Cystic Fibrosis

-Resp Problem w/ copious amounts of mucous.
For all resp problems involving mucous:
6 small meals
Fluids
No milk or milk products
-Postural drainage, chest percussions with cupped
hands
When draining lower lobes, head is dependent
Drain lower lobes before upper (only do at least 1 hr
after food).
Monitor/assess- clubbing
-Cystic Fibrosis affects the Pancreas
Pancreatic Enzymes with all food (Pancrease with all
food)
-Cystic Fibrosis clients excretes 4X the normal
amount of salt
Extra salt daily, with each meal
Advise against activities to produce stress
-Cystic Fibrosis is autosomal recessive (both parents
must carry for child to have it)
If only one parent has or carries, the child has no
chance of contracting CF
-Cystic Fibrosis has a growth problem/failure to thrive

Developmental Stages
A 15 month old can
Climb up and fall down stairs
Vocabulary:
1 year old (2-6 words)
18 months -2 years ( short sentences/4 word
sentences, up to 300 words)
3 year old (900 words)

Toddlers
Picky about food, this is normal
Newborn
Positive Babinski for 6-12 months after birth
If temp becomes low, put on a cap
Activities should be age AND condition appropriate
Preschooler
Can tie shoes
Can name 5 colors
School age
Rules and rituals dominate play
Likes to accomplish or produce
Adolescents

Have all permanent teeth except molars

Cardiac
Do not lie a cardiac problematic person flat/ supine!!
Do not use energy to walk to the car
-Nitroglycerin:
1 q 5 min X3
sublingual, dark bottle
will fizz under the tongue
may cause headache b/c it is a vasodilator
give nitro before calling 911
Coumadin
can cause bleeding
Melena is dark tarry stool from an upper GI bleed
Echymosis, petechiae, etc. could concern you
PT, prothrombin time
Therapeutic PT on Coumadin will be 1.5 times the
normal value
INR monitored (1/1.5-2/2.5)
-Melana
Either an upper GI Bleed or they are on Iron
-Do not INCREASE intake of green leafy vegetables,
continue to eat them as normal
-Cranberry juice increases INR and cause more
bleeding
-Must tell pt on Coumadin to not buy OTC vitamins,
failure to do so can be NEGLIGENT
OTC vitamins may have vitamin K
-OTC medications may be contraindicated with
Coumadin, may cause more bleeding
Aspirin
Gingko Biloba (for Memory)
Garlic
Ginger
-Can cross the placental barrier
Heparin is safe during pregnancy, it
CANNOT cross placental barrier
Pregnancy puts women at high risk for DVT, she may
need prophylactic heparin if she has DVT
DVT
What indicates a DVT
leg is edematous
painful
warm to touch
may be pink/red
Interventions for DVT
Measure both extremities daily for
comparison
Pain medication
Warm compresses to increase circulation
Venous (elevate leg) (V=legs up) (A=legs
down for arterial clots)
Heparin
What shows improvement of DVT
Decreased leg circumference

monitor for bleeding Digoxin Toxicity symptoms Nausea/Vomiting Anorexia Bradycardia Halo. possible toxicity Therapeutic Effects of Digoxin Slows and strengthens the heart Increases CO and BP Increases urine output Theophylline (aminophylline) Bronchodilator Accelerates everything Side effects Nausea/Vomiting Tachycardia Tachypnea Nervousness Insomnia Hypotension Always give bronchodilator before steroids Do not crush/ mix digoxin and theophylline together CHF and HF patients can have both Digoxin to slow and strengthen the heart Theophylline to help with expiratory wheezing Give these two meds to same patient.5-2. Thoracentesis.5 X 30) -Platelet count If 100.. double. tilted on left side a little.What concerns you for client with DVT Pulmonary Embolism: Petechiae on chest Chest pain Cough/SOB/Respiratory Problems Hemopsis Disorientation. Mental status Change Mental Status Change -Caused by: any time BLOOD is not getting O2 and getting O2 to the BRAIN Any respiratory problem Any cardiac problem Fluid volume deficit Fluid volume overload (pressure on the brain. Check digoxin level. clammy Thoracentesis Position: Side of bed. but separately Paracentesis. arms on bedside table If patient is too sick.000 or less. blurred Vision If ct on digoxin refuses breakfast and lunch today. right arm over the head post biopsy. combative. the client should be: more alert If decreases from normal to very below normal. EXHALE. hold and bear down til needle is in Do not cough during procedure After procedure monitor for signs of pneumothorax: Deviated trachea to one side Asymmetrical/ uneven chest movements Decreased breath sounds on one side Monitor for signs of hypovolemic shock: BP low (80/40) Rapid thready pulse Rapid shallow respirations Pale. semi-fowlers or fowlers Liver biopsy Position: Lay supine.. we want it to be normal (11-15) Big risk of bleeding with liver biopsy Big risk for Bile Peritonitis (leaking Bile into peritoneum) Peritonitis .lay on right side Lab before biopsy: Prothrombin time PT. sit up in bed with arms on table over bed Paracentesis Position: Side of bed. Liver Biopsy Have patient void (to move bladder out of the way) Have pt take deep breath. stabilize feet If sick. expect: Lethargic Malaise -Heparin Moniter PTT (normal 15-30) Therapeutic (1.Sodium If increases greatly. ICP) Electrolyte imbalance . cool.

chest tubes. keep sodium at a normal level Carbonated drinks are high in sodium Do not do anything to make you perspire more than usual Do not eat foods high in sodium Lithium is not effective for 2-4 weeks Lithium is a mood stabilizer. Myasthenia Gravis Feed a drooling patient Feed a trach patient Ambulate a chest tube client Cannot get total hip. panting keeps her distracted and will not allow her to push Second Stage of Labor 10 cm dilated perineal and rectal bulging crowning 100% or completely effaced Chorionic Villus Sampling Risk for spontaneous abortion Postpartum Immediately after: If fundus is lateral. always dress bad side first! Undress the GOOD side first Intrapartum Epidural anesthesia. firm and midline ..Can be caused by appendicitis or any other infection in the abdominal cavity Symptoms: Rigid/ board-like abdomen Shallow respirations (pushing on diaphragm) Severe abdominal pain TPN w/ Central Line -can cause pneumothorax. trachs. post op. Feed a dysphagia patient. foley catheter Strain urine for stones/renal calculi Can shave or prep surgery patient CNA Cannot. bulimia. empty bladder Fundus should be at level of umbilicus. the membranes must have ruptured. ADL’s Ambulate a patient with ataxia (gait problems) Ambulate a client 24 hours post laminectomy (back surgery) Ambulate client with a halo. pneumonectomy. etc What patient can we send to OB? -Non infectious Pediatric nurse can care for any age client with a compatible/similar diagnosis of a pediatric client.. she should not handle the medicle) ER nurse. dementia. anorexia. same distance then bring up good foot If right side is weak dress right side first. IF pediatric nurse comes to med surg. watch for deviated septum -can cause air embolus: Petechaie on chest Chest pain Cough/resp problems Mental status change Life Support/Ethics Only the parents of children can decide about continuation of life support Delegation Floating Nurse Give simplest patient Give OB nurse mastectomy. internal monitoring is needed Before applying electrodes. noninfectious. which client do u give? 12 hrs post hysterectomy? or Status asthmaticus 24 hours ago?. post heart cath etc out of bed for first time Give instructions Monitor vitals first 15 after blood infusion Determine if patient can have water LPN Assign simplest task but that can be performed with license Can perform teaching to patients but RN must supervise and make sure the patient has learned Lithium If patient is on Lithium.Give alzheimer’s. wounds CNA Can.give trauma. etc. Do Not give traction pt who’s husband was killed (even though they have psych issues. and presenting part must be low enough for identification Abruptio Placenta pain with bleeding Placenta previa painless bleeding First Stage of Labor Teach client to pant.correct answer Psych nurse. hysterectomy. DVT. for pts with bipolar disorder Cerebrovascular Accident Left stroke = Right sided weakness/issues Cane always goes in unaffected hand The cane and the bad foot forward same time.not take deep breaths because we do not want her to push.

to press against the bleed in the esophagus Keep scissors at bedside to cut in case of emergency to make room for intubation Concerns: Fresh fruits and fresh vegetables are rough and can tear the varices that have been controlled Frequent swallowing. have O2 / suction at bedside Radiation External radiation: Not radioactive Can be in a semi-private room Can have visitors Do not wash off painted markings around radiated area Do not apply lotion or powder on area prior to radiation. cool. place in lead lined container. Time. after chewing it becomes doughy .bleeding.If fundus is at umbilicus.burn abdomen. could be in shock What is most concerning in diet of esophageal varices client? Fresh fruit/veggies or Pretzels Pretzels are ok. facial edema and 3+ albumin in urine. what is priority? Risk for seizure. firm and midline. use lead tongs to pick it up. it will burn Nausea and vomiting CAN be a side effect Side effects are usually site specific head-alopecia mouth-stomatitis chest.soothe irritation Rinse mouth with miracle/magic mouthwash -no alcohol Do not use lemon/glycerine swabs! -will burn Do not use OTC mouthwash -alcohol Do not tell them to drink plenty of Orange Juice -will burn Do not use hard bristle toothbrush Buck’s Traction On correctly if patient is in good alignment Pt is supine Only elevate head 20-22 degrees -they may slide down in bed if higher Leg should not be rotated internally or externally Pt’s leg should not be elevated but straight out Esophageal Varices Causes: Alcohol. must stand 6 feet back Children should not be in room at all If radioactive implant is found outside pt’s body.indicates bleeding Pale. after that nurse must stand at door or at foot of bed Family CAN visit BRIEFLY. etc. clammy. PIH) Give a c-section (surgery patient) If you have no bed on OB but have an emergency CSection she can be sent to Med/Surg floor after she is stable signs of post partum psychosis-irritable and can’t sleep Stillborn birth Stay with family as long as needed then give privacy Someone will take a picture of baby after family leaves Magnesium Sulfate CNS Depressant Can be used for pregnancy induced hypertension Interventions with giving this: Knee jerk/DTR’s every hour Monitor respirations (keep 12-14) (the diaphragm is a muscle) Foley to monitor output (keep at least 30mL/hr) Concerning findings with Magnesium Sulphate: An increase in BP Preeclampsia Risk for seizures When seizure occurs. the patient has Eclampsia Symptoms: Facial Edema Edema in hands Increased bp proeteinurea(albumin) For pregnant patient with bp 160/100. but patient is still bleeding excessively Check perineum for lacerations If nurse floating to OB from Surgery Do not give OB Do not give High risk (15 year old.can cause diarrhea Internal Radiation: Radioactive private room far from nurses station Strict BED REST.can burn esophagus and cause a bleed Portal Hypertension Excessive gastro-esophageal Reflux Sengstaken Blakemore tube Used to press/ a balloon. Distance. call the radiation oncologist Stomatitis Rinse mouth with baking soda and water. Shielding Nurse can only be in room 30 minutes for direct pt care. no sitting in chairs.

Rheumatic. mastectomy. Pepcid. low residue diet to slow down bowels Low Residue= NO MILK PRODUCTS. ammonia level is sky high (possibly 140. etc but NOT RED . normal 10-40).CT Scan Contraindicated for pregnant women Tonsillectomy Post surgery Give popsicles/ jello. Zantac. may all have difficult times dealing with feelings/ anger. spinal cord injury. Endocarditis. tell them it is acceptable to express anger Colostomy. ammonia will bind with the increased loose stools and reduce symptoms of sky high ammonia. Let family and pt know it is acceptable.this could be mistaken for blood if vomiting occurs Do not give milk products -Mucous Lactulose (Cephalac) with Contrast Ask about allergies to shellfish or contrast dye Provide fluids post procedure Peptic Ulcer Disease H2 receptor blockers Tagumet. Carafate. skirt hem uneven Shoulder blades. ileostomy. iliac crest uneven Antacids Malox. terminal illness. therefore decreasing compulsive behavior Antipsychotics Used for schizophrenia Schizophrenia Keep the person in reality Tell the patient that no one else has seen the things they are seeing Do not tell them their hallucinations aren’t there or real because these things are real to them Back surgery/injury laminectomy. manipulation Antisocial Personality Disorder Have no responsibility or remorse. Mylanta given 1-2 hours after the meal Borderline Personality Disorder Who is most at risk: Person who was abused as a child Symptoms: Rage. Ammonia level lowers= less lethargic Newborn Assessment Look for fractured clavicle crepitus in right clavicle Chron’s and Ulcerative Colitis Irritated Bowels Diarrhea Give low fiber. poor work history Do not assign to do chore by themselves Assign to do task with 2-3 other people to make sure it is done OCD Never eliminate or forbid a compulsion of an OCD patient Do not interrupt an OCD Do not limit Goal for an OCD psychotherapy has very little effect want behavioral change. Pericarditis. discectomy. want them to change behavior want them to do creative activities instead of automatic/impulsive behavior do creative activity to cope with anxiety. it is hard for bowel to break down To replace nutrients lost in diarrhea high calorie high vitamin high protein Therapeutic Communication Allow angry patient to express anger. etc. spinal fusion . Losec Given 30 min-1hr before meal Potent laxative Hepatic Encephalopathy If Lactulose is given to this pt. aggression. intense relationships. Scarlet Fever Can be caused by strep throat Ask pts with these illnesses if they have had a sore throat or cold Tell pts with these illnesses not to be around crowded places Do not be in close contact with patient with infection Scoliosis Pants leg.

DPT immnization Respiratory Droplet Bacterial Meningitis Pertussis Scarlet fever Airborne/contact Chickenpox Contact Meningocele Good prognosis is expected with surgery Cholecystectomy They will probe in common bile duct to look for stones. Russell’s traction Keep bone in good alignment Prevent muscle spasms If not pulling. or weights are on floor. Pre-op about phantom limb sensation Tingling.keep tourniquet at bedside contracture-most serious Interventions Keep calcium gluconate at bedside incase calcium drops Keep trach set at bedside to prevent contracture only elevate stump for first 24 hours-to prevent edema and hemorrhage after first 24 hours lay stump flat at intervals. do not flex hip for 8 weeks Do not cross knees. pressure on neck. etc. itching. medicate and tell them this is ok You can have 3 major complications from amputations Infection Hemorrhage. do not adduct! Do not internally rotate Knee never higher than hip 1 day post op ambulate short distance 2-3 steps and place in a recliner with feet elevated Rheumatoid Arthritis Want exercise for joint mobility Increased periods of rest will cause stiffness .bleeding Pertussis Whooping cough Respiratory Droplets Immunization can cause seizures. If post-op. of fingers and toes Amputation If prosthesis causes severe pain REMOVE it! -this could break down the stump.e. ankles.Pt can stand and lie but has trouble sitting Always log roll can cause numbness and tingling/ parasthesia around mouth/perioral. gown and gloves Respiratory airborne Activities should be age appropriate keep on contact keep quiet and busy Thyroidectomy Patient at risk for damage/ partial removal to parathyroid this could decrease the client’s calcium Cellulits MRSA VRE Traction weights i.partial airway obstruction.means the neck is swelling Crowing respirations (inspiratory stridor). and cause need for further amputation Tell Ct. this could cause pain Total Hip Replacement Do not sit at a total 90 degree angle Do not bend at hip. swelling Frequent swallowing. they have phantom limb pain. turn patient prone Bacterial Meningitis Meningitis is neuro Respiratory Droplet precautions -mask within 3 feet Concerns Dressing is getting tighter. this may cause edema of duct The t-tube prevents the bile duct from closing With T-Tube Do not want bloody drainage Do not want over 500 mL in 24 hours Concerns: Clay colored stool Dark urine Chickenpox Incubation period 7-10 days Contact isolation.

or drooling patient CNA cannot feed a Myasthenia Gravis Diet Crutches 4 point gait. both crutches then swing good leg up stairs up stairs good foot first down stairs bad foot first DIC Paradoxical issue where pt bleeds and clots Monitor Hematocrit No liquids No steak and potatoes. Cholecystitis. and salivation CNA cannot feed a patient with dysphagia.both crutches and affected foot same time same distance. make door knobs larger. intervention for arthritic client give a warm bath in the morning warm compresses on joints prior to exercise tell them to do chores in early afternoon they have morning stiffness COPD Only gets 2L of O2. etc Soft foods Soft foods w/ sauces Developmental Stages 4 week old.they are neutropenic You CAN place patient with Appendicitis. they are inflammations! Anorexia Nervosa low self esteem anti. prevent oxygen toxicity They are always short of breath. this is normal Alzheimer’s These people like to wander Make sure their room is near a family room to ensure safety Goal for this patient Be able to do ADL’s as long as possible Goals involving recovery are unrealistic Vegetarians Deficient in B12. B12 is found in animal products Breast Cancer Biggest at risk Nullapara-no babies First baby after 30 mensus before 13 menapause after 55 If woman has more than one of these she is at a greater risk Dysphagia Parkinson’s.no weight bearing or amputee. crutch THEN opposite foot.Rest frequently but not for extended amount of time We want to EXTEND joints to prevent contracture. hot dogs. etc.baby steps. respiratory distress is when we need to be concerned Oxygen therapy Anything that could cause static electricity Nylon pajamas or blanket matchbox cars Anything that could get moist and harbor bacteria Stuffed animals/teddy bears HIV/AIDS Does not have to be in a private room Do not place with an infection.partial weight bearing. diverticulitis Are NOT infections. crutch THEN opposite foot 2 point gait. eating utensils larger. CVA. then bring good foot up the swing-to . or a trach patient.grasp finger and pull to mouth *Never give toddlers hot dogs or carrots! How to get child to cooperate? speak in age appropriate language about procedure tell them just before the procedure never tell them in detail tell them what you expect of them during and after the procedure . pancreatitis.crutch and opposite foot same time same distance 3 point gait.social wears big clothes is a perfectionist usually 15% under ideal body weight To assess progress do a daily weight in the morning after voiding Vasectomy Must have three sperm free specimens before considered sterile Each ejaculation will have decreased sperm until sperm free Use ice on incision Manipulation from surgery can cause discoloration of scrotum. Myasthenia Gravis First symptoms of all these are difficulty swallowing.

toes.adults for babies.they are only involved with data collection.never show them the equipment. given IM Right deltoid.put in syringe. vomiting Left upper quadrant pain Abdominal pain Numbness and tingling of fingers. do not call risk management just send the data afterwards Always chart that the Doctor was contacted. around mouth from low calcium Peritoneal Dialysis You want clear outflow. squirt into cheeks. dependent) elevating legs of arterial patient can cause pallor and blanching Pancreatitis Fatty foul smelling stools Nausea. if he was contacted Incidents: Give medication to wrong patient what do you chart? Demoral 50.can ride a bicycle Delirium. Do not Chart about it! Do not chart that Risk Management Team was contacted. wash with soap and water and THEN alcohol solution Delirium If spouse brings husband to ER with delirium. lie on side without the lung so they can expand the only lung they have Best air exchange is obtained in semi-fowlers Bulemia Nervosa Tooth decay Callouses on fingers -from gagging herself Ampicillin/ antibiotics observe for white spots in the mouth (candida) give nystatin or mycostatin swish and swallow. but hanging is D5NS. how do we chart? D5 NS discontinued. but if possible let them play with non-intimidating equipment 3 year old. not straight towards throat to prevent aspiration . not cloudy ICP Normal is 0-15 If pt has neuro surgery. D5 Half normal started.disoriented progressively. physician notified Do Not chart “wrong fluid” Risks Smoking Multiple sex partners SLE/Lupus Can be exacerbated by: Stress. albumin in urine(should be 0).disoriented to time and place ACUTELY. physician notified DO NOT Chart “wrong patient” If wrong IV is hanging. possibly for years Cervical Cancer 2-3 year old thinks dead person is asleep 4-5 year old blames themselves for the death of others and feel guilty Coping How do you know the parents of a terminally ill child are not coping? “My husband and I are strong and know our child will get better” Incident Reports Contact the physician and then complete incident report Hospital property. maybe for a couple hours Dementia. what question do we ask her? What medication is he currently on Lung resection/lobectomy Place on unaffected side as to expand the affected lung Best air exchange is obtained semi-fowlers Pneuonectomy Do not lie on unaffected side. how do we chart? Physician ordered D5 half normal saline. CHRONIC. physiological or psychological Butterfly rash over nose and cheeks Discoid lesions/coin like lesions over the body photo-sensitive Can damage Kidneys. Creatinine. head injury or CVA Place head at 30 or 45 degrees to prevent increased ICP Do not flex neck or hips! Do not sit at 90 degrees/high fowlers Do not lay flat/supine or prone MRSA and VRE Contact isolation. for pain 10 am. Output) Intermittent claudication pain with walking but subsides with rest arterial intervention (A = legs down. gown and gloves Wipe off equipment used on patient *when gloves are removed use alcohol solution EXCEPT with c-diff. nephritis (BUN.can ride a tricycle 5 year old.

difficulty seeing things up close Black older people Get bluish spots on the sacrum Glomerulonephritis Can damage the kidneys BUN CreatinineC Albumin Output Tetracycline Do not give with milk. food or antacids-will not absorb well Do not give to pregnant lady. halidol.can stain teeth Makes patient photo-sensitive Thorazine. TB positive Respiratory airborne Negative pressure vented to outside N95 Respirator.all make pt photosensitive people with SLE/Lupus are also photosensitive Elavil Causes photosensitivity Shows results in 2-4 weeks Bryant’s Traction Little bryant is 2 years or less 20 lbs or less has fractured femur or dislocated hip buttocks off mattress.can stain babies teeth Do not give to small children. elavil.it is liquid stool Must wear bag at all times.ampicillin can also cause diarrhea Ileostomy Do not irrigate. pain.bowel schedule not regulated If ct has not had stool in 3 hours. this is a concern! Must monitor electrolytes more closely for this than colostomy Colonoscopy Post colonoscopy may have rectal bleeding with clots (normal) Patient should not be on aspirin or steroids prior to procedure Addison’s Needs to ADD some cortisol (an anti-inflammatory) These people have no anti-inflammatory they can get critical fast! See them first for fever. signs of infection Older adults Do not drink enough water Eat less than they did earlier in life (still have appetite) Get up early and take naps Tympanic membrane thins (worse at hearing) Do not drive at night because of glare Presbyopia . Bactrim. legs straight up 90 degrees to mattress Renal Disease Restrict: Protein Potassium Sodium Fluids Lactated Ringer’s has sodium and potassium!! If they are on dialysis they CAN have protein *ALWAYS SEE FIRST patient unrelieved by pain meds 1 hour after administration! Or pain unrelieved by narcotic analgesia Nutrition Toddlers that drink too much milk may become anemic from lack of room for iron rich foods Babies’ milk consumption should be reduced once solid foods can be introduced in the diet How to get people who aren’t eating well to eat well Let person eat with other people Make the food attractive and appetizing Tuberculosis If sputum culture is Acid Fast Bacillus Positive ISOLATE. they cannot be burned for disposal) If they need to be taken out of the room Call ahead to place they are going to make sure they have a room ready (x-ray.) and put a SURGICAL MASK on patient for transport and give them a disposable recepticle (plastic bag) for tissue disposal early symptoms: cough chest pain low grade fever (esp in afternoon) night sweats anorexia weight loss Late symptoms: hemopsis Isoniazid (INH) and Rifampin can damage liver and kidneys . ct. mri etc. diaphoresis. Fitted/ Particulate Mask Family must wear surgical mask while at hospital (but not at home) Report TB to health department Teach to cover mouth/nose with tissue when cough or sneeze (cloth handkerchiefs are concerning.

you are negligent if you do not tell Do not drive or operate heavy equipment Pilocarpine Is a myotic.Intraocular Pressure Do not life or bend Do not do valsalva Glaucoma Do not give Atropine or Antihistamine .drying agents. it constricts the pupil affects aqueous humor more than the vitrus humor Timolol/ timoptic drops -Beta blocker Optic Drops Place finger in the inner canthus (tear duct) for 1 minute after administration to keep medicine from going systemic Cataracts Speak to them on unaffected side Aortic Anerysm Repair (arteriogram) Check all pulses Check lower extremities for cool temp and discoloration Check for bleeding (hypotension) Myasthenia Gravis Extremely weak muscles Difficulty swallowing Difficulty breathing Soft foods/ sauces. check again in 72 If site checked at 48 hours and is a 6 mm induration and 8 mm redness. . saliva. they’re already weak How do we know MG pt is getting worse? Drooping of 1 or both eyelids If you give Myasthenia Gravis pt Prostigman.stand directly in front to talk to them *If in ER and give benedryl.Teddy bear.. Glascow Coma Scale 7 or below is coma 3 is lowest score Raynaud’s Vasospasm of small vessels in the fingers and toes Causes numbness and tingling on exposure to cold Interventions: Do not smoke -vasoconstrictor Reduce stress Spica Cast Give toy too large to stick down into cast. will dry the eyeball They do not have peripheral vision.results are inconclusive at present.drug of choice for MG Peak in 30 min to 1 hour What doctors order do we question? He ordered valium for MG pt. .1 mL of solution Check site at 48 and 72 hours 10 mm induration is positive AIDS patients-5 mm positive If checking site at 48 hours and it is 8 mm induration.what would concern nurse if pt is on INH? Yellow skin and sclera (any answer involving the liver) Check BUN albumin Creatinine output (kidney fxn) Must be taken for 9-12 months! INH: vitamin b6 is given to prevent neuropathies Rifampin: can turn secretions (tears.this is a muscle relaxer. urine) orange * Peridium can turn urine red/orange Nurse is negligent if she does not tell TB patient? Do not be in contact with pregnant women or small children ( they are at high risk) TB Skin Test Anterior aspect of forearm 26-27 gauge needle Hold at 15 degree angle (intradermal) 0. no liquids etc. check again in 72 Dehydration monitor for seizures (mental status change) Tracheoesophageal Fistula Opening between trachea/esophagus Monitor for Aspiration Prostigman.. you would know. what would we expect? I can breathe and swallow better See the pt who needs prostigman first! They need help breathing! Eye Surgery Concern. etc.

rales. what concerns the nurse? BUN is 50 Gastrectomy or Gastric Bypass Dumping syndrome: For 30 minutes after eating with gastrectomy or gastic bypass patients they have symptoms of GI virus (diarrhea.. frothy sputum Right heart failure (COR PULMONALE) caused from left heart failure Right ventricular hypertrophy (trying to push the blood into already full lungs) System symptoms: JVD Ascites anascarca (generalized edema) Hepato/Spleno meglia *vesicular breath sounds normal *adventitious breath sounds abnormal (a for adven.causes increased salivary secretions/drooling Pt can do three things: Radiation Chemotherapy Surgery If they have surgery (laryngectomy) they will have a trach For trach pt: Use communication board After trach can be removed they have a permanent trach stoma 3 methods of speech after trach removal: Prosthesis-allows them to be able to cover stoma with finger and speak Electrolarynx.burp the words A thin scarf can be worn over stoma Cover stoma when putting on make-up Cover stoma when shaving the face Cover stoma when showering but not with a plastic bag Teach to install a smoke detector (they cannot smell smoke anymore) Teach someone to check food periodically (they can’t smell if it’s spoiled) Heart Failure Left Left=lung: Dyspnea Orthopnea Wheezing.Fractures Fractures of long bones can cause Fat Emboli Fat emboli: Petechiae on chest Chest Pain Cough Shortness of Breath Hemopsis Mental status change Laryngeal Cancer Difficulty swallowing. tell patient: take deep breath and HOLD IN .Sounds like a robot Esophogeal Speech. call doctor and ask to slow rate or decrease concentration TPN Monitor: glucose electrolytes if through central line monitor for: air embolus pneumothorax (deviated trachea or absent breath sounds. and abnormal) NG/TPN If infusing too fast or is too concentrated. unequal chest movements) When central line is inserted. rhonci Pleural effusion Pulmonary edema Pulmonary hypertension Pink.to prevent air embolus Aminoglycocides All “mycin” medications Can damage: hearing kidneys If client is on Vancomycin for MRSA. distention) Intervention: Rest/ lie down for 30 min after eating Do not give liquids with the meal.give 30-45 min before or 30-45 min after meal Give 6 small dry feedings Do not give concentrated sweets We want to promote protein for tissue repair Milwaukee Brace Used for scoliosis Worn 23 hours a day .Diarrhea If NG or TPN pt has diarrhea.

simple questions Always speak at a normal tone/volume and do not use gestures (this goes for hearing impaired patients too) Receptive Aphasia When patient doesn’t understand statement. BP cuffs on that arm No watches. not nuclear medicine Enema Turn patient on left side (direction of bowel) Manic Patient. bleeding Give Back brace-pathologic fractures of vertebrae can cause death Ambulate-drives calcium back into the bones Give fluids-excess calcium in blood can cause kidney stones Aphasia Expressive Aphasia Ask yes or no. etc. anemia. 1 and 1/2 times the normal amount of fluids? Give as ordered PTSD Don’t want to talk about it Show no emotion Flashbacks insomnia nightmares What would make the nurse feel the PTSD is improving? Talks a little about the incident in group therapy and cried Use finger tips not palms Start circular around nipple Extend and include the axilla If a mass is found. infection.Sickle Cell Anemia Interventions: Plenty fluids (most important) Oxygen Pain medication (poor circulation causes aching and pain) Apply heat to pains Do not travel by plane or go to high altitudes (Denver. anything tight on that arm At risk for lymphedema for life No injuries. put arm across chest do not let it hang down Tegretol Can damage bone marrow What lab would we monitor if client is on tegretol? CBC If pt is on Tegretol monitor for: Anemia Red Cells Bleeding Platelets Infection White cells Leukemia Immunosuppressed Neutropenic Thallium Stress Test. it will most likely be in the upper outer sector of breast While examining one side she can put her arm upward. sunburns. jewelry. IVs. Colorado) If doctor orders for a patient with sickle cell anemia. Say the same statement in the exact same words to let the mind program what is being said What concerns you with receptive aphasia patient being discharged this afternoon? Multiple family/ friends coming to visit. hand behind head or hand on hip mastectomy Don’t carry heavy bag on that side No sticks. PET Scan. Inappropriate Behavior Restrain only last resort Medicate only if last resort Always tell them that behavior is unacceptable first! Then remove them from the situation If violence is threatened. patient will not understand all the info . even pin pricks on that arm Never leave the arm dependent. MUGA Scan NPO 6-8 hours prior Nuclear Medicine *Bone Scan is only nuclear medicine test that is NOT NPO *Cardiac Cath is NPO 6-8 hours but uses dye. even at night it is elevated If standing in a long line. ask for assistance to take patient to room Self Breast Exam Pre-menopausal: do bse 7-10 days after period Post-menopausal: tell to do on the same day of the month every month Do this in front of the mirror or in the shower Multiple Myeloma Bone cancer Affects bone marrow Interventions Monitor CBC.

vertigo) Lyme Disease Bite from deer tick Doxicycline is drug of choice Bull’s Eye Lesion (remember you shoot deer.. rubella) Do not give to pregnant women May have slight fever after shot Do not give to a sick child Antibiotics/Cultures Always get a culture before starting antibiotic or it could ruin the culture Hepatitis A and E Oral-fecal transmission If they come in with vomiting and/or diarrhea-contact isolation gown and gloves with enteric precautions (disposable plates and utensils) Who is most at risk? child care worker (diaper changes) CNA (bed pans) people who eat fish from contaminated water The cook/chef who does not wash hands Hepatitis B.. pillows etc or Place in dark quiet room with distant/soft musiccorrect answer (helps with ringing in ears. 6 ounces of milk.an antifungal Chemo medication can damage liver and kidneys Who do we not give milk? Milk is hard for bowels to break down. 4 ounces of coffee. wear non skid shoes.C. bull’s eye) Best time to check for ticks-bath time Gout Build up of uric acid Caused by eating too much purine food red meats organ meats fish (sardines) Monitor uric acid levels No alcohol Reduce weight if overweight Meds Cholchicine Allopurinol ProBenicid First symptoms-pain or inflammation of great toe Osteoporosis Post menopausal women. how many milliliters? 30 mL = 1 ounce Menieres “menieres has fluid in the ears” Vertigo Dizziness Tinnitus (ringing in the ears) Stand immediately in front to speak to patient They are a fall risk Low sodium diet (fluid build up) Do not give foods high in sodium-Peanut butter is high in salt! Best for meniere’s client?? Elevate head of bed. What is best to advise a 62 year old woman? enroll in dance class -correct answer (any activity to keep calcium in bones) or take multivitamins (very little calcium in multis) Most at risk person-person who smokes or drinks alcohol .could cause spasm Let sit on parents lab-do not want them to cry and cause spasm If Inspiratory stridor.advise to remove risks for falls. “deer tick”.Renal What can damage kidneys? Lupus/SLE TB Medication (INH.D Dialysis Hemophilia IV Drug users Healthcare workers Unprotected Sex Epiglottitis Cherry red epiglottis Throat is rapidly swelling/edematous Have trach set equipment ready at bedside-risk of respiratory distress May be drooling (cannot swallow) Do not check or swab the throat . Chron’s Gastroenteritis Diverticulitis Ulcerative Colitis Immunization Live vaccines (varicella.partial airway obstruction! what do we do first? Head tilt chin lift! If your client this morning for breakfast had 3 ounces of juice. crowing respirations. Rifampin All “Mycin” drugs/ aminoglycosides can damage hearing and kidneys Amphotericin B. well fitted etc.

Padgets Disease Loss of bone mass.low calcium give Calcium Gluconate! *Frequent swallowing Tonsillectomy thyroidectomy rhinoplasty esophageal varices *Blood Once blood arrives at unit start ASAP. drooling. cool.D are not infectious they are standard precautions Surgery clients do not place with infectios clients Don’t mix infectious clients! *Blood transfusion Reaction Febrile reaction: fever and chills Allergic: pruritis. replaced with deformities Give (also for osteoporosis) Fosemex Actinel Boniva Give these with Vitamin D to aid in calcium absorption Give with lots of water on empty stomach Must sit or stand for 30 min-1 hour Placing clint into a room Condition and age appropriate AIDS Does not need private room Do not place with infectious clientneutropenic Diverticulitis.000 with bleeding gums *client with a head injury who returned home from ER 2 hours prior with a headache Need to check vitals.twisted testicle. singed nasal hair.C. pale.. toes around mouth. Hep B. pancreatitis. have an hour to get surgery *Post thyroidectomy. laryngectomy. appendicitis. BAD *restless and trouble breathing start oxygen and call doctor *restless and in pain align them if in traction/ cast etc *restless. etc. anaphylaxis Hemolytic: back and/or chest pain *Addison’s Patient with sore throat. tonsillectomy *Over 400 Blood Glucose *status asthmaticus who suddenly stopped wheezingthey’ve arrested. clammy elevate feet about a foot *panic and manic patient -safety risk to self/others . uticaria (hives). neuro status. etc. drowsy. * a baby with bulging fontanels GENERAL REVIEW WHO TO SEE FIRST? *Dysphagia (difficulty swallowing). if they are vomiting.within 30 minutes note: CNA cannot monitor vitals the first 15 minutes! student nurses can *client with prolapsed cord Interventions: knee chest position elevate hips Trendelenburg Sterile gloved hand to hold presenting part off cord (if dilated enough!) *client who has had ruptured membranes Check fetal heart rate *14 year old with edema and scrotal pain. (unless its a 6 month old/teething) *Pain 1 hour after pain medication or Pain unrelieved by pain medication *Post thyroidectomy with a dressing that is tighteningedema of airway! or Crowing respiration/inspiratory stridor Numbness or tingling in fingers.aspiration risk Increased salivary secretions. cholecystitis are not infectious Lupus.they can bleed and go into shock *Client with burned face. etc *Right pneumonectomy that is placed on left side *Mom not bonding with newborn who has a cleft lip *Platelet count of 80. diaphoresis and chilling *Open fracture of femur.

client is restless with petechiae on chest -correct answer! Client has restlessness (first symptom of hypoxia) Which would you see first? Post thoracotamy with closed drainage or Post thyroidectomy -correct answer or Bilateral knee replacement with wound vac How to put on sterile gloves How to get dressed and undressed for contact isolation Venturi Mask 21% is 1-2 L 35% is about 4 L QUESTION A DOCTOR’S ORDER IF A Steroid every other day for an Addison’s client Should Give every day for the rest of life . How to use it Exhale and take a slow very deep breath to make ball go up Deeper they inhale the higher the ball goes How to insert an NG tube How to insert a vaginal suppository Who do we see first? A COPD with resp 26 and O2 92% or 24 hours post head injury with GCS decreased from 14-12 or 12 hours post total knee.Correct answer Replace the trach? Making rounds. priority? Give pain meds! if a unit of blood has been in nursing unit for 10 minutes and thyroidectomy starts complaining of numbness around mouth. what do you do? Call code? Assess for breathing?. what is priority? The blood can be taken back to blood bank to be re-refrigerated (never put in any other refrigerator because it is not controlled) Check thyroidectomy! Heimlich Maneuver How to Remove a Trach How to Move Patient in Traction up In Bed Stabalize traction (put weights on bed) Head of bed down Get assistance to pull up Put HOB back up Replace traction weights How to draw up regular or NPH insulin Roll NPH Clean top of vial and inject air into NPH Inject air and clean top of regular DRAW UP REGULAR Draw up NPH How to use Metered Dose Inhaler (MDI) How to use a C-PAP Pursed Lip Breathing Take deep breath Hold 2-3 seconds Exhale slowly through pursed lips Purpose of Incentive Spirometer? Expand the lungs.note: never see first any patient with fixed pupils and glascow coma scale of 3 before other patients (others could be saved. ct’s IV site is red and edematous and is receiving O2 at 2L nasal cannula. pt having pain and pain meds are due. client is on ventilator and trach is out of place. what do you do? Replace oxygen (they may need it discontinued if they are doing better but if it is ordered put it back asap!) IV pump is beeping. O2 is out of nose but patient is fine. this person is unlikely to survive) PLACE IN ORDER (DRAG AND DROP) Removal of a central line SAMPLE QUESTIONS While talking with client and they fall over in a chair what to do first? apical pulse? Call for help? Tap shoulder and assess if unresponsive?correct answer! While making rounds.

bloody stool If heparin is ordered in mL Heparin is ordered in 5.000 UNITS Protime/ Prothrombin time ordered for Heparin Heparin is PTT Protime/ Prothrombin time and INR are for coumadin Valium or muscle relaxant for myasthenia gravis They already have weak muscles . NA and protein are restricted Plavix for a client with Ulcerative Colitis Nothing is given that could increase bleeding.000 or 10.Irrigate the colostomy at bedtime the day of surgery It doesn’t even function for 2-3 days You don’t irrigate for 5-7 days Lactated Ringers for Renal Patient Has sodium and potassium K.