Anda di halaman 1dari 19

5SIOLOGICAL ADAPTATION (34)

1) Inflammatory Bowel Disease: Dietary Recommendations (583)


low fiber
increased protein
decreased calories
Ulcerative Colitis and Crohns Disease

Eat foods high in protein and calories, and low in fiber


Identify foods that trigger clinical manifestations
Avoid caffeine and alcohol, take multivitamin w/ iron
Eat small frequent meals
Dietary supplements high in protein and low in fiber
Monitor for electrolyte imbalance especially potassium
Vitamin B12

Diverticulitis

2)
3)

4)

5)

Consume clear liquid until manifestations subside


Add fiber when solid foods are tolerated
Avoid seeds or indigestible material that can block diverticula (nuts popcorn)
Avoid alcohol. Limit fat intake to 30%, adequate fluids, bulk forming laxatives
Respiratory Management and Mechanical Ventilation:
Need for Suctioning
Suction secretions to maintain airway and tube patency
Disorders of the Eye: Expected Findings (122)
Retinal detachment- flashes of light and blind spots curtain closing over
eyes
Glaucoma- increased IOP causing gradual vision loss
Injury. Disease process, aging process
Macular degeneration(#1 cause of vision loss in ppl over 60), cataracts,
glaucoma
MD: lack of depth perception, object distortion, blurred vision, loss of
central vision, blindness
Cataracts: decreased visual acuity, blurred vision, diplopia, photo
sensitivity, halo around lights, visible opacity, absent red reflex
Glaucoma: headache, mild eye pain, loss of peripheral vision, inc. IOP,
photophobia, pupils non reactive to light
Disorders of the Eye: Analyzing Findings
IOP: 10-21 mm/Hg
Monitor for IOP
-monitor for decreased vision and light sensitivity
-Assess pt for aching or discomfort around the eye
-Tx severe plain and nausea with analgesics and antiemetics
Arthroplasty:
Prevent complication- DVT, anemia,
-Older adults @ higher risk

CPM
Prevent pressure ulcers
Using a Continuous Passive Motion Machine

Promote motion and prevent scar tissue formation


Avoid flexion of hip greater than 90 degrees, dont cross legs, abduction
pillow, raised toilet seat
-Full extention to perscribed amt of flexion
-Placed and initiated right after surgery
-stopped for meals

6) Cancer Disorders (981)


Laryngeal Cancer and Body Image Disturbance
Consult speech language path. for clients who have difficulty speaking
-Provide comfort to pt who have permenant loss of voice or disfigurment
-Refer to counseling servcies as needed
7) Burns: Prioritizing Emergency Interventions (829)
Airway
-fluid and electrolyte
-thermoregulation
-infection
Maintain Airway and Ventilation (cough deep breathe, suction, elevate
head of bed, oxygen),
monitor vitals
maintain cardiac output (IV access, fluid replacement in first 24 hours,
rapid replacement during emergent phase, isotonic crystalloid solutions such
as NaCl or Lactated Ringers, colloids such as albumin or synthetic plasma
expanders after first 24 hours. Maintain urine output, possible administration
of blood products),
monitor for shock, pain management (avoid IM or Sc administration, IV
opioid analgesics, monitor for respiratory depression, meds before dressing
change, nonpharm pain management),
prevent infection (restrict visitors, no plants or flowers, no fresh fruits or
vegetables),
nutritional support( may need increased calories up tp 5,000, increase
protein, may need TPN, )
Restore mobility,
psychosocial support
8) Electrolyte Imbalances: (472)
Safety, abcs
Evaluation of Potassium Chloride Therapy - hypokalmeia

Never administer by bolus, 5-10 mEq/hr


Assess for phlebitis
Monitor urine output
Diminished respirations and breath sounds

Monitor cardiac rhythm (especially pts taking Digoxin), LOC, bowel sounds,
kidney function, mg ca phosphorus, provide assistance with ADLs

9) Cardiovascular Diagnostic and Therapeutic Procedures: (294)


Assessing Arterial Line (296)
check placement
-keep pressure
-flush before between and after meds
-watch for clotting
Assess integrity of arterial waveform, monitor circulation in the limb with the
line( cap refill, temp, color). Monitor respiratory and cardiac status, placement,
prevent infection and blood clots
10) Cardiovascular Diagnostic and Therapeutic Procedures: (349)
ECG Abnormalities Following Myocardial Infarction (351)

Angina- ST depression/ T wave inversion indicates ischemia


MI- T wave inversion indicates ischemia, ST segment elevation indicates
injury, abnormal Q waves indicates necrosis

11) Head Injury: Monitoring CSF Leakage

Leakage from nose or ears


"halo" sign- yellow stain surrounded by blood on a paper towel,
fluid tests positive for glucose
-report to dr

12) Diabetes Mellitus Management: (914)


Client Education Regarding Medications

Rotate injection sites, dont aspirate for blood


Eat at regular intervals, avoid alcohol intake, adjust insulin to exercise
Take even if can't eat.
-Clear-cloudy-cloudy- clear pull in short acting first then long acting
-Must eat after injection or will have hypoglycemia

13) Tuberculosis: Client Teaching Regarding


Medication Therapy
Must take for 6-12 months
No alcohol, may interfere with BC, report yellowing skin, drink lots of water, notify
provider with vision or hearing changes
14) Aneurysms: 434
Signs and Symptoms of Aortic Dissection

Aortic Aneurysm

Gnawing feeling in abdomen, flank or back pain,


Pulsating abdominal mass (do not palpate)
Bruit. Increased BP
-Severe back pain
-Hoarsness, cough, SOB, difficulty swallowing
-Decreased urinary output

Aortic Dissection

Sudden stabbing, tearing, ripping, abdominal or back pain


Hypovolemic shock (diaphoresis, nausea, vomiting, faintness, apprehension)
decreased or absent peripheral pulses, neuro deficits, hypotension and
tachycardia (initially)

15) Hemodialysis and Peritoneal Dialysis: Complications (640)

Hemodialysis: clotting, air bubbles, temperature of dialysate, regulation of


ultrafiltration, hypotension, cramping, vomiting, bleeding, contamination,
hypovolemia, disequilibrium syndrome.
clotting/Infection of access site
-Disequilibrium syndrome
-use slow exchange rate
- Administer anticonvulsant/barbituates if needed
-Hypotensoin
-IV fluids
-Decreased HOB
-Anemia
-Monitor labs and provide blood products as needed
-Infectious Diseases
Peritoneal Dialysis: peritonitis, infection at access site, leakage, reflux, protein
loss, hyperglycemia, hyperlipidemia, hypertension, obstruction

16) Peptic Ulcer Disease: Complications (549)

Perforation/Hemorrhage: severe epigastric pain spreading across abdomen,


rigid board like abdomen, hyperactive to diminished bowel sounds, rebound
tenderness
Pernicious anemia: pallor, glossitis, fatigue, paresthesia. Will need B12
injections.
Dumping syndrome: syncope, pallor, palpitations, dizziness, headache
-Heartburn, bloating, N&V
-Pain, bloddy emisis or stools
-weight loss, med. side effects

17) Fluid Imbalances: (473)


Prioritizing Assessment Findings

Safey, abcs

18) Hemodynamic Shock: Ventricular Fibrillation (423)

can cause cardiogenic shock


-Dx- ECG, Ech, CT, Cardiac cath, chest x ray
-Tx- Cardiac cath, Anticoagulants, defib shock to fix rythem

19) Acute Kidney Injury and Chronic Kidney (674)


Disease: Evaluating Client Understanding

Drink2 to 3 L, stop smoking, lose weight, NSAIDS with caution, diabetic and
HTN control, take prescribed antibiotics. High protein diet, restriction during
oliguric phase, potassium and sodium restriction according to stage of
disease
-Instruct pt to take ALL prescribed meds and ATB
-Decreased dietary potassium, phosphate, and mag.
-Increase protein, possible TPN

20) Gastrointestinal Therapeutic Procedures: (523)


Teaching Colostomy Care

Educate and a support person


Odor causing foods: fish, eggs, asparagus, garlic, beans, and dark green leafy
vegetables
Gas causing foods: dark green leafy vegetables, beer, carbonated drinks,
dairy products, and corn. Yogurt may decrease gas
Ostomy involving small intestine: avoid high fiber foods for first 2 months,
chew food well, increase fluids, and evaluate for blockage with addition of
fiber
Filters, deodorizers, or breath mint can minimize odor when pouch is open
Encourage client to look at and touch stoma
Normal stoma appearance, symptoms of blockage

21) Respiratory Management and Mechanical Ventilation: (199)


Complications Following Extubation

RR > 30/min or <8/min


-BP or HR changes >20% baseline
-SaO2 <90%
-Dysrhythmias, increased ST segment
-Sig. decrease in tidal volume
-Labored resp. and increased use of accessory muscles
-Restlessness, anxiety, decreased LOC
-Monitor for resp. destress or airway obstruction such as ineffective cough,
dyspnea, and stridor

22) Heart Failure and Pulmonary Edema: 361

Manifestations of Left-Sided Heart Failure

Dyspnea, orthopnea, fatigue


Displaced apical pulse, S3 heart sounds
Pulmonary congestion(dyspnea, cough, pink frothy sputum)
Altered mental status
Manifestations of organ failure such as oliguria

23) Postoperative Nursing Care: Using an Incentive Spirometer (1104)

Use at least every 2 hours. Promotes lung expansion, prevents atelectasis

24) Peripheral Vascular Diseases: (394)


Clinical Manifestations of Thoracic Outlet Syndrome

Discoloration of hand, arm pain and swelling, blood clots, lack of color in hand
or arm, weak or no pulses, arm fatigue, numbness or tingling in fingers,
weakness of arm or neck, lump near collarbone, weakening grip
Neck, shoulder, and arm pain, numbness
-Impaired circulation and flushed sensations to the extremities
-Symptoms are reproduced when arm is positioned above the shoulder or
extended

25) Cancer Treatment Options: (999)


Dietary Considerations for a Client who has Stomatitis

Use non-alcoholic glycerin based mouth wash


Discourage consumption of salty, spicy, acidic foods
Eat soft, bland foods high in calories (mashed potatoes, scrambled eggs,
cooked cereal, milk shakes, ice cream, frozen yogurt, bananas, breakfast
mixes)
Oral hygiene before and after meals

26) Blood and Blood Product Transfusions: (450)


Infusion of Autologous Salvaged Blood

5 weeks up to 72 hours in advance


Salvaged blood from surgery can be recycled through cell-saver machine and
transfused
prescribed

27) Cardiovascular Diagnostic and Therapeutic Procedures:


Cardiac Catheterization Postoperative Care (294)

Apply an initial dressing of gauze and replace with transparent dressing w/i
24 hr
-x ray to ensure placement
-assess q8hr
- Use 10mL or < syringe to flush

-Clean port for 3 seconds and allow to dry


-flush before, between, and after meds
- no BP on arm with PICC

28) Disorders of the Male Reproductive System:


Delegation of Postoperative Care Following Prostate Surgery
vitals
29) Electrocardiography and Dysrhythmia Monitoring:
Monitoring a Client for Risk of Pulmonary Embolism

Caused by dysrythmia
-dyspnea, chest pain, air hunger, decreased o2

30) Noninflammatory Bowel Disorders:


Self-Management Strategies

High fiber diet


reduce stress
Instruct pt to limit irritating foods
Keep food diary

31) Emergency Nursing Principles and


Management: Mass Casualty Triage

Red- emergent
Yellow- need care soon
Green- walking wounded
Black- expected to die

32) Renal Diagnostic Procedures: IV Urography


33) Hyperthyroidism:
Postoperative Care following a Thyroidectomy

Keep trach @ bedside


Vitals, assess for bleeding, laryngeal

34) Heart Failure and Pulmonary Edema


Prioritizing Interventions

Class
Class
Class
Class

I: Pt exhibits no symptoms with activity


II: Pt has symptoms with ordinary exertion
III: Pt displays symptoms with minimal exertion
IV: Pt symptoms @ rest

BASIC CARE AND COMFORT (6)


35) Peptic Ulcer Disease: Prevention of Dumping Syndrome

instruct pt to avoid foods that cause distress


-Monitor for orthostatic changes in v/s and tachycardia at these findings are
suggestive of gastrointestinal bleeding
-Have pt lie supine after eating

36) Renal Calculi: Dietary Restrictions

Limit food high in animal protine


-reduce calcium intake

37) Mobility and Immobility: Quad Cane Use with Hemiplegia

Use cane on uneffected side


-Advance cane at same time as affected limb
-Stairs-Up with the good and down with the bad

38) Postoperative Nursing Care:


Prophylactic DVT Care

assess and compare peripheral pulses


-Caused by dehydreation, obesity, trauma, malignacy, Hx of thrombosis,
hormones, and use of indwelling cath
-Nursing actions: prevention, avaoid dangling pt for long periods,
anticoagulants, provide adequate hydration

39) Acute Kidney Injury and Chronic Kidney Disease:


Planning Dietary Restrictions

possible fluid restrictions


-Restrict K+, phosphate, & magnesium
Potassium and sodium regulated
-High protein and possible TPN

40) Disorders of the Male Reproductive System:


Preventing Complications following a Transurethral Resection of the Prostate

Urine should be light pink. If red increase irrigation


-If cath becomes obstructed turn of CBL and irrigate with 50mL
-Record amt. of irrigation and sub. from total to get true output
-Instruct pt not to urinate around cath-it will cause bladder spasem
-Monitor vitals and bleeding

HEALTH PROMOTION AND MAINTENANCE (2)

41) Health Promotion and Disease Prevention:


Safer Sex Practices

Abstienence is best
-Use condoms
-Get tested regularly

42) Health, Wellness, and Illness: Health Screening

-Physical assessment
-Evaluating health perceptions
-Identifying risks to health/wellness
-identify access to healthcare
-Identify obsticals to compliance and adhearance
-Belief in prescribed therapy
-Availibility of support system
-financial restricitions

PHARMACOLOGICAL AND
PARENTERAL THERAPIES (23)
43) Miscellaneous Pain Medications: Medication

Teaching for Allopurinol (Zyloprim)


Steven- Johnsons syndrom, joint pain, pain or blood in urine, yellow skin or
eyes
-drowsiness
-N&V diarrhea

44) Growth Factors:


Evaluating Epoetin Alfa (Epogen) Effectiveness

Monitor hematocrit lab values

45) Blood and Blood Product Transfusions:


Evaluating Therapeutic Response

Monitor Vitals I&O and Labs

46) Gastrointestinal Therapeutic Procedures:


Evaluating Clients Understanding of TPN

Must monitor glucose lvls closely durring TPN infusion


-Given through PICC or Central Line

47) Blood and Blood Product Transfusions:


Allergic Transfusion Reactions

Stop infusion

Change tubing
start IV of 0,9% sodium chloride.
Keep tubing, bags to send back to lab
Mild- Itching, urticaria, flushing- Administer benadryl
Anaphylactic- wheezing, dyspnea, chest tightness, cyanosis, hypotension
-maintain airway, admin. 02, IV fluids, antihistamines, corticosteroids, and
vasopressors

48) Acute Kidney Injury and Chronic Kidney


Disease: Medication Adverse Effects

Avoid antimicrobial, NSAIDs, ACE inhibitors, IV contrast dye


-Monitor Digoxin lvl & administer post dialysis
-kayexalate to increase elimination of serum potassium
-epogen, procrit, to increase RBS stimulation
-Iron supplement
-Lasix
-Amphojel- taken to stop phsophate absorption
-take 2 hr before or after digoxin

49) Medications Affecting Coagulation:


Self-Administering Enoxaparin (Lovenox)

-Injection given in R or L abdomen


-Take only as directed
-may inhibit blood clotting

50) Cardiovascular Diagnostic and Therapeutic


Procedures: Complications of IV Therapy

fluid overload
thrombophlebitis, infiltration
extravasation

PHARMACOLOGICAL AND
PARENTERAL THERAPIES (continued)
51) Diabetes Mellitus Management:
Administering Insulin

check glucose before meds


if take insulin must eat after

52) Hypertension: Recognizing Side Effects of Medications

-Hypotension
-edema
-ACE-unproductive cough

-monitor potassium

53) Gastrointestinal Therapeutic Procedures:


Calculating Protein Intake
0.8-/kg
54) Opioid Agonists and Antagonists:
Hypersensitivity to Morphine

Narcan- antagonist
Older pt do not metabolize as well
If Resp. rate falls below 8/min stop opioid and give narcan

55) Posterior Pituitary Disorders:

Plan of Care for Client who has Diabetes Insipidus


monitor Vitals and labs
-weigh daily
-IV therapy
-Fall precautions
-Add bulk foods and fruit juices
-Assess skin turgor and mucous membranes
-provide skin and mouth care
-encourage pt to drink in response to thirst

56) Opioid Agonists and Antagonists:


Expected Findings Following Administration of Naloxone (Narcan)
Increased respirations, pain returns, increased HR, increased BP
57) Seizures and Epilepsy:
Client Teaching about Phenytoin (Dilantin)

-If one med doesn't work dose is increased or another med is added
-Therapeutic lvl determined by blood test
-Med taken same time each day
-No oral contraception or warfarin
Dilantin Therapeutic Lvl 10-20

58) Medications Affecting Blood Pressure:


Monitoring Initial Dose of Lisinopril (Zestril)

may make pt feel dizzy


-Monitor BP, HR, and keep on falls precautions
-Remind pt top ask for assistance to get up and to move slowly

59) Blood and Blood Product Transfusions:

Interventions for Transfusion Reaction

Acute hemolytic Immediate

- This reaction may be mild or life-threatening.


- Clinical findings include chills, fever, low back pain, tachycardia, flushing,
hypotension, chest tightening or pain, tachypnea, nausea, anxiety, and
hemoglobinuria.
- This reaction may cause cardiovascular collapse, kidney failure, disseminated
intravascular coagulation, shock, and death.

febrile 30 min to 6 hr after transfusion

- Clinical findings include chills, fever, flushing, headache, and anxiety.


- Use WBC filter. Administer antipyretics.

Mild allergic During or up to 24 hr after transfusion

- Clinical findings include itching, urticaria, and flushing.


- Administer antihistamines, such as diphenhydramine (Benadryl).

Anaphylactic Immediate

- Clinical findings include wheezing, dyspnea, chest tightness, cyanosis, and


hypotension.
- Maintain airway; administer oxygen, IV fluids, antihistamines, corticosteroids, and
vasopressors.
Stop infusion, run normal saline in separate line, keep bag and line for testing
60) Electrolyte Imbalances: (494)
Treating Hypomagnesemia less than 1.3

-DC mag-losing meds (loop diuretics)


-Administer oral or IV mag sulf Im can cause pain and tissue damage, oral can
cause diarrhea and increase mag depletion
eIncourage food high in mag: dairy, dark green leafy veggies

61) Menstrual Disorders and Menopause:


Adverse Effects of Medications ,Menopausal Hormone Therapy
-

increased risk for blood clots


long term use increases cancer risk

62) Vitamins, Minerals, and Supplements:


Adverse Effects of Garlic Therapy

Effect blood clotting, inhibits platelet formation


Increased bleeding with lovenox, odor in colostomy

63) Cardiovascular Diagnostic and Therapeutic


Procedures: Verifying Tip Placement of PICC Line

x ray verification prior to use


Use 10mL or < syringe
Tape cath hub to minimize manipulation
Remove dressing from distal to proximal
note length to help detect cath. migration

64) Cardiovascular Diagnostic and Therapeutic


Procedures: Accessing Implanted Port

Local anesthetic, Palpate port body septum to ensure accurate insertion of


needle. Alcohol for 2-3 seconds, use non-coring (Huber) needle
x ray to confirm placement
-document cath placement @ beg. and end of shift (and any time py is
moved)
-check readings for hemodynamic cath
-use 0.9% sodium chloride of flushing no heparin
-Avoid air embolisim
-risk for pneumothorax
-Risk for dysrhythmias with insertion/movement of line

65) Cardiac Glycosides and Heart Failure:


Evaluating Client Understanding of Digoxin Administration (361)

Apical HR for one full minute


Hold if apical HR is <60bpm per min
-Watch for N&V
-Monitor ECG, BP
-Take same time each day
-take 2 hr before or after antacids
If you miss dose take it as soon as you remember
Therapeutic level 0.5-2.0

REDUCTION OF RISK POTENTIAL (21)


66) Pulmonary Embolism: Interventions (258)

Administer O2 therapy
High fowlers
initiate and maintain IV therapy

administer meds (anticoagulants and thrombolytic therapy)


Provide emotional support
Monitor changes in LOC and mental status

67) Cardiovascular Diagnostic and Therapeutic


Procedures: Postoperative Expected Findings Following Coronary Artery Bypass Graft
(294)

Splint incision with deep breathing and coughing


Consult resp. services
Continually monitor HR and rythem
Hypertension and Hypotension
Chest tube dreain >150mL/hr could mean hemorrage
control plan
Monitor fluid and electrolyte

68) Inflammatory Bowel Disease: (580)


Interpreting Laboratory Results

HGB & HCT decreased


ESR Increased
WBC increased
Platelet count increased
Serum albumin decreased
K, Mg, C decreased

69) Arthroplasty:
Postoperative Care Following a Knee Arthroplasty (759)

Prevent complication- DVT, anemia,


-Older adults @ higher risk
CPM, avoid pillows behind knees, keep heels off of bed, analgesics,
antibiotics, anticoagulant, ice , neurovascular status

Prevent pressure ulcers

70) Hyperthyroidism: (868)


Monitoring Laboratory Results

Serum TSH test- decreased


-FTI and T3 increased
-Thyroid-releasing hormone- failure of expected rise

71) Diabetes Mellitus Management:

Glycosylated Hemoglobin Test

4-6% normal
target <7%, good glycemic control
Indicates Blood sugar for last 120 days

72) Cancer Screening and Diagnostic Procedures:


Assessing the Need for Intervention (990)

CEA
PSA
AFP

73) Postoperative Nursing Care: (1104)


Recognizing Risk Factors for Atelectasis

Snoring, Stridor,
Monitor Blood o2 lvl

74) Tuberculosis: Interpreting a Mantoux Skin Test (249)

Red spot- no reaction


Raised red bump- reaction
48-72 hours after injection
More than 10mm induration, positive. Confirm with chest xray

75) Electrocardiography and Dysrhythmia


Monitoring: Priority Analysis of an ECG Strip (312)

MI (chest pain and ST depression or elevation)

76) Acute Kidney Injury and Chronic Kidney Disease:


Recognizing Priority Laboratory Values

Serum creatinine gradual increases 1-2mL/dL q 24-48 hr or 1-6 in ine week


BUN increased to 80-100 w/i week
Urine specific gravity >1-1.01

77) Diabetes Mellitus Management: (912)


Evaluating Client Teaching Regarding Foot Care

Keep feet clean and dry


Wear shoes always
Inspect feet daily
Wear socks
Wash with mild soap and warm water, test water with hands first
Nailcare after showering
Separate overlapping toes
Leather shoes preferred, no open toed or open heel shoes

Cotton or wool socks


Avoid prolonged sitting, standing, or crossing legs

78) Angina and Myocardial Infarction:


Monitoring for Complications (349)

Acute MI- Decreased cardiac output


Cardiogenic shock/HF: tachycardia, hypotension, dec. urinary output, altered
LOC, res. Distress, dec pulses, cool clammy skin
Ventricular aneurysm/rupture d/t necrotic tissue result of MI: sudden chest
pain, dysrhythmia, sever hypotension
DysrythmiaIschemic mitral regurgitation-development of new cardiac murmur

79) Gastrointestinal Therapeutic Procedures:


Appropriate Client Teaching about Paracentesis (523)

Explain procedure and purpose


-Local anesthetics at insertion site
-Pressure or pain when needle is inserted
Assess clients knowledge of procedure

80) Chest Tube Insertion and Monitoring: (191)


Observing the Water-Seal Chamber for an Air Leak

Continuous bubbling means there is an air leak


Intermediate bubbling is normal
Continuous bubbling in suction chamber only

REDUCTION OF RISK POTENTIAL (continued)


81) Coagulation Disorders: (467)
Thrombocytopenia

ITP- Autoimmune where lifespan of platelets is decreased can result in severe


hemorrhage
Unusual spontaneous bleeding

82) Hemodialysis and Peritoneal Dialysis:


Assessing an Arteriovenous (AV) Graft (640)

Check for palpable thrill, auscultate bruit, distal pulses, circulation)

83) Preoperative Nursing Care:


Recognizing Deviations in Laboratory Values (1082)

CBC: WBC (4,500-11,000), RBC(4.2-6.1), Platelets (150,00-450,00)


Hgb: 12-18

Hct: 35-52
Serum electrolyte: K (3.5-5), Na (135-145), Cl (98-106), C (8.6-10), P(2.7-4.5),
Mg(1.6-2.6)
Serum creatinine (0.5-1.3)
BUN (8-25)
ABGs: ph (7.35-7.45), PaCO2 (35-45), HCO3(22-26), PaO2(80-100)

84) Acute Kidney Injury and Chronic Kidney Disease:


Interpreting Laboratory Values (674)

AKI
Serum creatinine gradual increases 1-2mL/dL q 24-48 hr or 1-6 in one week
BUN increased to 80-100 w/i week
Urine specific gravity >1-1.01
CKD
Hematuria, proteinuria, decreased specific gravity
BUN as high as 180 to 200
Creatinine, 4 over time. As high s 15 to 30
Decreased Na and Ca, Increased K, P, Mg
Decreased H&H

85) Spinal Cord Injury:


Assessment of a Client who has a Cervical Injury

C4 or above poses risk for impaired spontaneous ventilation because of the


involvement of the phrenic nerve
Bladder management for spastic bladder (catheter)
Glucocorticoids, plasma expanders, H2 agonists, vasopressors, muscle
relaxants, antimuscarinic, stool softeners, analgesics, anticaogulants
Oxygen, incentive spirometer, cough and deep breathe

86) Respiratory Management and Mechanical


Ventilation: Choosing Appropriate Oxygen Equipment (199)

Nasal Cannula- 24-44%, 1-6L/min


Simple face mask- 40-60% at 1-6L/min. 5l/min to flush CO2 from mask
Partial rebreather- 60-70% at 6-11L/min
Nonrebreather- 80-90% at 10-15Lmin
Venturi-mask- 24 to 55% at 2 to 10L/min, for clients with chronic lung disease
Aerosol mask-24-100% at leas 10L/min. for facial trauma, burns, or thick

secretions
T piece-24-100% at least 10L/min. For pt with tracheostomy, laryngectomy,
or ET

SAFETY AND INFECTION CONTROL (4)


87) Seizures and Epilepsy:

Recognizing At-Risk Client (62)

Genetic predisposition (absence seizures more common in children)


-Acute febrile state
-Head trauma
-Cerebral edema
-Abrupt cessation of antiepileptic drugs
-Infection
-Metabolic disorder
-Brain tumor
Exposure to toxins
-Hypoxia
-Acute drug & alcohol withdrawal
-Fluid and electrolyte imbalances
Older adult: cerebrovascular disease
Triggering factors: excessive stress, inc physical activity, hyperventilation,
fatigue, alcohol ingestion, excessive caffeine, flashing lights, cocaine aerosols
inhaling glue

88) Infection Control: Evaluating Appropriate Use


89) Cancer Treatment Options:
Planning Care for Client Undergoing Brachytherapy

private room
warning sign
dosimeter
visitors can stay for 30 minutes, must be at least 6 feet away
pregnant or under 16b cannot enter
If it falls out put in lead lined container using tongs
Remain in position to prevent dislodgement
Call for assistance with elimination

90) Cancer Treatment Options:


Precautions for Client who is Immunocompromised (999)

Avoid crowds
-Take Temp daily
-Avoid food that could contain bacteria (fresh fruits and veggies, undercooked
meat, fish, eggs, pepper, paprika
-Avoid yard work, pet litter
-Avoid FLuids that have set out at room temp for more than 1 hour
-Was dishes in hot soapy water, after one use
-Wash toothbrush in dish washer or with bleach
-Do not share toiletry
Monitor temp and wbc
Fever greater than 37.8(100) should be reported \
Monitor skin and mucous membranes for infection

Cultures before antimicrobial therapy


Neutropenic precautions when wbcs are less than 1000