive: Both parents must be heterozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring. With each pregnancy, there is a 1:4 chance of the infant having the disease. However, all children of such patterns CAN get the disease – NOT 25% of them. This is the transmission for sickle cell anemia, cystic fibrosis, and phenylketonuria (PKU).

- X-linked recessive trait: The trait is carried on the X chromosome, therefore, usually affects male offspring, e.g., hemophilia. With each pregnancy of a woman who is a carrier there is a 25% chance of having a child with hemophilia. If the child is male, he has a 50% chance of having hemophilia. If the child is female, she has a 50% chance of being a carrier.

Hydration is very important in treatment of sickle cell disease because it promotes hemodilution and circulation of red cells through the blood vessels.

Important terms:- Heterozygous gene (HgbAS) sickle cell trait- hom*ozygous gene (HbSS) sickle cell disease- Abnormal hemoglobin (HGBS) disease and trait

Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron deficiency. Folic acid is given only to stimulate RBC synthesis.

Have epinephrine and oxygen readily available to treat anaphylaxis when administering l-asparaginase.

Prednisone is frequently used in combination with antineoplastic drugs to reduce the mitosis of lymphocytes. Allopurinol, a xanthine-oxidase inhibitor, is also administered to prevent renal damage from uric acid build up during cellular lysis.

METABOLIC AND ENDOCRINE DISORDERS

An infant with hypothyroidism is often described as a “good, quiet baby” by the parents.

Early detection of hypothyroidism and phenylhetonuria is essential in preventing mental retardation in infants. Knowledge of normal growth and development is important, since a lack of attaintment can be used to detect the existence of these metabolic/endocrine disorders and attainment can be used for evaluating the treatment’s effect.

Nutrasweet (aspartame) contains phenylalanine and should not therefore, be given to a child with phenylketonuria.

Diabetes mellitus (DM) in children was typically diagnosed as insulin dependent diabetes (Type I) until recently. A marked increase in Type II DM has occurred recently in the US, particularly among Native-American, African-American, and Hispanic children and adolescents. Adolescence frequently causes difficulty with management since growth is rapid and the need to be like peers makes compliance difficult. Remember to consider the child’s age, cognitive level of development, and psychosocial development when answering NCLEX-RN questions.

When child is in ketoacidosis, administer regular insulin IV as prescribed in normal saline.

There has been an increase in the number of children diagnosed with Type II diabetes. The increasing rate of obesity in children is thought to be a contributing factor. Other contributing factors include lack of physical activity and a family history of Type II diabetes.

SKELETAL DISORDERS

Fractures in older children are common as they fall during play and are involved in motor vehicle accidents.

Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse.

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Fractures involving the epiphyseal plate (growth plate) can have serious consequences in terms of growth of the affected limb.

Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider.

Pin sites can be sources of infection. Monitor signs of infection. Cleanse and dress pin sites as prescribed.

Skeletal disorders affect the infant’s or child’s physical mobility, and typical NCLEX-RN questions focus on appropriate toys or activities for the child who is on bedrest and/or immobilized.

Children do not like injections and will deny pain to avoid “shots.”

A brace does not correct the curve of a child with scoliosis, it only stops or slows the progression.

Corticosteroids are used short term in low doses during exacerbations. Long-term use is avoided due to side effects and their adverse effect on growth.

MATERNITY NURSING

ANATOMY & PHYSIOLOGY OF REPRODUCTION

The menstrual phase varies in length for most women.

From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period.

Sperm lives approximately 3 days and eggs live about 24 hours. A couple must avoid unprotected intercourse for several days before the anticipated ovulation and for 3 days after ovulation in order to prevent pregnancy.

Because some women experience implantation bleeding or spotting, they do not know they are pregnant.

Look for signs of maternal-fetal bonding during pregnancy. For example: talking to fetus in utero, massaging abdomen, nicknaming fetus are all healthy psychosocial activities.

For many women, BATTERING (emotional or physical abuse) begins during pregnancy. Women should be assessed for abuse in private, away from the male partner, by a nurse who knows local resources and how to determine the safety of the client.

Practice determining gravidity and parity: A woman who is 6 weeks pregnant has the following maternal history:

- Has a 2 yr. old healthy daughter.- Had a miscarriage at 10 weeks, 3 years ago.- Had an elective abortion at 6 weeks, 5 years ago. With this

pregnancy, she is a gravida 4, para 1 (only 1 delivery after 20 weeks gestation).

Practice calculating EDB (estimated date of birth). If the first day of a women’s last normal menstrual period was October 17, what is her EDB using Nagele’s rule? July 24. Count back 3 months and add 7 days (always give February 28 days).

At approximately 28 to 32 weeks gestation, the maximum plasma volume increase of 25 to 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 to 42%. High Hct values may look “good,” but in reality represent pregnancy-induced hypertension and a depleted vascular space.

Hgb/Hct data can be used to evaluate nutritional status. Example: a 22-year old primigravida at 12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31%. She has gained 3 pounds during the first trimester. A weight gain of3.5 to 5 pounds during the first trimester is recommended and this client is anemic. Supplemental iron and a diet higher in iron are needed.

Foods high in iron: fish and red meats; cereal and yellow vegetables; green leafy vegetables and citrus fruits; egg yolks and dried fruits.

As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta). Teach the woman that a side-lying position increases perfusion to uterus, placenta, and fetus. Recent research indicates that the knee-chest position is best for increasing perfusion and that the side-lying position (either left or right side-lying) is the second most desirable position to increase perfusion. Prior to this research, the left side-lying position was usually encouraged.

Fetal well-being is determined by assessing fundal height, fetal heart tones/rate, fetal movement and uterine activity (contractions). Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action! Remember, the normal FHR is 110 to 160 bpm.

Danger signs during pregnancy. Teach clients to immediately report any of the following danger signs. Early intervention can optimize maternal and fetal outcome.

Possible indications of preeclampsia/eclampsia:- Visual disturbances- Swelling of face, fingers or sacrum- Severe, continuous headache- Persistent vomiting

Signs of infection:- Chills- Dysuria- Temperature over 100.4 F- Pain in abdomen- Fluid discharge from vagin* (anything other than normal

leukorrhea)- Change in fetal movement and/or increased FHR

Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of vitamins. However, only the healthcare provider can prescribe prenatal vitamins. It is the nurse’s responsibility to teach about proper diet and taking prescribed vitamins, if prescribed by the healthcare provider.

It is recommended that pregnant women drink one quart of milk/day. This will ensure that the daily calcium needs are met an help to alleviate the occurrence of leg cramps.

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FETAL/MATERNAL ASSESSMENT TECHNIQUES

In some states, the screening for neural tube defects through either maternal serum AFP levels or amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with both false positives and false negatives.

When an amniocentesis is done in early pregnancy, the bladder must be full to help support the uterus and to help push the uterus up in the abdomen for easy access. When an amniocentesis is done in late pregnancy, the bladder must be empty to avoid puncturing the bladder.

Early decelerations, caused by head compression and fetal descent, usually occur between 4 and 7 cm and in the 2nd

stage. Check for labor progress if early decelerations are noted.

If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (i.e., knee-chest position) or push the presenting part off the cord until IMMEDIATE Cesarean delivery can be accomplished.

Late decelerations indicate uteroplacental insufficiency and are associated with conditions such as postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae.

When deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia, the situation is OMINOUS (potentially disastrous) and requires immediate intervention and fetal assessment.

A decrease in uteroplacental perfusion results in late decelerations; cord compression results in a pattern of variable decelerations. Nursing interventions should include changing maternal position, discontinuing Pitocin infusion, administering oxygen and notifying the healthcare provider.

The danger of nipple stimulation lies in controlling the “dose” of oxytocin stimulated from the posterior pituitary. The chance of hyper-stimulation or tetany (contractions over 90 seconds or contractions with less than 30 seconds in between) is increased.

Percutaneous umbilical blood sampling (PUBS) can be done during pregnancy under ultrasound for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis, and some genetic testing can be done using this method.

The most important determinant of fetal maturity for extra-uterine survival is the L/S ratio (2:1 or higher).

INTRAPARTUM NURSING CARE

Be able to differentiate true labor from false labor.

True labor:- Pain in lower back that radiates to abdomen- Accompanied by regular, rhythmic contractions- Contractions that intensify with ambulation- Progressive cervical dilation and effacement

False labor:- Discomfort is localized in abdomen - No lower back pain

- Contractions decrease in intensity and/or frequency with ambulation

Know normal findings for clients in labor:- Normal FHR in labor: 110 to 160 bpm- Normal maternal BP: <140/90- Normal maternal pulse: <100 bpm- Normal maternal temperature: <100.4 F

Slight elevation is often due to dehydration and the work of labor. Anything higher indicates infection and must be reported immediately.

Admission procedures:- vulvar/perineal shave (may not be done)- enema: may be refused by woman due to pre-labor diarrhea

or recent, large bowel movement. An enema should not be administered to a client in active labor. If head is floating, watch for cord prolapse.

Meconium-stained fluid is yellow-green and may indicate fetal stress.

Breathing techniques such as deep chest, accelerated, and cued are not prescribed by the stage and phase of labor, but by the discomfort level of the laboring woman. If coping is decreasing, switch to a new technique.

Hyperventilation results in respiratory alkalosis due to blowing off too much CO2. Symptoms include:

- Dizziness- Tingling of fingers- Stiff mouth- Have woman breathe into her cupped hands or a paper bag

in order to rebreathe CO2.

Determine cervical dilation before allowing client to push. Cervix should be completely dilated (10 cm) before the client begins pushing. If pushing starts too early, the cervix can become edematous and never fully dilate.

Give the oxytocin after the placenta is delivered because the drug will cause the uterus to contract. If the oxytocic drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the client to hemorrhage and infection.

Application of perineal pads after delivery:- Place two on perineum- Do NOT touch inside of pad- DO apply from front to back, being careful not to drag pad

across the anus.

Methergine is NOT given to clients with hypertension due to its vasoconstrictive action. Pitocin is given with caution to those with hypertension.

FULL BLADDER is one of the most common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus, what action should be taken first? First, perform fundal massage; then have the client empty her bladder. Recheck fundus q15 minutes X 4 (1 hour); q30 minutes X 2 hours.

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If narcotic analgesics (codeine, meperidine) are given, raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about drowsiness as a side effect.

A 1st degree tear involves only the epidermis. A 2nd degree tear involves dermis, muscle, and fascia. A 3rd degree tear extends into the anal sphincter, and a 4th degree extends up the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations.

If it was documented that the fetus passed meconium in utero or the nurse noted LATE passage of meconium in delivery room, the neonate MUST be attended by a pediatrician, neonatologist, and/or nurse practitioner to determine, through endotracheal tube observation and suction, the presence of meconium below the cords. It can result in pneumonitis/meconium aspiration syndrome, which will necessitate a sepsis workup including a chest x-ray early in the transitional newborn period.

Do not wait until a 1 minute Apgar is assigned to begin resuscitation of the compromised neonate.

Apgar scores of 6 or < at 5 minutes require an additional Apgar assessment at 10 minutes.

IV administration of analgesics is preferred to IM for the client in labor because the onset and peak occurs more quickly and duration of the drug is shorter.

IV administration:- Predictable onset: 5 minutes- Peak: 30 minutes- Duration: 1 hour

IM administration:- Onset: within 30 minutes- Peak: 1 to 3 hours after injection- Duration: 4 to 6 hours

Tranquilizers (ataractics and/or phenothiazines) Phenergan, Vistaril, are used in labor as analgesic-potentiating drugs to decrease maternal anxiety.

Agonist narcotic drugs (Demerol, morphine) produce narcosis and have a higher risk for maternal/fetal respiratory depression. Antagonist drugs (Stadol, Nubain) have less respiratory depression but MUST be used with caution in a mother with preexisting narcotic dependency since withdrawal symptoms occur immediately.

Pudendal block and subarachnoid (saddle block) are used only for second stage of labor. Peri/epidural may be used for all stages of labor.

The first sign of block effectiveness is usually warmth and tingling of ball/big toe of foot.

Discontinue continuous infusion at end of Stage I or during transition to increase pushing effectiveness.

Regional block anesthesia and fetal presentation- Internal rotation is harder to achieve when the pelvic floor is

relaxed by anesthesia resulting in persistent occiput posterior position of fetus.

- Monitor for fetal position. REMEMBER, mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position.

- Regional blocks, especially epidural and caudal, often result in assisted (forceps or vacuum) delivery due to the inability to push effectively in 2nd stage.

Nerve block anesthesia (spinal or epidural) during labor blocks motor as well as nerve fibers. Vasodilation below the level of the block results in blood pooling in the lower extemities and maternal hypotension. Approximately 20 minutes prior to nerve block anesthesia, the client should be hydrated with 500 to 1000 cc of lactated ringers IV. Monitor maternal vital signs and FHR q5 to 15 minutes. If hypotension occurs – turn the client to her side, administer O2 at 10 L/min by facemask, and increase IV rate.

NORMAL PUERPERIUM

Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. The first 10 to 12 days post-delivery, values of 25,000 mm3 are common. Elevated WBC and the normal elevated ESR may confuse interpretation of acute postpartal infections. For example, if the nurse assesses a client’s temperature to be 101 F on the client’s second postpartum day, what assessments should be made before notifying the physician? Assess fundal height and firmness, perineal integrity, check for a positive Homan’s sign and other symptoms, i.e., burning on urination, pain in leg, excessive tenderness of uterus.

Client/family teaching is a common area for NCLEX-RN questions. Remember, when teaching the first step is to assess the client’s (parent’s) level of knowledge and identify their readiness to learn. Client teaching regarding lochia changes, perineal care, breastfeeding, sore nipples are commonly tested content.

After the 1st PP day, the most common cause of uterine atony is retained placental fragments. The nurse must check for presence of fragments in lochial tissue.

Women can tolerate blood loss, even slightly excessive blood loss, in the postpartal period due to the 40% increase in plasma volume during pregnancy. In postpartal period can void up to 3,000 cc/day to reduce this volume increase that occurred during pregnancy.

Client should void within 4 hours of delivery. Monitor closely for urine retention. Suspect retention if voiding is frequent and <100 cc per voiding.

Women often have a syncopal spell (faint) on the first ambulation after delivery (usually related t ovasomotor changes, orthostatic hypotension). The astute nurse will check for client’s Hgb and Hct for anemia and the blood pressure, sitting and lying for orthostatic hypotension.

Kegel exercises: increase integrity of introitus and improve urine retention. Teach client to alternate contraction and relaxation of the pubococcygeal muscles.

Assess for thromboembolism: Examine legs of PP client daily for pain, warmth, and tenderness or a swollen vein which is tender to touch. Client may or may not exhibit a

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positive Homan’s sign (dorsiflexion of foot causes compression of tibial veins and pain if thrombus is present).

“Postpartum blues” are usually normal, especially 5 to 7 days after delivery (unexplained tearfulness, feeling “down,” and a decreased appetite). Encourage use of support persons to help with housework for first two postpartum weeks. Refer to community resources.

Remember RhoGAM is given to a Rh-negative mother who delivers a Rh-positive fetus and has a negative direct Coombs. If the mother has a positive Coombs, there is no need to give RhoGAM since the mother is already sensitized.

Because Rh Immune Globulins suppress the immune system, the client who receives both RhoGAM and the Rubella vaccine should be tested for rubella immunity at 3 months.

THE NORMAL NEWBORN

PHYSICAL ASSESSMENT: A detailed physical assessment is performed by the nurse or physician. Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations of the newborn. Observations must be recorded and the physician and the physician notified regarding abnormalities.

It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalhematoma (blood under the periosteum). The caput crosses suture lines and is usually present at birth, while the cephalhematoma does NOT cross suture lines and manifests a few hours after birth. The danger of cephalhematoma is increased by hyperbilirubinemia due to excess RBC breakdown.

These neurological reflexes are transient, and, as such, disappear usually within the first year of life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects. Anticipate NCLEX-RN questions regarding normal newborn reflexes. Physical assessment questions focus on normal characteristics of the newborn and the differentiation of conditions such as caput succedaneum and cephalhematoma.

The umbilical cord should always be checked at birth. It should contain 3 vessels, 1 vein which carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the placenta. This is the opposite of normal circulation in the adult. Cord abnormalities usually indicate cardiovascular or renal anomalies.

Postnatally, the fetal structures of foramen ovale, ductus arteriosus and ductus venosus should close. If they do not, cardiac and pulmonary compromise will develop.

Suctioning the mouth first and then the nose. Stimulating the nares can initiate inspiration which could cause aspiration of mucus in oral pharynx.

Circumcision has become controversial since there is no real medical indication for the procedure and it does not cause trauma and pain to the newborn. It was once thought to decrease the incidence of penile and cervical cancer, but some researchers say this is unfounded.

HYPOTHERMIA (heat loss) leads to depletion of glucose and, therefore, the use of brown fat (special fat deposits fetus puts on in last trimester which are important to thermoregulation)

for energy, resulting in ketoacidosis and possible shock. Prevent by keeping neonate warm!

Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC destruction) occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic. Typically, NCLEX-RN questions ask about normal problem of physiologic jaundice which occurs 2 to 3 days after birth due to the liver’s inability to keep up with RBC destruction and bind bilirubin. Remember, unconjugated bilirubin is the culprit.

Do not feed a newborn when the respiratory rate is over 60. Inform the physician and anticipate gavage feedings in order to prevent further energy utilization and possible aspiration.

A 7 lb. 8 oz. baby would need 50 calories X 7 lbs = 350 calories plus 25 calories (1/2 lb. or 8 oz.) = 375 calories per day. Most infant formulas contain 20 calories/ounce. Dividing 375 by 20 = 18.75 ounces of formula needed per day.

Teach parents to take infant’s temperature BOTH axillary and rectally. While axillary is recommended, some pediatricians will request a rectal temperature (core).

- AXILLARY: Place thermometer under arm and hold thermometer in place 5 minutes.

- RECTALLY: Use thermometer with BLUNT end. Insert thermometer ¼ to ½ inch and hold in place for 5 minutes. Hold feet and legs firmly.

HIGH-RISK DISORDERS

Clients with prior traumatic delivery, history of D&C, multiple abortions (spontaneous or induced), or daughters of DES mothers may experience miscarriage or preterm labor related to INCOMPETENT CERVIX. The cervix may be surgically repaired prior to pregnancy, or DURING gestation. A CERCLAGE (McDonald’s suture) is placed around the cervix to constrict the internal os. The cerclage may be removed prior to labor if labor is planned or left in place if cesarean birth is planned.

Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed with appendicitis.

A client who is 32 weeks gestation calls the healthcare provider because she is experiencing dark, red vagin*l bleeding. She is admitted to the emergency room where the nurse determines the FHR to be 100 bpm. The client’s abdomen is rigid and boardlike, and she is complaining of severe pain. What action should the nurse take first? First, the nurse must use knowledge base to differentiate between abruptio placentae (this client) from placenta previa (painless bright red bleeding occurring in the third trimester). The nurse should immediately notify the healthcare provider and no abdominal or vagin*l manipulation or exams should be done. Administer O2 per face mask. Monitor for bleeding at IV sites and gums due to the increased risk of DIC. Emergency Cesarean section is required since uteroplacental perfusion to the fetus is being compromised by early separation of the placenta from the uterus.

Clients with abruptio placentae or placenta previa (actual or suspected) should have NO abdominal or vagin*l

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manipulation. NO Leopold’s maneuvers. NO vagin*l exams. NO rectal exams, enemas, or suppositories. NO internal monitoring.

Disseminated intravascular coagulation (DIC) is a syndrome of abnormal clotting that is systematic and pathologic. Large amounts of clotting factors, especially fibrinogen, are depleted causing widespread external and/or internal bleeding. DIC is related to fetal demise, infection/sepsis, pregnancy-induced hypertension (Preeclampsia) and abruptio palcentae.

Podophyllin, which is usually used to treat HPV, is contraindicated in pregnancy because it is associated with fetal death, preterm labor, and cervical carcinoma.

Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found), or eating raw meat.

Rubella is teratogenic to the fetus during the FIRST trimester, causing congenital heart disease and/or congenital cataracts. All women should have their titers checked during pregnancy. If a women’s titer’s are low, she should receive the vaccine AFTER delivery and be instructed not to get pregnant within 3 months. Breastfeeding mothers may take the vaccine.

Although Metronidazole (Flagyl) is the treatment of choice for some vagin*l infections, its use is contraindicated in the first trimester of pregnancy, and its use during the second trimester is controversial. Medications usually recommended for the non-pregnant client with STDs may be CONTRAINDICATED for the pregnant client due to effect on the fetus.

The outcome of adolescent pregnancy depends on prenatal care. NUTRITION is a key factor since the adolescent’s physiological needs for growth are already increased, plus the additional stress of pregnancy.

Although the toxic side effects of magnesium sulfate are well known and watched for, it is just as important to get serum blood levels of magnesium sulfate above 4 mg/dl in order to prevent convulsions and reach therapeutic range.

Hold next dose of magnesium sulfate and notify healthcare provider if any toxic symptoms occur (<12 respirations/minute, urine output <100 cc/4 hours, absent DTRs, Magnesium sulfate > 8 mg/dl).

When administering magnesium sulfate. ALWAYS have antidote available (calcium gluconate, 20 ml vial of 10% solution).

Tachycardia is the major side-effect of tocolytic drugs, which are bete adrenergic agents such as terbutaline (Brethine) or ritodrine (Yutopar) used to stop preterm labor. Teach the client to take her pulse prior to administration and withhold medication if pulse is not within the prescribed parameters (usually whitheld if pulse >120 to 140). If administration is via a continuous pump, teach client to monitor pulse periodically.

In 1978, the FDA banned the use of oxytocin for ELECTIVE inductions. The healthcare provider must provide, for the record, the medical reason for oxytocin use.

Dystocia frequently requires the use of oxytocin for augmentation or induction of labor. Uterine tetany is a harmful complication and careful monitoring is required. The desired effect is contractions q2 to 3 minutes, with duration of contractions no longer than 90 seconds. Continuously monitor FHR and uterine resting tone. If tetany occurs, turn off Pitocin, turn client to a side-lying position, and administer O2 by facemask. Check output (should be at least 100 cc/4 hours). Oxytocin’s most important side effects is its antidiuretic (ADH) effect, which can cause water intoxification. Using IV fluids containing electrolytes decreases the risk of water intoxification.

The uterus is most sensitive to becoming tetanic at the beginning of infusion. The client must ALWAYS be attended and contractions monitored. Contractions should last NO longer than 90 seconds to prevent fetal hypoxia.

Women with previous uterine scars are prone to uterine rupture especially if oxytocin or forceps are used. If a woman complains of a sharp pain accompanied by the abrupt cessation of contractions, suspect uterine rupture, a MEDICAL EMERGENCY. Immediate surgical delivery is indicated to save the fetus and the mother.

Rarely are antihypertensive drugs used in the preeclamptic client. They are given only in the event of diastolic blood pressure over 110 mmHg. (CVA danger). Drug of choice is Hydralazine HCL (Apresoline).

Altough delivery is often described as the “cure” for preeclampsia, the client can convulse up to 48 hours after delivery.

The major goal of nursing care for a client with preeclampsia is to maintain uteroplacental perfusion and prevent seizures. This requires the administration of magnesium sulfate. Withhold administration of magnesium sulfate if signs of toxicity exist: respirations <12/minute, absence of DTRs, and urine output <30 ml/hour.

Nursing care during labor and delivery for the client with cardiac disease is focused on prevention of cardiac embarrassment, maintenance of uterine perfusion, and alleviation of anxiety.

Should these clients experience preterm labor, the use of beta-adrenergic agents such as terbutaline (Brethine) and ritodrine HCL (Yutopar) are contraindicated due to the chance of myocardial ischemia.

Normal diuresis, which occurs in the postpartum period, can pose serious problems to the new mother with cardiac disease because of the increased cardiac output.

Coumadin may NOT be taken during pregnancy due to its ability to cross the placenta and affect the fetus. HEPARIN is the drug of choice; it does NOT cross the placental membrane.

Recent research has found that Helicobacter pylori, (the bacterium that causes stomach ulcers) infection is another possible causative factor in hyperemesis. Other pregnancy and non-pregnancy risk factors for hyperemesis gravidarum include first pregnancy, multiple fetuses, age under 24,

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history of this condition in other pregnancies, obesity, and high fat diets.

In severe cases of hyperemesis gravidarum, the healthcare provider may prescribe antihistamines, vitamin B6, or phenothiazines to relieve nausea. The provider also prescribe metoclopramide (Reglan) to increase the rate the stomach moves food into the intestines, or antacids to absorb stomach acid and help prevent acid reflux.

Women who suffer from hyperemesis gravidarum are often deficient in thiamin, riboflavin, vitamin B6, vitamin A, and retinol-binding proteins.

GLUCOSE SCREEN: Client does NOT have to fast for this test. 50 gm of glucose is given and blood is drawn after one hour. If the blood glucose is greater than 135 mg/dl, the na three-hour glucose tolerance test (GTT) is done.

High incidence of fetal anomalies occurs in pregnant diabetic women. Therefore, fetal surveillance is very important. Ultrasound exam. Alpha-fetoprotein (to determine neural tube anomalies). Non-stress and contraction stress tests.

Oral hypoglycemics are not taken in pregnancy due to potential teratogenic effects on fetus. Insulin is used for therapeutic management.

When a woman is admitted in labor with diagnosis of diabetes mellitus. She is more prone to preeclampsia, hemorrhage and infection. Delivery is often scheduled between 37 to 38 weeks gestation to avoid the end of the 3rd trimester of pregnancy because this is a VERY difficult time to maintain diabetic control.

It is useful to discontinue long-acting insulin administration on the day before the delivery is planned since insulin requirements are less in labor and drop precipitously after delivery.

Estrogen-containing birth control pills affect glucose metabolism by increasing resistance to insulin. The intrauterine device may be associated with an increased risk of infection in these already vulnerable women.

If a woman is medicated, the responsible adult accompanying her must sign the necessary consent forms. State laws differ as to the acceptability of a friend signing the consent form rather than a relative.

Babies delivered abdominally miss out on the vagin*l squeeze and are born with more fluid in the lungs, predisposing the newborn to transient tachypnea (TTN) and respiratory distress.

The preferable low-transverse uterine incision usually results in less postoperative pain, less bleeding, and less incidents of ruptured uterus. The classical, vertical incision on the uterus may involve part of the fundus, resulting in more postoperative pain, bleeding, and an increased chance of uterine rupture.

Due to the exploration and cleansing of the uterus just after delivery of the placenta, the amount of lochia may be scant in the recovery room. However, pooling in the vagin* and uterus while on bedrest may result in blood running down the client’s leg when she first ambulates. Cesarean birth clients have the

same lochial changes, placental site healing, and aseptic needs as do vagin*l birth clients.

A laparotomy of any kind, including cesarean birth, predisposes the client to postoperative paralytic ileus. When the bowel is manipulated in surgery, it ceases preistalsis, which may persist. Symptoms include: absent bowel sounds, abdominal distention, tympany on percussion, nausea and vomiting, and of course, obstipation (intractible constipation). Early ambulation is an effective nursing intervention.

POSTPARTUM HIGH-RISK DISORDERS

Nurse must be especially supportive of postpartum client with infection because it usually implies isolation from newborn until organism is identified and treatment begun. Arrange phone calls to nursery and window viewing. Involve family, spouse, significant others in teaching, and encourage other family members to continue neonatal attachment activities.

Most common iatrogenic cause of UTI is urinary catheterization. Encourage clients to void frequently and not ignore the urge. IV antibiotic are usually administered to clients with pyelonephritis.

Remember, the risk of postpartum infections increases for clients who experienced problems during pregnancy (e.g., anemia, diabetes) or experienced trauma during labor and delivery.

Clients taking anticoagulants can usually expect to have heavy menstrual periods.

In most cases, a mother who is on antibiotic therapy can continue to breastfeed unless the healthcare provider thinks the neonate is at risk for sepsis by maternal contact. Sulfa drugs are used cautiously in lactating mothers because they can be transferred to the infant in breast milk.

Many times mastitis can be confused with a blocked milk sinus, which is treated by nursing closer to the lump and by rotating the baby on the breast. Breastfeeding is not contraindicated for women with mastitis, unless pus is in the breast milk, or the antibiotic of choice is harmful to the infant. If either of these occurs, milk production can still be fostered by manual expression.

During medical emergencies such as bleeding episodes, clients need calm, direct explanations and assurance that all is being done that can be done. If possible, allow support person at bedside. Risk-management principles state that the suit-prone client is one who feels things are being hidden from her or that adequate attention is NOT being give to HER problem.

Risk factors for hemorrhage include: dystocia, prolonged labor, over distended uterus, abruptio placentae, and infection.

What immediate nursing actions should be taken when a postpartum hemorrhage is detected?

- Perform fundal massage- Notify the healthcare provider if the fundus does not become

firm with massage

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- Count pads to estimate blood loss- Assess and record vital signs- Increase IV fluids (additional IV line may be indicated)- Administer oxytocin infusion as prescribed

NEWBORN HIGH-RISK DISORDERS

“Jitteriness” is a clinical manifestation of hypoglycemia and hypocalcemia. Laboratory analysis is indicated to differentiate between two etiologies.

To avoid metabolic problems brought on by cold stress, the first step and number one priority, in management of the newborn is to prevent loss of body heat, followed by ABCs. Neonates produce heat by non-shivering thermogenesis, by burning brown fat. The neonate is easily stressed by hypothermia and develops acidosis from hypoxia. Prevent chilling (keep under radiant warmer or in isolette). If cold, the first signs exhibited are prolonged acrocyanosis, skin mottling, tachycardia, and tachypnea. If cold stressed, warm slowly over 2 to 4 hours since rapid warming may produce apnea. The neonate needs glucose, he/she has little glycogen storage and needs to be fed.

The lower the score on the Silverman-Anderson index of Respiratory Distress, the better the respiratory status of the neonate. A score of 10 indicates that a newborn is in severe respiratory distress. This is the exact opposite of the method used for Apgar scoring.

WATCH the newborn Hct; it is difficult to oxygenate either an anemic newborn (lack of oxygen-carrying capacity) or a newborn with polycythemia (Hct >80%, thich, sluggish circulation).

The PO2 should be maintained between 50 to 90 mmHg. PO2 <50 signifies hypoxia, PO2 > 90 signifies oxygen toxicity problems.

Antibiotic dosage is based on the neonate’s weight in kilograms. Peak and trough drug levels are drawn to evaluate if therapeutic drug levels have been achieved. Closely monitor the neonate for adverse effects of ALL drugs.

Sepsis can be indicated by both a temperature increase and a temperature decrease.

Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. Close monitoring of therapeutic levels and observation for side effects are required.

Renal immaturity in the preterm infant makes the monitoring of IV fluid administration and drug therapy crucial. Closely monitor BUN and creatinine levels when administering the “mycin” antibiotics to treat infections in the neonate.

If tube passes into trachea, newborn can make NO noise, i.e., no crying. Newborn may gag, cough, or become cyanotic.

To assess for skin jaundice, apply with thumb over bony prominences to blanch skin. After removing thumb, area will look yellow before normal skin color reappears. The best areas for assessment are the nose, forehead, and sternum. In dark-skinned infants, observe conjunctival sac and oral mucosa.

Lab tests measure total and direct (conjugated, excretable, non-fat soluble) bilirubin levels. The dangerous bilirubin is the unconjugated, indirect (fat-soluble), which is measured by subtracting the direct from the total bilirubin.

Maintenance of hydration is crucial for all infants. The preterm infant is already at risk for fluid and electrolyte imbalances due to increased body surface area from extended body positioning and larger body area in related to body weight. Phototherapy treatment for hyperbilirubinemia (level > 12 mg/dl) increases the risk for dehydration.

PSYCHIATRIC NURSING

THERAPEUTIC COMMUNICATION / TREATMENT MODALITIES

The purpose of therapeutic interaction with clients is to allow them the autonomy to make choices when appropriate. Keep statements value free, advice free, and reassurance free. Remember, JUST THE FACTS! NO OPINIONS!

What action should the nurse take in a “psychiatric situation” when the client describes a physical problem? Assess, assess, assess! If the client with paranoid schizophrenia on the psychiatric unit complains of chest pain, take his/her blood pressure. If the OB client who has delivered a dead fetus complains of perineal pain – look at the perineal area (she may have a hematoma). Just because the focus of the client’s situation is on his/her psychological needs, it does not mean that the nurse can ignore physiological needs.

Remember, nurses are “nice” people, but they are also therapeutic.

Basic communication principles can be applied to all clients:- Establish trust.- Demonstrate a non-judgmental attitude- Offer self; be emphathetic, NOT sympathetic- Use active listening- Accept and support client’s feelings- Clarify and validate client’s statement- Use matter-of-fact approach

Remember, a nurse’s nonverbal communication may be more important that his/her verbal communication.

A question concerning nurse-client confidentiality often appears on the NCLEX-RN. For the nurse to tell a client she/he will not tell anyone about their discussion, puts the nurse in a difficult position. Some information MUST be shared with other team members for the client’s safety (e.g., suicide plan) and optimal therapy.

Nausea is a common complaint after ECT. Vomiting by the unconscious client can lead to aspiration. Because post-ECT clients are unconscious, the nurse must observe closely for the possibility of aspiration, i.e., MAINTAIN A PATENT AIRWAY!

ANXIETY DISORDERS

Common physiological responses to anxiety include increased heart rate and blood pressure; rapid, shallow

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respirations; dry mouth, tight feeling in throat; tremors, muscle tension; anorexia; urinary frequency; palmar sweating.

Anxiety is very contagious and is easily transferred from client to nurse AND from nurse to client. FIRST, the nurse must assess his/her own level of anxiety and remain calm. A calm nurse assists the client to gain control, decrease anxiety, and increase feelings of anxiety.

When a client described a phobia or expresses an unreasonable fear, the nurse should acknowledge the feeling (fear) and refrain from exposing the client to the identified fear. After trust is established, a desensitization process may be prescribed. Desensitization is the nursing intervention for phobia disorders. The nurse should:

- Assist client to recognize factors associated with feared stimuli that precipitate a phobic response.

- Teach and practice with client alternative adaptive coping strategies such as the use of thought substitution (replacing a fearful thought with a pleasant thought), and relaxation techniques. Role-playing is useful when the client is in a calm state.

- Expose client progressively to feared stimuli, offering support with the nurse’s presence.

- Provide positive reinforcement whenever a decrease in phobic reaction occurs.

- NOTE: In all likelihood, the desensitization process will be overseen by a mental health practitioner (NP psych CNS, or psychologist).

The nurse should place an anxious client where there are reduced environmental stimuli – a quiet area of the unit, away from the nurse’s station.

The best time for interaction with a client is at the completion of the performed ritual. The client’s anxiety is lowest at this time; therefore, it is an optimal time for learning.

Compulsive acts are used in response to anxiety, which may or may not be related to the obsession. It is the nurse’s responsibility to help alleviate anxiety. Interfering will increase anxiety. These acts should be allowed as long as the client’s acts are free of violence. The nurse should:

- Actively listen to the client’s obsessive themes- Acknowledge effects that ritualistic acts have on the client- Demonstrate empathy- Avoid being judgmental

For clients with postraumatic stress disorder, the nurse should:

- Actively listen to client’s stories of experiences surrounding the traumatic event

- Assess suicide risk- Assist client to develop objectivity about the event and

problem solve regarding possible means of controlling anxiety related to the event

- Encourage group therapy with other clients who have experienced the same or related traumatic events

SOMATOFORM DISORDERS

Be aware of your own feelings when dealing with this type of client. It is a challenge to be non-judgmental. The pain is real to the person experiencing it. These disorders cannot be explained medically: they result from internal conflict. The nurse should:

- Acknowledge the symptom or complaint- Reaffirm that diagnostic test results reveal no organic

pathology- Determine the secondary gains acquired by the client

DISSOCIATIVE DISORDERS

The nurse should be aware that ALL behavior has meaning.

Avoid giving clients with dissociative disorders too much information about past events at one time. The various types of amnesia, which accompany dissociative disorders, provide protection from pain. Too much, too soon, may cause decompensation.

PERSONALITY DISORDERS

Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety and cause difficulty in relating and working with other individuals. NCLEX-RN questions test personality disorder content by describing management situations.

Persons with a personality disorder are usually comfortable with their disorder and believe that they are right and the world is wrong. These individuals usually have very little motivation to change. Think of them as a CHALLENGE.

EATING DISORDERS

People with Anorexia gain pleasure from providing others with food and watching them eat. These behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare food for unit-based activities.

People with Bulimia often use syrup of ipecac to induce vomiting which may cause cardiovascular problems such as congestive heart failure (CHF). Because CHF is not usually seen in young people, it is often overlooked. Assess for edema and listen to breath sounds.

Physical assessment and nutritional support are a priority; the physiological implications are great. Nursing interventions should increase self-esteem and develop a positive body image. Behavior modification is useful and effective. Family therapy is most effective since issues of control are common in these disorders. (Therapy is usually long term).

MOOD DISORDERS

Depressed clients have difficulty hearing and accepting compliments because of their lowered self-concept. Comment on signs of improvement by noting the behavior, e.g., “I noticed you cobed your hair today” NOT, “You look nice today.”

The most important signs and symptoms of depression are a depressed mood with a loss of interest or pleasure in life. The client has sustained a loss. Other symptoms include:

- Significant change in appetite often accompanied by a change in weight – either weight loss or gain

- Insomnia or hyperinsomnia (usually sleeping during the day – often because the client is not sleeping at night due to anxiety).

- Fatigue or a lack of energy

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- Feelings of hopelessness, worthlessness, guilt, or over-responsibility

- Loss of ability to concentrate or think clearly- Preoccupation with death or suicide

The nurse knows depressed clients are improving when they begin to take an interest in their appearance or begin to perform self-care activities, which were previously of little or no interest.

The nurse should suspect an imminent suicide attempt if a depressed client becomes “better,” e.g., happy or even elated. Be aware – a happy affect may signify that the client feels relieved that a plan has been made and he/she is ready for the suicide attempt.

When dealing with a depressed client, the nurse should assist with personal hygiene tasks and encourage the client to initiate grooming activities even when he/she does not feel like doing so. This helps promote self-esteem and a sense of control.

An important intervention for the depressed client is to sit quietly with the client. When answering NCLEX-RN questions, remember that you are working at Utopia General and there is plenty of time and staff to provide ideal nursing care. Do not let realities of clinical situations deter you from choosing the best nursing intervention. The best intervention is to sit quietly with the client, offering support with your presence.

There are always drug questions on the NCLEX-RN. Here are some tips: Know common side effects for drug groups. For example:

- Anti-anxiety drugs = sedation, drowsiness- Antidepressant drugs = anticholinergic effects, postural

hypotension- MAO inhibitors = hypertensive crisis

Know specific problems or concerns for drug therapy. For example:

- Lithium requires renal function assessment and monitoring- Phenothiazines cause extrapyramidal effects (EPS); tardive

dyskinesia can be permanent if client is not assessed regularly for signs of tardive dyskinesia!

Know specific client teaching for drug therapy. For example:- Phenothiazines = photosensitivity, need to wear protective

clothing, sunglasses- MAO inhibitors = dietary restrictions to prevent hypertensive

crisis

Monitor serum lithium levels carefully. The therapeutic range is between 0.5 and 1.5 mEq/L. the therapeutic and toxic levels are very close in reading. Signs of toxicity are evident when lithium levels are more than 1.5 mEq/L. Blood levels should be drawn 12 hours after LAST dose.

Manic clients can be very caustic toward authority figures. Be prepared for personal “put downs.” Avoid arguing or becoming defensive.

What activities are appropriate for a manic client? = Noncompetitive physical activities, which require the use of large muscle groups.

Where should a manic client be placed on the unit? = Make every attempt to reduce stimuli in the environment. Place the client in a quiet part of the unit.

What interventions should the nurse use if a client becomes abusive?

- Redirect negative behavior or verbal abuse in a calm, firm, non-judgmental, non-defensive manner

- Suggest a walk or physical activity- Set limits on intrusive behavior. For example, “When you

interrupt, I cannot explain the procedure to the others; please wait your turn.”

- If necessary, seclude or administer medication if client becomes totally out of control. Always remember to use compassion because nurses are “nice” people.

Two atypical antipsychotic drugs are also indicated for mania (risperidone and olanzapine).

THOUGHT DISORDERS: SCHIZOPHRENIA

There are five types of schizophrenia specified under the DSM-IV-TR. The DSM-IV-TR is a diagnostic manual prepared by the American Psychiatric Association that provides diagnostic criteria for all psychiatric disorders.

Observe for increased motor activity and/or erratic response to staff and other clients. The client may be experiencing an increase in command hallucinations. When this occurs, there is an increased potential for aggressive behavior. THINK PRN!

When evaluating client behaviors, consider the medications the client is receiving. Exhibited behaviors may be manifestations of schizophrenia or a drug reaction.

Use Bleuler’s four As to help remember the important characteristics of schizophrenia:

- Autism (preoccupied with self)- Affect (flat)- Association (loose)- Ambivalence (difficulty making decisions)

Do not argue with a client about their delusions. Logic does NOT work, it only increases the client’s anxiety. Be matter-of-fact and divert delusional thought to reality. Trust is the basis for all interactions with these clients. Be supportive and non-judgmental. Stress increases anxiety and the need for delusions and hallucinations. Do not agree you hear voices (you should be the client’s contact to reality), but acknowledge your observation of the client, for example, “You look like you’re listening to something.”

Know the side effects of drugs commonly used to treat schizophrenia since client behavioral changes may be due to drug reactions instead of schizophrenia.

SUBSTANCE ABUSE

Know what defense mechanisms are used by chemically dependent clients. Denial and rationalization are the two most common coping styles used – their use must be confronted so accountability for the client’s own behavior can be developed.

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What basic needs have priority when working with chemically dependent clients? Nutrition is a priority. Alcohol and drug intake has superseded the intake of food for these clients.

What behaviors are expected during withdrawal? In the alcoholic, delirium tremens (DT) occurs 12 to 36 hours after the last intake of alcohol. Know the symptoms (tachycardia, tachypnea, diaphoresis, marked tremors, hallucinations, paranoia). In drug abuse, withdrawal symptoms are specific to the type of drug.

What medications can the nurse expect to administer to chemically dependent clients? In treating alcohol withdrawal, Librium or Ativan are commonly used. Antabuse is often used as s deterrent to drinking alcohol. Client teaching should include the effects of consuming any alcohol while on Antabuse. Encourage client to read all labels of over-the-counter medications and food products, which may contain small amounts of alcohol.

What type of therapy is used with chemically dependent clients? Group therapy is effective as well as support groups such as Alcoholics Anonymous, Narcotics Anonymous, etc.

Harm reduction is a community health strategy designed to reduce the harm of substance abuse to families, individuals, community, and society.

- More compassionate drug treatment options including abstinence and drug substitution models.

- HIV related interventions such as needle exchanges- Directed drug use management should the client wish to

continue use- Changes in laws concerning possession of paraphernalia

ABUSE

Select only one nurse to care for an abused child. Abused children have difficulty establishing trust. The child will be less anxious with one consistent caregiver.

Women who are abused may rationalize the spouse’s behavior and unnecessarily accept the blame for his actions. The woman may or may not choose to press charges. Be sure to give her the number of a shelter for “help line” for future occurrences, as well as develop a safety plan.

It is difficult for an elderly person to admit abuse for fear being placed in a nursing home or being abandoned. Therefore, it is imperative to establish a trusting relationship with the elderly client.

Rape victims are at high risk for Post Traumatic Stress Disorder (PTSD). Immediate intervention to diminish distress is vital. The nurse should also assess for and intervene for sequellae such as unwanted pregnancy, sexually transmitted diseases, and HIV risk.

Questions on the NCLEX-RN regarding physical/sexual abuse usually focus on three aspects:

- Physical manifestations of abuse- Client safety- Legal responsibilities of the nurse – In children, the nurse is

legally responsible to report all suspected cases of abuse. In intimate partner abuse, it is the adult’s decision; the nurse should be supportive of their decision. Remember to document objective factual assessment data and the client’s exact words in cases of sexual abuse/rape.

ORGANIC MENTAL DISORDERS

Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a history. Such changes are usually due to a specific stressor, and treatment for the causative stressor will usually result in correcting the confusion.

Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego.

Nursing interventions for the confused elderly should focus on:

- Maintaining the client’s health and safety- Encouraging self care- Reinforcing reality orientation (e.g., “Today is Monday,” and

call the client by name).- Providing a consistent, safe environment – engage client in

simple tasks, activities to build self-esteem

Providing consistent caregiver is a priority in planning nursing care for the confused older client. Change increases anxiety and confusion.

May also use atypical antipsychotics such as resperidine, quetiapine, olanzapine, Clozaril is not a front-line agent due to side-effects. May also give mood stabilizers and antianxiety medications as indicated.

The basic difference between delirium and dementia is that delirium is acute, and reversible, whereas dementia is gradual and permanent.

CHILDHOOD AND ADOLESCENT DISORDERS

Children also experience depression, which often presents as headaches, stomachaches, and other somatic complaints. Be sure to assess suicidal risks, especially in the adolescent.

The client’s lack of remorse or guilt about their antisocial behavior represents a malfunction of the superego or conscience. The id functions on the basic instinct level and strives to meet immediate needs. The ego is in touch with external reality and is the part of the personality that makes decisions.

Important points to remember when answering NCLEX-RN questions:

- These children may be involved in self-fulfilling prophecy (e.g., “Mom says that he/she is a trouble-maker, therefore, he/she must live up to Mom’s expectations”).

- Confront the client with his/her behavior, e.g., lying. This gives the client a sense of security.

- Provide consistent interventions – helps to prevent manipulation. Inconsistency does not help the client develop self-control.

GERONTOLOGICAL NURSING

Changes in the heart and lungs result in less efficient utilization of O2, which reduces an individual’s capacity to maintain physical activity for long periods of time. Physical training for older persons can significantly reduce blood

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pressure and increase aerobic capacity. NCLEX-RN questions ask about teaching and designing rehab programs for the elderly – they should contain something about exercise and nutrition.

Older persons often complain that they cannot get to sleep at night and do not sleep soundly even after they fall asleep. This is because they have shorter stages of sleep, particularly shorter cycles from stages 1 to 4 and REM sleep (stage 4 is deep sleep). They are easily awakened by environmental stimuli. They often compensate by napping during the day, which leads to further disruptions of night sleep. A common response is use of prescription sleeping pills which can create still further problems of disorientation, etc.

Both systolic and diastolic blood pressure tend to increase with normal aging, but the elevation of the systolic is greater. REMEMBER the physiologic of blood pressure, which is expressed as a ratio of systolic to diastolic pressure. Systolic refers to the level of blood pressure during the contraction phase whereas diastolic refers to the stage when the chambers of the heart are filling with blood.

Dysrhythmias in the elderly are particularly serious since older persons cannot tolerate decreased cardiac output, which can result in syncope, falls, and transient ischemic attacks (TIAs). Pulse may be rapid, slow, or irregular.

Angina symptoms may be absent in the elderly or they may be confused with GI symptoms.

With aging, the muscles that operate the lings lose elasticity so that respiratory efficiency is reduced. Vital capacity (the amount of air brought into the lungs at one time) decreases. Breathing may become more difficult after strenuous exercise or after climbing up several flights of stairs. The rate of decline has been found to be slower in more active persons. The nurse should encourage older persons to remain physically active for as long as possible. Declining muscle strength may impair cough efficiency. This fact makes older persons more susceptible to chronic bronchitis, emphysema, and pneumonia.

COPD is the major cause of respiratory disability in the elderly.

Aging changes that contribute to chronic constipation:- The number of enzymes in the small intestine is reduced and

simple sugars are absorbed more slowly, resulting in decreased efficiency of the digestive process.

- The smooth muscle content and muscle tone of the wall of the colon decrease. Anatomical changes in the large intestine result in decreased intestinal motility.

- Psychological factors, as well as abuse of over-the-counter laxatives

- Decreases in fluid intake and mobility contribute to constipation

Tooth loss is NOT a normal aging process. Good dental hygiene, good nutrition, and dental care can prevent tooth loss.

Older persons appear to eat small quantities of food at mealtimes. This is because the digestive system of older persons features a decrease in contraction time of the muscles and more time is needed for the cardiac sphincter to open. Therefore, it takes more time for the food to be

transmitted to the stomach. Thus, the sensation of fullness may occur before the entire meal is consumed.

Older persons have a higher risk of developing renal failure because normal age-related changes result in compromised renal functioning. The nurse should pay careful attention to urinary output in older clients because it is the first sign of loss of renal integrity.

Kegel exercises consist of tightening and relaxing the vagin*l and urinary meatus muscles. These exercises have been very successful in reducing the incidence of incontinence. They must be done consistently, and they can be done unobtrusively at home.

The elderly with incontinence may seek isolation, thereby predisposing themselves to loneliness.

15 to 30% of community-based elderly and almost 50% of elderly living in nursing homes suffer from difficulties with bladder control. Older persons may be more sensitive to alcohol and caffeine since these substances inhibit the production of antidiuretic hormone (ADH). An assessment of sensitivity to bladder problems is essential when planning nursing care.

MEDICATION ALERT:- As one ages, the total number of functioning glomeruli

decreases until function has been reduced by nearly 50%. This decrease in the filtration efficiency of the kidneys has grave implications for persons who are taking medication. Of particular importance are penicillin, tetracycline, and digoxin, which are primarily cleared from the blood stream by the kidneys. These drugs remain active longer in an older person’s system. Therefore, they may be more potent, indicating a need to adjust the dosage frequency of administration.

Alzheimer’s disease is the most common irreversible dementia of old age. It is characterized by deficits in attention, learning, memory, and language skills. Discuss the problems family members have in dealing with Alzheimer’s clients in relation to the following disease manifestations:

- Depression- Night wandering- Aggressive or passiveness- Failure to recognize family members

Strokes from cerebral thrombosis are more common in older persons than are strokes from cerebral hemorrhage. Clots tend to develop when patient is awake or just arousing.

Normal loss of brain cells is compounded by alcohol, smoking, and breathing polluted air. In relation to such losses, the nurse should teach to shop at uncrowded times in stores that are familiar to them, slow down well in advance of traffic signals, stay in the slower lane of the freeway, avoid freeways during rush hours, and leave for appointments well ahead of time.

The most common endocrine disorders in the older adult are thyroid dysfunctions and diabetes.

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Impaired mobility, impaired skin integrity, decreased peripheral circulation, and a lack of physical activity place the elderly at risk for developing decubitus ulders.

Ways to help prevent/decrease the occurrence of falls:- Adequate lighting- Pain the edges of stairs a bright color- Place a bell on the elderly person’s cat (since cats move

quickly and get underfoot)- Wear proper footwear that supports the foot and contributes to

balance (made of non-slippery materials).

Peripheral circulation decreases as one ages. Regular assessment of the feet is very important because it increases the opportunity to discover and treat skin care problems early. These problems could become more serious because of decreased circulation.

Older persons have a dry, wrinkled skin because they lose subcutaneous fat and the second layer of skin, the dermis, becomes less elastic.

Diminished eyesight results in:- A loss of independence (ADL and driving)- A lack of stimulation- The inability to read- A fear of blindness

Lower the tone of your voice when talking to an older person who is hearing-impaired. High-pitched tones (i.e., women’s voices) are the first hearing to go, therefore, lowering the pitch of your voice increases the likelihood that an older person with a hearing loss will be able to hear you speak.

Presbycusis (age-related hearing loss) can result in decreased socialization, avoidance of friends and family, decreased sensory stimulation, and hazardous conditions when driving.

Use frequent touch to decrease the sense of isolation and to compensate for visual and sensory loss.

Older persons undergo a great many changes, which are usually associated with LOSS (loss of spouse, friends, career, home, health, etc.). therefore, older persons are extremely vulnerable to emotional and mental stress.

INTEGRITY VS. DESPAIR is Erikson’s final stage of growth and development. Reminiscing is a means of setting one’s life in order (accepting life and self), which is the task of this stage of Erikson’s development theory. The goal of this stage is to feel a sense of meaning in one’s life, rather than to feel despair or bitterness that life was wasted. The major task of old age is to redefine self in relation to a changed role. Those persons who had been in charge of situations most of their lives may now fund themselves in dependent positions. The role adjustment is a major task of old age.

Think about the following situations and discuss the nursing care for each.

- A nursing supervisor who has had a stroke and is sent to a long term facility for rehabilitation.

- An oil company executive retires after 42 years with the company to travel in his recreational vehicle wit his wife and dog.

- Shortly after their 53rd wedding anniversary, a woman who has never worked outside the home loses her husband to brain cancer.

There are many conditions that can imitate dementia in the older adult. A key role for the nurse is to complete assessment to rule out other possible causes.

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FAQs

What is the average HESI A2 score? ›

Is the HESI A2 Difficult? The HESI test can be a challenging test to pass. The average cumulative score on the test is 49%, while most nursing programs require a passing score of at least 75%.

Is HESI or teas harder? ›

Both standardized tests can be challenging, although the TEAS covers more general knowledge you may already feel confident about. And while the HESI A2 has more questions, a wrong answer has a smaller impact on your overall score. How do nursing schools decide which test to require?

How do I get a high score on the HESI exam? ›

How to Prepare for HESI Exams
  1. Make sure you understand the format, duration and methods of the exam.
  2. Make a study plan. ...
  3. Invest in additional test prep resources.
  4. Organize a study group with your classmates.
  5. Take practice exams.

Is HESI a good predictor of NCLEX? ›

HESI Exit Exam benchmark scores of 850 and 900 predict students' success on the NCLEX-RN. Test preparation and remediation policies impact students' success on the NCLEX-RN.

What is a 75% on the HESI? ›

HESI Score Conversion Chart
ScorePercentagePerformance
> 90090% to 100%Excellent
850 to 89980% to 90%Above Average
800 to 84975% to 80%Average
< 799< 75%Failure

Is an 89 on the HESI good? ›

90% to 100% Students with these scores have a comprehensive knowledge base of chemistry which provides an excellent science preparation for success in nursing or health professions school. 80% to 89% Students with these scores should be well prepared to enter nursing or health professions school.

What is the hardest test in nursing? ›

Passing the NCLEX is essential to begin your nursing career, but it is also one of the most challenging exams you will ever take.

Which is harder HESI or NCLEX? ›

The two exams comprise individual difficulty levels, with Hesi being harder than the Nclex, as most students portray. Although the hesi exam can be harder for many students, undertaking a well-planned test preparation ahead of the exam can benefit you.

Can you get a 100 on the HESI? ›

HESI scores are based on a percentage system so the highest score is 100%. There are a lot of sections and subsections in this exam. Since each school has its own requirements as to which subsections students take, a percentage-based system is the only way to make it work for everyone.

How many hours should I study for the HESI? ›

As a general rule of thumb, it's helpful to give yourself a minimum of one week for each of the four academic test sections. Some students benefit from longer and some can be successful even with less time to study.

What do most people score on the HESI? ›

So I would consider a 70-79% need some remediation, 80-85% a decent score (but could use some improvement), 85-90% great at the material (average), 90-100% excellent at the material (above average).

What is a 650 on the HESI? ›

800 to 849 -- below average chance of doing well. 750 to 799 -- extra preparation should be taken. 700 to 749 -- extra preparation and additional studying needed. 650 to 699 -- highly likely of failing. 649 and below -- poor performance likely.

What HESI score is equivalent to passing NCLEX? ›

There is solid science behind your HESI exams. Research shows that the HESI Exit Exam has a 96-99% estimated prediction of success on the NCLEX exam. That means that most students who score 900 or above are likely to pass the NCLEX exam.

How do you know if you passed the HESI exam? ›

Know That There Is No “Pass” or “Fail”

The HESI exam is scored on a scale ranging from 750 to 900, with 900 being the best score possible. While you don't actually “pass” or “fail” the HESI exam, every school has their own set score, and which subtests, are required for admittance into the program.

What is the minimum passing score for HESI? ›

What scores do I have to attain on the HESI A2 Exam? Each section must be passed with a 75% or higher.

What is an acceptable HESI score? ›

The HESI Exit Exam score range is between 0 to 1500. The acceptable HESI score is 850 while the recommended HESI score is 900. You need to earn a minimum score of 850 in order to be considered ready to take the NCLEX licensing exam.

Is the HESI A2 harder than the NCLEX? ›

Although the hesi exam can be harder for many students, undertaking a well-planned test preparation ahead of the exam can benefit you. The Hesi score equivalent to the Nclex passing score is 96-99%, meaning students who achieve a 900-score level or above will likely excel in their Nclex exam.

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